Treatment of Acute, Unstable Chest Wall Injuries

Not Applicable

• Conditions: Flail Chest; Blunt Injury of Thorax; Chest Wall Injury Trauma; Rib Fracture
• Interventions: Procedure: Surgical fixation

• Registration Number: NCT01367951
• Lead Sponsor: Unity Health Toronto

Brief Summary

Unstable chest injuries are common in poly trauma patients. They can lead to severe pulmonary restriction, loss of lung volume, difficulty with ventilation and can render the patient to require intubation and mechanical ventilation. Traditionally these injuries have been treated non-operatively, however in the past decade there has been numerous studies suggesting improved outcomes with surgical fixation. Surgical fixation can significantly decrease time spent in ICU as well as day on mechanical ventilation. The investigators aim is to conduct a randomized control trial of these injuries, to compare non-operative treatment with surgical fixation. The investigators' hypothesis is that surgically treated patient will have significantly improved outcomes compared to those treated non-operatively.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2011-05-27
• Study First Submitted QC: 2011-06-04
• Study First Posted: 2011-06-07
• Study Start: 2011-07
• Primary Completion: 2018-12
• Status Verified: 2021-06
• Last Update Submitted: 2021-06-16
• Last Update Posted: 2021-06-18
• Study Completion: 2021-12

Recruitment & Eligibility

• Status: UNKNOWN
• Sex: All
• Target Recruitment: 207

Inclusion Criteria

• Age >16 or skeletal maturity

• Meeting one of the two indication for surgical fixation of chest wall injury:

  1. Flail chest, defined as follows:

     • 3 unilateral segmental rib fractures; OR
     • 3 bilateral rib fractures; OR
     • 3 unilateral fractures combined with sternum fracture/dissociation Note: at least 3 of the rib fractures involved in the flail segment must demonstrate displacement.

  2. Severe deformity of the chest wall (Diagnosed by CT scan). Defined as follows:

     • Severe (100%) displacement of 3 or more ribs OR
     • Marked loss thoracic volume/caved in chest (>25% volume loss in involved lobe(s)); OR
     • Overriding of 3 or more rib fractures (by minimum 15mm each); OR
     • Two or more rib fractures associated with intra-parenchymal injury - ie ribs in the lung, in the parenchyma

Exclusion Criteria

• Anatomic location of rib fractures are not amenable to surgical fixation (eg fractures directly adjacent to spinal column)
• Rib fractures primarily involving floating ribs (ribs 10-12)
• Home Oxygen (O2) requirement
• Other significant injuries that may require long term intubation:
• Severe pulmonary contusion (Defined as PaO2/FIO2 ratio <200 with radiological evidence of pulmonary infiltrates WITHIN 24 hours of THORACIC TRAUMA)
• Severe head injury/Traumatic brain injury - (GCS ≤ 8 at 48 hrs post injury. If unable to assess full GCS due to intubation or other causes, GCS motor ≤4 at 48 hrs post injury)
• Upper airway injury requiring long term intubation and mechanical ventilation (e.g. tracheal disruption)
• Acute quadriplegia/quadraparesis
• Head and neck burn injuries, or inhalation burn injuries
• Dementia or other inability to complete follow-up questionnaires
• Medically unstable for OR (e.g. haemodynamic instability, acidosis, coagulopathy, etc.)* or unlikely to survive 1 year follow-up, in the opinion of the attending physician
• Lack of informed consent from patient or substitute decision maker
• Randomization > 72 hours from injury
• ORIF > 96 hours from injury (if randomized to surgical fixation group)
• Age > 85

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Surgical fixation	Surgical fixation	* The fractures will be reduced and stabilized by use of plates and screws * Attempt will be made to stabilize ribs 3-7, as these are surgically accessible and most important in maintaining integrity of the chest cavity. * Goal is not to fix all the fractures, but to fix sufficient fractures to create an internal splint and allow chest wall motion to occur as a unit. In case of fibs fractured at numerous locations, as many fragments will be reduced and stabilized as necessary to ensure movement as a unit. * Chest tube(s) will be placed at the discretion of the treating surgeon in patients with pre-operative or intra-operative violation of the pleural cavity (ie pre-op pneumothorax/haemothorax, iatrogenic pleural injury). No post-operative drains will be inserted.

Primary Outcome Measures

Name	Time	Method
Ventilator-free days (VFD)	28 Days	To compare early surgical fixation versus conventional, non-surgical treatment of unstable chest injuries on the basis of our primary outcome measure of days spent free from a mechanical ventilator in the first 28 days following injury.

Secondary Outcome Measures

Name	Time	Method
Number of days in the Intensive Care Unit (ICU)	12 months	The total number of days in ICU will be calculated over the 12 months period post injury. If no ICU stay is needed the total days in ICU will be 0.
Rate of Pneumonia	12 months	The number of times patient is diagnosed with pneumonia over 12 months post injury
Amount of pain medication administration, converted to oral morphine equivalence	4 weeks	The total daily pain medication administration will be calculated, and converted to daily oral (PO) morphine equivalence.
Pulmonary function assessment	12 months	spirometry measurement of total lung capacity (TLC), forced vital capacity (FVC) and forced expiratory volume at 1 second (FEV1), measured at 3 months and at 12 months post injury
Rate of return to work	12 months	to assess if patient has returned to work at 12 months, and at what capacity
assessment of functional health and well being	12 months	Using SF-36 questionnaire we will assess the patient's well-being and functional health

Trial Locations

Locations (1)

St. Michael's Hospital; 🇨🇦 Toronto, Ontario, Canada