Three common exposures of the chest wall for rib fixation: anatomical considerations

Blunt chest wall trauma: Rib fractures and associated injuries

ABSTRACT

Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021)

Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.

Validation of current procedural terminology codes for surgical stabilization of rib fractures

INTRODUCTION

Current procedural terminology (CPT) codes for surgical stabilization of rib fractures (SSRF) are based solely on the number of ribs fixed, tricotomized at 1-3, 4-6, and ≥ 7. Our objective was to validate CPT codes against operative time at our institution, as well as further stratify complexity by rib fracture location and surgical approach. The purpose of this study is to validate the current CPT coding schema for SSRF, and to identify potential modifiers that are associated with increased case complexity. We hypothesized that operative time is associated with CPT code, number of fractures repaired, exposure technique, and fracture location.

METHODS

Retrospective review of SSRF cases from October 2010 to March 2020. The primary outcome was the length of the operation (minutes). Predictor variables were CPT code, number of fractures repaired (grouped similarly to CPT codes), fractures repaired:ribs repaired ratio > 1, fracture location (sub-scapular vs. other), and positioning/exposure (supine, lateral, prone, and multiple). Kaplan-Meier time-to-event analyses were used to assess relationship with operative time.

RESULTS

188 patients underwent repair of 904 fractures. Operative time was significantly associated with both number of ribs repaired and number of fractures repaired (p<0.01). Although operative time varied significantly by CPT group (p<0.01), there was no significant difference between the 4-6 rib and the ≥ 7 rib groups (p = 0.33). By contrast, each group was significantly different from the others when organized by number of fractures repaired (p = 0.04). Operative time was significantly longer when the fractures repaired:ribs repaired ratio was > 1 (p<0.01), even after stratifying by number of ribs repaired. Both multiple positions/exposures (p<0.01), and repair of ≥ 1 sub-scapular fracture (p<0.01) were significantly associated with operative time.

CONCLUSION

Number of fractures repaired provided a more accurate estimation of operative time as compared to number of ribs repaired. Based on these data, we recommend altering the CPT schema for SSRF to involve number of fractures repaired, with modifiers for both multiple positions/exposures and repair of sub-scapular fractures.

Late Operative Rib Fixation is Inferior to Nonoperative Management

BACKGROUND

Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center.

METHODS

ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls.

RESULTS

Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days.

DISCUSSION

Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.