Pediatric first rib fractures

First rib fractures are associated with a high incidence of thoracic, vascular, abdominal, and central nervous system injuries. Usually reported in the adult population, first rib fractures are infrequently described in the pediatric population. We take this opportunity to describe six pediatric patients who sustained traumatic first rib fractures. Overall, five patients required operative intervention. Two patients sustained major vascular injuries which were detected on physical examination and confirmed by arch aortography. In view of the high percentage of patients with vascular injury, first rib fracture in a pediatric patient should prompt a search for major vascular injury.     

Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures

Background

Intramedullary fixation of rib fractures with generic Kirschner wires has been practiced for over 50 years. However, this technique has not been advanced to address reported complications of wire migration and cut-out. This biomechanical study evaluated a novel rib splint designed to replicate the less-invasive fixation approach of Kirschner wires while mitigating their associated complications.

Methods

The durability, strength, and failure mode of rib fracture fixation with intramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs were loaded to failure to determine their strength and to induce realistic rib fractures. Subsequently, fractures were stabilised with a novel rib splint made of titanium alloy with a rectangular cross-section that was secured with a locking screw. All fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load magnitude to determine their durability. Finally, constructs were loaded to failure to determine their residual strength and failure modes.

Results

Native ribs had a strength of 9.7 ± 5.0 N m, with a range of 3.5-19.6 N m. Fracture fixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out. Dynamic loading caused no significant decrease in construct stiffness (p = 0.85) and construct subsidence remained on average below 0.5 mm. The residual strength of splint constructs after dynamic loading was 1.1 ± 0.24 N m. Constructs failed by splint bending in 44% of specimens and by developing fracture lines along the superior and inferior cortices in 56% of specimens. Regardless of the failure mode, all rib splint constructs recoiled elastically after failure and retained functional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex.

Conclusions

Rib splints can provide sufficient stability to support respiratory loading throughout the healing phase, but they cannot restore the full strength of native ribs. Most importantly, rib splints mitigated the complications reported for rib fracture fixation with generic Kirschner wires, namely implant cut-out and migration through the lateral cortex. Therefore, rib splints may provide an advanced alternative to the original Kirschner wire technique for less-invasive fixation of rib fractures.     

Upper rib fractures following median sternotomy

First and second rib fractures occurred in 11 (16%) of 69 patients undergoing median sternotomy. Although 6 patients had no symptoms related to the rib fractures, 5 patients had postoperative chest, shoulder, and arm pain suggestive of angina pectoris or postpericardiotomy syndrome. The correct diagnosis of pain related to postoperative upper rib fracture may be made by direct visualization of the fracture on supine anteroposterior radiographs, elicitation of pain by palpation of the rib or motion of the upper extremity, lack of response to nitroglycerin, and negative electrocardiogram and cardiac enzyme levels. Upper rib fractures following median sternotomy are usually radiographically detectable within the first three postoperative days. Placement of the Ankeney sternal retractor with the upper blade in a lower position (fourth intercostal space) may reduce the incidence of this postoperative complication.     

Management of the patient with rib fractures

Rib fractures commonly result from blunt chest wall trauma and are often associated with significant morbidity and mortality. Patients often develop a vicious cycle of pain, requirement for opioid analgesia, respiratory dysfunction, hypostatic pneumonia and ultimately respiratory failure. This is more common in those with high-risk features such as increasing age, respiratory comorbidities and significant burden of injury. Poorly managed chest wall pain can lead to prolonged hospital stay, including critical care admission, invasive ventilation and increased likelihood of morbidity and death. Protocolized assessment and management is recommended to ensure high-risk patients are identified early and ensure that a holistic package of care including physiotherapy, incentive spirometry, multi-modal stepwise analgesia and laxatives are provided for all patients. Regional anaesthesia and surgical fixation should also be considered early for high-risk patients. A multidisciplinary approach is essential to maximize patient experience and outcome.     

Delayed life-threatening hemothorax associated with rib fractures

We present two cases of delayed, massive, life-threatening hemothorax due to intercostal hemorrhage in association with fractured ribs and severe blunt chest trauma (SBCT), a combination we have not seen described in the literature. Blunt chest trauma is not benign. Significant intrathoracic injuries are frequent although usually not life threatening. However, associated extrathoracic injuries are also common and much more lethal. Most cases of hemo- and pneumothorax associated with SBCT can be treated without thoracotomy. However, rapid blood loss requires immediate open thoracotomy and surgical attention. Several days of observation in hospital may be required for patients with SBCT and fractured ribs even without any other obvious intra- or extra-thoracic injuries. Vigorous activity or chest physical therapy may be dangerous during the first several days after the injury.     

Catheter epidural analgesia in serial rib fractures

According to our results, permanent epidural anaesthesia was significantly superior to systemic opioid treatment in patients with serial rib fractures. The main advantages were not only continuous pain relief despite the fact that the nonepidural control group required more than twice the dosage of morphine derivatives; also, the respiratory and pain-related recovery time was reduced. Another advantage was the selective effect (due to the local application) on respiratory pain and therefore on respiration as a whole. Deep breathing and expectoration were easier, so that the use of respirators and other artificial breathing aids could be avoided or at least reduced in duration in some cases. This makes the method particularly suitable for use in the management of polytraumatized patients. The standard dose was a mixture of 3.3 mg morphine and 37.5 mg bupivacaine (= 1/3 ampoule morphine + 15 ml Carbostesin 0.25%) every 12 h. When morphine was temporary contraindicated (frequently the final diagnosis in the case of an "acute abdomen" delayed the administration of morphine) the use of bupivacaine alone provided a satisfactory result for a certain time (we never observed tachyphylaxis). Additional systemic pain relievers were only necessary when the patient was suffering from pain caused by other injuries beyond the area of effectiveness of the epidural catheter (the only obvious disadvantage of the local application technique). On the other hand, epidural anaesthesia enabled us to treat a patient's lower-leg fracture by interlocking nailing, while adding only 0.01 mg fentanyl (= 2 ml Fentanyl Janssen) and 1.2 mg flunitrazepam (Rohypnol).     

Surgical management of multiple rib fractures: a case report of rib stapler]

A 66-year-old woman with multiple rib fractures was successfully treated with the use of Rib Staplers (Judet's struts made of titanium). Rib Staplers are effective for the stabilization of fractured ribs even if fracture lines are oblique.     

The significance of first and second rib fractures

There are differing opinions in the literature regarding the significance of first rib fractures. The plan at Westmead Centre is to standardize the initial assessment of patients with such fractures. A 3 year retrospective study of 170 trauma victims who sustained fractured ribs, was undertaken. Of the 15 patients with first rib fracture, all were involved in motor vehicle accidents. Over two-thirds of these patients sustained major chest injuries. Multisystem trauma involving cranial, abdominal or skeletal injury was common. One patient died as a result of head injury. Similar results were observed in 13 patients with second rib fractures. Brachial plexus injuries were noted in two patients with first rib fracture. Despite follow-up of high-risk patients at an interval which varied from 1 to 2 1/2 years after the original injury, major subclavian artery injury was not detected in patients with first rib fracture. From this experience and a literature review, we suggest that the general nature of trauma is similar in patients with first rib fracture to that in patients with second rib fracture. Patients with first rib fracture should be closely examined for neurovascular compromise. Guidelines for the use of angiography are discussed. If there is no evidence of neurovascular injury at presentation, and there is no other thoracic injury, recovery should be uneventful.     

The significance of first rib fractures in children

Purpose

The purpose of the study was to determine if first rib fractures are associated with an increased incidence of thoracic vascular injury in pediatric patients.

Methods

The medical records of all children diagnosed with a first rib fracture or a central vascular injury after blunt trauma treated at a state-designated level 1 pediatric trauma center from 2000 to 2009 were reviewed.

Results

Thirty-three children (0.27% of patients; mean age, 10.9 ± 0.9 years) were identified with either a first rib fracture or thoracic vascular injury owing to blunt trauma. Thirty-two children had a first rib fracture, and only 1 child (3%) had significant thoracic vascular injury. Mediastinal abnormalities (indistinct aortic knob) were identified in 3 children, 2 with first rib fracture on initial chest radiograph. Despite a normal cardiovascular examination result, 25 (74%) children with a normal mediastinum on screening chest radiograph underwent computed tomography. No child with a normal mediastinum on initial chest radiograph was found to have associated intrathoracic injuries requiring further intervention. In children with first rib fractures and a normal mediastinum by screening chest x-ray, the negative predictive value for thoracic vascular injury was 100%.

Conclusions

Children with first rib fractures without mediastinal abnormality on chest radiograph require no further workup for thoracic vascular injury.     

Impact of rib fixation on quality of life after major trauma with multiple rib fractures

Introduction

Multiple rib fractures have been shown to reduce quality of life both in the short and long term. Treatment of rib fractures with operative fixation reduces ventilator requirements, intensive care unit stay, and pulmonary complications in flail chest patients but has not been shown to improve quality of life in comparative studies to date. We therefore wanted to analyse a large cohort of multiple fractured rib trauma patients to see if rib fixation improved their quality of life.

Epidural analgesia improves outcome after multiple rib fractures

BACKGROUND: Rib fractures are common and associated with significant pulmonary morbidity. We hypothesized that epidural analgesia would provide superior pain relief, and reduce the risk of subsequent pneumonia. METHODS: A prospective, randomized trial of epidural analgesia versus IV opioids for the management of chest wall pain after rib fractures was carried out. Entry criteria included patients older than 18 years with more than 3 rib fractures and no contraindications to epidural catheter placement. RESULTS: From March 2000 to December 2003, 408 patients were admitted with more than 3 rib fractures; 282 met exclusion criteria, 80 could not be consented, and 46 were enrolled (epidural n = 22, opioids n = 24). The groups were comparable for mean age, injury severity score, gender, chest Abbreviated Injury Scale, and mean number of rib fractures. The epidural group tended to have more flail segments (38% vs 21%, P = .20) and pulmonary contusions (59% vs 38%, P = .14), and required more chest tubes (95% vs 71%, P = .03) Despite the greater direct pulmonary injury in the epidural group, their rate of pneumonia was 18% versus 38% for the intravenous opioid group. When adjusted for direct pulmonary injury, there was a greater risk of pneumonia in the opioid group: OR, 6.0; 95% CI, 1.0-35; P = .05. When stratified for the presence of pulmonary contusion there was a 2.0-fold increase in the number of ventilator days for the opioid group: incident rate ratio, 2.0; 95% CI, 1.6-2.6; P < .001. CONCLUSIONS: The use of epidural analgesia is limited in the trauma population due to numerous exclusion criteria. However, when feasible, epidural analgesia is associated with a decrease in the rate of nosocomial pneumonia and a shorter duration of mechanical ventilation after rib fractures.