Rib fractures in the Elderly

1. Rib Fractures in the Elderly
A Case for Rib Plating
Francis R. Ali-Osman MD
Medical/Surgical Director of Critical Care Deer Valley Medical Center
HonorHealth

2. Chest Trauma (a persistent problem)
• Accounts for 10-15% of trauma admissions
• Associated in 25% of traumatic deaths
• Rib fractures occur in up to 39% of blunt
trauma patients
– associated with significant thoracic and non-
thoracic injuries
• Rib fractures alone can lead to pulmonary
insufficiency and prolonged convalescence
• 60% of patients who suffered flail chest do not
return to full-time employment even at 5 years
post injury

3. Flail Chest
• Defined as 3 or more ribs with segmental fractures
• Epidemiology
– Incidence 10-15% of severe chest traumas
– Bimodal distribution
• Younger trauma patients
• Older patients with osteopenia
• Mechanism
– Blunt forces
– Deceleration injuries
• Associated Injuries
– Scapula fractures
– Clavicle fractures
• Prognosis
– Varies depending on underlying pulmonary injury or other concomitant
injuries

4. • Retrospective cohort study
• 171 patients
• 4 groups
– 1) 15-44 y/o w/ 1-4 rib fractures
– 2) 15-44 y/o w >4 rib fractures
– 3) > 44 y/o w/ 1-4 rib fractures
– 4) > 44 y/o w/ >4 rib fractures
• Group 4 had increased ventilator days, ICU stay, and hospital
stay
• Conclusion: Patients over age 45 with >4 rib fractures are at
increased risk for adverse outcomes

5. Survey given to 101 patients who met
inclusion criteria
50 responses
Results:
Pain was gone at 5.4 +/- 1.1 weeks
Satisfaction (SSRF) was 9.2 +/- 0.2
90% of employed patients returned to
same work at 8.5 +/- 1.2 weeks

6. Conclusions: The operative group demonstrated a significant reduction in total ventilator days as
compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P =.040). Patients with SRF were
permanently liberated from the ventilator within a median of 1.5 days(0-8 days).

7. Matrix Rib
Plates are precontoured to fit an average rib shape,
which mini​mizes intraoperative bending
-Intramedullary splints allow minimally invasive
procedures
-Locking design for increased stable fixation
-Designed to be used without removing the
periosteum

8. Surgical Technique
• Double lung ventilation
• Lateral decubitus position
• Minimal thoracotomy incision ***
• Superior and inferior flaps
• Latissimus sparing (can divide
longitudinally if necessary) ***
• Division of serratus and dissection to
periosteum
• Manual reduction of fracture
• Measurement of rib
• Placement of plate
• 24 fr fluted JP placed in pleural
space
• Pleural lavage until clear
• Layered closure

13. Case 1
• 63 y/o male who fell from a roof on
January 15, 2015
• His injuries included multiple left
sided rib fractures including a flail
segment
• He went to the operating room the
next day for rib fixation

26. Pulmonary Function Tests

27. Case 2
• 63 year old male involved in
motorcycle crash on Feb 12, 2015
• Injuries included fractures of ribs 3-8
posteriorly and ribs 4-7
anterolaterally
• Got epidural on day of admission
• Taken to the operating room for rib
fixation on Feb 13, 2015

37. Pulmonary Function Tests

38. G60 Rib Fixation Data for 1 Year
Fall From Horse
Fall from Ladder
Fall from Roof
Motor vehicle Crash
Motorcycle Crash
Pedestrian strcuk
MECHANISM NUMBER PERCENTAGE
Fall From Horse 2 15.4
Fall from Ladder 1 7.7
Fall from Roof 1 7.7
Motor vehicle Crash 2 15.4
Motorcycle Crash 6 46.2
Pedestrian strcuk 1 7.7

39. G60 Rib Fixation Data for 1 Year
• Operations - 13
• Mean age - 65.7 (61 – 74)
• Mean BMI - 31.6 (26.5 – 40.3)
• Mean number ribs plated - 4.9 (3 – 10)
• Mean number of days until surgery – 3.4 (1 – 6)
• Flail Chest – 4 (30.8%)
• Discharge Disposition – 7 home (53%), 6 acute rehab
(46.2%)
• No tracheostomies
• Epidurals – 6 (46.2)
• Mean HOLS – 13.2 (5 – 17)

40. G60 Rib Fixation Data for 1 Year
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Mean FEV1 Pre-
Op
Mean FEV1 POD
2-4
Mean FEV1 POD
5-7
FEV1
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Mean FVC Pre-
Op
Mean FVC POD
2-4
Mean FVC POD
5-7
FVC
35.7 34.6
50.7
35.4 35.0
50.1

41. Conclusions
• Rib fractures and their complications remain a
significant source of morbidity and mortality in the
elderly
• A majority of rib fractures can and should be managed
non-operatively
• Rib fixation should strongly be considered in patients
with flail chest, significant displacement of fractures
and worsening or refractory respiratory insufficiency
• More research is needed ***

42. Rib Plating Team
Alicia Mangram MD, FACSAlexzandra Hollingworth MD, FACS
Francis Ali-Osman MD
Joseph Sucher MD, FACS
Gina Shirah MD

43. QUESTIONS?