Bradley Putty, MD, Trauma and Critical Care, Trauma Medical Director at Baylor Scott & White Medical Center – Grapevine talks about rib plating procedures for trauma patients with severely injured ribs.
Interview conducted by Ivanhoe Broadcast News in December 2017.
Trauma and critical care, that could be anything, is it mostly ER type stuff?
Dr. Putty: It is not exactly ER type stuff, but frequently the hospital stay does begin in the emergency department. When very, very severely injured patients who need a lot of support present themselves to first responders, a hospital trauma team frequently will be activated. The patient comes to that hospital’s ER and we respond as a team, as a trauma team. We assess the patient, try to figure out what is going to threaten their life most immediately, address it, stabilize them and then move them to the operating room, or to the radiology suite for intervention or up to the ICU or if they are stable we would lead them to appropriate hospital unit.
Give me a brief background of your military experience?
Dr. Putty: I have been in the United States Air Force since the late 90’s, including serving in the capacity of trauma overseas for several years. I was stationed at Landstuhl, which is our trauma facility that receives all the combat causalities evacuated out of Africa, Europe and the Middle East, Southwest Asia. We do not have any operations going on currently in Europe, but anybody that is critically ill that is not related to combat is also referred there to the ICU.
Okay, so you got a lot of your experience, did you go to the Air Force Academy?
Dr. Putty: No I went to Texas A&M University.
Okay, but you got a lot of experience with trauma, so you have seen all kinds of things. Barbara described her accident to us and it sounded pretty severe, she was very fortunate; but she was also banged up pretty badly. Would you tell us a little bit about what you saw when she came in?
Dr. Putty: My partner was the trauma surgeon on call when Barbara arrived. He assessed her in the initial resuscitation and one of the first things that they noted was that severe pain in her chest and her back affected her ability to breathe. On the X-ray he noticed that she had a partial crushed left upper chest, upper mid chest and a hemothorax. Right away he knew she was in trouble.
Describe it a little bit more from the point of view of how these collapsed ribs or this rib cage that was closing in on her was having a impact on her ability to breathe?
Dr. Putty: The mechanics of breathing involve expanding your chest wall by contracting the muscles that are between your ribs and your diaphragm, and that elevates and stretches out your ribs but then that draws the lungs with it and creates a sub-atmosphere pressure to draw a breath in. When you disrupt the stability of the chest wall by breaking the ribs, especially if it associated with significant displacement, you are not able to make those movements. On one side of her body when she tried to breathe mechanically, she was having a hard time because her chest wall was partially collapsed, decreasing the available volume for lung expansion. In addition it causes extreme pain when you move. When you move those ribs in close proximity to each other, the broken ends and even if you were able to take a deeper breathe mechanically the pain associated with that frequently limits you to short shallow breaths.
To what degree was she in danger of even dying from all this?
Dr. Putty: Respiratory failure without adequate analgesia, that is pain control, can ensue in the days and hours following the initial presentation. There is a risk for respiratory failure, without stabilization and support of oxygen, supplementation, and support of her pain through aggressive analgesia’s regiments or pain medicine, pain catheters.
What is the level of your trauma center here and the thing that actually helped her tremendously?
Dr. Putty: Barbara came into our care about one year after we began our active pursuit of level two trauma verification by the American College of Surgeons Committee on Trauma. Her accident was right down the road and it did not take EMS long to transport Barbara here. She thinks that that helped her tremendously.
What do you think?
Dr. Putty: I like to think we did her some good.
Well it sounds like if you did not have the facilities here she would have had to be transported to someplace else.
Dr. Putty: Yes, if Barbara did not have a facility capable of taking care of her injuries, she would have to be transported a longer distance.
And that would have added to the risk, I suppose?
Dr. Putty: It does add to the risks.
After you got her stabilized and saved her from any further damage then the decision was made to move towards this rib plating procedure?
Dr. Putty: Yes sir.
So that is kind of where you come in? You and your partners, let us call it a team?
Dr. Putty: Yes sir, one of the things done was giving her oxygen support and aggressive pain support through regional pain catheters. We have a very robust program for our anesthesiologist to help with early pain control that can contribute towards respiratory compromise.
Then early operative stabilization of her ribs was considered. Because her ribs were a little bit more difficult, we did have a two surgeon approach which turned out to be necessary because of her injuries. When you do an open reduction in the operating room you have to physically pull the ribs back into alignment and usually the displacement is only a centimeter or two. While it can require quite a bit of effort, it generally does not require two people. In this case, because her ribs was so high and so severely displaced by several centimeters and by levels, it took two of us to get her ribs to back in alignment.
Tell us what are these rib plates and how do they work?
Dr. Putty: The rib plates are titanium plates that are conformed relatively to a shape of a rib. They fit on the outer surface of their rib, and are affixed to their rib with screws that go through the full depth and anchor into both cortices. Essentially they provide the stabilization once you reduce the fracture. That means the rib cannot move, not be displaced during the movement and this gives the rib time to heal.
If you think about somebody’s bone breaking,for example, a forearm; you would never ask them to lift things, especially without stabilization. You go in and at least put a cast on if it was a minor fracture. If it was a major fracture with significantly displacement you would want to put them back in alignment and then provide some stabilization with a metal plate or rod and that would allow the bone to heal for a period of time. Eventually you start using that arm again.
When your ribs are broken you cannot stop using them, you’ve got to keep breathing.
The only alternative, if the injury is severe enough to cause respiratory failure, is to put the patient on a breathing machine, expand their lungs up as much as you can with mechanical ventilation, and then wait for their ribs to begin to heal. This can take two to three weeks.
Is that the way they used to have to treat something like this?
Dr. Putty: Yes sir. One of the down sides to the conventional treatment has to do with their functional capability afterwards. You may get a patient through the respiratory failure and save their life. Eventually you get them off the breathing machine, but you may have to provide them a surgical airway to have help facilitate that.
They may leave the hospital and then find that they cannot use their arm very easily. The patient cannot lift things because again the ribs do play a vital role in your upper extremity movement. A patient who is a young, vibrant, healthy, athletic person may not be able to resume normal activities for several months.
So these pains you call them rib fixation?
Dr. Putty: Yes sir, this is the operation that we performed on Barbara, referred to as an operative or open reduction and internal fixation. Essentially you expose the bone as you would any bone that you are going to internally fix and you reduce it or that bring the bone back into alignment. Then you place the fixation device, in this case it is a rib plate, on and fix it with screws.
So when was all of this approved, when did you start using these rib plates?
Dr. Putty: Well rib plating has been around for close to nearly 20 years. We started seeing good data, good evidence come out around 2000. Rib plating really had not really catch on until the late 2000’s when one of the companies decided to make some unique rib plates. Other companies since then have got into the business including the company that supplied her rib fixation plates.
I have previously done this prior to moving to North Texas and rib plating is one of the proceduress that we brought to this area. It is not just rib fixation because people are fixing ribs before, but fixation of ribs that require what I would call difficult exposure, ribs that are beneath the scapula that are posterior that are difficult to expose.
How would you describe the procedure, the devices themselves and the procedures, compared to the old way that you had to treat people?
Dr. Putty: I think that the recent development in advent of rib fixation technology is quite a breakthrough. For decades the medical community has struggled with how to treat these patients. People has used things like iron lungs, they have used external piercings of the skin and muscles with suspension, using pulleys and ropes to try to help stabilize the chest wall, they used taping, all sorts of different technologies have been attempted in the past over decades. None have really found favor with the medical community.
I think with new bio materials, titanium plates that are not completely ridged but offer much more stability then a non fixed rib, the patient is able to enjoy some stability. They can breathe without significant pain, they can have restoration of their chest wall as God intended to be and yet they can still have freedom to breathe without a noncompliant plate restricting that motion of those ribs.
It has been about a year for Barbara and you are still seeing her from time to time, she is still having a little problem with her hand because of some nerve things. She still has does not have complete use of her hand the way she once did, will she get that back?
Dr. Putty: Frequently these rib fractures or chest walls deformities are associated with other injuries. I n Barbara’s case she did suffer severe injury to her shoulder and her brachial plexus, that is the nerves the comes out of the spinal cord and supply the upper extremity of the arm with sensation and movement function.
For a long time she has had difficulty with that arm; it improved post-operatively, but again our operation was just to restore mechanical stability to her chest wall, we did not do anything for the nerves; that is just a slow healing process and she has seen quite a bit of process over the last several months as those nerves have healed and she has approved. I think she still have some issues with her shoulder that she is working on, she has been working with occupational therapy Our plan is for Barbara to a shoulder specialist to see if there is any further operative therapy that could benefit her.
Would that be more of an orthopedic person?
Dr. Putty: Yes sir that would be an orthopedic surgeon who specializes in the shoulder.
She has made a pretty remarkable recovery based on the damage that was done?
Dr. Putty: Yes sir, I think that Barbara has enjoyed quite a recovery, she is back at work; that would have been a huge loss for not only her. One of the benefits of this operation, as I mentioned earlier, is that patients do enjoy an earlier returned to work.
In Barbara’s case, she needs to use her arms, her hands; that is crucial. While she could not work for several weeks afterwards, she was able to return.
Studies also show that with rib fixation you can get back to work 50 percent earlier then without insignificant fractures.
You and your team I imagine must get a lot of satisfaction out of seeing somebody like Barbara recover from something like this?
Dr. Putty: It is very fulfilling to have patients that come in so broken and not knowing what they will be able to do. You are able to give them a service that gets them back, to not just life but life abundance; a good level of function where they can be vibrant and productive and return to their lively hood as well as the activities they enjoy. Be that golf, or knitting, or swimming, or hiking, it is a great feeling and it is why we do this.
This is one of those amazing breakthroughs; 20 years is not that long?
Dr. Putty: Yes, no. Some of the early pioneers 15 to 20 years ago set out and did a few small series of these. Today rib fixation is gaining prevalence. This is all due to the wonderful efforts of the biomedical engineers out there that have been really working hard to figure out a solution to this problem. So kudos to those guys, those are really the unsung heroes, the guys that made this possible.
Tell me about the procedure and the way these are screwed in?
Dr. Putty: The patient is fixed with a long plate. The plate is conformable to the shape of the ribs so it is adaptable to everybody’s anatomy. You will have a plate, it is initially curved but not exactly to the shape of the rib. The surgeon can shape this long plate and conform it just to that shape needed. And then you fix it to the different ends of the ribs by drilling and then screwing the screws in place. You drill right through the rib, right through the hole.
And do they stay in for the rest of your life?
Dr. Putty: They do. You see them at the TSA when you walk through and you have to hold your arms up for the X-ray machine. Normally, the plates do not set off metal detectors because they are titanium. These are also MRI compatible, so a patient could still have an MRI The plates are very light weight. I’ve never had a patient complain about them.
So what happens, the muscles kind of grow around, in and around them, or do they stay separately, these little metal plates?
Dr. Putty: The intercostal muscles are between each rib, on the surface of the rib and so you put these in without really ever having to take the intercostals muscles down off of the rib unless you are performing a particular procedure and the muscles of the chest wall that lay over the rib if their mobilized you just return them to the normal position if you had to split them or cut through them, you just re-attach the muscle over the ribs once they are fixed.
It does several things at once?
Dr. Putty: Yes sir, the rib plating as I mentioned can help with respiratory function when it is compromised. Importantly rib plating can help you get back to your regular activity, moving around without debilitating pain.
It reduces pain, in a sense.
Dr. Putty: Yes sir.
It takes away that potential for that inflammation, from the grinding of the bones.
Dr. Putty: If you ask patients who have had this, such as Barbara, they will tell you the discomfort is night and day. You trade off discomfort, you create a long incision, you go through muscle, which then is going to be sore after it heals, but when you talk to them they compare it to the pain of the bone grinding against the ends of the bones grinding against one another, they will tell you it is night and day difference.
Anything else about the procedure, or the success you are having it with it? What kind of a difference is the procedure making for people who have these traumatic injuries?
Dr. Putty: Well in our own experience patients who have undergo rib fixation get home twice as often as patients who go without the rib fixation.
Okay, so they in a sense you are cutting the hospital time in half?
Dr. Putty: After a patient recovers in the hospital from their injuries they have basically three places to go, they can go home, they can go to a skilled nursing facility, or they can go to inpatient rehab. We have compared patients with severe chest wall injuries to those who undergo rib fixation for extrememely severe chest wall injuries. Those who had the rib fixation are twice as likely to go home as to one of those other places to recover.
END OF INTERVIEW
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