Surgical stabilization of traumatic flail chest is superior to conservative management

Abstract

<p>A critical appraisal and clinical application of Marasco SF, Davies AR, Cooper J, et al. Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest. <em>Journal of the American College of Surgeons</em>. 2013;216(5):924-932. doi: <a href="https://doi.org/10.1016/j.jamcollsurg.2012.12.024">10.1016/j.jamcollsurg.2012.12.024</a>.</p>

Surgical rib fixation as an alternative method of treatment for multiple rib fractures: an audit of results compared with traditional medical management

“…3,5,6 Over the years, multiple publications have demonstrated a clear reduction in the need for opioid analgesia, incidence of pneumonia, shorter ventilation times and ICU stay and generally, a better outcome when surgery was offered over BMT. 1,2,5,6,10,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] Unfortunately, in South Africa, not all patients have access to all of the BMT strategies, including options in advanced pain management.…”

“…The impact of rib fractures on prolonged disability is usually greater than traditionally expected; chronic pain is considered to be present in 22% of cases (could be as high as 59%) and some form of disability in 53% of cases 6 months after injury. [10][11][12][13][14][15][16][17][18][19][20][21][22] Attempts to provide rigidity to the chest wall in the event of fractures is not a new proposition, multiple techniques have been used along the years to achieve stability with variable success.…”

“…Efforts to advance the surgical fixation of flail chest and multiple rib fractures to the level of standard of care have not met the expectations or received the approval of many surgeons, mostly due to lack of appropriate evidence and familiarity with the procedures. 11 Evidence in favour of surgical stabilisation of rib fractures has been limited by the quality of the studies as with other trauma related issues, [11][12][13][14][15][16][17][18][19][20] however, the accumulated evidence both from randomised clinical trials and from the systematic reviews and metanalysis consistently favours rib fixation over medical management. 1,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] This mounting experience points to significant advantages such as the reduced incidence of pneumonia and respiratory failure, shorter ventilation time, shorter ICU and hospital stay with minimal complications as well as faster return to productive life, all of which result in improved quality adjusted life-years and costs.…”

“…11 Evidence in favour of surgical stabilisation of rib fractures has been limited by the quality of the studies as with other trauma related issues, [11][12][13][14][15][16][17][18][19][20] however, the accumulated evidence both from randomised clinical trials and from the systematic reviews and metanalysis consistently favours rib fixation over medical management. 1,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] This mounting experience points to significant advantages such as the reduced incidence of pneumonia and respiratory failure, shorter ventilation time, shorter ICU and hospital stay with minimal complications as well as faster return to productive life, all of which result in improved quality adjusted life-years and costs. 1,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] At our institution, all patients with rib fractures were admitted to a trauma ICU ward and offered the standard of care as per protocol of the unit, including intravenous analgesi...…”

“…1,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] This mounting experience points to significant advantages such as the reduced incidence of pneumonia and respiratory failure, shorter ventilation time, shorter ICU and hospital stay with minimal complications as well as faster return to productive life, all of which result in improved quality adjusted life-years and costs. 1,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] At our institution, all patients with rib fractures were admitted to a trauma ICU ward and offered the standard of care as per protocol of the unit, including intravenous analgesia; oxygen, nebulised bronchodilators as needed, mechanical ventilation when indicated, management of associated injuries and active physiotherapy. A computed tomography scan (CT) of the chest was obtained and three-dimensional (3-D) volume reconstructions performed to evaluate the thoracic skeleton and assess indication for surgery.…”