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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 35-40

Complications from Pulmonary Contusions after Rib Plating: A Case Series and Lessons Learned

1 Department of Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
2 Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA

Date of Submission10-Jan-2019
Date of Acceptance11-Jan-2019
Date of Web Publication30-Dec-2019

Correspondence Address:
Patrick Greiffenstein
Department of Surgery, Tulane University School of Medicine, New Orleans, LA
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jctt.jctt_17_19

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Background: Surgical stabilization of rib fractures (SSRF) is increasing in popularity with low reported complication rates. Pulmonary contusion (PC) has been cited as a relative contraindication to SSRF in cases of patients with respiratory failure due to chest wall injury. However, the reported experience and clinical data regarding PC on this topic remain limited. The objective of this study was to describe the experience treating patients with moderate-to-severe PCs utilizing SSRF and identify risk factors for pulmonary complications postoperative acute respiratory distress syndrome (ARDS).
Methods: The trauma registry of a Level 1 trauma center was reviewed from 2015 to 2019, and patients who underwent SSRF were assessed. Computed tomography was examined, and PC score was calculated in patients with a documented PC by a researcher and verified by a board-certified radiologist using the PC score as described by Chen et al. Demographic, clinical, and outcome data were analyzed and reported.
Results: Ninety-two patients were included in the initial analysis as having undergone SSRF in the study period. The patients were 72.8% male and averaged 5.5 ± 4.4 days from admission to SSRF. Nine patients with severe chest trauma and PCs underwent SSRF. Of these patients, four had severe bilateral PCs and five had severe unilateral PC, totaling >20% of total lung capacity. Three patients had ipsilateral moderate-to-severe PCs with traumatic pneumatoceles. They underwent SSRF within 48 h of admission per standard practice. They were all placed in the lateral decubitus position with the affected side up. Their intraoperative courses were complicated by bloody secretions present in the endotracheal tubes. Only one patient had lung isolation using dual-lumen endotracheal intubation and had an uneventful perioperative course. Postoperatively, the other two patients developed severe ARDS that required mechanical ventilation for several days, significantly complicating their recovery.
Discussion: This case series highlights the relative risk of SSRF in patients with significant PC. Early SSRF in patients with PC ≥3 was associated with ARDS when patients did not undergo intraoperative lung isolation. In two patients with severe PC, the contusions themselves did not produce respiratory failure on admission; however, intraoperative positioning resulted in the aspiration of bloody secretions from the contused lung into the unaffected lung, causing severe postoperative ARDS. Suggested measures to prevent future events may include isolating the contused lung intraoperatively or delaying SSRF until contusion has resolved, if feasible.

Keywords: Acute respiratory distress syndrome, flail chest, pulmonary contusion, rib plating

How to cite this article:
Tumminello M, Smith A, McGrew P, Meade AE, Guidry C, Mcginness C, Duchesne J, Greiffenstein P. Complications from Pulmonary Contusions after Rib Plating: A Case Series and Lessons Learned. J Cardiothorac Trauma 2019;4:35-40

How to cite this URL:
Tumminello M, Smith A, McGrew P, Meade AE, Guidry C, Mcginness C, Duchesne J, Greiffenstein P. Complications from Pulmonary Contusions after Rib Plating: A Case Series and Lessons Learned. J Cardiothorac Trauma [serial online] 2019 [cited 2022 Jan 28];4:35-40. Available from: https://www.jctt.org/text.asp?2019/4/1/35/274399

  Introduction Top

Rib fractures are identified in 10% of all injury victims and are associated with significant pulmonary-related morbidity (33%) and mortality (12%).[1] Techniques and surgical equipment for rib fixation have become more refined, and surgical stabilization of rib fractures (SSRF) has gained popularity, leading to more promising clinical outcomes. The reported complication rate in prospective studies is <1%, although the overall incidence of respiratory complications related to SSRF is currently unknown. The results of a meta-analysis and cost-effectiveness analysis show that acute SSRF results in reduced mortality and medical complications, along with being a more cost-effective approach than conservative management.[2] However, often, rib fractures are associated with other chest wall injuries (CWIs) including pulmonary contusions (PCs) and resulting respiratory failure.

PC can be a driving factor behind respiratory failure in blunt trauma patients. Studies have shown a correlation between PC and acute respiratory distress syndrome (ARDS), with risk calculated to be approximately 40% for patients with PC involving 20% or more of their total lung volume.[3],[4] Intraoperatively, patients with PCs tend to develop complications at a higher rate and have a more complicated postoperative course and a longer recovery period than those without contusions.[5] Specifically, patients with PCs are at higher risk of developing ARDS and pneumonia and have an increased mortality rate of 10%–25%.[3] Therefore, PCs have been cited as a relative contraindication to SSRF with patients in respiratory failure.[5] Yet it is currently not well understood if the PCs themselves, or other factors associated with operating on patients with PCs, are the driving factors behind postoperative complications in this subset of patients. Quantification of PCs on computed tomography (CT) may be a helpful way of understanding the comprehensive severity of a patient's CWI. PC scoring methods, such as the method described by Chen et al., can aid providers in determining the severity of injury.[6]

Here, we report our experience with SSRF in patients who presented with PC and two cases among these in which both patients developed ARDS peri-operatively, resulting in intubation for several days and a complicated postoperative hospital course. Ultimately, both patients were extubated and discharged in a stable condition.

  Methods Top

The trauma registry of our level 1 Trauma Center was queried for patients with PCs from January 2015 to May 2019. The time frame was selected because this was when operative fixation was being routinely performed for severe crush injuries of the chest and archived radiographic studies were accessible for the queried patients. Patients in that cohort who underwent SSRF were noted, and their electronic medical records (EMRs) were carefully examined. Admission CT scans of the chest were thoroughly reviewed, and scoring of PC was undertaken utilizing the criteria described by Chen et al. Briefly, volumetric estimation of lung parenchyma affected by PC was performed in two planes (axial and coronal). PCs on CT were scored as unilateral minor (PC = 1), bilateral minor (PC = 2), unilateral severe (PC = 3), or bilateral severe (PC = 4). PCs were considered severe if > 20% of the total lung capacity was contused. Of the 94 patients who underwent SSRF, nine patients presented to the emergency department with PC scores of 3 or 4. Demographics, such as age and sex, as well as clinical data, such as comorbidities, days from admission to SSRF, intraoperative positioning, and single versus dual lumen (DL) intubation, were documented using the EMR. Postsurgical complications and outcomes were also reported and analyzed. Simple statistical analysis was performed utilizing standard software (Excel, Microsoft Corp., Redmond, WA, USA).

  Results Top

Of the 94 patients who underwent SSRF, 33 patients had a documented PC on admission. After reviewing and scoring those CT scans with evidence of PC, nine patients were documented to have severe PCs, with a score of 3 or 4. Of the remaining patients with mild PC, none were found to have respiratory complications postoperatively.

All the nine patients were male, and their average age was 48.3 ± 13.8 years (range: 24–66 years) [Table 1]. The average number of days from hospital admission to SSRF was 4.4 ± 3.1 days (range: 2–10 days). Three patients had severe bilateral contusions (PC = 4), whereas seven presented with severe unilateral PC (PC = 3). All patients were placed in the lateral decubitus position intraoperatively and were intubated via endotracheal tube during the procedure.
Table 1: Subject characteristics

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Three patients underwent SSRF >72 h after admission (range: 6–10 days). One had DL endotracheal tube (DL) intraoperatively, and the other two had single lumen (SL). None developed postoperative respiratory complications. The remaining six patients underwent SSRF within 72 h of their injury. Three had DL intraoperatively, and none of these developed postoperative complications. The remaining three patients had severe unilateral PC, underwent SSRF in 2–3 days following their injury, and had no preoperative respiratory insufficiency. Two of these patients (cases 1 and 2) had SL intubation intraoperatively, significant intraoperative bloody secretions in their endotracheal tubes, and worsening hypoxia intraoperatively and developed severe ARDS requiring prolonged intubation and mechanical ventilation for 5 and 6 days, respectively [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Based on this experience, the remaining patient (case 3) underwent lung isolation using DL intubation and bronchoscopy with noted bloody secretions in the proximal bronchi of the affected side which were lavaged prior to extubation postoperatively and was extubated without further complications [Figure 5] and [Figure 6]. Of note, only patients with pulmonary lacerations/pneumatoceles who were intubated with SL tube had intraoperative hypoxia associated with bloody secretions. One patient had diffuse bilateral PCs which involved >40% of his total lung volume but without severe obliterative disease or pulmonary lacerations/pneumatoceles. The latter had no intraoperative hypoxia or notable endotracheal secretions.
Figure 1: Case 1: Preoperative three-dimensional reconstruction from computed tomography scan showing multi-level flail segments of ribs 4.8 on the right side (a) and coronal cut showing severe ipsilateral pulmonary contusion with pneumatocele (b)

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Figure 2: Case 1: Preoperative anteroposterior view plain chest radiograph showing severe right-sided opacification from pulmonary contusion (a) and the same patient immediately following surgical stabilization of rib fractures showing marked opacification of the contralateral lung fields

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Figure 3: Case 2: Preoperative three-dimensional reconstruction from computed tomography scan showing severely displaced fractures of ribs 4–10 on the right side (a) and coronal cut showing severe ipsilateral pulmonary contusion with obliteration of alveolar aeration in the lower lobe (b)

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Figure 4: Case 2: Preoperative anteroposterior view plain chest radiograph showing severe right-sided opacification from pulmonary contusion (a) and the same patient immediately following surgical stabilization of rib fractures showing marked opacification of the contralateral lung fields

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Figure 5: Case 3: Preoperative three-dimensional reconstruction from computed tomography scan showing complex, displaced fractures of ribs 3–9 on the right side (a) and coronal cut showing severe ipsilateral pulmonary contusion with pneumatoceles (b)

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Figure 6: Case 3: Preoperative anteroposterior view plain chest radiograph showing severe right-sided opacification from pulmonary contusion (a) and the same patient immediately following surgical stabilization of rib fractures showing improved bilateral aeration of all lung fields

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  Discussion Top

Rib fractures are often associated with high-speed blunt trauma and typically accompanied by other serious injuries. The optimal management of rib fractures has been debated in terms of operative versus conservative management. The mainstay of conservative management includes conventional pain control methods (oral analgesia, regional anesthesia, patient-controlled analgesia systems, pleural infusion catheters, and epidural analgesic), aggressive pulmonary toilet, and mechanical ventilation.[7] Although significant debate remains, increasingly positive results are being reported from both prospective observational trials and retrospective clinical analyses, indicating a clear role for SSRF in some severe cases of rib fractures. The most recent guidelines and consensus papers state that operative fixation is indicated in cases of severe respiratory insufficiency due to multiple, unstable rib fractures (“flail chest”).[1],[2],[8] In such cases, there appears to be a significant outcome benefit, with regards to days of mechanical ventilation, need for tracheostomy, and mortality, among others. Further consensus statements suggest a possible benefit from fixation of patients with severe CWIs who fail medical management and have severely displaced rib fractures regardless of respiratory status.[8]

Despite the increasing enthusiasm for SSRF, specific contraindications have not been forthcoming either from published reports or as part of the numerous cohort studies. General contraindications such as avoiding hardware implantation in an infected or potentially infected field, correction of coagulopathy, and preoperatively stabilizing a patient are mentioned, but potential contraindications such as presence of severe traumatic brain injury; spinal cord injury; or other chronic conditions such as cardiac, renal, or hepatic insufficiency in the setting of severe crush injuries of the chest wall have not been examined in the reported literature. Advanced age, on the other hand, has been the focus of attention since Dr. Bulger's landmark examination of outcomes from rib fractures[9] More recent work by Fitzgeraldet al. suggest that SSRF should be offered more liberally to victims of severe CWI over the age of 65 precisely because of their frailty and lack of respiratory reserve.[10],[11] By the same token, one might argue that any condition that impairs optimal respiratory function such as senile frailty, muscular deconditioning, spinal cord injury, and lung parenchymal disease such as chronic obstructive pulmonary disease or pulmonary edema might be an initial indication in favor of, rather than against, operative fixation if other indications exist. Given the relative safety of the procedure (reported incidence of significant complications in prospective trials is <1%), and assuming no more than the standard anesthesia risks, SSRF may improve respiratory function and overall clinical outcomes by restoring chest wall mechanics and ventilatory capacity, particularly in otherwise compromised patients.

PC is often present in cases of severe CWI and represents another factor in the respiratory equation. Despite the obvious association, very little has been specifically described regarding PC in SSRF. One notable exception is Voggenreitner's retrospective analysis of patients who underwent SSRF in their single-institutional experience.[12] They noted, as with other studies, a significant outcome benefit in patients who underwent SSRF with regard to liberation from mechanical ventilation except in those patients who presented with significant PC. For the latter, SSRF did not result in earlier liberation from mechanical ventilation when compared to their matched cohort of patients without PC who did not undergo SSRF.

It has been suggested based on previous animal studies that respiratory failure from severe CWI is primarily a function of parenchymal injury or PC rather than any significant effect of the rib fractures themselves.[13] The preponderance of evidence and our own experience suggests that the opposite is true and PC is a relatively minor factor in most cases of respiratory failure due to CWI with severe rib fractures. Nevertheless, there is a close association between the presence of PC and the development of ARDS. Volumetric analysis of patients with PC has shown a significant correlation between the total volume of PC and ARDS. Two such studies have noted that in patients with >20% total lung volume, PC can be predicted to develop ARDS 40% of the time with 90% specificity.[3],[4] Despite the association, ARDS was a relatively rare event in our patient cohort. Severe ARDS was not present preoperatively in any of our patients, and only two patients developed ARDS postoperatively. When examining these cases, it was noted that both patients underwent SL endotracheal intubation and that both had significant lung parenchymal injury with traumatic lung lacerations and pneumatoceles. In addition, both were noted to have copious bloody secretions in their airway during surgery and increasing oxygen requirements that were exacerbated postoperatively. One patient remained intubated postoperatively and continued to have high ventilator requirements for the next 5 days. The other was extubated immediately postoperatively, but developed worsening respiratory insufficiency and was intubated within 24 h of surgery. Both had ARDS by Berlin criteria, and both required advanced ventilator support until successful liberation from the ventilator.

Intra-alveolar hemorrhage can result in severe ARDS by inducing profound inflammation and causing severe bronchiolitis. It is possible that other factors such as transfusion-associated acute lung injury or volume overload causing pulmonary edema could have played a part. Although one patient did receive a blood transfusion postoperatively, he was already suffering from severe ARDS, and this was not temporally worsened by the transfusion of two units of packed red blood cells. Furthermore, neither patient received intravenous fluids in excess of a 2 L net fluid balance postoperatively. Therefore, volume overload pulmonary edema is unlikely the primary cause of the severe hypoxia.

Nor is PC alone the likely cause of ARDS in these patients, given the experience of other patients in our cohort. Three patients with severe PC underwent SSRF several days after their injury, when PC had cleared significantly, and none had the complication of postoperative ARDS. In these patients, intraoperative ventilation via a SL endotracheal tube was safe in the absence of intra-alveolar hemorrhage. While the single patient with severe PC who underwent early (hospital day 3) SSRF and SL intubation did not develop postoperative ARDS, it was noted that he had a diffuse pattern of PC in both lungs and that there was an absence of parenchymal lacerations on his CT. There was also a notable absence of intra-alveolar hemorrhage during intubation. Furthermore, following the above experience and seeking to test our hypothesis that intra-alveolar hemorrhage could be present in patients with PC, one patient underwent an intraoperative bronchoscopy and lung isolation during his SSRF. No thoracoscopy was planned, and DL intubation was undertaken in order to isolate both lungs. Prior to positioning, a flexible bronchoscope was used to examine the affected side, and confirmation of severe intra-alveolar hemorrhage with copious blood clots was noted in the proximal second-order bronchi of all the three lobes of the right lung. The patient underwent lavage, and SSRF in a lateral decubitus position with the affected side up without respiratory complications and a successful extubation in the operating room. His respiratory function improved postoperatively from preoperatively, and he was discharged home on postoperative day 3 without complications.

  Conclusions Top

The challenge of introducing a new mode of therapy is often that unexpected complications arise and identification of the precise pathophysiology can be elusive. SSRF has emerged as an important tool in the armamentarium of the surgeon treating patients with severe CWIs, but many questions about its use, including indications and contraindications, remain incompletely answered. Although some authors cite PC as a contraindication to SSRF, the available literature does not fully support that recommendation (Nirula).[14] Rather, PC is a relative contraindication on the basis that it may mitigate some of the beneficial effects of SSRF, in particular earlier liberation from mechanical ventilation. However, although precise numbers are not properly reported, a significant proportion of patients undergoing SSRF in recent years have not suffered respiratory failure preoperatively and more importantly, the majority of patients in our own institution have not had severe or even significant PC despite often severe CWIs. Therefore, PC is not a prominent disease process in the majority of patients undergoing SSRF.

Nevertheless, we report two cases of otherwise healthy young men who did not have respiratory insufficiency despite suffering from both severe PC and severe CWIs preoperatively but developed severe ARDS following SSRF. Although their outcomes were ultimately favorable, one cannot ignore the severe impact of several days of mechanical ventilation and the concomitant risk of mortality and significant long-term respiratory compromise that could have resulted.

Based on our analysis of our experience in treating patients with severe chest wall trauma, the salient conclusion is that intra-alveolar hemorrhage resulting from severe pulmonary parenchymal trauma caused aspiration pneumonitis intraoperatively that resulted in severe ARDS following SSRF. Based on this limited cohort analysis, risk factors for this include lateral decubitus position, early SSRF (within 5 days of injury), and SL endotracheal intubation. Care should be taken in performing SSRF in patients with significant traumatic lung parenchymal injury, and intraoperative lung isolation should be exercised in these patients.

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  References Top

Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017;82:618-26.  Back to cited text no. 1
Swart E, Laratta J, Slobogean G, Mehta S. Operative treatment of rib fractures in flail chest injuries: A meta-analysis and cost-effectiveness analysis. J Orthop Trauma 2017;31:64-70.  Back to cited text no. 2
Miller PR, Croce MA, Bee TK, Qaisi WG, Smith CP, Collins GL, et al. ARDS after pulmonary contusion: Accurate measurement of contusion volume identifies high-risk patients. J Trauma 2001;51:223-8.  Back to cited text no. 3
Becher RD, Colonna AL, Enniss TM, Weaver AA, Crane DK, Martin RS, et al. An innovative approach to predict the development of adult respiratory distress syndrome in patients with blunt trauma. J Trauma Acute Care Surg 2012;73:1229-35.  Back to cited text no. 4
Sarani B, Schulte L, Diaz JJ. Pitfalls associated with open reduction and internal fixation of fractured ribs. Injury 2015;46:2335-40.  Back to cited text no. 5
Chen J, Jeremitsky E, Philp F, Fry W, Smith RS. A chest trauma scoring system to predict outcomes. Surgery 2014;156:988-93.  Back to cited text no. 6
Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: Indications, technique, and outcomes. J Bone Joint Surg Am 2011;93:97-110.  Back to cited text no. 7
Pieracci FM, Lin Y, Rodil M, Synder M, Herbert B, Tran DK, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016;80:187-94.  Back to cited text no. 8
Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma 2000;48:1040-6.  Back to cited text no. 9
Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB 3rd. Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a level I trauma center. J Trauma Acute Care Surg 2017;82:524-7.  Back to cited text no. 10
Kane ED, Jeremitsky E, Bittner KR, Kartiko S, Doben AR. Surgical stabilization of rib fractures: A single institution experience. J Am Coll Surg 2018;226:961-6.  Back to cited text no. 11
Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest-outcomes of patients with or without pulmonary contusion. J Am Coll Surg 1998;187:130-8.  Back to cited text no. 12
Craven KD, Oppenheimer L, Wood LD. Effects of contusion and flail chest on pulmonary perfusion and oxygen exchange. J Appl Physiol Respir Environ Exerc Physiol 1979;47:729-37.  Back to cited text no. 13
Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: Indications, technical issues, and future directions. World J Surg 2009;33:14-22.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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