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No Longer a Waiting Game

Treatment for patients with complex rib fractures used to be a waiting game. MUSC Health trauma surgeon Evert A. Eriksson M.D., remembers being taught in medical school to provide only supportive care, often including mechanical ventilation, to the most severely injured patients, those with “flail chest,” and wait for the ribs to mend well enough for normal breathing to resume. In flail chest, at least two ribs are broken in two places, compromising the chest wall’s rigidity and leading to difficulties breathing and severe pain. Unfortunately, due to prolonged periods on the respirator, these patients had a higher risk of pneumonia and often required narcotics for pain control.

The wait is over. New rib fixation technology and minimally invasive techniques for its implantation enable rib stabilization in patients with flail chest, leading to better respiration and lower rates of ventilator usage.¹ These encouraging findings led surgeons to extend the use of surgical rib fixation to patients who begin to fail ventilation and to those with major chest wall injuries who do not require ventilation. “We’re changing how we manage rib fractures,” says Eriksson. “We can now put in specially designed plates to fix the ribs and get these patients out of the hospital faster, decrease their pain and get them back to their lives sooner. Their ICU length of stay and their risk of pneumonia go down.”

The Chest Wall Injury Society (CWIS; https://cwisociety.org/) recently conducted a survey of trauma surgeons to learn when they opted for surgical rib fixation. For patients with three or more rib fractures with at least 50 percent displacement, there was a split decision, with roughly half of respondents opting for surgical fixation and half opting for a “wait and see” approach. The CWIS is sponsoring a multicenter trial to test whether surgical fixation improves pain control, breathing function and quality of life in these patients. Eriksson is the principal site investigator for MUSC Health, which is the second center in the nation to open the trial and currently the second highest-enrolling site. Eriksson also serves on the national research committee and guidelines committee for the CWIS.—KIMBERLY MCGHEE

References

1. Pieracci FM, et al. J Trauma Acute Care Surg. 2016 Feb;80(2):187-194.