Rib Fracture Management (eBook)

Marc de Moya, MDAssociate Professor of SurgeryDivision of Trauma, Emergency SurgeryMassachusetts General HospitalHarvard Medical School165 Cambridge StreetSuite 810Boston, MA  02114John Mayberry, MDSaint Alphonsus Regional Medical Center999 North Curtis Road, Suite 407Boise, Idaho 83706

Foreword 5
Preface 6
Contents 7
Contributors 9
1: History of Rib Fracture Management 11
The Ancients 11
The Indians and Greeks 14
The Romans 14
Islamic Surgeons 15
Medieval Surgeons 16
Eighteenth- and Nineteenth-Century Surgeons 18
Awakenings 19
Mechanical Ventilation Slows Rib Fracture ORIF Development 21
The Recognition That Rib Fractures Are a Marker for Non-thoracic Injuries 23
Resurgence of Chest Wall ORIF 23
Acceptance of ORIF 29
Minimally Invasive Approach 29
References 31
2: Chest Wall Anatomy 35
Surface Anatomy 35
Bony Thorax 37
Sternum 37
The Rib Cage 38
The Spine 39
The Musculature of the Chest Wall 40
Primary Respiratory Muscles 40
Accessory Muscles of Inspiration 40
Accessory Muscles of Expiration 41
Nerves 42
Vasculature of the Chest Wall 43
References 43
3: Pathophysiology of Rib Fractures and Lung Contusion 44
Anatomy and Physiology 44
Anatomy of the Chest Wall 44
Ribs 44
Sternum 45
Muscles 45
Respiratory Physiology 46
Pathophysiology 46
Rib Fractures 46
Flail Chest 47
Pulmonary Contusion 47
Pneumothorax 49
Hemothorax 50
Special Considerations 50
Geriatric Patients 50
Pediatric Patients 51
References 51
4: Scoring Systems of Blunt Thoracic Trauma and Rib Fractures 53
General Properties of Scoring Systems 53
Ideal Characteristics of a Chest Wall Scoring System 55
Current Chest Wall Injury Scoring Systems 56
Chest Wall Organ Injury Scale 56
Rib Fracture Score 58
Chest Trauma Score 58
RibScore 58
Clinical Rib Score 59
Future Directions 60
References 61
5: Medical Management of Rib Fractures 63
Initial Evaluation 63
Management 64
Patient Disposition 64
Pulmonary Care 66
Fluid Management 67
Pain Management 67
Multimodal Pain Regimen 67
Regional Anesthesia 70
Venous Thromboembolism Prophylaxis 71
Nutritional Support 71
Complications 72
References 73
6: Lung Contusion Management: Invasive and Noninvasive 76
History 76
Epidemiology 76
Pathophysiology 77
Diagnosis 77
Initial Chest Radiograph 78
Lung Ultrasonography 78
Thoracic CT Scan Imaging 78
Lung Contusion Management 82
Lung Contusion Management: Noninvasive 82
Clinical Guidelines and Protocols 83
Lung Contusion Management: Invasive 84
Lung Contusion and CT Scan Predictors of Need for Mechanical Ventilation 86
Thoracic Trauma Severity Score on Admission to Predict ARDS 86
Measurement of Lung Contusion Volume by CT Imaging to Predict ARDS 87
Measurement of Lung Contusion Volume by Lung Ultrasonography to Predict ARDS 88
Management of ARDS Due to Lung Contusion 88
References 89
7: Rib Fracture and Lung Contusion: Impact on Pulmonary Function Tests 92
Pathophysiology 92
Acute Impact 94
Risk Stratification Based on Pulmonary Function Tests 95
Long-Term Impact 96
References 98
8: Indications for Rib Fixation 100
Guidelines for Rib Fixation 100
Indications for Rib Fixation: Anatomical Considerations 101
Flail Chest 101
Chest Wall Deformity 102
Symptomatic Rib Fracture Nonunion or Chronic Malunion 103
Open Rib Fracture 103
Acute Pulmonary Herniation 103
Number of Rib Fractures or Severely Displaced Fractures 103
Indications for Rib Fixation: Physiologic Considerations 104
Failure to Wean from the Ventilator 104
Poor Pulmonary Mechanics 104
Indications for Rib Fixation: Quality of Life 105
Pain Control 105
Reduced Long-Term Pain and Disability 105
Indications for Rib Fixation: Other 106
Thoracotomy for Other Indications 106
Age 106
Contraindications for Rib Fixation and Special Considerations 106
Location of Fractures 107
Pulmonary Contusion 107
Traumatic Brain Injury 107
Timing of Fixation 107
References 108
9: Slipping Rib Syndrome and Other Causes of Chest Wall Pain 112
Anatomy 112
Slipping Rib 114
History 114
Pathophysiology 115
Prevalence 115
Symptoms 116
Diagnosis 116
Treatment 117
Costochondritis 117
Tietze’s Syndrome 118
Xiphodynia 119
References 120
10: Rib Fracture Management Algorithm for the Traumatically Injured, Non-intubated Patient 124
References 127
11: Non-union 129
Definition of Non-united Rib Fractures 129
History 129
Bone-Healing and Non-union Theory (BHN Theory) 131
Literature Review 133
The Oregon Health and Science University Experience 134
The University of Minnesota Experience 134
The Sheffield Experience 136
Non-union of First Rib Fractures 137
Nonoperative Management of Non-united Rib Fractures 137
References 138
12: Operative Techniques 141
Positioning 141
Supine 141
Lateral 142
Prone 142
Incisions 142
Exposure 144
Retraction 145
Orthopedic Principles 146
Reduction of Fracture 146
Hardware Securement 146
Closure 149
Multiple Layers 149
To Drain or Not to Drain 149
Adjuncts to SSRF 149
Bronchoscopy 149
Thoracic Cavity Lavage 150
Analgesia 150
References 150
13: Review of Currently Available Tools of the Trade 151
Historical Repairs 151
Absorbable Prostheses 153
RibLoc®: Rib Fracture Plating System and U Plus Chest Wall Plating System 155
Anterior Cortical Plates 157
MatrixRIB™ Fixation System 157
RibFix Blu™ Thoracic Fixation System 158
StraCos 158
KLS Martin Rib Fixation 159
Intramedullary Fixation 159
References 162
14: Postoperative Complications After Rib Fracture Repair 164
References 168
15: Billing and Coding 169
General Principles 169
Basic Coding Principles 171
Open Reduction and Internal Fixation Codes 171
Hardware Insertion Documentation 171
Additional Common Procedures 172
Chest Procedures: Open 172
Chest Procedures: Thoracoscopic 173
Additional Add-On Codes 175
The Elusive 22-Modifier 176
Managing Denials 177
References 177
16: Future Directions 178
Identification of Rib Fracture Patients at Risk for Complications 179
Analgesia 181
Surgical Stabilization of Rib Fractures 182
Indications for and Timing of Surgery 182
Barriers to Surgery 184
Operative Technique 185
Reporting and Treatment of Complications 187
Systems Issues 188
Outcomes 190
References 191
Index 193