If you’re an emergency physician practicing in the UK you may be a bit surprised to hear about a trial published this week looking at the use of open reduction and internal fixation of rib fractures, and more specifically flail chests. Surgical management of rib fractures is something that took place 40-60 years ago, but in the modern world it’s arguably not routine. So many thanks to @traumagasdoc for asking the question after it came up at a trauma meeting in London.
A quick look around the internet reveals some rather alarming photos from trauma.org of external fixation devices of the past. These external fixation devices remind me of some medieval torture devices and I guess it’s no surprise that they fell from favour.
On the other hand we know that there is a significant morbidity associated with flail chest in trauma. In addition to the underlying lung contusion the pain and potential mechanical instability of a large flail segment can lead to pneumonia, pain and a prolonged hospital stay. Pain, a known complication and a prolonged hospital stay would serve as just reasons to perform an open fixation for many orthopaedic injuries – so why not the ribs?
Following a short debate on Twitter it seems that surgical management has not dissapeared everywhere with colleagues in Australia and Yorkshire talking about it’s use in 2013. Perhaps our headline is a little disingenuous, in some places it has already returned (if it ever went away).
So, it’s interesting, it’s potentially useful, but what about some evidence that it works? Well lucky us there is a paper in the Journal of Critical Care on exactly this topic. Abstract below
So perhaps it is time to reconsider the possibility of surgical fixation for patients with blunt trauma.
Patients were considered for surgical rescue therapy (SRF) if standard analgesia and physio support failed and patients ended up heading for ventilatory support. This is a reasonable group in my opinion, SRF is clearly invasive and has risks so focusing it as a therapy on those failing standard management seems wise.
We also need to consider the exclusions in this study as they are a little odd. Patients with a low GCS and those that died in hospital. The reasons for this are unclear, especially in hospital mortality as death is a jolly important outcome for patients and in severe injury studies I feel that it has an important place when looking at outcomes. They do state that they excluded death reporting as there were no deaths in the SRF group – but I’m not sure this is wise.
Lastly, the numbers here are very small. 11 controls and 10 intervention patients.
The operative group demonstrated a significant reduction in total ventilator days as compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P = .040) with patients with SRF coming off the ventilator with a median of 1.5 days (0-8 days).
In fact all the outcomes they looked at were better following surgical fixation. Patients appeared to do better but as the numbers are so small no statistical difference was demonstrated.
So the results are impressive at first look….but…..
- The before/after design will always be exposed to the potential that we are seeing the effects of time rather than intervention.
- The small numbers mean that we may be seeing a type 1 error.
- In the control group patients were not selected for therapy. In the intervention group some patients were declined for surgical fixation. This is not then a comparable group.
- Although the differences in groups are not statistically different, they look as if they may well be and I would want to know a lot more about the patient characteristics and their injury patterns.
In addition, a recent meta-analysis of papers comparing surgical and non-surgical fixation suggests a benefit for patients in terms of ICU LOS and complications of the injury. However, there were only 2 RCTs in this analysis amongst 11 papers analysed.
As my good friend Bernard Foex tells me, this is a hypothesis generating study. I’d love to see more & even better I’d love to see an RCT, but that may not happen. The authors give a fair and balanced discussion of their findings with links to other case series in the literature. It’s reasonably well balanced and they mention many of the concerns raised in this review. I would agree that we would benefit from seeing data from a larger series of patients, and ideally from a well constructed clinical trial.
If nothing else I’m pleased to see the debate come again and for our surgical colleagues to keep thinking and researching techniques that may benefit our patients.
So, back to @traumagasdoc and his original question. We have answered the question about whether people are doing it (they clearly are) but this study does not as yet tell us whether it’s a brilliant idea or just a hypothesis.
- Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care. 2013 Sep 24. pii: S0883-9441(13)00288-8. doi: 10.1016/j.jcrc.2013.08.003. [Epub ahead of print] Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Fakhry SM, Minshall CT.
- Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg. 2013 Feb;216(2):302-11.e1. doi: 10.1016/j.jamcollsurg.2012.10.010. Epub 2012 Dec 5. . Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM.
- Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg. 2012 Aug;215(2):201-5. doi: 10.1016/j.jamcollsurg.2012.02.023. Epub 2012 May 4.Bhatnagar A, Mayberry J, Nirula R.