Tag Archives: rib fracture

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.

Abstracts, Thorax

Best Of AAST 2021: Liposomal Bupivacaine For Rib Fractures

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The mainstays of rib fracture management are pain control and pulmonary toilet. The pain part of the equation can be managed in many ways, using topical, oral, IV, and injectable medications.

Rib blocks have been a mainstay for achieving some degree of local pain control. Classically, xylocaine was injected in the area around the costal nerve at or proximal to the fracture site. Then we found that if we combined the anesthetic agent with epinephrine, we could prolong the effect. New, longer-acting agents came around, and we could achieve a longer duration of action.

Then there is the new kid on the block: liposomal bupivacaine, also known as Exparel in the US.  The manufacturer was able to take molecules of bupivacaine and encapsulate them in a lipid membrane. When injected, these little liposomes slowly release their cargo, with a more prolonged anesthetic effect. Allegedly.

Sounds great! But does it work? The group at University of Cincinnati designed a prospective, double-blinded, randomized placebo control study of liposomal bupivacaine vs saline injection for pain control in up to six rib fractures. Subjects had significant injury as measured by their inability to achieve at least 50% of the desired inspiratory capacity. The authors monitored a number of respiratory parameters, as well as the pain score.

Here are the factoids:

  • Two cohorts of 50 patients were recruited, one received liposomal bupivacaine in up to six rib fractures, and the other received saline injections
  • The bupivacaine group achieved higher incentive spirometry volumes over the first two days, by about 200 cc
  • There was no change in daily pain scores in either group
  • Both groups showed a similar decrease in opioid use over time
  • Hospital and ICU lengths of stay were the same, and there were no complications or adverse events

Bottom line: Hmm. What’s going on here? There is a moderate amount of literature out there that does indicate a positive effect from liposomal bupivacaine in other conditions. But there are also some blinded, randomized studies that fail as well. So there are three possibilities:

  1. Liposomal bupivacaine isn’t a panacea, and works better in some situations than others
  2. This study failed to show a real difference for some reason
  3. A combination of both

This is a relatively small study, and the authors were not able to share their power analysis. They did not state if the spirometry volumes were significantly different, although I’m not sure 200 cc is clinically relevant. Maybe. But pain scores remained similar and opioid use declined as expected in both. 

These kinds of studies can be important. The difference in cost between injecting liposomal bupivacaine ($19 / ml) vs regular bupivacaine (10 cents / ml) vs saline/nothing (free) is striking. The premium price for the liposomal form needs to have a clear benefit or a cheaper product should be used.

Here are my questions for the presenter and authors:

  • Was your study big enough to show a result? Show us your power analysis.
  • How significant was the incentive spirometry result. Was the difference clinically noticeable?
  • What is your takeaway for this study? Your conclusion parrots the results. What will you do differently now, if anything?

Reference: INTERCOSTAL LIPOSOMAL BUPIVACAINE INJECTION FOR
RIB FRACTURES. AAST 2021, Oral abstract #20.

Thorax

Detecting Rib Fractures In The Elderly

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It’s well known that our elders do less well than younger folks after injury. The number of complications is higher, there tends to be more loss of independence during recovery, and mortality is increased. This is not only true of high energy trauma like car crashes, but also much lower energy events such as a fall from standing.

Rib fractures are common after falls in the elderly and contribute to significant morbidity if not treated adequately. Traditionally, they are identified through a combination of physical exam and chest x-ray. Unfortunately, only half of rib fractures are visible on x-ray. It falls to the physical exam to detect the rest.

A group at Beth Israel Hospital in Boston explored the utility of using chest CT in an attempt to determine if this would result in more appropriate and cost-efficient care in the elderly. They performed a retrospective study of 3 years of their own data on patients aged 65 or more presenting after a mechanical fall and receiving a rib fracture diagnosis. Imaging was ordered at the discretion of the physician. A total of 330 patients were elderly, fell, and had both chest x-ray and chest CT obtained. This was a very elderly group, with a mean age of 84 years!

Here are the factoids:

  • Rib fractures were seen on chest x-ray in 40 patients (12%) and on CT in an additional 56 ; 234 patients had no fractures on either
  • When fractures were seen on both studies, CT identified a median of 2 more fractures than chest x-ray
  • Patients with fractures not seen on chest x-ray were admitted significantly more often than those without fractures (91% vs 78%)
  • Mortality, admission to ICU, ICU length of stay, and hospital length of stay were not different if fractures were seen only on CT
  • CT scan identified new issues or clarified diagnoses suggested by chest x-ray in 14 cases, including one malignancy
  • Rib detail images were obtained in 13 patients and proved to be better than chest x-ray, but not quite as good as CT scan

Conclusion: use of CT for rib fracture diagnosis resulted in a few more admissions, but no change in hospital resource utilization, complications, or mortality.

Bottom line: Hmm…, read the paper closely. The authors conclude that more patients with CT-only identified rib fractures are admitted. But compared to what? Unfortunately, patients without rib fractures on CT. What about comparing to patients who had fractures seen on chest x-ray too? If that number is the same, then of what additional use is CT? Identifying a few incidentalomas?

Given that there is no change in the usual outcome measures listed here, it doesn’t seem like there is any additional benefit to adding CT. And I can see a lot of downsides: cost, radiation, and possible exposure to IV contrast. In my mind, there is still nothing that beats a good physical exam and a chest x-ray. Skip the CT scan. And don’t even think about ordering rib detail images! That’s so 1990s. And even if no rib fractures are seen on imaging, physical exam is the prime determinant for admitting your patient for aggressive pain management and pulmonary toilet.

Reference: Chest CT imaging utility for radiographically occult rib fractures in elderly fall-injured patients. J Trauma 86(5):838-843, 2019.

Abstracts, Thorax

Best Of EAST 2020 #3: Rib Fixation In The Elderly

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Elderly falls have reached epidemic proportions. Although the most common injury from these falls is rapidly become head injury with or without intracranial blood, rib fractures are a close second. Treatment of rib fractures usually involves multiple interventions such as pulmonary toilet, multimodal pain management, and therapies to enhance mobility. And in some cases, operative fixation is entertained.

Rib fracture fixation has typically been used in patients who are dependent on a ventilator due to their fractures, or have significantly displaced or very painful fractures. There is little data on the impact of using rib plating in elderly patients. The group at New York Presbyterian Hospital in Queens NY analyzed one year of TQIP data to assess the impact of this technique in trauma patients older than 65.

They reviewed the data, looking at mortality, intensive care unit and hospital lengths of stay, tracheostomy, and pneumonia rates. They matched patients who had rib fixation with similar patients who did not. They then sliced and diced the data to see if there were differences in these outcomes with early vs late (> 48hrs) repair.

Here are the factoids:

  • The authors obtained data on almost 14,000 patients meeting study criteria, but of those only 278 underwent rib fixation and 220 were eligible for matching
  • Overall, patients who underwent fixation tended to have higher rates of flail chest, earlier intubation, higher injury severity score, and increased intensive care unit admission rates
  • Mortality for all patients who underwent fixation was significantly lower than those who did not (4% vs 10%)
  • The early fixation group had significantly fewer ventilator associated penumonias, shorter ICU length of stay (6 vs 10 days) and shorter hospital length of stay (9 vs 15)
  • There were no differences in mortality or ventilator days

The author’s conclusions matched the bullet items above.

My comment: This is one of those papers that demonstrates something that we should have already recognized. I wish I had thought of it! It points us toward considering this procedure in our elderly rib fracture patients. Even though patients undergoing fixation were sicker and had more serious injuries, their survival rate was significantly higher.

However, it also leaves us with more work to do. It is a database study, so it’s not possible to go back and find additional information on the study subjects. Knowing selection criteria and operative details would be very helpful. And the overall numbers are low, so more benefits may come to light if we had the statistical power to focus on mortality and ventilator days.

Here are my questions for the authors and presenter:

  1. Have you considered using a larger dataset to get additional information? The mortality and ventilator days in the early vs late subsets were not statistically significant. This might be due to the lack of statistical power from the small number of patients.
  2. Can you speculate on the financial impact of using expanding the use of rib fixation in the elderly? The clinical impact is clear. It looks like the cost savings to the hospital from the reduced ICU and hospital length of stay alone would far offset the cost of performing the procedure, especially if done early.
  3. What selection criteria should be used for choosing the right patients for the procedure? This is probably outside the scope of the study, but it would be interesting to hear you speculate.

This is an important paper and I really look forward to hearing the details!

Reference: Rib fixation in geriatric trauma: mortality benefits for the most vulnerable patients. EAST Annual Assembly abstract #3, 2020.

Thorax

Detecting Rib Fractures In The Elderly

Leave a comment

It’s well known that our elders do less well than younger folks after injury. The number of complications is higher, there tends to be more loss of independence during recovery, and mortality is increased. This is not only true of high energy trauma like car crashes, but also much lower energy events such as a fall from standing.

Rib fractures are common after falls in the elderly and contribute to significant morbidity if not treated adequately. Traditionally, they are identified through a combination of physical exam and chest x-ray. Unfortunately, only half of rib fractures are visible on x-ray. It falls to the physical exam to detect the rest.

A group at Beth Israel Hospital in Boston explored the utility of using chest CT in an attempt to determine if this would result in more appropriate and cost-efficient care in the elderly. They performed a retrospective study of 3 years of their own data on patients aged 65 or more presenting after a mechanical fall and receiving a rib fracture diagnosis. Imaging was ordered at the discretion of the physician. A total of 330 patients were elderly, fell, and had both chest x-ray and chest CT obtained. This was a very elderly group, with a mean age of 84 years!

Here are the factoids:

  • Rib fractures were seen on chest x-ray in 40 patients (12%) and on CT in an additional 56 ; 234 patients had no fractures on either
  • When fractures were seen on both studies, CT identified a median of 2 more fractures than chest x-ray
  • Patients with fractures not seen on chest x-ray were admitted significantly more often than those without fractures (91% vs 78%)
  • Mortality, admission to ICU, ICU length of stay, and hospital length of stay were not different if fractures were seen only on CT
  • CT scan identified new issues or clarified diagnoses suggested by chest x-ray in 14 cases, including one malignancy
  • Rib detail images were obtained in 13 patients and proved to be better than chest x-ray, but not quite as good as CT scan

Conclusion: use of CT for rib fracture diagnosis resulted in a few more admissions, but no change in hospital resource utilization, complications, or mortality.

Bottom line: Hmm…, read the paper closely. The authors conclude that more patients with CT-only identified rib fractures are admitted. But compared to what? Unfortunately, patients without rib fractures on CT. What about comparing to patients who had fractures seen on chest x-ray too? If that number is the same, then of what additional use is CT? Identifying a few incidentalomas?

Given that there is no change in the usual outcome measures listed here, it doesn’t seem like there is any additional benefit to adding CT. And I can see a lot of downsides: cost, radiation, and possible exposure to IV contrast. In my mind, there is still nothing that beats a good physical exam and a chest x-ray. Skip the CT scan. And don’t even think about ordering rib detail images! That’s so 1990s. And even if no rib fractures are seen on imaging, physical exam is the prime determinant for admitting your patient for aggressive pain management and pulmonary toilet.

Reference: Chest CT imaging utility for radiographically occult rib fractures in elderly fall-injured patients. J Trauma ePub ahead of print, Jan 23, 2019.