Complications from Pulmonary Contusions after Rib Plating: A Case Series and Lessons Learned

Abstract

Background: Surgical stabilization of rib fractures (SSRF) is increasing in popularity with low reported complication rates. Pulmonary contusion (PC) has been cited as a relative contraindication to SSRF in cases of patients with respiratory failure due to chest wall injury. However, the reported experience and clinical data regarding PC on this topic remain limited. The objective of this study was to describe the experience treating patients with moderate-to-severe PCs utilizing SSRF and identify risk factors for pulmonary complications postoperative acute respiratory distress syndrome (ARDS). Methods: The trauma registry of a Level 1 trauma center was reviewed from 2015 to 2019, and patients who underwent SSRF were assessed. Computed tomography was examined, and PC score was calculated in patients with a documented PC by a researcher and verified by a board-certified radiologist using the PC score as described by Chen et al. Demographic, clinical, and outcome data were analyzed and reported. Results: Ninety-two patients were included in the initial analysis as having undergone SSRF in the study period. The patients were 72.8% male and averaged 5.5 ± 4.4 days from admission to SSRF. Nine patients with severe chest trauma and PCs underwent SSRF. Of these patients, four had severe bilateral PCs and five had severe unilateral PC, totaling >20% of total lung capacity. Three patients had ipsilateral moderate-to-severe PCs with traumatic pneumatoceles. They underwent SSRF within 48 h of admission per standard practice. They were all placed in the lateral decubitus position with the affected side up. Their intraoperative courses were complicated by bloody secretions present in the endotracheal tubes. Only one patient had lung isolation using dual-lumen endotracheal intubation and had an uneventful perioperative course. Postoperatively, the other two patients developed severe ARDS that required mechanical ventilation for several days, significantly complicating their recovery. Discussion: This case series highlights the relative risk of SSRF in patients with significant PC. Early SSRF in patients with PC ≥3 was associated with ARDS when patients did not undergo intraoperative lung isolation. In two patients with severe PC, the contusions themselves did not produce respiratory failure on admission; however, intraoperative positioning resulted in the aspiration of bloody secretions from the contused lung into the unaffected lung, causing severe postoperative ARDS. Suggested measures to prevent future events may include isolating the contused lung intraoperatively or delaying SSRF until contusion has resolved, if feasible.