{"id":7565,"date":"2017-01-24T19:06:33","date_gmt":"2017-01-25T02:06:33","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=7565"},"modified":"2023-03-03T09:56:47","modified_gmt":"2023-03-03T16:56:47","slug":"team-steps-plate-treat-injured-ribs","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/team-steps-plate-treat-injured-ribs\/","title":{"rendered":"Team steps up to plate to treat injured ribs"},"content":{"rendered":"
<\/div>
\"This
This X-ray image shows the severe loss of volume in Ken Custy\u2019s right lung (left side of the image) caused by multiple broken ribs and blood in the pleural cavity.<\/figcaption><\/figure>\n

Nobody wants to break an arm or leg. But there is a tried-and-true method for allowing an injured limb to heal: immobilize it with a cast and maybe watch signatures from well-wishers collect on it.<\/p>\n

It\u2019s not so easy when ribs fracture. The bony structures are attached to the chest wall and involved in every breath. \u201cWe use casts so injured body parts don\u2019t move during healing,\u201d said Erik Peltz, DO, assistant director of Trauma and Acute Care Surgery (TACS) at University of Colorado Hospital. \u201cHow can you not breathe?\u201d<\/p>\n

There is therefore plenty of discomfort when a person breaks a single rib or maybe two. A cough or sneeze can be agonizing. But the ribs generally will heal in several weeks, and painkillers and restricted activity will help the patient get through the ordeal.<\/p>\n

That relatively easy route wasn\u2019t open to Ken Custy, however. In mid-June, the 62-year-old saddled up a horse he boards northeast of Denver. The saddle cinch wasn\u2019t quite secure, and it slipped. The horse panicked, bucked several times, and threw Custy off. He fell heavily on his right side, the wind knocked out of him.<\/p>\n

\"An
A CT of Custy\u2019s chest shows how his injury separated several ribs on the right side, pulling them away from the chest wall. The displacements appear as a separate line of white circles adjacent to his right lung (left side of the image).<\/figcaption><\/figure>\n

Custy knew he was hurt, but he got back on the horse with the help of a couple of guys who ran over and rode around the pen for 15 minutes or so.<\/p>\n

\u201cIt\u2019s a cowboy thing,\u201d Custy explained.<\/p>\n

When he decided to quit, a woman who works at the stable helped Custy get his horse unsaddled and followed him home, where his wife Carol met him and drove him to the Emergency Department at UCH.<\/p>\n

\u201cI was feeling pretty poorly about that time,\u201d Custy recalled.<\/p>\n

Rocked ribs<\/strong><\/p>\n

That was understandable. Custy had broken 8 of the 12 ribs on his right side in the fall. Five broke in two places, leaving them floating free of the chest wall. He\u2019d also bruised and lacerated his right lung. That caused a \u201csignificant\u201d air leak, and blood entered the cavity surrounding and lining the lung, said Peltz, who took on Custy\u2019s case when he arrived at the ED.<\/p>\n

Custy went to the hospital\u2019s Surgical\/Trauma Intensive Care Unit, where staff helped to manage his breathing and pain, which was considerable. For a week, Peltz and his team consulted with Custy and his family. They decided to wait in hopes of the ribs beginning to heal together, but his punctured lung slowly collapsed, cutting its capacity by 30 percent. He was at risk for pneumonia and \u201cpermanent, severe pulmonary disability,\u201d Peltz said.<\/p>\n

On the last day of June, Peltz and cardiothoracic surgeon Robert Meguid, MD, MPH<\/a>, decided Custy couldn\u2019t afford to let nature take its healing course. They turned to hardware to repair the fractures: horseshoe-shaped titanium devices fitted over the front and back of each rib and secured with screws. These \u201crib plates\u201d also helped to stabilize Custy\u2019s chest wall, Meguid said. He and Peltz also drained blood out of the pleural cavity, allowing the right lung to expand. In addition, they found that a shard of one of the fractured ribs had sliced his diaphragm, exposing a portion of his liver. They repaired that laceration during the procedure.<\/p>\n

\"An
Square shapes on the left are the rib plates Peltz and Meguid used to stabilize Custy\u2019s fractures.<\/figcaption><\/figure>\n

Less than two weeks after the surgery, Custy left UCH, weak and 20 pounds lighter, but free of chest tubes and supplemental oxygen. In early October he was still doing some physical therapy and managing what he described as \u201cdullish\u201d nerve pain and stiffness, but he said he now has the \u201cprospect of normalcy.\u201d He has gone back to horse riding and hopes to hit the ski slopes again this season with Carol.<\/p>\n

\u201cI feel like I\u2019m recovering steadily,\u201d Custy said.<\/p>\n

Teaming up to tame trauma<\/strong><\/p>\n

Rib-plating technology isn\u2019t brand-new, nor was Custy\u2019s case the first collaboration between Peltz and Meguid. They did their first plating procedure together three years ago. But they\u2019ve handled a half dozen in the past six months, in large part because of a protocol they\u2019ve developed to identify the most serious rib fracture cases, like Custy\u2019s, as early as possible, and surgically stabilize them with the plates. Ideally, that happens within 72 hours, Peltz said, although Custy\u2019s case was a bit different because his lung injury worsened over a period of days.<\/p>\n

The rib-fracture protocol, in turn, reflects the growth and sophistication of TACS, which launched in 2013 to beef up and streamline surgical and critical care to severely injured patients at UCH. Between fiscal year 2014 (which began July 1, 2013) and fiscal year 2016, the number of trauma cases at UCH increased by nearly a quarter. The number of the most serious cases, as measured by the Injury Severity Score, grew by more than a third during that period (see graph)<\/em>.<\/p>\n

The increasingly serious traumas, many involving the chest wall, call for multidisciplinary care that extends well beyond the operating room, Meguid said. The process includes not only making joint decisions on the most appropriate procedure, but also managing the patient\u2019s entire course of recovery, through post-op, critical care, discharge, follow-up clinic visits, and therapy.<\/p>\n

\"Dr.
Erik Peltz, DO (left), and Robert Meguid, MD, repaired Custy\u2019s ribs with the plates. Peltz holds a tool used to bend the plates into shape during the procedure.<\/figcaption><\/figure>\n

Peltz explained that full recovery relies on support and active management from a multidisciplinary team, including surgery, surgical critical care and physical and occupational therapy \u2013 all essential components of the trauma system developed at UCH. The system gives patients the best chance to rehabilitate and achieve the full benefits of the surgical management, he noted.<\/p>\n

Surgical synergy<\/strong><\/p>\n

Peltz and Meguid said their clinical partnership has made them better, which in turn pays off for patients. \u201cWe could do the rib-plating procedure independently, but together we\u2019re more efficient and can optimize the care we deliver our patients,\u201d Peltz said.<\/p>\n

\u201cWe learn from each other,\u201d Meguid said.<\/p>\n

But they readily admitted that working together requires commitment and planning. For a procedure like Custy\u2019s for example, separate nursing and anesthesiology teams from Trauma and Cardiothoracic Surgery are both present in the OR.<\/p>\n

That demands strong working relationships and systems to respond quickly to situations like Custy\u2019s nasty equine spill. As Peltz put it, \u201cYou have to be flexible and ready to act. Nobody anticipates traumas happening three months ahead.\u201d<\/p>\n

\u201cThere was a roomful of providers,\u201d Custy recalled. \u201cThe dream team was all there.\u201d<\/p>\n

The TACS team works to promptly respond to and quickly stabilize trauma patients, but they base subsequent clinical decisions on close observation of what happens in the time that follows. Custy said he gained an appreciation of the team\u2019s patience in making decisions about his care.<\/p>\n

\u201cIt was a long hospital stay, but I understand why,\u201d he said. \u201cIt was wise to get all the right physicians together and wait on the surgery. It might not have been as successful otherwise.\u201d He added that all his nurses and other providers were \u201cefficient, but they didn\u2019t hurry through anything.\u201d<\/p>\n

The long-range view should, in turn improve both the duration and quality of Custy\u2019s life, Peltz concluded.<\/p>\n

\u201cHe should be able to resume all normal activity, with no shortness of breath,\u201d he said. \u201cWithout the rib plates, he might have spent months to years trying to recover and not gotten back to baseline. Working together, and combining the expertise of trauma surgery, thoracic surgery and surgical critical care gives us the best opportunity to return patients, like Ken, to the life and activities they enjoyed before their injuries.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

Nobody wants to break an arm or leg. But there is a tried-and-true method for allowing an injured limb to heal: immobilize it with a cast and maybe watch signatures from well-wishers collect on it. It\u2019s not so easy when ribs fracture. 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