So I'm Jose Diaz, if I didn't mention it earlier. I currently practice at the University of Maryland at Shock Trauma, and I run the acute care surgery component. My only disclosure is that I have previously spoken and educated for AcuMed. Quickly move along on some of these initial slides. We've heard a little bit about the perspective of anatomy. My perspective is looking at the anatomy is typically how do I approach the repair. And from a critical structural aspect, I think that it's important to look at injuries associated with it between the second and the seventh rib, as those are the ones that are primarily associated with the mechanical structure of the chest wall and function. And so when you're looking at the images, those are usually where I begin to initially focus. As far as muscles as well as vasculature, my perspective, again, is how do I get there in terms of current surgical techniques, with the goal being to minimize the degree of surgical insult associated with some of these injuries. And it's also important to have some degree of historical perspective. I mean, in previous, almost 20 years ago, when we first started doing these, the incisions that we were using were huge. I mean, they're thoracotomy size incisions. And occasionally some of the reconstruction still requires that level of reconstruction and incision and exposure. I bring this slide only to remind you that this is the current AAST-AIS injury score. And the fact that the injury score really doesn't do chest wall injury justice from the perspective of rib fractures. And I reference you also to the article that was previously mentioned in terms of the CCWIS description of injury pattern. And how to approach it as far as, you know, whether or not operative management is indicated or whether or not it's something that could be managed non-operatively. We talked a little bit about paradoxical wall motion. It's relatively rare, as was discussed just a minute ago. And most often you see it radiographically. And even sometimes I've seen a few images like the one on the right where, you know, there is no paradoxical wall motion. It's mostly what you see is the patient splinting in trying to keep from actually having that move. From an imaging standpoint, I think pretty much everybody gets a CT scan if they are close enough to an emergency department, right? The ABC is airway breathing CT scan pretty much these days. You can't get through ED without getting a CT scan of one part of your body or something. The critical aspect that I think that at this point, most of the literature demonstrates that identifying an injury is best seen on an axial two-dimensional CT scan. And current technology demonstrates that pretty well with different techniques. 3D is really more for operative management in terms of, you know, how are you gonna position the patient? What is gonna be your specific approach? Are you gonna have to mobilize the scapula? Can you do a muscle sparing oblique incision? Are you gonna have to prone the patient? All of this is gonna be related to how you're gonna plan your operative management. A little historical slides. This is 1994. I mean, this is a while ago. And this is the data back then. I'm not gonna read it to you, but basically the injury pattern were pretty significant, right? You know, a lot of this was pre-airbag era when a lot of the motor vehicle crashes, you know, the patients either weren't wearing a seatbelt because, you know, seatbelts came into play in the 1970s. In the actual airbags, nobody actually had an airbag in their car unless they spent a lot of money in the 90s, 80s, and 90s. Jump ahead almost 20 years, and the injury pattern is the same. The number's a little bit different, but again, you know, the number of rib fractures as was described just a minute ago is still a significant morbidity. There's a lot of older gentlemen and ladies doing all kinds of stuff, me included. They're out there, you know, falling and, you know, trying to live our life. So the injury patterns are also a little bit different because our, you know, bone densities are different now. Flail chest is continues to be an issue. And this is just a small study, you know, for an example standpoint. Usually the mechanisms are your higher energy, typically motor vehicle crashes. And of course, these patient population usually ends up getting intubated. And the pattern that was described is pretty consistent. You know, either patients fail, have respiratory failure on the scene, they have respiratory failure in the trauma bay, or you decide to admit them to an IMC and you think that they're doing fine, and about within 12 to 24 to 36 hours later, they end up being intubated. And the patient that still is smoking gets intubated sooner. And that patient almost guaranteed that they end up with a pneumonia. A number of rib fractures has been discussed for a long time. Dr. Holcomb, before he went off to war and became famous with the proper study, was actually looking at some of this stuff and demonstrated that younger patients, as would expect, did better than older patients. And those with more rib fractures ended up with worse outcomes. And the half a dozen rib fracture studies that was almost now 15 years old in terms of the NTDB study also described the injury pattern as well as the clinical outcomes. You know, a significant majority of these patients, almost half, ended up on mechanical ventilation. As a result, they ended up in your hospital and ICU longer. They ended up with a significant mortality still associated typically not only with their injury pattern, but typically also with their hospital-acquired infection, whether it's a pneumonia, bloodstream infection, or a UTI, or due to their primary injury pattern. And the injury patterns are described. Pneumonia, or clinical outcomes, pneumonia. Patients progressing ARDS, those who presented with a pneumothorax. Aspiration, empyema. Many of these patients presented typically with either a pneumothorax or hemothorax, ended up with a chest tube. You know, you put in a little bit of blood, a little serum inside a chest wall cavity, and then put a foreign body in there, like a chest tube, the risk of an empyema is significant. I didn't describe Dr. DeBose's study from the AASD that demonstrated a high incidence of empyema associated with chest tubes. I also make mention that was described just earlier, is that epidurals did not impact the clinical outcome. And if you look at the NTDB studies that I showed you earlier, the incidence of use of epidurals and rib fractures in the NTDB studies is less than 10%. And in my institution, we say that every patient with a rib fracture is supposed to get an epidural. But yet only 10% of them actually do. So there's been a bunch of studies dating back to the late 1990s in terms of looking at rib fractures. There are some randomized trials. Most of these have been outside the U.S. There's now a few in the U.S. that have specifically looked at this. Of course, most of these have poor quality. And it's been a difficult challenge convincing those who have not gotten on the bandwagon and drank the Kool-Aid to actually think about utilizing rib fixation for bad rib fractures. Primarily because we've done this for 100 years and some of these ribs actually heal and most people actually do well, except that we never have any of these patients actually follow up with us, by the way. So anyway, looking at this particular meta-analysis, most of the data supports the use of rib stabilization. Here with the mechanical ventilation, demonstrates increased improvement with the use of rib fractures and stabilization. That obviously demonstrates improved ICU length of stay as well as mortality as well. And then of course the hospital length of stay. The issue with hospital-acquired infections, also pneumonia, decreased incidence of pneumonia. This is a study that probably got most of us who weren't already drinking the Kool-Aid interested. This is Fred Parichi's study out of Denver. Very interesting study from the perspective. He actually convinced his partners that we needed to take a look at this in a more scientific manner. He got some very big names to agree, Dr. Moore and Dr. Djurkovic to agree that let's take a look at this, let's not stabilize anybody for a year and then come back the next year and we're gonna stabilize those with certain criteria. You know, basically patients with flail chest, patients with three or more rib fractures with bicortical displacement, not just three rib fractures in a row, but with displacement. And then those with 30% or failure rate. And then they looked at specifically the outcomes associated with stabilization comparing both groups. Respiratory failure, tracheostomy, pneumonia, ventilator days, tracheostomy linked to stay, daily maximum sinus barometry volume, narcotic requirements, and mortality. You know, this is a typical image that you get. This is one of the operative managements that you typically end up with, both the axial scans and a 3D reconstruction. And this is just one type of rib plating that you see where the clinical improvement after stabilization. The other question that just typically has been brought up is, you know, should we, fixing someone who has had, and what about their incidence of complications? What about, you know, fixing someone who's had a chest event for a while? What about the, you know, the patient who gets ejected and has a significant injury? You know, the concern that, you know, whether or not to put foreign body into the site. This particular study looked at the overall risk of surgery associated with an implanted, and the risk in this study was only 10%. With infection, 2.2%, and fracture-related infection, only 1.3%. The symptomatic non-union was only 1.3%. Pulmonary complications were found in 30% of patients, with the overall mortality in this series only 3%. A third appeared to be a result of thoracic injuries, primarily as their primary cause of death. What about pulmonary complications? We've also talked about, well, a patient is intubated, they're intubated because of increased O2 requirement and respiratory failure. Maybe we should wait. Well, maybe we should not. In this particular study that is relatively new, was presented at the AAST last year, looked at a series of patients who underwent rib fixation and radiographic pulmonary contusion, and adjusted for ISS, and the ICU stay was shorter when they were stabilized, as well as patients with moderate contusions who underwent stabilization had fewer ventilator days. So there probably is something there in terms of the mechanical stabilization. Maybe it includes pulmonary function, and even someone on a ventilator. This, of course, is a retrospective, it is an association, it is not yet a direct correlation. In this study, they looked at the association of hospital-level ICU and whether or not patients' outcomes in the older patient population. Admission location for older patients with isolated rib fractures was a variable across hospitals, but hospitalization at a center with a greater ICU use was associated with clinical improvement. And this basically is your geriatric protocol. Do you admit your geriatric patient over 65 with an ISS score close to 15 to an IMC, or are you admitting them to an ICU where you have a higher level, especially that patient with a rib fracture? Those patients with rib fractures in this particular study were admitted to an ICU, had better outcomes. So, in conclusion, to give my colleagues a little more time, rib fractures are bad, stabilizing those patients with significant displace with flail chest, with patients who have respiratory failure, patients with pulmonary contusions, patients who've needed chest drainage due to significant hemo and pneumothorax who do not improve. You should consider, at this point, and patients to undergo surgical stabilization. Why? Because they have better outcomes. They have all those metrics that we use to determine whether or not the patients do well. Better length of stay, lower infection rate, hospital-acquired infection rate, as well as there is developing data from many of our colleagues that look at this that they have an early return to work and early return to function and back to what they were doing before. That data we have rarely had from the perspective that most of these patients don't come back to see us. Less than 20% of our trauma patients ever come back to see us. Thank you.

rib fractures

chest wall

CT scans

surgical stabilization

research