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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 28-31

Intraoperative evaluation by ultrasound of multiple rib fractures in trauma patients


1 Department of Anesthesiology, Fundación Valle del Lili, Cali, Colombia
2 Division of Thoracic Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
3 Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA

Date of Web Publication22-Dec-2021

Correspondence Address:
Mauricio Velasquez
Carrera 98#18-49, Fundación Valle del Lili, Cali
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jctt.jctt_7_20

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  Abstract 


Introduction: Increased interests in surgical approaches for multiple rib fractures in trauma patients have emerged lately. A novel strategy based on intraoperative ultrasound (US) assessment to locate these fractures has been proposed to perform smaller incisions for thoracic wall reconstructions. We aimed to describe variations of site, size, and direction of surgical incisions before and after US use intraoperatively for localization of rib fractures.
Materials and Methods: In this pilot study, ten trauma patients with multiple rib fractures requiring thoracic wall reconstruction were prospectively included during a 9-month period. Computer tomography of the thorax was used for determining surgical incisions. Before surgical incision, US was used for the identification of rib fractures and for marking a different surgical incision. In each patient, qualitative comparisons of surgical incision marks before and after US were performed.
Results: The qualitative analysis demonstrated that five patients (5/10) had a change in the direction of the incision and also in five patients (5/10) there was a change in the size of the incision. In those five patients in whom the length and size of the incision changed, there was a median length reduction of the incision of 3 cm (interquartile range 2–3).
Conclusions: In this pilot study, we observed that trauma patients with multiple rib fractures requiring thoracic wall reconstruction may benefit from intraoperative assessment of US for targeted surgical planning. US might offer advantages for surgical planning before defining the final surgical approach.

Keywords: Rib fractures, thoracic wall, ultrasonography


How to cite this article:
Cruz G, Sanchez AI, Puyana JC, Velasquez M. Intraoperative evaluation by ultrasound of multiple rib fractures in trauma patients. J Cardiothorac Trauma 2021;6:28-31

How to cite this URL:
Cruz G, Sanchez AI, Puyana JC, Velasquez M. Intraoperative evaluation by ultrasound of multiple rib fractures in trauma patients. J Cardiothorac Trauma [serial online] 2021 [cited 2022 Jan 19];6:28-31. Available from: https://www.jctt.org/text.asp?2021/6/1/28/333279




  Introduction Top


Rib fractures are very common in thoracic trauma. They affect all age groups and are associated with increased morbidity, mortality, and hospital and intensive care unit length of stay.[1] Recently, there is an increased interest in surgical approaches since thoracic wall reconstruction has shown decreasing hospital and intensive care unit length of stay[2],[3],[4],[5],[6],[7] and complications such as pneumonia[2],[3],[5],[6] and tracheostomy needs.[5],[7]

Plain chest radiograph is the initial assessment tool for patients with thoracic trauma. Nonetheless, it has a limited value to characterize rib fractures.[8] Computed tomography with three-dimensional reconstruction provides important information regarding number, location, and displacement of rib fractures, becoming essential for operative planning.[8] Ultrasound (US) is a broadly used diagnostic method easy to employ, portable, and without radiation. It has emerged as an important tool in the operative room to locate more precisely the exact place of rib fractures.[9] To the best of our knowledge, comparisons between this imaging diagnostic tools regarding surgical planning, patient positioning, and surgical incisions in trauma patients with multiple rib fractures have not been made.[9]

For trauma patients with multiple rib fractures, smaller incisions might decrease surgical trauma. Therefore, it is important to be more precise in the location of rib fractures for surgical decision-making. This study aimed to qualitatively describe the variations of site, size, and direction of surgical incisions, before and after US was performed intraoperatively to localize rib fractures for thoracic wall reconstructions.


  Materials and Methods Top


This pilot study was conducted during January-August of 2019 at a single university hospital that also meets all the criteria that a United States level I trauma center must fulfill to be designated as such by the American College of Surgeons. Adults (patients aged equal or older than 18 years) with thoracic trauma and multiple rib fractures whom required thoracic wall reconstruction were selected for inclusion in the study. Patients with severe traumatic brain injury (Glasgow Coma Scale <8) and patients with rib fractures underneath the scapula were excluded from the study.

Trauma patients admitted to the emergency department with thoracic injuries were initially assessed with the advanced trauma life support protocols.[10] Patients hemodynamically stable, in which life-threatening injuries were ruled out, and other higher specific co-existing injuries properly managed, were scheduled for thoracic wall reconstruction. All patients underwent a computer tomography with three-dimensional reconstruction for surgical planning. Computer tomography in our institution was performed in a 64-slice multidetector scanner.

On average, within 72 h of injury, patients were brought to the operative room. Patients were positioned in the decubitus lateral position and therefore markings for surgical incisions were performed using the computer tomography images for surgical planning. Herein, and before surgical incision, US was performed in all patients to localize the rib fractures. US was performed using a 12-MHz linear transducer by a trained surgeon in acute care surgery. The US operator was blinded to the computer tomography results. Using local signs of injury (e.g. wounds, lacerations, and ecchymosis) the operator oriented the probe to localize the rib fractures. The rib fractures were marked in the skin of the patient when the operator identified a loss of bone cortex continuity, a clear disruption of the anterior echogenic cortical margin of the rib evaluated. Using these marks, the thoracic surgeon depicted new marks for surgical incision and the procedure was performed. In each patient, a qualitative comparison of surgical incision marks before and after US was performed.

De-identified information on demographics and injury severity scores were recorded. Information regarding the number of rib fractures was obtained from computer tomography reconstructions. The number of rib fractures fixed during thoracic wall reconstruction was obtained from the surgical records. Outcome variables were the length, and direction of surgical incision marks. For the descriptive data analysis, absolute and relative frequencies were provided for summary of qualitative variables, and medians and interquartile ranges (IQRs) were provided for summary of quantitative variables. This study was approved by the Institutional Review Board on Biomedical Research of our institution.


  Results Top


Ten trauma patients with multiple rib fractures who underwent thoracic wall reconstruction were included in this pilot study. Three (3/10) were women and seven (7/10) were men. The median age was 54.5 years (IQR 36–60). The median injury severity score was 18 points (IQR 11–25). The median number of rib fractures identified on computer tomography was 7 (IQR 5–9) and the median number of corrected fractures during thoracic wall reconstructions was 6.5 (IQR 5–8).

The qualitative analysis demonstrated that after US use, five patients (5/10) had a change in the location and direction of the incision, and also in five patients (5/10) there was a change in the size of the incision. In those five patients in whom the size of the incision changed after US use, the median reduction in the length of the incision was 3 cm (IQR 2–3).

[Table 1] depicts the demographics, injury scores, number of rib fractures and rib reconstructed during surgery, and the change in size, location, and direction of surgical incision marks. [Figure 1] and [Figure 2] depict changes in location and direction in surgical incision markings before and after US use. [Figure 3] and [Figure 4] depict changes in the size of surgical incision markings before and after US use.
Table 1: Demographics, injury scores, and surgical findings in patients with thoracic trauma and multiple rib fractures who required thoracic wall reconstruction

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Figure 1: Changes in location and direction in surgical incision markings before ultrasound use

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Figure 2: Changes in location and direction in surgical incision markings after ultrasound use

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Figure 3: Changes in size of surgical incision markings before ultrasound use

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Figure 4: Changes in size of surgical incision markings after ultrasound use

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  Discussion Top


In patients with thoracic trauma and multiple rib fractures, there is an increasing interest in thoracic wall reconstructions mostly due to improvements in clinical outcomes when compared to conservative treatment.[1],[7],[11] Computer tomography with three-dimensional reconstruction has been accepted as the gold standard for surgical planning in this group of trauma patients.[12] However, it is nevertheless challenging in the operating room to accurately locate rib fractures for properly performing the surgical incision even for experienced thoracic or trauma surgeons.[11]

Our results showed that thoracic US allowed a reliable surgical planning. It changed the direction of the incision in half of the patients, and it also decreased the length of the incision. At the operative room, physical examination may yield the location of rib fractures when crepitation is present. However, this might be biased by hematomas, patients' fat tissue, and trauma mechanisms.[13] Thoracic US has shown a high sensibility to diagnose fractures and its performance in the operative room may be useful for surgical planning.[9],[13] Sonographic signs of rib fractures were: disruption to echogenic cortical margin, acoustic edge shadow, or reverberation artefact.[14] For the detection of rib fractures, thoracic US had a sensitivity between 78% and 90%.[13] The literature has also indicated that thoracic US might have benefits in terms of costs, absence of radiation, and simplicity.[11] It will be very interesting to prove these benefits in larger and prospective multi collaborative studies.

Limitation must be acknowledged. The US in the thoracic wall decreased its discrimination for rib fractures in the area under the scapulae and the infraclavicular portion of the first rib. In addition, obese patients or those with large mammary tissue might present a diagnostic challenge.[9],[15] The pleura have a similar sonographic appearance to the rib cortex, costal cartilage calcification at the costochondral junctions might give rise to pseudo fractures; these might confound unexperienced operators.[13] In this pilot study, we did not find those difficulties in this group of trauma patients. However, caution must be taken to acknowledge and overcome those difficulties. In addition, the descriptive nature of this study might prevent the generalization of these results to other populations.


  Conclusion Top


Multiple rib fractures are common in thoracic trauma in our population. US has become a diagnostic method broadly used in the emergency setting. Intraoperative, US in patients with thoracic trauma and multiple rib fractures may offer advantages for planning targeted surgical incisions.

Ethical clearance

The Institutional Review Board at the Fundación Valle del Lili approved the study protocol. Informed consent was obtained from every volunteer enrolled in the study.

Acknowledgments

This study was presented at the 2020 Chest Wall Injury Society –Virtual Summit.

Financial support and sponsorship

This work was supported by the Center for Clinical Research at the Fundación Valle del Lili.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Majercik S, Pieracci FM. Chest wall trauma. Thorac Surg Clin 2017;27:113-21.  Back to cited text no. 1
    
2.
Coughlin TA, Ng JW, Rollins KE, Forward DP, Ollivere BJ. Management of rib fractures in traumatic flail chest: A meta-analysis of randomised controlled trials. Bone Joint J 2016;98-B: 1119-25.  Back to cited text no. 2
    
3.
Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: A systematic review and meta-analysis. Ann Surg 2013;258:914-21.  Back to cited text no. 3
    
4.
Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013;216:924-32.  Back to cited text no. 4
    
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Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: A meta-analysis. J Am Coll Surg 2013;216:302-110.  Back to cited text no. 5
    
6.
Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52:727-32.  Back to cited text no. 6
    
7.
Velasquez M, Ordoñez CA, Parra MW, Dominguez A, Puyana JC. Operative versus nonoperative management of multiple rib fractures. Am Surg 2016;82:e103-5.  Back to cited text no. 7
    
8.
Livingston DH, Shogan B, John P, Lavery RF. CT diagnosis of Rib fractures and the prediction of acute respiratory failure. J Trauma 2008;64:905-11.  Back to cited text no. 8
    
9.
Battle C, Hayward S, Eggert S, Evans PA. Comparison of the use of lung ultrasound and chest radiography in the diagnosis of rib fractures: A systematic review. Emerg Med J 2019;36:185-90.  Back to cited text no. 9
    
10.
American College of Surgeons. Advanced trauma life support: Student course manual. 10th ed. Chicago, IL, 2018.  Back to cited text no. 10
    
11.
Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017;48:307-21.  Back to cited text no. 11
    
12.
Kani KK, Mulcahy H, Porrino JA, Chew FS. Thoracic cage injuries. Eur J Radiol 2019;110:225-32.  Back to cited text no. 12
    
13.
Turk F, Kurt AB, Saglam S. Evaluation by ultrasound of traumatic rib fractures missed by radiography. Emerg Radiol 2010;17:473-7.  Back to cited text no. 13
    
14.
Napier D. Ultrasound in the diagnosis of rib fracture following blunt chest trauma: A case study. Sonography 2019;6:84-90.  Back to cited text no. 14
    
15.
Hurley ME, Keye GD, Hamilton S. Is ultrasound really helpful in the detection of rib fractures? Injury 2004;35:562-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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