Page 87 - JSOM Spring 2024

Management of Rib Fractures in
the Combat Environment

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Shane Smith, MD, MSc *; Richard Hilsden, MD, MBA ; Petrease Patton, MD, MSc ;
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Kelly Vogt, MD, MSc ; Andrew Beckett, MD, MSc ; Ian M. Ball, MD, MSc 6

ABSTRACT
Rib fractures in combat casualties are an under-appreciated in- respiratory failure. Overall mortality from rib fractures in
jury, and their treatment may become more common as more civilian populations can be as high as 20%. 11–13 This whole
patients survive because of modern body armor and point-of- sequence is driven by the inadequate treatment of pain; there-
injury care. The combat environment has challenges such as fore, adequate analgesia is essential for early mobilization and
equipment availability and sterility. A simple and thoughtful cough, reducing the morbidity and mortality associated with
rib fracture treatment algorithm may be useful to reduce the these injuries. It was our experience in the deployed environ-
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morbidity and mortality of rib fractures in the combat envi- ment that rib fracture care is easily overlooked. We believe that
ronment. Intravenous lidocaine infusions for patients with injured soldiers would benefit from a thoughtful approach to
traumatic rib fractures may have important combat applica- their rib fractures.
tions. We propose an algorithm for the management of combat
casualties with traumatic rib fractures.
Discussion
Keywords: military medicine; rib fractures; lidocaine; combat Current analgesia strategies have inherent limitations, contrib-
medicine; pain management uting to inadequate treatment of rib fracture pain. Epidurals
can be effective in a civilian hospital but are pragmatically
difficult in the combat setting. Moreover, the prolonged main-
tenance of sterility in forward surgical units is difficult, and
Introduction
the sequelae of spinal infections are devastating. Epidurals
Rib fractures in the combat environment can be under- can cause hypotension because of sympathetic suppression
appreciated injuries because of the presence of other severe and and peripheral vasodilation that can mimic ongoing hemor-
dramatic wounds of the combat casualty. The wars in Afghan- rhage. Even in the civilian population, epidurals are not ap-
istan and Iraq yielded some of the most devastating survivable propriate or possible in up to 80% of trauma patients; 15–18 the
injury patterns in the history of warfare. Improvised explosive contraindication rate could be even higher in severely injured
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devices caused horrific extremity injuries, but advances in tacti- soldiers.
cal combat casualty care with point-of-injury tourniquets saved
many lives. Junctional injuries to the axilla and groin were Pain management commonly relies on opioid analgesics,
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managed by rapid evacuation, junctional hemorrhage con- which can be used safely with care. However, opioids cause re-
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trol, and new techniques in aortic occlusion. Body armor spiratory depression, the very event we are working to prevent
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increased in prevalence and became more sophisticated, re- in rib fracture patients. There is a need for combat- oriented
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sulting in more casualties surviving with multiple injuries that research into non-opioid analgesic protocols. Adjuncts such
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required ongoing care. Soldiers were saved by their body armor as nonsteroidal anti-inflammatory drugs (NSAIDs) and acet-
and emergent care; these survivors lived to suffer from ongo- aminophen 9,21 are relatively safe in the young, healthy mili-
ing injuries, including multiple rib fractures. Concussive and tary population and should be used as first-line therapy. They
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kinetic energies that once would have killed the patient now may decrease the need for an opioid, but their analgesic ef-
result in a live patient with broken ribs. In the Joint Theatre ficacy is often inadequate in isolation. Intrapleural catheter
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Trauma Registry, 2.6% of patients had rib fractures recorded, administration of local anesthetic has demonstrated similar
and this accounted for 25% of thoracic injuries. 10 efficacy to epidurals but can be complicated by catheter mi-
gration or pneumothorax. There are also significant challenges
Pain caused by traumatic rib fractures impedes the patient’s to the maintenance of sterility in a combat environment. The
ability to cough and clear secretions. This can result in retained efficacy of nerve blocks, intrapleural anesthesia, and thoracic
secretions that promote bacterial colonization and the devel- paravertebral blocks is debated. It was recently shown that
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opment of pneumonia. The patient can develop atelectasis, liposomal bupivacaine injection is not effective in reducing
leading to hypoxemia, increased shunt fraction, and eventually pain scores, opioid requirement, or length of stay in patients
*Correspondence to Shane.Smith@lhsc.on.ca
1 Maj Shane Smith and LCol Richard Hilsden are affiliated with Royal Canadian Medical Service, Department of Surgery, and Office of Aca-
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demic Military Medicine, Western University, London, ON, Canada. Dr. Petrease Patton is affiliated with the Department of Medicine, West-
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ern University, London, ON, Canada. Dr. Kelly Vogt is affiliated with the Department of Surgery, Western University, London, ON, Canada.
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5 LCol Andrew Beckett is affiliated with the Royal Canadian Medical Service and Department of Surgery, University of Toronto, Toronto, ON,
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Canada. Maj Ian M. Ball is affiliated with the Royal Canadian Medical Service and the the departments of Medicine, Epidemiology and Biosta-
tistics, and Academic Military Medicine at Western University, London, ON, Canada.
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