Rib Fracture Management in the Older Adult; an Opportunity for Multidisciplinary Working

Subspecialty Section

Rib fracture management in the older adult; an opportunity for multidisciplinary working

Lauren Richardson and Shvaita Ralhan

The elderly will soon make up the largest number of patients sustaining major trauma; a fall from standing height is their most common mechanism of injury1. Rib fractures are a common consequence of blunt chest trauma and are important to recognise and diagnose as complications can be fatal. They can be considered a surrogate for major trauma as up to 90% of patients will Lauren Richardson is an ST7 Registrar go on to have additional injuries identified2. The older in Geriatric and General Medicine working in the Thames Valley. Whilst adult presents a unique challenge. Their injuries are often undertaking a fellowship in Perioperative under-estimated and therefore under-triaged. Delays to Medicine she helped to develop the diagnosis are not uncommon3. Major Trauma Geriatric service at the John Radcliffe Hospital in Oxford.

he mortality and thoracic deal with. Decisions regarding which team morbidity in the elderly as these patients should be admitted under can a result of rib fractures is therefore be contentious. Nationally, there is double that of their younger significant variation, and even in institutions counterparts. In elderly patients, such as ours where pathways do exist, Tfor each additional rib fracture, mortality conflicts often arise as to where the patient increases by 19% and the risk of pneumonia should be managed and by whom. increases by 27%4. It is therefore not surprising that older adults who sustain rib This article aims to address the key issues fractures have increased lengths of stay and that arise when managing older adults with more prolonged intensive care admissions5–7. rib fractures and highlights the importance of tailoring clinical care to their specific needs. Shvaita Ralhan trained in Geriatric and Elderly patients whose injuries are not General Internal Medicine in London, recognised at the front door are usually Imaging and is now a Consultant in Perioperative spread across a number of different bed Medicine at the John Radcliffe Hospital. bases within the hospital. They are often on A plain chest radiograph will only detect She is interested in major trauma in medical wards where staff have comparatively 50% of rib fractures8 whereas computerised older patients and has set up the Major limited experience in managing traumatic tomography (CT) is significantly more Trauma Geriatrics service in Oxford. injuries. Older adults who sustain rib sensitive and is therefore the recommended fractures are often frail and comorbid. Their imaging modality9. Due to underlying She is passionate about teaching, has injuries cause decompensation of their osteoporosis, the elderly can sustain life- completed a Masters in Clinical Education, medical problems and delirium which in turn threatening injuries following what can and runs the Perioperative Medicine leads to complex discharge planning; issues be perceived as minor insults. Therefore, fellowship programme in Oxford. that surgical teams do not feel best placed to as clinicians, we should have a very low

threshold for performing cross sectional Analgesia imaging if chest injuries are suspected; Risk factor Score particularly in this patient group. The Morbidity and mortality presence of flail chest is associated with from rib fractures occurs Age 1 Score 1 for each additional 10-year increase after the age of 10 significant mortality (15-17%)10; paradoxical as a result of respiratory movement of the flail segment during complications. Direct Number of rib fractures 3 Score 3 for each additional rib fracture inspiration restricts the underlying lung trauma, impaired gas tissue, increases the likelihood of lung exchange and pain- Chronic lung disease 5 contusion and leads to ineffective ventilation. induced hypoventilation predispose to atelectasis, Anticoagulant use pre-injury 4 retention of pulmonary Risk stratification Oxygen saturations 2 Score 2 per 5% reduction in oxygen secretions, pneumonia saturations; starting at 94% There are a number of risk stratification scores and respiratory failure. that have been validated for use in rib fractures. Adequate analgesia is Table 1: Battle Score. In our centre we use the Battle Score11 which therefore the cornerstone comprises a number of factors that are known of effective rib fracture to influence outcomes (Table 1). management. Final risk score Probability of developing complications The final score is then converted to a As a general rule, percentage risk of developing complications escalation of analgesia 0-10 13% (Table 2). Complications in this instance is guided by the risk 11-15 29% refers to mortality, morbidity (including stratification score all pulmonary complications), admission although in our 16-20 52% to intensive care and prolonged inpatient experience, individual admission (greater than 7 days). patient requirements 21-25 70% can vary hugely. Lower With a point given to each decade of life, scores are treated with 26-30 80% the elderly automatically score highly. For oral analgesia in the first 31+ 88% example, an 80-year-old with a background instance whereas the of asthma and atrial fibrillation who is taking highest scores should Table 2: Probability of complications. Apixaban will score 16 on the Battle Score be referred for specialist without having even sustained a fracture. pain team input and Additionally, this scoring system does not consideration of regional make any adjustment for patients with lower anaesthesia. Battle score Recommendation baseline saturations; such as those with Chronic Obstructive Pulmonary Disease Locally, patients are Conservative 0 -10 simple oral analgesia, may be safe for (COPD). grouped depending discharge home on their Battle Score Progressive 11-20 consider PCA Other validated scores include the Rib Score (Table 3). (RS), Rib Fracture Score (RFS) and the Chest Aggressive 21-30 PCA and consideration of regional anaesthesia Trauma Score (CTS). In a recent comparison It is vital that patients of these three scores12, the CTS was felt to be are able to cough and Emergent 31 or more urgent assessment for regional anaesthesia most useful in predicting outcomes in patients take a deep inspiration. over the age of 65. A score of six or more If pain is continuing to Table 3: Battle score and recommendations. was associated with an increased mortality, limit effective respiration increased length of stay and increased rates or engagement with of pneumonia. This scoring system puts less physiotherapy then analgesia must be up- Analgesia should therefore always be reviewed emphasis on patient specific characteristics titrated as a priority. Elderly patients with in a patient who is newly confused. but gives points for injury related factors cognitive impairment may not always be able to including the number of ribs fractured, articulate that they are in pain and so attention There are several factors that must be bilateral fractures and the presence of should be paid to non-verbal and observational taken into account when prescribing in the pulmonary contusions13. cues. These include autonomic changes, facial elderly. Non-steroidal anti-inflammatory expressions and drugs (NSAIDs) are often contra-indicated body language in the older adult due to pre-existing medical as well as conditions such as heart failure, renal failure inter-personal or risk of gastro-intestinal bleeding. Codeine “Morbidity and mortality from rib fractures interactions. and oral morphine are renally excreted and Tools such as should be used with extreme caution in renal occurs as a result of respiratory complications. The Abbey impairment due to the risk of accumulation. Direct trauma, impaired gas exchange and Pain Scale14 or Oxycodone is therefore preferred. With Visual Analogue all routes, opioids can cause hypotension, pain-induced hypoventilation predispose to Scales should sedation, falls and delirium. atelectasis, retention of pulmonary secretions, be considered. Alongside many The use of Patient Controlled Analgesia (PCA) pneumonia and respiratory failure. Adequate other causes, requires both cognitive ability and manual pain is also a dexterity. Patients who are confused, have analgesia is therefore the cornerstone of well-recognised concurrent upper limbs injuries or those with effective rib fracture management.” trigger for severe arthritis are likely to have difficulties delirium. and this must be taken into consideration. >>

Regional anaesthesia reduces the systemic Other considerations Rib fracture patients admitted under opioid burden which is particularly important the care of Trauma and Orthopaedics in the elderly who are more susceptible Chest physiotherapy is essential for all patients (in contrast to General Medicine or to side effects15. Conventional techniques with rib fractures18. Evidence also supports the Cardiothoracics) tend to be polytrauma to manage rib fractures include epidural use of humidified oxygen and saline nebulisers patients who have additional injuries. analgesia, paravertebral and interpleural to help with secretion clearance19. In patients This adds an extra layer of complexity to blocks. However, these their management. are relatively contra- In particular, indicated in those who are patients with spinal anti-coagulated16; which “Rib fracture patients admitted under the care of injuries who require accounts for a moderately immobilisation or large proportion of older Trauma and Orthopaedics (in contrast to General spinal precautions adults. Epidurals in are at higher risk of particular also come with Medicine or Cardiothoracics) tend to be polytrauma deterioration from a other added side effects patients who have additional injuries. This adds an chest point of view as including hypotension, their ability to comply urinary retention and the extra layer of complexity to their management.” with physiotherapy potential for motor block and clear secretions which can limit mobility17. is limited. It is Serratus anterior and erector spinae blocks with lung contusions, clinicians should have a important that this increased risk is are comparatively newer techniques which low threshold for starting antibiotics if infection recognised from the outset as these have fewer side effects and very few contra- is suspected; though to our knowledge, there patients usually require rapid escalation of indications; making them an ideal option for the is currently no evidence to support their use analgesia; often irrespective of their risk elderly population. prophylactically. stratification score.

Risk stratification tools such as the Battle score are useful to help communicate the severity of an injury to both patients and families. In turn, they can also be used to introduce discussions around escalation of treatment. Many patients who sustain rib fractures are elderly and frail with multiple comorbidities and ensuring that appropriate ceilings of care are put in place in a timely manner is essential.

Surgical fixation

Surgical fixation aims to stabilise the chest wall to facilitate effective respiration but is a somewhat controversial area and consensus on management is required; particularly in the elderly population. Several studies have proposed that fixation in patients with severe flail chest can lead to a reduction in the incidence of pneumonia, reduced length of intensive care admission, improved Figure 1: 3D rib fracture reconstruction. Image courtesy of Dr Ed Sellon MRCS MSc(SEM) FRCR RAMC, Consultant Radiologist, Oxford University Hospitals NHS Foundation Trust. lung function and earlier return to work20–22.

However, the majority of trials have only included patients that are eligible for mechanical intubation and ventilation and therefore omit the frail elderly. A study published earlier this year looking at non-flail injuries has suggested that surgical fixation can improve the primary outcome of pain control at two week follow- up23. However, patients aged over 80 were actively excluded. There remains a paucity of robust evidence when it comes to surgical management in the older adult.

Our experience

Whilst orthogeriatrics is a well-established model in hip fracture care, most geriatricians do not have experience in managing patients with rib fractures. Perioperative medicine is a rapidly emerging speciality and, in this context, we have recently become one of a few centres in the UK to launch a Major Trauma Geriatrics service. This has provided us with an insight into the challenges we face in caring for these patients.

It is clear that management of elderly patients with rib fractures requires a multidisciplinary approach from physicians, trauma and orthopaedic surgeons, thoracic surgeons and specialist pain teams including anaesthetists who are skilled at performing regional blocks. This however raises questions about where these patients should be managed and by whom. Physicians are not traditionally trained to manage rib fractures and nursing staff on medical wards often not Locally, we have developed a rib fracture Choice of analgesia is limited in the context familiar with patient-controlled analgesia working group and pathway; aiming to raise of cognitive impairment, comorbidities and or epidural catheters. Conversely, surgeons awareness of chest wall trauma in older adults concurrent use of anticoagulation. As a are arguably not best placed to care for the and promote prompt recognition of injury result, these patients are at particularly high complex elderly who do not require operative through early CT. Appropriate analgesia risk of deterioration and it is therefore vital intervention. Inter-disciplinary learning and is guided by the Battle Score and patient that care is escalated early. Multi-disciplinary shared decision making is therefore key. pathways through the hospital are facilitated rib fracture working groups, clear clinical by early senior clinical review. Through clear pathways, expansion of orthogeriatric/ In our experience, there are relatively few lines of communication and collaborative perioperative medicine services and further anaesthetists who are skilled in the newer learning we are aiming to improve the quality research to help guide best practice are all regional anaesthetic techniques which may be of care for these patients. required if we are to improve outcomes for more suited to the elderly population. This this patient group. n means that their availability can be limited; The Future especially out of hours when increasing References constraints on emergency operating theatre Many elderly patients admitted with rib capacity means that these patients are often not fractures have their diagnosis delayed as References can be found online at seen as a priority. their injuries are not immediately recognised. www.boa.ac.uk/publications/JTO.