Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer

Skedros, John G.; Mears, Chad S.; Langston, Tanner D.; Boerum, Don H. Van; White, Thomas W.

doi:10.1016/j.ijscr.2014.08.023

Cited by 9 publications

(4 citation statements)

References 29 publications

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“…Lateral fracture series may be accessed with the patient in the classical lateral decubitus position via a longitudinal incision between 7 and 9 cm long, placed along the anterior border of the latissimus dorsi. At this point care should be taken to avoid damage to the long thoracic nerve (14). Posterior fractures are usually the hardest to repair as they are adjacent to transverse processes, angulation of the rib, and subscapular location.…”

Section: Operationmentioning

confidence: 99%

Chest wall stabilization in trauma patients: why, when, and how?

Campos¹,

White²

2018

J. Thorac. Dis.

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Blunt trauma to the chest wall and rib fractures are remarkably frequent and are the basis of considerable morbidity and possible mortality. Surgical remedies for highly displaced rib fractures, especially in cases of flail chest, have been undertaken intermittently for more than 50 years. Rib-specific plating systems have started to be used in the last 10 years. These have ushered in the modern era of rib repair with chest wall stabilization (CWS) techniques that are safer, easier to perform, and more efficient. Recent consensus statements have sought to define the indications and contraindications, as well as the when, the how, and the technical details of CWS. Repair should be considered for patients who have three or more displaced rib fractures or a flail chest, whether or not mechanical ventilation is required. Additional candidates include patients who fail non-operative management irrespective of fracture pattern and those with rib fractures who need thoracic procedures for other reasons. Traditionally, unstable spine fracture and severe traumatic brain injury are definite contraindications. Pulmonary contusion's role in the decision to perform CWS remains controversial. A range of rib-specific plating systems are now commercially available.

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Section: Operationmentioning

confidence: 99%

Chest wall stabilization in trauma patients: why, when, and how?

Campos¹,

White²

2018

J. Thorac. Dis.

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“…24 Because of the smaller incisions of ITP, another potential advantage is the reduction in direct trauma to the chest wall, potentially leading to improved respiratory function postoperatively compared with an open thoracotomy of an ETP. 25 This reduction in the trauma to the structures during ITP might help to reduce in pain in the postoperative period and a lower requirement for interventional pain procedures. While our study showed equivalent MEQ in both the ITP and ETP cohort, the ETP cohort required more neuraxial opiate delivery preoperatively, which may have been driven by an expectation of increased postoperative pain prior to the transition to ITP at our institution.…”

Section: Discussionmentioning

confidence: 97%

“…One potential advantage to ITP is improved visualization of the rib fractures with more limited incisions particularly in challenging areas of the chest wall, such as subscapular and far posterior rib fractures 24 . Because of the smaller incisions of ITP, another potential advantage is the reduction in direct trauma to the chest wall, potentially leading to improved respiratory function postoperatively compared with an open thoracotomy of an ETP 25 . This reduction in the trauma to the structures during ITP might help to reduce in pain in the postoperative period and a lower requirement for interventional pain procedures.…”

Section: Discussionmentioning

confidence: 99%

Prospective single-center paradigm shift of surgical stabilization of rib fractures with decreased length of stay and operative time with an intrathoracic approach

Tay-Lasso

Alaniz

William

et al. 2022

J Trauma Acute Care Surg

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Intrathoracic surgical stabilization of rib fractures allows for a novel approach to rib fracture repair. This approach can help minimize muscle disruption, which may improve patient recovery compared with traditional extrathoracic plating. We hypothesized patients undergoing intrathoracic plating (ITP) to have a shorter length of stay (LOS) and intensive care unit (ICU) LOS compared with extrathoracic plating (ETP). METHODS:A prospective observational paradigm shift study was performed from November 2017 until September 2021. Patients 18 and older who underwent surgical stabilization of rib fractures were included. Patients with ahead Abbreviated Injury Scale score ≥3 were excluded. Patients undergoing ETP (July 2017 to October 2019) were compared with ITP (November 2019 to September 2021) with Pearson χ 2 tests and Mann-Whitney U tests, with the primary outcome being LOS and ICU LOS. RESULTS:Ninety-six patients were included, 59 (61%) underwent ETP and 37 (38%) underwent ITP. The most common mechanism of injury was motor vehicle collision (29%) followed by falls (23%). There were no differences between groups in age, comorbidities, insurance, discharge disposition and injury severity score (18 vs. 19, p = 0.89). Intrathoracic plating had a shorter LOS (10 days vs. 8 days, p = 0.04) when compared with ETP but no difference in ICU LOS (4 days vs. 3 days, p = 0.12) and ventilator days. Extrathoracic plating patients more commonly received epidural anesthesia (56% vs. 24%, p < 0.001) and intercostal nerve block (56% vs. 29%, p = 0.01) compared with ITP. However, there was no difference in median morphine equivalents between cohorts.Operative time was shorter for ITP with ETP (279 minutes vs. 188 minutes, p < 0.001) after adjusting for numbers of ribs fixed. CONCLUSION:In this single-center study, patients who underwent ITP had a decreased LOS and operative time in comparison to ETP in patients with similar injury severity. Future prospective multicenter research is needed to confirm these findings and may lead to further adoption of this minimally invasive technique.

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“…Damage to the nerve may also be caused by the initial, direct thoracic trauma and by rib fractures. Neurological deficit must be documented prior to SSRF, but such damage may be difficult to detect because of the severity of trauma and the recumbency of the patient 26 . Posttraumatic winging of the scapula can also be a result of any disruption of the chain between the axial and appendicular skeleton, such as a sternoclavicular or acromioclavicular dislocation and clavicular or scapular fracture, which can be aggravated by ipsilateral upper rib fractures 27 .…”

Section: Step 5: Surgical Techniquementioning

confidence: 99%

Surgical Stabilization of Rib Fractures

Fokin

Hus

Rodríguez

et al. 2020

JBJS Essential Surgical Techniques

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Background: Rib fractures are a common thoracic injury that is encountered in 20% to 39% of patients with blunt chest trauma and is associated with substantial morbidity and mortality 1 , 2 . Traditionally, the majority of patient with rib fractures have been managed nonoperatively. Recently, the utilization of surgical stabilization of rib fractures has increased considerably because the procedure has shown improved outcomes 3 - 5 . Description: Surgical stabilization should be considered in cases of multiple bicortically displaced rib fractures, especially in those with a flail chest and/or a concomitant ipsilateral displaced midshaft clavicular fracture or sternal fracture, as such cases may result in thoracic wall instability. For surgical stabilization of rib fractures, we classify rib fractures by location, type of fracture, and degree of displacement after obtaining thin-sliced chest computed tomography (CT) scans. The incision is selected depending on the fracture location, and the surgical technique is chosen relevant to the type of fracture. Single-lung intubation is preferred if there is no severe contralateral pulmonary contusion. We favor performing video-assisted thoracoscopy if possible to control bleeding, evacuate hematomas, repair a lung, and perform cryoablation of the intercostal nerves. A lateral approach is considered to be the main surgical approach because it allows access to the majority of rib fractures. A curvilinear skin incision is made overlying the fractured ribs. Posterior rib fractures are exposed through a vertical incision within the triangle of auscultation, and anterior fractures, through a transverse inframammary incision. The muscle-sparing technique, splitting alongside fibers without transection, should be utilized if possible and supplemented by muscle retraction. For surgical stabilization of rib fractures, we currently prefer precontoured side and rib-specific plates with threaded holes and self-tapping locking screws. Polymer cable cerclage is used to enhance plating of longitudinal fractures, rib fractures near the spine, osteoporotic ribs, and injuries of rib cartilage. The third to eighth ribs are plated most often. Intercostal muscle deficit, if present, is repaired with a xenograft patch. In comminuted rib fractures, the bone gap is bridged with bone graft. Surgical stabilization of rib fractures is recommended within the first 7 days after trauma, preferably within the first 3 days 6 - 8 . Alternatives: Nonoperative treatment alternatives include (1) epidural analgesia when not contraindicated because of anticoagulant venous thromboembolism prophylaxis 9 , 10 ; (2) thoracic paravertebral blockage, e.g., serratus anterior or erector spinae plane nerve block ...

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Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer

Abstract: HighlightsLong thoracic nerve injury is a potential complication of rib fracture fixation.Long thoracic nerve injury from rib fracture fixation has not been reported.Long thoracic nerve injury can be corrected surgically by pectoralis major transfer.

Cited by 9 publications

References 29 publications

Chest wall stabilization in trauma patients: why, when, and how?

Chest wall stabilization in trauma patients: why, when, and how?

Prospective single-center paradigm shift of surgical stabilization of rib fractures with decreased length of stay and operative time with an intrathoracic approach

Surgical Stabilization of Rib Fractures

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