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Use of Pain Scale and Arterial Oxygen Partial Pressure as Screening Internal Fixation Indications for Patients with Multiple Rib Fractures

ObjectiveTo explore the feasibility to use pain scale and arterial oxygen partial pressure(PaO2)as screening internal fixation indications for patients with multiple rib fractures. MethodsClinical data of 48 patients with multiple rib fractures who were admitted to Shanghai Pudong Hospital from September 2010 to February 2013 were retrospectively analyzed. Visual analogue scale (VAS) was used for pain assessment. Twenty-four patients whose VAS was greater than or equal to 6 and PaO2 was less than 60 mm Hg 3 days after injury were chosen as the experimental group, including 16 males and 8 females with their age of 49.29±15.73 years. Another 24 patients whose VAS was less than or equal to 5 and PaO2 was greater than 60 mm Hg 3 days after injury were chosen as the control group, including 19 males and 5 females with their age of 48.63±13.49 years. Patients in both groups received rib internal fixation with steel plates. Three days and 1 week after surgery respectively, VAS and PaO2 were compared between the 2 groups. ResultsIn the experimental group, VAS 3 days after surgery was significantly lower than preoperative VAS (4.09±0.93 vs. 8.21±1.18, P < 0.05), and VAS 1 week after surgery was significantly lower than preoperative VAS (3.20±0.98 vs. 8.21±1.18, P < 0.05). In the control group, there was no statistical difference between VAS 3 days after surgery and preoperative VAS (P > 0.05), and there was no statistical difference between VAS 1 week after surgery and preoperative VAS (P > 0.05). Three days after surgery, PaO2 of the experimental group was significantly higher than preoperative PaO2 (61.00±3.47 mm Hg vs. 53.00±3.97 mm Hg, P < 0.05). There was no statistical difference between PaO2 3 days after surgery and preoperative PaO2 in the control group (66.71±5.15 mm Hg vs. 66.00±5.00 mm Hg, P > 0.05). Three days after surgery, pneumonia occurred in 4 patients in the experimental group and 2 patients in the control group (χ2=0.762, P > 0.05). Three days after surgery, pain scale reduction of the experimental group was significantly higher than that of the control group (4.13±1.45 vs. 0.00±0.42, P < 0.05). One week after surgery, pain scale reduction of the experimental group was significantly higher than that of the control group (5.04±1.23 vs. 0.08±0.28, P < 0.05). Three days after surgery, PaO2 increase of the experimental group was significantly higher than that of the control group (7.42±3.59 mm Hg vs. 0.21±0.98 mmHg, P < 0.05). ConclusionIt's reasonable and feasible to use pain scale greater than or equal to 6 and PaO2 less than 60 mm Hg as internal fixation indications for patients with multiple rib fractures.

Finite Element Modeling and Clinical Analysis of Internal Fixation of Multiple Rib Fractures and Flail Chest Using Four-claw Ti-planes

Objective To evaluate clinical efficacy of four-claw Ti-planes for internal fixation of multiple rib fractures and flail chest. Methods Clinical data of 93 patients with multiple rib fractures and flail chest who were admittedto Shanghai Pudong Hospital from December 2011 to November 2012 were retrospectively analyzed. There were 78 male and 15 female patients with their age of 20-80 years. All the patients received internal fixation of rib fractures using four-clawTi-planes. Finite element modeling and analysis were performed to investigate biomechanical behaviors of rib fractures after internal fixation with four-claw Ti-planes. Results The average number of rib fractures of the 93 patients was 5.9±2.1，and each patient received 3.8±1.3 four-claw Ti-planes for internal fixation. The operations were performed 6.3±3.2 days after admission. After the rib fractures were fixed with four-claw Ti-planes，rib dislocations and chest-wall collapse of flail chest were restored，and patients’ pain was relieved. Postoperative CT image reconstruction of the chest showed no dislocationor displacement at the fixation areas of the four-claw Ti-planes. Rib fractures were stabilized well，and normal contours of the chest were restored. Finite element analysis showed that the maximum bearable stress of the rib fractures after internal fixation with four-claw Ti-planes was twice as large as normal ribs. Conclusion Clinical outcomes of four-claw Ti-planesfor internal fixation of rib fractures are satisfactory with small incisions and less muscle injury of the chest wall，so this technique deserves wide clinical use.

電視胸腔鏡聯合形狀記憶環抱接骨板治療多發性肋骨骨折

目的探討應用電視胸腔鏡聯合形狀記憶環抱接骨板治療多發性肋骨骨折的方法和療效。方法自 2009年 1～ 12月上海交通大學醫學院附屬新華醫院（崇明）胸心外科收治 38例多發性肋骨骨折患者（內固定組），均行電視胸腔鏡探查、止血、胸腔內血凝塊清除、肺裂傷修補，應用電視胸腔鏡定位肋骨骨折部位，切開復位，并采用形狀記憶環抱接骨板行肋骨內固定。選擇 2008年 1 ～ 12月我科收治的 44例胸部創傷經保守治療的患者作為對照（非內固定組）。術后觀察兩組患者的胸痛緩解時間、坐起時間、下床時間、住院時間、胸壁畸形、骨折愈合時間及相關并發癥（肺不張、肺部感染）發生情況。結果內固定組患者均臨床愈合，治愈率為 100%。平均手術時間 48.2 min，術后胸痛明顯緩解，平均 2.5 d可坐起， 6.8 d可站立行走，平均住院時間為 10.2 d，原有的胸壁畸形均矯正、平均骨折愈合時間為 4周，無明顯并發癥發生。內固定組患者的胸痛緩解時間、坐起時間、下床時間、住院時間、胸壁畸形、骨折愈合時間及相關并發癥（肺不張、肺部感染）發生率均短于或少于非內固定組（ P＜ 0.05）。內固定組隨訪 38例，隨訪時間 2～ 14周，均復查胸部 X線片，未見明顯并發癥發生，無再次骨折，接骨板無松動、斷裂。結論應用電視胸腔鏡聯合形狀記憶環抱接骨板治療多發性肋骨骨折具有創傷小、操作簡便、固定可靠、組織相容性好及并發癥少等優點，有利于促進骨折愈合和呼吸功能改善，是治療多發性肋骨骨折較理想的方法。

Surgical and traditional methods for the treatment of multiple rib fractures: A systematic review and meta-analysis of randomized controlled trials

ObjectiveTo evaluate the effect of surgical and traditional treatments for multiple rib fractures through systematic review and meta-analysis.MethodsCNKI, Wanfang, VIP, PubMed, OVID, EMbase, The Cochrane Library, Thieme and Springer Link database for information from inception to July 2019 were screened by computer. Randomized controlled trials (RCTs) of surgical and conventional methods for the treatment of multiple rib fractures were screened, assessed and extracted. RevMan 5.3 software was used for meta-analysis.ResultsTwelve studies were included, including 1 039 patients. There were 512 patients in the operation group and 527 patients in the traditional treatment group. The results of meta-analysis showed that there was a significant difference between the two groups in the incidence of pneumonia (RR=0.41, 99%CI 0.29 to 0.58, P<0.000 01), incidence of atelectasis (RR=0.24, 99%CI 0.06 to 0.94, P=0.007), duration of mechanical ventilation (SMD=–2.64, 99%CI –4.38 to –0.91, P<0.000 1), duration of intensive care unit stay (SMD=–1.33, 99%CI –2.26 to –0.40, P=0.000 2), duration of hospital stay (SMD=–2.25, 99%CI –3.30 to –1.19, P<0.000 01)and incidence of chest wall deformity (RR=0.08, 99%CI 0.04 to 0.17, P<0.000 01). There was no significant difference between the two groups in the hospital mortality (RR=0.75, 99%CI 0.23 to 2.46, P=0.53), incidence of tracheostomy (RR= 0.69, 99%CI 0.39 to 1.21, P=0.09), ventilator support rate (RR=0.65, 99%CI 0.41 to 1.05, P=0.02) and chest drainage time (SMD=–2.58, 99%CI –6.41 to 1.25, P=0.08).ConclusionSurgical treatment of multiple rib fractures can reduce pulmonary complications, shorten hospital stay, and reduce the incidence of chest wall deformity, which is conducive to rapid recovery and improves quality of life.

聚左旋乳酸可吸收肋骨釘治療重癥肋骨骨折患者的適應證探討

摘要： 目的 探討聚左旋乳酸可吸收肋骨釘治療重癥肋骨骨折患者的適應證，總結其應用經驗。 方法 2005年6月至2008年8月，我科對46例（男31例，女15例；年齡15～61歲，平均年齡38歲）合并多根多段肋骨骨折、連枷胸、大出血和胸內外復合傷患者行開胸手術治療，根據骨折特點分類，用聚左旋乳酸可吸收肋骨釘固定骨折肋骨,同時處理相應的胸內外復合傷。 結果 圍術期死亡1例，術后第3 d死于突發腹腔大出血。44例患者術后胸壁穩定，自主呼吸，排痰良好。隨訪45例，隨訪時間6個月~3年，隨訪期間有39例胸壁穩定，胸部X線片示：固定處無透明帶，對位愈合良好；有4例患者出現可耐受的胸痛；7例患者有13處固定后肋骨移位，分別出現在gt;3 cm劈裂或斜形骨折、老年皮質較薄、多發性肋軟骨骨折和雙側肋骨骨折患者中。 結論 斷面相對較整齊有移位的橫形骨折、3cm以內較短的劈裂或斜形骨折、合并線性胸骨骨折是采用可吸收肋骨釘固定骨折肋骨首選的適應證；對粉碎性骨折和gt;3 cm較長的劈裂斜形骨折，不宜采用；軟骨部、老年骨皮質較薄骨折應慎重選用。

疼痛和動脈血二氧化碳分壓作為肋骨骨折患者手術指征的臨床分析

目的 探討疼痛和動脈血二氧化碳分壓（PaCO2）作為胸外傷肋骨骨折手術指征的可行性，為肋骨內固定手術提供一條合理、可行的手術指征。 方法 選取2006年1月至2009年9月復旦大學附屬華山醫院南匯分院上海南匯中心醫院24例肋骨骨折3 d后主動疼痛評分gt;6分、伴或不伴有PaCO2gt;50 mm Hg患者，采取隨機抽簽法將24例患者分為兩組，手術固定組：12例，男8例，女4例；年齡 43.80±15.00歲；行爪形鋼板內固定手術；保守治療組：12例，男7例，女5例；年齡46.20±10.70歲；采取保守治療。術后1周、2周觀察疼痛評分、PaCO2和肺部感染發生率等。 結果 術后1周手術固定組疼痛評分小于保守治療組（1.25±0.97分vs. 6.17±1.03 分，Plt;0.05），PaCO2（44.00±5.00 mm Hg vs. 49.00±5.00 mm Hg，Plt;0.05）和肺炎發生率(8.33% vs. 50.00%，Plt;0.05)低于保守治療組。所有患者均得到隨訪，隨訪時間2周，術后2周手術固定組疼痛評分小于保守治療組(0.83±0.83分vs. 4.75±1.14分，Plt;0.05)。 結論 疼痛評分結合PaCO2作為肋骨內固定手術的手術指征具有可行性。

創傷性肋骨骨折的處理：廣東胸外科行業共識（2017 年版）

Three-point Bending Test of Two Methods for Rib Internal Fixation

ObjectiveTo use claw-shaped blade plate and self-made 'titanium clip' blade plate for rib fracture fixation, and compare outcomes of these two internal fixation methods through mechanical tests. MethodsThoracic cage specimens of six adults (male)corpses were numbered. Bilateral 4th, 6th and 8th thoracic ribs of each corpse were taken from the rib nodules (0%)to costal cartilage junction (CJJ points, 100%)along the long axis of the ribs. Rib fragments about 130 mm in length with 50% locus were selected for mechanical tests of the lateral area. A total of 36 rib fragments were sampled and numbered. Each rib fragment was placed on electronic universal mechanical tester. A span of 100 mm and a loading speed of 2.5 mm/min were set to perform a three-point bending test until specimens fractured. The loads at displacement of 2, 4, 6, 8, 10, 15 and 20 mm respectively and maximum load were recorded, then the load-displacement curve was drawn. Above rib fragments were randomly divided into 2 groups, which were fixed using 'titanium clip' blade plate (titanium plate group)and claw-shaped blade plate (claw-shape group)respectively. Three-point bending test was performed under above loading conditions until the fixed specimens fractured again, and relevant data were recorded. ResultsBefore fixation, there was no statistical difference in maximum load and peak deformation of the 4th, 6th and 8th ribs between the 2 groups (P > 0.05). Maximum load and peak deformation of the 4th, 6th and 8th ribs in the claw-shape group after fixation were statistically different from those before fixation (P < 0.05). Maximum load and peak deformation of the 4th, 6th and 8th ribs in the titanium plate group after fixation were also statistically different from those before fixation (P < 0.05). After fixation, maximum loads of the 4th, 6th and 8th ribs in the claw-shape group were statistically different from those in the titanium plate group (P < 0.05), but there was no statistical difference in peak deformation between the 2 groups (P > 0.05). ConclusionsFractured ribs fixed with 'titanium clip' blade plates are more stable and stronger than those fixed with claw-shaped blade plates.

連枷胸內固定手術方法的臨床應用比較

摘要： 目的 比較4種對多根、多段肋骨骨折內骨的內固定方法，總結其治療經驗。 方法 2006年7月至2009年7月三峽大學仁和醫院收治75例多根、多段肋骨骨折患者，男51例，女24例；年齡17～74歲,平均年齡43.50歲。致傷原因為:交通傷44例,高處墜落傷21例,撞擊傷10例；采用鋼絲固定5例，鋼板固定12例，Judet固定架固定51例，人工合成樹脂骨內固定7例。 結果 75 例患者均采用內固定手術治療，術后胸廓恢復正常形態，縱隔擺動消失，疼痛和呼吸困難明顯改善；隨訪6個月~2年，復查胸部X線片示：鋼絲固定的患者中有2例發生2處固定移位，其余患者無再次移位，恢復良好。 結論 內固定手術治療是治療多根、多段肋骨骨折患者的有效方法，但各有利弊，應嚴格掌握手術適應證。

Choice of Surgical Pathway and Incision for Multiple Fractured Ribs

目的探討多發性肋骨骨折切口及手術入路選擇 方法回顧性分析赤峰學院附屬醫院2000年6至2013年12月手術治療58例多發性肋骨骨折患者的臨床資料，其中開胸組46例，胸腔鏡組12例，男43例、女15例，年齡36（15～61）歲。 結果開胸手術組平均手術時間152 min，平均住院時間16 d；腔鏡鏡手術組平均手術時間125 min，平均住院時間12.5 d。46例開胸手術患者中44例術后胸壁穩定，自主呼吸排痰良好，16例肺挫傷較重有呼吸綜合征（ARDS）傾向，術后經12～148 h呼吸機支持后恢復，1例死于合并食管下段破裂，術后第3 d突發腹腔大出血，分析為外傷性腹主動脈瘤破裂。3例患者切口部分裂開，均為環抱器骨板，1例胸骨骨折胸大肌皮瓣拉攏縫合治愈，另2例中1例取出裸露骨板，1例換藥及二期縫合治愈。45例患者返院及電話隨訪6個月至3年，開胸組39例胸壁穩定，胸部X線片固定處均有骨伽形成，全組無難以耐受的肋間神經痛，腔鏡手術組切口及固定肋骨處愈合良好。 結論實際操作中可根據骨折形態特點以后外側“～”切口及垂直切口為基礎做多種變形。胸腔鏡下手術切口設計時要根據骨折斷端位置，可能出現的胸內臟器血管損傷，綜合考慮切口布局；最好操作孔及進鏡孔處有骨折斷端，方便內外結合固定，節省手術時間；同時要考慮出血臟器損傷的部位，方便止血修補或中轉開胸；操作孔可以3～5個。