Rib Fracture Management: A Practical Manual

In recent years the approach towards rib fractures has evolved.  Abandoned in the past, due to inadequate instrumentation and lack of evidence, rib fixation has recently re-emerged as a treatment option for trauma patients.  There have been a number of advances over the last 25 years that now allow surgeons to internally fix rib fractures that otherwise may have not had other options.  However, as a result there has been a rapid increase in literature and many institutions interested in initiating rib fixation programs. Due to a variety of practitioners involved namely, trauma surgeons, orthopedic surgeons, and thoracic surgeons there has been no comprehensive guide to patient selection, technique, and post-operative care.  
The purpose of this text is to fill the educational gap for those trauma, orthopedic, and thoracic surgeons interested in learning the cutting edge evidence-based approaches to treatment of rib fractures. This topichas caught the interest of many and has been a recurrent theme at surgical meetings over the last two years. Although there has been ever increasing levels of interest and experience nationally there are many questions which remain.
This text will provide not only the theoretical background for improving outcomes in those with rib fractures but also serve as a practical guide to those interested in starting new programs. The text will include tips and tricks that can be used in the OR or at the bedside to improve patient care. Therefore, the focus will be on a comprehensive review but also including tips and tricks from the most experienced surgeons around the country who are performing internal fixation for rib fractures.

• Language: English
• Publisher: Springer
• Release date: Sep 3, 2018
• ISBN: 9783319916446

Book preview

© Springer International Publishing AG, part of Springer Nature 2018

Marc de Moya and John Mayberry (eds.)Rib Fracture Management https://doi.org/10.1007/978-3-319-91644-6_1

1. History of Rib Fracture Management

Michael Bemelman¹  , William Long²   and John Mayberry³  

(1)

Elisabeth Two Cities Hospital, Tilburg, The Netherlands

(2)

Legacy Emanuel Medical Center, Portland, OR, USA

(3)

St. Lukes Wood River Medical Center, Ketchum, ID, USA

Michael Bemelman

Email: [e-mail]

William Long

Email: [e-mail]

John Mayberry (Corresponding author)

Email: [e-mail]

Keywords

History of rib fracture managementRib fracture management historyRib fracture ORIFHistory of the management of sternal fracturesRib fracture operative reduction and internal fixation (ORIF) techniquesOperative reduction and internal fixation (ORIF) techniques

The Ancients

The occurrence of injury in everyday life and in battle makes it likely that ancient surgeons were familiar with chest wall injuries. Although communities were primarily rural, urban centers of several thousand people were present in Sumer (present-day Iraq) as early as 4000 BCE and in Egypt by 3500 BCE [1]. Multilevel dwellings, temples, canals, bridges, and extensive walls were built. Both the Sumerians and the Egyptians had a professional military with battalions of foot soldiers and fighting units including chariots and archers. Rib fractures, flail chest, and open chest wounds occurring during farming, construction projects, and conflicts were surely similar to what surgeons treat today [2] (Table 1.1, Fig. 1.1).

Table 1.1

Description of rib fractures occurring following a traumatic event 4000 years ago in Egypt

From Dupras TL, Williams LJ, De Meyer M, Peeters C, Depraetere D, Vanthuyne, Willems H. Evidence of amputation as medical treatment in ancient Egypt. Int J Osteoarchaeol. 2010;20:405–23, with permission

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Fig. 1.1

4000-year-old rib fractures without evidence of healing found in a tomb in Dayr al-Barsha, Egypt (From Dupras TL, Williams LJ, De Meyer M, Peeters C, Depraetere D, Vanthuyne, Willems H. Evidence of amputation as medical treatment in ancient Egypt. Int J Osteoarchaeol 2010; 20:405–23, with permission)

Sumerian tablets dating to 3000 BCE provide the first written descriptions of medical care [1, 3]. Asu, Sumerian general practitioners, used hot water, oils, wine, and honey to cleanse and dress wounds. They were aware of the risk of infection, ummu (hot thing). The Sumerians had medical corps accompanying their armies in the field.

An Asu may have performed the first recorded thoracotomy, perhaps to drain an abscess or hematoma. The cuneiform etchings suggest an invasive procedure through the ribs:

three ribs…fourth rib cut open…fluid ([3], p. 52).

The Smith Surgical Papyrus dating to 1600 BCE Egypt provides the first known mention of rib injuries in the ancient medical literature [4]. The unknown author describes rib sprains, dislocations, and open chest wounds with rib fractures but curiously does not mention simple rib fractures. Breasted (the translator of the Smith Surgical Papyrus) conjectures that the omission of simple rib fractures in the treatise may have been a scribal error ([4], p. 401).

The treatment for rib sprains and dislocations was supportive binding:

Thou shouldst bind it with ymrw; thou shouldst treat afterward with honey every day until he recovers ([4], p. 461).

Breasted conjectured that ymrw was a medication, but he found no mention of it in the Egyptian materia medica ([4], p. 262).

Ancient Egyptian surgeons were familiar with open chest wounds with rib fractures but did not offer any optimistic treatment strategy:

If you examine a man having a break in the ribs of his breast, over which a wound has been inflicted; and you find that the ribs of his breast crepitate under your fingers, you should say concerning him: …An ailment not to be treated ([4], p. 462).

The Indians and Greeks

The Indian surgeon Sushruta (600–500 BCE) emphasized the splinting of rib fractures:

In the case of a fracture of one of the parsaka (ribs), the patient should be lubricated with clarified butter. He should then be lifted up and the fractured rib, whether left or right, should be relaxed by being rubbed with clarified butter. Strips of bamboo … should be placed over it and the patient should be carefully laid in a tank or cauldron full of oil with the bamboo splint duly tied up with straps of hide ([5], Vol. 2, Ch. 3).

Sushruta described marmas as anatomic regions that surgeons should be wary of and which when injured could lead to death ([5], Vol. 2, Ch. 6):

A hurt to the hridaya-marma, which is situated in the thorax between the two breasts and above the pit of the abdomen … proves fatal within the day.

An injury to the stana-mula-marmas, situated immediately below each of the breasts and about two fingers in width fills the thorax with deranged (tissue), brings on cough, difficult breathing, and proves fatal.

Thus we see the first medical literature descriptions of the sequelae of sternal fracture, blunt cardiac injury, pulmonary contusion, and hemopneumothorax.

Hippocrates (400 BCE) also recommended chest wall splinting:

…in case of coughings, sneezing and other movements they serve as separate supports for the chest… ([6], p. 81)

Hippocrates expressed optimism for the treatment of flail chest:

Do not make the bandaging tighter than suffices to prevent the respirations from shaking the part, or than is necessary to bring the edges of the separated fractures into touch with one another; nor is it intended to prevent coughing and sneezings, but to act as a support for the avoidance both of forcible separation and shaking ([6], p. 81).

Contemporary with Sushruta and Hippocrates were unidentified surgeons in China. Unfortunately, the vast majority of their writings have been lost, believed destroyed by an angry King after the famous surgeon Hua T’o offended him. From the sophistication of the surviving surgical descriptions, we may surmise that Chinese surgeons of 400 BCE had also developed sophisticated approaches to rib fractures, flail chest, and open chest wounds [3].

The Romans

Celsus (25 BCE–50 CE) wrote an excellent anatomic description of the twelve ribs:

These bones are curved at their highest point, and below these they are triangular, and become gradually wider as they approach the spine. As they become wider, they become blunter. And they too at the lowest part soften into cartilage at the back and float, as it were, since they are unconnected with any other bone except at the top, but there they held in place by very strong muscles and sinews ([7], Book VII, Ch. 1).

Celsus taught that an incomplete rib fracture will be painful but will not cause hemoptysis and will heal within 21 days. He recommended bandaging and patience ([7], Book VII, Ch. 4). He firmly stated, however, that complete rib fractures are harbingers of infection and advocated drainage of abscesses when they occurred without delay. He recognized that a persistent draining sinus would indicate the infected rib would have to be excised ([7], Book VIII, Ch. 9, [8], p. 232).

To Soranus (78–117 CE) is attributed the distinction of being the first in the known literature to recommend an acute surgical intervention for rib fractures. He advocated excision of fracture fragments for the relief of pain:

But if any great necessity compel us, owing to the pleura being irritated, we must divide the skin and lay bare the broken part of the rib; and then putting the instrument for protecting membranes under the rib, to prevent the pleura from being wounded, cut off properly and remove the irritating pieces of bone ([8], p. 232).

Galen (129–216 CE) also performed chest wall surgery. He described a gymnast who injured his sternum and who developed an abscess at the site 4 months later. Galen not only drained the abscess but, recognizing that the sternum was necrotic, went on to resect much of it, even exposing the heart and draining pericardial pus ([9], p. 12). Galen stated the patient would likely not have survived without this aggressive resection but recommended that surgeons not emulate his example without a thorough knowledge of chest anatomy.

Islamic Surgeons

Albucasis (Abu ‘l-Qasim Khalaf ibn ‘Abbas al-Zahrawi, d. 1013 CE), the Cordovan surgeon of the tenth century whose textbook On Surgery and Instruments was the standard in Europe for several generations, recommended setting posterior rib fractures:

by leveling out the fracture with the fingers in any manner you can so that the form is as it should be; then apply the plaster and bind the broken bone with a splint, if necessary ([10], p. 730).

He recommended ignoring anterior fractures since they are only contused, because they are cartilaginous. ([10], p. 730).

Albucasis further noted that if there is a depressed fracture of the ribs, then the patient will have a vehement pain and a piercing sensation like that of pleurisy, since the bone is piercing the pleura. ([10], p. 730). For treatment he referred to the ancients who either filled the depression with wool soaked in warm oil and bandaged the chest or, following the advice of Soranus, excised the depressed portion. He warned, however, of the risk of a postoperative abscess.

For displaced sternal fractures, Albucasis recommended reduction by placing a pillow between the shoulders while the patient is supine and by manipulating the shoulders and the chest wall:

Then apply over it a plaster and a pad and place over that a splint of thin willow board or brier or similar light wood, first wrapping it in cloth; then gently bind this upon the fractured bone several times, tying it firmly; then inspect it constantly, and whenever it loosens tighten it ([10], p. 728).

The Persian Avicenna (Ibn Sina a.k.a. the Prince of Physicians) completed his five-volume Canon of Medicine prior to his death in 1037 CE [11]. All five volumes have recently been translated into English. Avicenna’s descriptions of chest wall anatomy and function are so advanced that his teachings could stand alone in a modern textbook ([11], p. 71–3).

Avicenna likewise recommended operative management for extreme cases:

If the fractured rib strongly resists going back and the fractured part hits the veil and harms it, you should cut the skin until you reach the fracture. Then, place the tool that protects the peritoneum under the rib so that the peritoneum does not come out. Softly and gently cut that part of the rib bone that hits the veil and harms the veil and bring it out. Then if warm swelling does not appear, bring the cut area together and place treating ointments on it and tie it, and if warm swelling emerges, dip the pads in suitable oil and place them on it. Give medication and food that relieve the warm swelling to the patient. The patient should sleep on the side that has less pain [12].

Medieval Surgeons

Theodoric Borgognoni, an Italian surgeon of the thirteenth century, included an entire chapter on rib fractures in his Chirurgia [13]. To relocate depressed rib fractures, he wrote:

…have the patient brought to a bathtub, and after dipping his hands in turpentine, he would rub on honey, pitch or bird lime, and would place his hands, pressing on the spot where the break was, and suddenly lift up, and do this repeatedly until the rib returned to its proper place ([13], Book 2, p. 191).

He also described a limited thoracotomy for blunt injury where the bone has punctured the diaphragm:

… then it is necessary to cut at the point of injury and disclose the broken rib. Protect the pleura by placing an instrument under the rib so that it cannot harm it. Then it is easy to excise that part of the bone which is puncturing the pleura; afterwards follow the regular treatment for wounds ([13], Book 2, p. 191–2).

Guy de Chauliac of fourteenth-century France provided what may be the first known description of serial irrigation of the pleural space to prevent empyema ([14], p. 339). He recommended enlarging a penetrating thoracic wound to encourage pleural drainage and then described daily instillation of warm wine or dilute honey with rotation of the patient and subsequent observation of the effluent. When the fluid became clear, the irrigations were discontinued.

Hieronymus Brunschwig of Germany published Das Buch der Cirurgia: Hantwirckung der Wundarztny in 1497 [15, 16]. From a 1525 English translation of the section entitled The brekking of the ribbes:

E shall knowe that ther is ribbes longe & shorte. And the shorte ribbes breke not nyghe by the backe. Ye other ribbes breke in many places and they be sotime croked & bowed inward and is not broke. And somtyme outward also. And somtyme ye fracture is deedly by loge endurynge of payne and sotyme it is not deedly and shortely heled. And this ye may knowe hereafter written, the first ye must with your hade fele the broke place. And yf there be ony crackynge then is it broke. And yf there benone euyll accedence to se it is good to helpe. And as they bowe inward so be they euyll to helpe. And yf the ribbes be ferre sonken in that mebres be sore wounded inward it is deedly or el les longe sykenes. And that may be knowe by the short brethe and by blood spyttynge coghynge with the styche and payne in the side [15].

Brunschwig reiterated the teachings of Albucasis and Theodoric advising attempts at manual reduction with the fingers if possible, with adhesive plasters if necessary, followed by the placement of plaster wraps. For comminuted fractures he repeated the advice of Soranus: asserting an incision followed by removal of rib fracture fragments may be necessary.

Ambroise Paré of the sixteenth century wrote several descriptions of severe chest wall injuries [17]. Following a battle between the French and the Spanish, he treated a man shot by an arquebus where the ball passed through the chest and created an open chest wound with comminuted rib fractures:

I saw he cast blood out of his mouth and his wounds. Moreover he had a great difficulty of breathing, and cast out wind by the said wounds with a whistling, in so much that it would blow out a candle, and he said he had a most sharp prickling pain at the entrance of the bullet. I do believe and think it might be some little pieces of bones which pricked the lungs. When they made their systole and diastole, I put my finger into him; where I found the entrance of the bullet to have broken the fourth rib in the middle and scales of bones which the said bullet had thrust in, and the outgoing of it had likewise broken the fifth rib with pieces of bone which had been driven from within outward. I drew out some but not all, because they were deep and very adherent ([17], p. 55–6).

Paré dressed the open chest wounds with linen gauze soaked in egg yolks, turpentine, and oil of roses. His dressing, he stated, allowed for the flux of blood but did hinder that the outward air did not enter into the chest. He bound him up, but not hard, to the end he might have easy respiration.

And as for the pain which he said he felt at the entrance of the bullet … that was because the lungs by their motion beat against the splinters of the broken rib. Now the lungs are covered with a coat coming from the membrane called pleura, interweaved with nerves of the sixth conjugation from the brain, which was cause of the extreme pain he felt; likewise he had a great difficulty of breathing, which proceeded from the blood which was spilled in the thorax, and upon the diaphragm, the principle instrument of respiration, and from the laceration of the muscles which are between each rib which also help also to make the expiration and inspiration ([17], p. 57).

Eighteenth- and Nineteenth-Century Surgeons

In 1702, John Moyle, in One of Her Majesty’s Ancient Sea-Chirurgions, wrote (italics his):

If the Rib is broke or diſplaced you must lay the Patient on the well fide over ſome round Substance, as the Bilge of a Cask, or a Gun (his Clothes being off) and let your Affistant bend his Body downwards and ſo will extention be made, that ſo with your hands you may place the ends oſ the Rib together. But if it is diflocated and will not be reduced this way, then do this.

Lay on the Part the Stitch Plaster, made of Maſtich, Gypſum, Terib. and aviarium Gluten mixed, ſowing Tape to the outfide of it to haul by when you have occaſion; and when it hath lain on long enough ſo as to stick fast, then lay the Man in the pasture as beſore,and hale up forcibly by the strings, and the Rib will come into his Place.

Then Embrocate with Ol. Rof. and apply the defenſive minor, as in the Catalogue, and make decent Rouling; and at last Emplast. Catagmatic.

But be ſure here to let Blood, for this is abſolutely convenient, and give the Man Spruce Beer or the Traumatic’s which you will find in the Catalogue; and let him have a breathing ſweat, to hinder the Coagulation oſ the Blood, and heal inwardly, and let him have the freſh and wholſome Diet [18].

In 1743, Heister, the famed German surgeon, reinforced previous recommendations for manual reduction manually and surgical removal of rib fragments that irritated the pleura ([19], Vol. 1, p. 124–5). Like many trauma and thoracic surgeons of today, Heister believed retained hemothorax was at high risk of empyema and recommended preemptive drainage ([19], Vol. 1, p. 124–5).

Heister’s descriptions of bandaging of the chest for clavicle, scapular, sternal, and rib fractures were meticulous. He recommended continuing the bandaging onto the lower chest til the whole disordered part of the thorax is thus invested ([19], Vol. 2, p. 313). In cases where the rib fracture(s) required reduction, he advised adding a soft splint and/or plaster to the bandaging.

Guthrie and Larrey, English and French military surgeons of the Napoleonic Wars, respectively, wrote extensively of the treatment of chest injuries. Both recommended incision into severe blunt and simple penetrating chest wall injuries for removal of bone splinters ([9], p. 194).

In 1830, John Hennan of the University of Edinburgh wrote:

In every injury of the chest a firm elastic bandage is an indispensible assistant in the cure; the motions of the ribs are not only restrained, but the parts are powerfully supported by its application; if fracture has taken place in many of the bones, we have no other means so perfect of retaining them in their place… ([9], p. 196).

In 1830, William Lawrence of St Bartholomew’s Hospital in London wrote:

Fractures of the ribs are much more common than those of the sternum. When these take place at the anterior part, or sides of the chest, the accident is generally easily recognizable by putting the hand where the violence has been received, or where the patient says there is considerable pain. The movements of the chest produce a sensible grating, or crepitus, and the patient experiences great pain from the motions of the broken ends of the bone in the chest.

Treatment – If the chest could be kept perfectly at rest – if the patient did not employ the intercostal muscles at all, there would be no movement of the fractured ends of the bones, and no material pain … We endeavor to accomplish this as well as we can, by covering the part, either by a broad bandage of calico or flannel, or by including it in a broad kind