Tag Archives: fixation

Thorax

Best Of EAST #11: Rib Fracture Fixation vs Epidural Analgesia

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Rib fracture fixation has really taken off over the past five years for management of select rib fracture patterns. There are probably two mechanisms by which it improves pain control and speeds recovery.

The first is purely mechanical. In patients with flail chest, there is impairment of chest wall mechanics that decreases ventilatory efficiency and often leads to prolonged intubation and pulmonary complications. The other is the control of pain associated with multiple or displaced rib fractures.

The trauma group at the Brown University Alpert Medical School performed a TQIP database analysis that attempted to tease out the pain component in this equation. They compared outcomes from patients who underwent rib fixation or epidural analgesia within 72 hours of admission. They looked at a single year of TQIP data for adults with rib fractures, and excluded those who had TBI or died within 24 hours. Specific outcomes were pulmonary complications, lengths of stay, and mortality.

Here are the factoids:

  • There were just over 1,000 patients in each of the rib fixation and epidural analgesia groups
  • A much larger percentage of patients undergoing fixation had a diagnosis of flail chest (43% vs 13%) and a higher ISS (17 vs 14)
  • Early rib fixation was associated with an added 1.5 day length of stay, but this was not statistically significant
  • Early fixation was significantly associated with a higher risk of unplanned intubation
  • There were no differences in respiratory failure, VAP or mortality between the groups

The authors concluded that rib fracture fixation was associated with longer hospital length of stay but less risk of unplanned intubation. They suggest that patients should receive early referral to centers where both interventions are available so appropriate candidates can undergo fixation.

Bottom line: I’m struggling a bit here. When I read the title I thought I might learn something more about my therapeutic choices for patients with more complicated rib fractures. But this was not even a “how we did it” paper, but a “how hundreds of other centers did it” study. For a subject like this, a database study like this injects quite a bit of selection bias that just can’t be removed. 

For example, look at the huge (3x) difference in flail chest between the groups. Clearly, patients with a flail have a higher ISS and hospital length of stay, and are much more likely to selected for fixation. Thus, that diagnosis alone will skew the data more than the choice of procedure. I would suggest that simple descriptive and regression analyses is not adequate to answer your questions. Some type of propensity matching for ISS or at least AIS chest is probably required.

The only statistically significant result in the abstract was the decreased risk in unplanned intubation. Again, it’s difficult to say whether this is related to the larger percentage of patients who had flails who had their risk decreased by the procedure.

Here are my questions for the authors and presenter:

  1. Did you exclude all patients with TBI? Why not keep those with mild TBI (GCS 14-15), since they should behave similar to those without head injury?
  2. Why did you restrict your dataset to patients who underwent either procedure within the first 72 hours? This seems like an arbitrary time frame. Do you have a sense of the distribution of time interval until either procedure? As a thought experiment, let’s say that the mean (or median) time to either of the procedures was 5 days. You would be sampling the small, early tail of patients who had an intervention before day 3. In that case, your study might not be representative of of real life.
  3. Did you analyze the chest diagnoses and/or AIS  chest? Controlling or propensity score matching for this may have yielded additional information.
  4. You concluded that patients should be referred to centers where the best care can be provided. Isn’t this what we do already?

This is an interesting paper, and I’m hoping that you have more data to present than would fit in the abstract!

Reference: COMPARISON OF SURGICAL STABILIZATION OF RIB FRACTURES VS EPIDURAL ANALGESIA ON EARLY CLINICAL OUTCOMES. EAST 35th ASA, oral abstract #29.

Equipment, Surgery

Pelvic Binder Orthosis vs Pelvic External Fixation

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Yesterday, I wrote about the open book, A-P compression mechanism, pelvic fracture. In the “old” days, the recommended management for an unstable pelvis like these was application of an external fixator. In some textbooks, it was even suggested that this should be done (by orthopedics) in the resuscitation room. High volume trauma centers with ortho residents could actually pull this off, but not many others.

As the idea of pelvic orthotic binders caught on (T-POD, sheeting, etc) and was adopted by prehospital providers, and then trauma teams, the use of initial external fixation dropped off. But the idea that external fixation was the most desirable or most effective lingered on. A study from Memphis finally sheds some light on the answer to this question.

image

A 10 year retrospective review was carried out on patients presenting with multiple or severe pelvic ring fractures who had early stabilization of the pelvis. Stabilization consisted of external fixation early on, and gradually shifted to pelvic orthotic devices over the study period. They ultimately analyzed outcomes for 93 patients in each treatment group.

The authors found that transfusion needs were dramatically reduced with the orthotic devices (5 units vs 17 units at 24 hours) compared to the orthotics. About a quarter of patients in each group went to angiography, and even in those patients the transfusion need remained lower in the orthotic device group. Hospital length of stay was also significantly shorter in this group (17 vs 24 days). There was no difference in mortality.

Bottom line: Although this is a small, retrospective study it easily showed significant results and will probably never be repeated. Use of a pelvic orthotic device (POD) resulted in less blood replacement and shorter stays in hospital. This technique is simple, cheap and quick, an ideal combination. But does a sheet count as an orthotic device? We don’t know. It’s really cheap, but probably a bit less controlled than a POD. If you have a real POD in your ED or your ambulance, use it. If not, apply the sheet, which will be described tomorrow with other binders.

Tomorrow: what’s the “best” pelvic binder?

Reference: Emergent pelvic fixation in patients with exsanguinating pelvic fractures. JACS 204:935-942, 2007.

Equipment, Pelvis

Pelvic Binder Orthosis vs Pelvic External Fixation

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In the “old” days, the recommended management for an unstable pelvis was application of an external fixator. In some textbooks, it was even suggested that this should be done (by orthopedics) in the resuscitation room. High volume trauma centers with ortho residents could actually pull this off, but not many others.

As the idea of pelvic orthotic binders caught on (T-POD, sheeting, etc) and was adopted by prehospital providers, and then trauma teams, the use of initial external fixation dropped off. But the idea that external fixation was the most desirable or most effective lingered on. A study from Memphis finally sheds some light on the answer to this question.

A 10 year retrospective review was carried out on patients presenting with multiple or severe pelvic ring fractures who had early stabilization of the pelvis. Stabilization consisted of external fixation early on, and gradually shifted to pelvic orthotic devices over the study period. They ultimately analyzed outcomes for 93 patients in each treatment group.

The authors found that transfusion needs were dramatically reduced with the orthotic devices (5 units vs 17 units at 24 hours) compared to the orthotics. About a quarter of patients in each group went to angiography, and even in those patients the transfusion need remained lower in the orthotic device group. Hospital length of stay was also significantly shorter in this group (17 vs 24 days). There was no difference in mortality.

Bottom line: Although this is a small, retrospective study it easily showed significant results and will probably never be repeated. Use of a pelvic orthotic device (POD) resulted in less blood replacement and shorter stays in hospital. This technique is simple, cheap and quick, an ideal combination. But does a sheet count as an orthotic device? We don’t know. It’s really cheap, but probably a bit less controlled than a POD. If you have a real POD in your ED or your ambulance, use it. If not, apply the sheet as described below.

Reference: Emergent pelvic fixation in patients with exsanguinating pelvic fractures. JACS 204:935-942, 2007.

Thorax

Fixation of Rib Fractures

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Yesterday, I wrote about nonoperative management of rib fractures. Currently, the majority of rib fractures in this country are managed this way. During the past decade, a number of surgical rib fixation systems have been developed. The question is, when do you really need to consider this more invasive and potentially costly intervention? A review article from this hospital published earlier this year digs into the subsets of patients for whom operative management.

The Eastern Association for the Surgery of Trauma recently surveyed their own members, members of the Orthopedic Trauma Association, and a number of thoracic surgeons on the topic of operative rib fracture management. About 75% believed that operative fixation was indicated in some patients, but only about 20% or trauma surgeons and orthopedic surgeons and about half of thoracic surgeons had actually performed it.

The proposed benefits of surgical fixation are faster return of pulmonary function, fewer complications due to shorter ventilator time, shorter ICU and hospital lengths of stay, and a faster return to work. This review article found that these benefits were real when the technique is applied to select patients.

The authors found that:

  • The best indication is flail chest and respiratory failure without pulmonary contusion
  • Non-intubated patients with flail chest and deteriorating pulmonary function are also candidates
  • Reduction of pain and disability from symptomatic malunion or nonunion is a weaker indication due to sparse literature support
  • Other factors such as acute pain, open fractures, fracture repair while performing a thoracotomy for other reasons and chest wall deformity are weakly supported by the literature at best
  • There is no clear winner in the battle of hardware fixation systems

Bottom line: Operative rib fixation is indicated in patients with flail chest and pulmonary problems without significant pulmonary contusion, and in those with symptomatic mal- and non-unions. Flail chest patients benefit from early fixation, while the mal/nonunion groups should have fixation later once this condition is identified. Consideration for other indications should carefully take into account the cost, risk, and benefit to the patient. The literature is very weak in this regard, and a great deal more work is necessary to ensure that these techniques are not overused. 

Reference: Operative treatment of chest wall injuries: indications, technique, and outcomes. JBJS 93:97-110, 2011.