Clinical Research Of Rib Fracture And Clinical Anatomically Measurements Of Ribs

[Background]The incidence of chest trauma is observably increasing in recent years. A large amount of statistical data show that the incidence of chest trauma accounts for 10%-15% of all kinds of trauma. Death cases which were directly caused by chest trauma accounted for 25% of traumatic death cases. Chest trauma also indirectly lead to other 25% of trauma patients’death. Blunt chest trauma, mostly of rib fractures, are common in hospitalized patients. Many patients of rib fractures may get no symptoms at all, or only mild ones so it should be noted that the statistical incidence of rib fracture is below the actual one because of misdiagnose and missed diagnosis.Simple rib fracture has some bad impacts on patients, including hypopnea caused by chest-wall pain, pulmonary complications after the decreasing of clearance ability of airway, and pulmonary contusion, pneumothorax, hemothorax combined with rib fractures, etc. Mild rib fractures show mild symptoms and have good outcome, so conservative treatment, including sedation, anti-infection, ventilation assistance, and external fixation is enough if there was no severe complication. Howerver, complicated and severe rib fractures often accompany progressive aggravated symptoms and bad prognosis, especially in flail chest which caused by multiple rib fractures. Leading to serious respiratory and circulatory dysfunction, flail chest has a high clinical death rate because of hypoxemia and respiratory distress syndrome caused by chest wall malacia and paradoxical respiration after loss of braced structures. Therefore, clinical doctors should pay more attention to positive treatment towards rib fractures, especially complicated and severe fractures.Treating methods of rib fractures are increasing nowadays with the development of many related clinical research and divided into two parts, namely conservative treatment and surgery treatment. For single rib fracture, treatment are mainly about activity limitation, anti-infection, analgesia, fluid supplement and prevention of complications, sometimes supported by ventilation. As a regular treatment method, adequate analgesia is of great importance in both surgical patients and non-surgical patients for decreasing the incidence of complications and improving the prognosis.Chest external fixation is mostly used in severe rib fractures, such as multiple fractures and flail chest, effectively correcting paradoxical respiration and improving respiratory function. Chest external fixation is easy-operating and effective, meanwhile, it limits the respiratory movement of the injured side of chest and extend the duration for bed rest so that the likelihood of pulmonary infection and atelectasis will rise with it. In the meantime, chest external fixation may cause the intercostal nerves and vessels harm without dealing the fractured bones and lead to the deformity of chest wall. Based on reason given above, chest external fixation is no longer being a method of long-term fixation.Carter was the pioneer of ventilator treatment for firstly performing tracheotomy and intermittent positive pressure ventilation in 1951. Since then, mechanical ventilation has been being a standard treatment in most of major hospitals. The regular indications of mechanical ventilation include more than eight fractures, multiple organ injuries and failure in oxygenation after humidified inhalation of oxygen. Though mechanical ventilation has remarkable effect on multiple rib fractures, but its disadvantages are still existed. The short-term complications of mechanical ventilation are pneumothorax, hypotension, arrhythmia, and son on. Long-term application of ventilator increases the probability of pulmonary infection and the difficulty in weaning process of ventilator so it is very hard to master the indications.Obviously, conservative treatment have marked drawbacks in curing rib fractures, especially severe and complicated fractures. So surgeons have looked forward to surgical treatment long before. Large amount of clinical data indicate that operational internal fixation can relieve the respiratory and circulatory dysfunction brought by rib fractures caused by chest trauma. Compared to conservative ventilator treatment, operational internal fixation can not only shorten the LOS(length of stay) in ICU(intensive care unit) and duration of ventilator treatment, but also reduce the incidence and mortality of complications, for instance, pulmonary infection and septicemia. Even more important, operational treatment has better economic benefits for its shorter time of ventilator treatment and hospital stay, lower dose and less hospitalization expenses. Hence, more and more scholars have accepted the concept of early operational fixation towards severe and complicated rib fractures in right patients. Generally approved indications of operational internal fixation for rib fractures is stated as follows:chest deformity with paradoxical respiratory, without severe lung contusion; obvious displacement of fracture segments or segmental, comminuted fracture which are about to injure nerves and vessels, respiratory dysfunction after conservative treatment; simple fracture with intractable chest pain, dyspnea and hemopneumothorax; with exploratory thoracotomy of other operations; poor effect of mechanical ventilation or difficulty in weaning process of ventilator; high demand of aesthetics and permission of economic condition. To improve treatment effect, surgery fixation should be took into first consideration when faced to complicated and severe rib fractures.Although surgical treatment has incomparable advantages above, large-scale clinical promotion is still far away. The major reasons lie in low level of clinical evidence, inadequate understanding among clinical doctors, grasping of surgical indications, and economic restrictions. In addition, designing deficiencies of surgical fixation devices and the high rate of related postoperative complications are important factors which should not be neglected. Kinds of current-used rib fixation devices are commonly flawed, for not fitting ribs’ anatomy and difficulty in operation, leading to postoperative pain and discomfort. Some patients even require a second operation to remove fixation devices. Therefore, a complete and systematic measurement of several critical anatomical data of ribs and design of new-type, anatomical, good-histocompatibility, safe, efficient, non-toxic and easy-to-operate ribs fixation devices are of great importance and being an urgent problem in clinical work. This research is based on issues above and is about to solve it.[Objective]To conduct epidemiological survey about rib fractures in China; To verify the advantages of surgery in curing severe rib fractures; To get the ribs’ average anatomical parameters of Chinese people, including width, thickness of upper or lower edge, anterior and posterior twist angle, arc length, radian, and intercostal length, by imaging and anatomical measuring, in order to design new-type, easy-to-operate anatomical rib fixation devices with high-strength, good-elasticity, better-biocompatibility, safety and efficiency, attempting to provide new means and standards of treatment in chest trauma and improve the level of overall treatment.[Method]1.Epidemiological survey about rib fractures was conducted to obtain data of rib fractures, including predilection sites, number of fracture, and so on. Clinical analysis was also performed between effects of different treatments in order to verify the advantages of surgery in curing severe rib fractures.2.CT data (DICOM format) of 150 patients (male 86, female 64) performed with Chest CT scan were randomly extracted from Guangzhou Military Command of PLA for the period of September 2013 to March 2014 and divided into two parts, namely elderly people (over 60-year age) and young-middle-aged people (under 60).3.The raw CT data were lead in Mimics 10.01 and used in three-dimensional reconstruction of thorax. Ribs were divided into three parts as anterior, lateral and posterior areas according to two body surface projection lines, namely anterior axillary line and near outside of paravertebral line, which correspond respectively with angulus costae and vanishing point of costal groove. After three-dimensional reconstruction, anatomical parameters of bilateral rib 3-7, including width, thickness of upper or lower edge, anterior and posterior twist angle, arc length, radian, and intercostal length were measured.4.10 adult thorax of corpses (male 6, female 4), provided by Department of anatomy in Southern Medical University, were used for body measurement of the same anatomical parameters above. All cases have complete thoracic structure, without chest trauma and deformity.5.Using statistical software, analysis for above-mentioned measured data between different methods, ages and sex were performed.[Results]l.In Chinese people, rib fractures mostly strike rib 3-7. Fractures are more common in lateral areas than other two areas. Compared to conservative treatment, surgical treatment have prominent advantages on curative effect and economic benefits.2.Imaging measurement:From rib 3 to rib 7, the width of rib increases markedly, while the anterior and posterior twist angle are decreasing, which are in line with the ribs’ anatomical characteristics of becoming flat from top to bottom; In every single rib, there are difference between thickness of upper and lower edge; The arc length, radian and intercostal length also showed a trend of increase from rib 3 to rib 7, widening the inner diameter of thorax gradually.3.Anatomical measurement:As to target parameters, there was no significant statistically difference between CT measure and anatomical measure (p>0.05).4.Except for very few paramter, various anatomical parameters of rib3-7 show significant statistically difference between sex groups of Chinese adults (P<0.05), while most of anatomical parameters show no significant statistically difference between age groups (P>0.05).[Conclusion]On the basis of epidemiological survey of rib fractures in China, this research, closely related to clinical work, conducted anatomical and imaging measurement about rib 3-7 of Chinese adults and provide anatomical bias for designing and manufacturing new-type anatomical fixation devices of different types, sizes and shapes. All measured parameters show no significant statistically difference between imaging measure and anatomical measure, which indicated the preoperative CT three-dimensional reconstruction’s positive value in accurately locating fractures. In the meantime, new-type anatomical fixation devices will be used in operational internal fixation, so as to shorten the operation time, reduce the incidence rate of complications and improve patients’ prognosis, which are of great clinical significance.