Management of Multiple Rib Fractures-Results from a Major Trauma Centre with Review of the Existing Literature

Management of multiple rib fractures-results from a Major Trauma Centre with the review of the existing literature Chowdhury D.1*, Okoh P.2, Dambappa H.3 DOI: https://doi.org/10.17511/ijmrr.2020.i06.01 1* D. Chowdhury, Specialty Registrar, Emergency Medicine, Royal Preston Hospital, England, United Kingdom. 2 P. Okoh, Specialty Registrars, Emergency Medicine, Royal Preston Hospital, England, United Kingdom. 3 H. Dambappa, Specialty Registrars, Emergency Medicine, Royal Preston Hospital, England, United Kingdom.


Introduction
The main respiratory complications that arise from fractured ribs are multifactorial. It is well known that inadequate pain management in these patients leads to complications arising from poor ventilatory function. With an already compromised underlying pulmonary system, this compounds the effect on an already failing system leading to significant pulmonary complications. Rib fractures in the form of flail segments pose a particular problem in this regard.
When one considers an elderly patient with limited Functional Residual Capacity with an underlying diagnosis of chronic obstructive airway disease, the addition of the presence of a flail segment will invariably lead to respiratory embarrassment either acutely and /or lead to pulmonary complications in the form of basal atelectasis and pneumonia.
The main determinants of the rib score generally underpin the number of ribs that are fractured as well as the age of the patient directly correlate with morbidity and mortality. The traditional rib score is the product of the number of breaks and the sides with the addition of the age factor. Our rib score is more detailed and encompasses several other variables that have been thought to indicate a more accurate picture of mortality and morbidity.
It is recognized that if there are four or more fractures that are associated with a higher mortality rate and if there are 7 or more fractures then the mortality rate can be as high as 29%. In the presence of the flail segment, the mortality rate is noted to be higher at 33% perhaps due to further respiratory embarrassment stemming from the paradoxical movement of the ribs on respiration

Methods and Material
The data collected from the TARN (Trauma Audit Research Network) registry with individual case reviews over a consecutive period of 12 months, studying patients with rib fractures.
This was done in our Major Trauma Centre in the North West of England.
Inclusion criteria for the study were all patients with rib fractures irrespective of whether it was the primary or secondary diagnosis. The individual patients were tabulated based on their ISS (Injury Severity Score).
Exclusion criteria were any patients who died followed transfer to the major trauma ward. The individual patients were studied and subgroup analysis was done on rib fixation. The average number of ribs fixed were also studied with the length of stay in the hospital included in the analysis.
The patients were followed up until the time of discharge to assess for any complications. With regards to the subgroup analysis of the complications, the research group is currently evaluating this and our findings will be published in a follow-up article. Also, the analgesic requirement of the individual patients was studied and tabulated according to their needs.
The current study noted that there was an overlap between patients receiving an epidural and the group receiving opioids. Further subgroup analysis would be a feature in future articles comparing the effect on the individual analgesic modality. There were no ethical concerns raised during the process of data collection as all the data was anonymized.

Conclusion
The mainstay management of rib fracture is the provision of adequate analgesia and the prevention of respiratory complications that can all stem from poor ventilatory function amongst other patient factors and injury patterns. Through the decades, surgical stabilization has gained pace and has found its niche in the management of rib fractures.
What does the study add to the existing knowledge?
The reader would agree that this indeed a large study that raises the scope for a detailed in-depth analysis of various factors. The current study has identified that the individual mechanism of injuries that lead to rib fractures can be studied and appropriate primary prevention management strategies implemented. Through this article, we hope the reader would appreciate the scope for a further study comparing the traditional rib score with the new proposed rib fracture score. The current study has appreciated the fact that the traditional rib fracture score does not incorporate the significant factors that significantly contribute to the outcome of the overall rib fracture management.
Through this article, we sincerely hope that the orthopedic surgeons/cardiothoracic surgeons would consider operative interventions in patients that have significant rib fractures but do not necessarily meet the currently proposed criteria. With time we hope that the surgeons would have a lower threshold for operative intervention to maximize patient outcomes. Larger multicentric randomized controlled trials are needed to demonstrate the difference in outcomes in these two groups for comparative analysis.