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Hello, everyone. I do apologize for the delay. Um We're just having a few issues with cameras, so unfortunately, we can't see our speaker. We've got a lovely photo though that you can see. Um So like I said, apologies for the delay. If you can pop all your questions in the chat, that would be great. And at the end of the event, we'll have your feedback form will be sent to you in your and it'll be in your inbox once completed, you'll have your attendance certificate on your medal account without any further ado I'm gonna hand you straight over. Ok, thank you very much. Hi. Um Thank you, everyone. Um My name is Francisco and I'm a consultant thoracic surgeon in Oxford University Hospitals. And I'm delighted to have uh been allocated this talk on Blanchet Trauma, which is a um interest of mine and it dates back about at least 15 years. Um So in the first part of the presentation, I'll go over the best evidence, uh I could find and ongoing trials. And then in the second part will be much more as we say, surgery hands on and I'll show you different type of surgeries to uh repair rib fractures. So the first bit will be a little bit more meat in terms of uh you know, uh writing and words on your screen. The second part will be much more images, surgery and uh a bit more I think uh engaging as well. So, refracture is still associated with significant morbidity and mortality due to pulmonary complication. Comparing uh multiple refracture flail chest is associated with worse outcomes and higher incidence of respiratory compromise and other injuries. Um So the reason being that when there is enough energy in the trauma to break the ribs in multiple points is often also associated with other fractures such as uh clavicle femur spine and so on. So the management of blanches stroma has been for a long time. Only medical and ed was about controlling the pain, giving respiratory support and physiotherapy. And they were considered the gold standards in the management of blanch stroma and refractures over the past decades. Um probably the last two decades, there's been a growing interest in repairing the rib fractures, especially for flail chest. However, there is no consensus regarding the indication and base selection for rep fixation. So what is that the common ground they have we have nowadays. So the number of refractions seems something that um many centers consider very important when deciding whether to manage conservatively or surgically blan chest Roma three or more refractures or at least one dislocated over one shaft width, meaning a uh comminuted and this um and dislocated fracture, the pain has to be high. There are so many scales but it needs to be pain that requires opiates or other source of hormones of treatment. They are not just simple tablets including uh local anesthetic infusions. The treatments can be with open induction or internal fixation, internal fixation. Uh A bit of a fancy name for defining conservative management while also AK a letting the ribs fractures heal on their own, the pre and postoperative care equals in treatment in the control group. This is about research. So whether you allocate the patient to refresh your fixation or or or uh supportive management alone is important that uh the uh each group of the study will receive every other uh intervention that is the same and then, you know, then no, the supportive management includes pain management, bronchodilator, oxygen, mechanical ventilation, pulmonary physical therapy, and many other things. So in trauma surgery, there is increasing scientific evidence that includes a observational study could add value to meta analysis without decreasing the quality of the results. This is particularly uh relevance in um blanches trauma because of the lack of large randomized controlled trials. So at the observational study in larger sample size might enable evaluation of small treatment effects subgroups and infrequent outcomes measures while also providing information about uh the results, the overall results. So let's start with one. So there is a, a meta analysis that looks at the uh combined effect of, of um uh 33 studies uh that collectively have 5874 patients with flow chest or multiple refractures. 1255 received reluxation and 4600 did not receive uh operative treatment. So if we look at how they build the study, just to give you an idea how they are done this um this uh metanalysis and where they also observation or small um number study are included, you see how rigorous is the process and how ultimately you only had 33 studies. The primary outcome measure that they looked at was mortality during hospitalization. The secondary out out measure were hospital l stay ICU L stay mechanical ventilation duration, incidence of pulmonary complication, tracheostomy, complication, revision, surgery and removal of the um the implants. Uh So you can comment on this and it's something that we will go over this presentation. Taking mortality as a primary outcome measure is quite an outdated point of view on blanches a part uh management because the point of view of more modern uh studies is much more focused on quality of life. Long term a uh the primary, the pr mortality and blanch stroma, they are, is not a reliable or effective manner to measure the our uh um care and our management of the patient because only seldom rib fixation or no rib fixation are directly linked with mortality. So in any case, going back to this review, 25 studies reported on mortality, a brief fixation resulted in a significant reduction on mortality compared to non operative treatment. So, if you can see here your plot uh measure and all the studies have been analyzed, you can see how he's leaning towards the left. And if you see one of the names uh on the right side, the skin is Marasco and she's an incredible researcher on Blanches Roma. If you want to uh do a review, I would really suggest to start with her studies and her name. Um So then they looked at the hospital lentus stay and there were um a uh refixation did not result in a significantly national of hospital lentus stay very interesting. Again, uh fixing the ribs or not fixing the rib fractures normally does not make your patients stay less in hospital. But if you look at the ICU L to say there is reduction of the time the patient stays on a ventilator stays on ICU. If you fix a refractures, the same is for duration of mechanical ventilation, fixing refractions reduces the duration of mechanical ventilation, at least in this uh meta analysis as you can see how spread out was the final plot. But nonetheless, uh there was a um tender trend, clear trend and some also significant results in in favor of rfra fixation and so surgical a approach. So when we look at a combination of observation of plus randomized control trials because I said there are not many but there are some randomized control trials that compare the conservative and the surgical management of blunt chest trauma. So we can say that refixation significantly improves short term outcomes for patients with flailed chest. Although the indication the patient shock subgroup who would benefit the most is remains unclear. So the question that they're asking in these metanalysis of observational a random muscular trial is who we should operate and who we shouldn't. So in in this um metanalysis of seventh random control trial, there only were 538 patients, you know, divided by seven studies, what they found and the surgical treatment has short, shorter length of hospital stay, uh shorter length of icu stay and shorter duration of mechanical ventilation. But as you can see, this randomized control trial were underpowered and here you have, you know, the numbers, if you go quickly through, you can see some studies like there's a 41 male and nine female, 40 male and six female. So these are really small studies. Uh as as you know, if you have an underpowered randomized control trial, you have to be very careful with drawing conclusions for that. So there is also something that is very important in these studies. There is an inherent bias by trauma and thoracic surgeons in deciding who to approach and who not to approach for. Uh for including a study on management of blanch trauma. And there is a trend in the studies, you can gather from analyzing trials of favoring younger patients and fitter patients because there is a feeling that if you do including a study of refixation, an elderly individual, you might have a bias in the study results and statistical analysis because of the comorbidities of that patient. But there is also the other side of the coin here because if we don't include the elderly, which are the ones that probably are, are benefiting the most from refraction fixation. We are missing out on analyzing the patients that should actually be included in our study. So that is an American study um that is called non flail. Uh And um so they, they looked at non flail chest and um there was a lot of uh wealth of information that came out of a retrospective study by Cube and also from the North Flare random trial that was done in North America in 12 centers. Um They compare it surgical fixation within 72 hours versus medical management. And the inclusion criteria for them was three or more rib fractures, regardless of having a flail chest or not. The primary outcome was pain and, and follow up and spirometry and pleural complication. You can see here how they didn't take mortality as one the primary outcome, which is a much more modern and updated uh view on blunt chest trauma. So what they saw you see again, small numbers, 100 and 10 patients out of 12 centers, but they saw a benefit from fixing the refractures even in the not in the presence of flail chest. So there is a study that is uh run uh in uh the Netherlands and fix this study had great promise. Um uh although it's been delayed significantly by COVID and then the recruitment numbers have gone down a lot and we're still waiting for the final results to be uh uh published. And this sample size was 100 and 80. And then we come to the one that I am most proud of. This is uh the or I study the or if study is run in the United Kingdom, it started with six centers. I am the principal investigator and um he's going to recruit 524 patients when he's completed. Um We are um you know, going to complete the study. This slide that I'm presenting to you is slightly old. We are now about 450 we are aiming to finish uh hopefully by June 24. And this is going to be by far the single largest randomized controlled trial ever conducted on comparing refixation versus supportive management. Uh And we are very hopeful that we will get a final and answer about uh the correct management of blanch trauma. Uh Yes, you can see here how we started with a few centers uh and then it spread out to many others. So it is um about rib fixation and versus supportive management. The patient should be uh suitable for um the inclusion. So they need to be fit for surgery. They have a clinical flail chest or they have three or more refractures. And then in addition, either a clinical flail, chest, respiratory difficulty or uncontrollable pain with standard the modalities. So, well, these are in exclusion criteria if they are too young. Um there is no upper age, they can be 100 or eight years old and it's ok. They require uh they have thoracic injury required and Magy operations are like, you know, big hemothorax or they cannot be operated within the 1st 72 hours. We, what we're looking at is um quality of life. So, as I was telling you before, this is a quality of life questionnaire based study. What we look at is the quality of life of this patient at three months, six months and 12 months after the intervention, the intervention can be supportive management plus surgical approach to refractures or support management alone. What we look at how well they're doing? Are they back to work? Are they still taking painkillers? Are they breathing? Ok. How many pneumonias they had? And all of that, it's a very questionnaire and patients seem to enjoy it. Yes. Could you click on, um, can you see on your screen? There's something that says uh that you're sharing your screen. Could you click on the hide button for me? OK, perfect. Sounds lovely. Thank you. Um Yes. Um So consideration on RF so there is, you know, when you're running a study like this, you have to go have to go through a loop, a lot of loopholes and logistic difficulties. And so you have to clo work very closely with the intensivist because most of this patient will be either a level two or level three care I meaning an HD or an ICU. Um you have to fight against dogmas. They are believers and nonbelievers and some doctors as well do not really base their practice on the the latest evidence, but on the evidence they've been do uh had for the majority of their career, especially late in their career, they are a bit more reluctant to change practice and they, you know, they have seen many things, they have seen many studies, seen many young doctors coming up with new ideas and they are more reluctant to change their practice. And there are also a lot of logistic about arranging different units, thoracic trauma. Um the patient might need neurosurgical approach and um general surgery, abdominal surgery and so on. And also the ethical aspect of consenting patients, they are ventilated, meaning they are, you know, uh fully sedated and they are not ventilator. So you have to consent them through their relatives. The recruitment um is being started in, in uh 2018, we had a huge delay. Well, we are basically stand down during COVID and in 2021 but we are restarted and it's, it's going well. Um So again, uh other point of view on the blunt chest program management is about seeing this as a collaborative effort and a team effort. Um So you have to look also at your uh anesthetic colleagues, they can help you a lot and we are utilizing um uh blocks paravertebral anterior serrator locally anesthetic infusion. And this is greatly beneficial to your patients regardless whether you fix the surgically the rib fractures or if you don't. Mhm And um you have to look out at pulmonary complications. These are the most common complication your patient will experience and it is very challenging to measure the benefit of your intervention and whether physiotherapy helps or not. Um because you can do like in this study, an incentive spirometer measuring, but you have to consider that you are not um you don't have any chance. These are no elective patient, you can't study them before the trauma and after the trauma to measure how they are before and after obviously, this patient have an accident. And so you cannot compare before and after the intervention, nonetheless, measuring, for example, the incentive immediately after the trauma event and then at three months or six months can help demonstrate improvement. Um And then economics, economics is a huge factor in uh managing rib fractures and especially refractures managed surgically. We have to consider that healthcare in in the world is moving more and more about uh a cost effectiveness um point of view. So when we are approaching a certain management modality, we have to demonstrate that not only benefits the patients but benefits the hospital and benefits society as a whole. So there are a different two channels to consider when you're managing blunt chest trauma, One is what it costs to the hospital and the other what it costs to society. So let's say that's um we will prove and some of your uh medical students when you be practicing, you know, in five or 10 years re surgical refixation, as I hope as a researcher will be standard of care and not the object of run the mi controlled trials anymore. So that will be more costly because uh the titanium plates and screws we use are expensive and surgical time and theater time is one of the most expensive things that are in hospital. So what we need to look at is, well, we're spending more money in hospital. What are we doing for society? The issue is that if you don't fix the ras often that person will remain unable to go back to full time work to back to his normal tasks, especially if he was a non sedentary job. He wasn't an office job. Sometime their partner needs to become a carer for that individual because they have some degree of disability, they can have frequent chest infections and taking a lot of time off work or going back and never going back to work full time. So as you can see, it's quite a complex issue and in and in and, and that is why the managers and statistician and clinicians, they are analyzing blanches from a man pathway management management pathways have to look a little bit more, Uh you know, beyond just the hospital, have to look at what happens to the patient when they leave the hospital. So now we move on. Um So to how you do it, let's say that you have a patients with blunt chest trauma and multiple refractures and you decided that you want to fix these ribs. If you decide that you don't want to fix them. Well, that's very easy. You keep them on a ventilator, you keep them on opio opioids, you give them a bit of physiotherapy. Antibiotic is if you get a chest infection and then you wait for them to heal. But if you decide that you want to repair the refractures, what you're aiming as is preserving lung function, reducing pain, reducing the hospital comorbidities are meaning that domino effect of complication where you don't fix the ribs fractures, improving that chas mobility and increase the percentage of return to full employment and try to optimize cost as I just mentioned to you. So the principle of surgical approaches is minimize the impact on the chest wall to preserve the function of the chest wall muscles. These are trauma patients. So there is non elective surgery happens overnight or it happens late, happens over the weekends. Versatility and knowledge of multiple thoracic approaches is very important in this subgroup of thoracic patients. Uh It's better to prefer a combination of small incision, the long uh tracht incision because they can get infected. And uh the need for 90 degree and minimal invasive uh tools uh is very important. Obviously, we don't want to harm our patients ever. So the principle when you're operating on the chest wall, you always have to remember that just below the chest wall, there are the lungs, the heart, the spleen, the liver and so on. So, surgical strategy, what do we do? Shall we do a vat or uh AK A thos copy? How many ribs should we fix when to perform? For rib fixation? What technique we should use? And which surgical approach? I'll answer each one of these questions very soon. So, should we do a THSC toy? The answer seems to be yes, not just from this study that the only one I could find from my clinical practice retaining hemo thoracis are very common in rib fracture patients, especially uh with flail. They might not be obvious because the patient received act trauma and admission to hospital. These uh hemo thoracis that develop slowly over one or two days and you are only monitoring the patient maybe with x rays and there's maybe some blunting of the costophrenic angle. And you don't realize and the, you know, ICU do not realize that that's a building up a hemothorax. So they should have a throop evacuation of hemothorax because that prevents empyema. So how many ribs? So there's not a lot of information about how many fracture rib we should fix. There are only two retrospective studies. Um The index of broken to fix ribs was 0.50 0.7 which in other words means fixing one out of two or three out of four rib fractures, there's no, not enough evidence to answer the question, but it seems that if we repair them all, there might be a better total lung capacity at three months. Um The rule of thumb we keep using in our T SA is that we try to minimize the approach the incision in the chest and we try to fix every visible refraction we can access. And if you are not satisfied, we add further incision. So we prefer to fix more bony damage. And we accept a slightly higher number of uh soft tissue incisions because we believe soft tissue will heal much quicker than a fractured rib. So when should we do it? Well, that's very interesting when you're considering fixing some refractions, you have to think that that's usually not a life saving procedure is something that you look at the long term results and long term benefit. So for example, if someone has a fracture, spleen and multiple fractures, which is a very common combination, they go to general surgery, they have a laparotomy or they go to interventionalist that have the, the spleen coiled, but the spleen is the priority, not the ref fractures. Ok. Uh Even if you have refracture in hemothorax, most of the time, the refracture are always, you know, scratching. Uh the pleura have grazed the lung and you insert the chest string, you evacuate the hemothorax and the patient is stable enough to go ahead and, and have other surgery or have the rib fracture fixed later. So, in the observational study, the refraction are normally fixed between the third and the seventh day after admission. What is very interesting to see and then most of the randomized controlled trials uh uh demand that the patient get surgery within the 1st 72 hours after admission. As you can see, the contradiction, isn't it? So most practice and observational study or real life practice, the patient had their fracture ribs fixed after three days of admission. Wh in the studies that we are running, we asked the hospital, the carers and the healthcare professionals to perform refraction fixation within three days. Mm These are the principle of uh uh mm he bone healing. So, restoration of anatomy, stable fracture fixation, preservation of blood supply and early mobilization. This is something that is the same for any bone you want to fix. So, also for, for ribs, and let's remind yourself a little bit of the anatomy. Um So we have the anatomy of the anterior chest wall. Um These are lights uh that go through all the uh insertion of the muscle. Obviously, we don't have enough time today, but just reminded, you have, the pectoral is made your first big muscle, anterior upper chest wall and the pectoralis minor, which is just below and has different insertions. Then you have the external oblique which originates from the fifth to 12 ribs and inserts on the anterior isla crest. This is a muscle. We wouldn't normally touch with the thoracic surgery, meaning elective general thoracic surgery. But for trauma incision, we often do. So you need to revise your anatomy before considering doing trauma surgery later. Uh the serratus anterior, very important for refracture fixation and also for uh local anesthetic infusion. If you injure this nerve, you can have a medial scapular winging and latissima Dorsa. Latissimum Dorsa is the muscle of the thoracic surgeon is the one we access all the time. So most thoracic surgeon and also trauma surgeon that they are qualified to do uh urgent evacuation of uh of then we have uh infrascapular muscles, uh rhomboid major and Rhomboid Manor. Uh They are coming into play with some uh uh older technique of the refraction fixation. Now, with advanced instrumentation and uh angle instruments, they are um getting uh surgical incision less and less. And that's to the advantage of the patient because they can give laterals of winging, which is actually the annoying one if you want to use a simple word because you know, it's the one that you can actually see that winging scapula sticking out of the chest and then trapezius to be high on the posterior chest wall. And uh it is um not often uh uh utilize for tracht is in trauma surgery, but it's important to know, especially when you are going to um switch you back together with your incision. So, planning your surgical approach, the approach depends on the number and locations of refractures. And also you have to consider the morbidity of your approach. How many muscles are you transecting? Which versus the one you want to spare and the extent of the incision, everything we do in surgery can help or be a cause of trouble according to our preparation prior to the procedure. So let's look at a few different ones. So you will have in this series of slides, the blue circles or G green circle. Um it re refers to what the rib fracture are broken and the yellow dotted line is what you're going to try to do your incision. Ok. So what you're going to do after this median incision, you're gonna lift the pectoralis uh major and then you will have access to the ribs there. It's very good for the second to fourth rib anteriorly. Then you're going to have an extended anterior approach. And you can see how we started having a long and complex um median approach. And even uh like a inverted y incision, we prefer to do four small incisions. One would be trans pectoral trans pectoral incision. And then the second one would be the inframammary incision. Then when you have isolated lateral, you can do an axillary incision. As you can see, you can reach for the 4 to 8 lateral refractions and extend the lateral. You can then have a combination of uh a inverted L incision and then axillary incision, posterolateral high. So a position will be like a punch surgical second or third. This is quite um this is only this approach only in the eventuality. You don't have any minimal invasive brick fracture fixation tools. Otherwise it's better to avoid this incision, posterolateral. This is very versatile. This is the most common traffic uh approach. It can fix ribs from 4 to 8. The patient is in a standard position for thoracic surgeon. They are all very comfortable to do this incision. So it is one of the most common approaches and then paraspinal paraspinal the patient will be prone. So it it presents difficulty with ventilation and is not utilized that often. So how are you gonna position your patient to perform these incisions? This is not something that comes out of a book. This is my own personal experience. So you can see in the majority of case your patient will be in a lateral position. Ok. Standard lateral surgical position. Well, only in the case you really intend to do paraspinal, you go prone. And if you want a purely anterior fixation, you're gonna be at your patient's supine or supine with an arm or two arms out. So, planning a surgical approach, just uh you know, you have to consider the scapula up above the T two, medial spine T three and usually a three just below the inferior angle. This is when the patient is standing. When uh I will comment later about this, then that is your anterior anatomy. You always have to think what it looks from the outside and what are the bones, they are below the surface and below the muscles. Also, uh everyone giggles normally with these lights, you have to consider how your patient looks. If they are very skinny, they are very stocky. And as mentioned before, the inframammary incisions. Well, the uh the infra the transector incision in a female, especially in uh in fertile age. But meaning that you're gonna cut through the breast gland, which is a highly disfiguring incision for a young woman. So maybe you have to opt for another uh approach. You can see here how we have done an inframammary incision. These are real life cases and it permits to access the anterior aspect of the 4th 5th and 6th rib, uh planning a surgical approach. So normally I would ask the audience to tell me what they think we should do here. But you can see these lights, you can see the refracture, they are anterior, OK, probably fourth to sixth to seventh. And the best approach is an inframammary incision with a possible posterior extension. Uh It's better always to start with a small incision and then extend it if required. When planning your surgical approach, you should do an axilla and you do an axillary incision. Be careful with the uh nervo vascular bundle of the long thoracic nerve and all the complication that cast in this could cause. As you can see, we pre we put a titanium plate where we preserve the neva neovascular bundle. So again, so in this case, the second rib badly fractured anteromedially and third rib anterolaterally. What incision, what would you do? A prolonged axillary? So again, in this case, we did a pectoris lifting through median incision or horizontal transoral incision. That would be the best approach. Uh pectoralis lifting and trans pectoral incision. Just to give you an idea what they are. Uh In the case of trans pectoral incision, we are going here when we're doing a median incision is the same you would do for a stot toy. The main difference obviously that you don't cut the sternum, but you just extend your dissection, lifting the pectoral muscles, which with the transoral incision as the name might suggest you just cut through the fibers and then split them apart to have access to the ribs. Um Yeah. So this is, you know, you can do this incision and if you really have a badly damaged chest wall, this would be probably an incision. Um Will you do for someone who had a safety uh belt injury? And they have um one side of the chest or maybe impact on a passenger side impact and one side of the chest is particularly uh damaged. So sometime as you can see in this picture that the sternum looks really bad, you can see the sternum in this case, was not only transversely fractured, was also longitudinally fractured. Something that is normally quite challenging to fix. So what we did in that case, oh and also what was going on here, there was some missing part of bone because the bone was um in crumbles, there were crumble of bones. So can you fix a fracture with a gap? So what I'm saying now is something that the industry doesn't like me to say because it is off label. The use of titanium plates to fix rib fractures with a gap is off label. And you should be aware if you are a surgeon. You should the the industry al always recommends to have uh do have no gap in your r fixation, but we do use it and uh with very little complication rate actually, no complication rate. And uh but certainly it's different because I've been doing, I've been using titanium plates since 2007. If you are a new operator, it's better. You just do exactly as the industry tells you for, you know, two or 300 cases and then maybe try to do something off label. Um So yeah, this was the X ray of the case I showed you before. So we did put and this is the CT scan uh ignore the pneumoperitoneum that is visible in the front. This was another, this patient also had a laparotomy. Uh But you can see how we place these two plates uh vertically and uh how the sterum looks stable. Now, this is a new on old trauma, completely different patient. You can see this patient admitted these clavicular plates were not placed by us. Uh She is um horse trainer and she has uh you know, already fallen off the horse another time. And did she admitted to the hospital with this with this x-ray? And you can see it zoom in how many refresh you can count there. I can see at least five and this is act scan. You can see how comminuted and overlapping and how um damage is the chest wall. Here, there's also an anterior pneumothorax there and lung contusion emir trauma to the l. So something we use very often to plan a surgical approach is 3D reconstruction, reading the CT scan for trauma might not be, you know, ev everybody's favorite thing to do. Uh But when you put it on a 3D, you can see how obvious it all becomes. So you have the fourth, the fifth, the 6th, 7th and the eighth rib and the ninth rib. So it is very simple. Once you achieve a 3D reconstruction from your radiology department to plan your surgery, you can see what the scapular is and you know that once you will be the patient in a lateral position with the arm above and the scapula rotated a bit externally, you will have a perfect access with a poster lateral approach. Yeah, as I would say, so this is the x-ray of the patient I showed you before with our all clavicular plates and the new uh surgical fixated ribs there with new plating. Uh Something is very important to remember as you are doing your first um cases of brief fixation is comparing the city to the surgical positioning once you're positioning your patient. So when you look at the CT, the scapula, the tip of the scapula is on the eighth rib. Once you position your patient on the table in a lateral position, the tip of the scapula will be on the fifth or the sixth rib, but most common on the fifth rib. So be very careful about considering this and then also thoracic patient that listening to this might consider to break the bed and we normally, as we normally do in lung resections for lung cancer. And it's a common thing for thoracic surgery to break the surgical bed. But be very careful when you do this with refractures because that can misalign the ends the stumps on the brief fractures and you might end up having the stump of the fifth rib facing the sixth and so on the stample, the 63 facing the seventh. So if you want to break the bed, do it very little or maybe use a, a small bean bag just to have a little bit of stretch of the skin, but don't fully break the the bed as you would normally do in a in a lung cancer because that can come with big mistakes. Uh So planning the surgical approach, um there was, you know, you can see an example here again of uh posterolateral approach. You can see how many ribs you can see and then there is a scapula elevator trying to show the upper border of the fourth rib. Uh And finally, paraspinal approach. I admit this is not my picture, the only one you've seen now, but I never done it. I only asked a colleague if you could share it with me. Um I think because of the huge amount of muscle damage. Um I'm not a fan of paraspinal and most trauma and surgeons do not fix paraspinal fractures. But as you can see here, the technique, this beautiful picture that this colleague share with me. Uh you can see uh the rectos muscle and below, you're gonna have your uh head of rib and the transverse processes. Uh surgical approaches again, muscle sparing thot toy. And you can see here how on the left, you have very little, you know, muscle damage and you know, the incision is big, but it's only fats and skin that you're actually cutting most of the muscle in this approach are preserved. You can clearly see how you need to lift up and you can have access to a refracture blood. But the apart from the triangle of auscultation, nothing else has been kept in this case. And then additional incision as I was measuring before we have a poster lateral approach here, we probably fixed 56 cribs and there was one that we really wanted to fix but was too low, maybe 9 to 10. So instead of doing a huge extended incision, we just did a very small one down here and we fixed those one or two ribs that were too far away from our main incision. And then the evolution of the surgical approaches, minimal invasive technique. As you can see here, we are using a minimally invasive system here to drill and pass on the um and pass the uh drill bit through that guide and down. And you can see how everything is concealed through our main incision and a small additional incision. And then you know, I just show you the minimal invasive and some other times you have to be very maximally invasive. This horrible case that II will I still remember was a cyclist that was basically skewered by a um a signpost. And so he had a very extensive rib damage and chest wall. You can see also his clavicle and he is missing part of his intercostal muscle. Incredibly after all this. And I think he also had a splenectomy. Um He did recover very well when somebody asked me if I believe in refracture, you know, I would quote to them, do you think a patient like this would ever heal without reflux? And uh this is um the evolution or something I wanted to mention just in passing and something a little bit more inspiring for you and for the all the medical students, my mentors uh appro made me, you know, they taught me how to do r fixation. But many years down the line, I was uh involved in a pioneering operation a first time. Um Well, first time in the UK and a part of the operation was the first time in the world which I combined my knowledge about refracture and chest and blanch chest trauma fixation to do a pioneering operation with the utilization of allograft. So, a cadaveric donor, um sternum and clavicle to reconstruct the chest wall with a cadaveric um donor. And this is was on the newspaper on the, on the television. It just uh you know, because I know many of your medical students never underestimate how far could a uh something you learn during your training or your medical school or something you only seen on a book? How many years down the line might have something that you actually used to help a patient? You can see it was a very complex history. 10 years breast cancer. She has atic on the left and this is again, her uh ct scan doing the allograft had a, a very good effect on her and that we've been going ahead and do more of these uh surgeries. And this is it for me. I think I catch up a little bit with the delay. There was initially and I'm very happy to take your uh question. I hope you enjoyed. And I put here my contact of my um media and my social media have multiple social media mainly because I normally post in the other uh educational events that I am going to deliver as um this one on my social media. So if you wanna save it, uh you know, for your perusal, I'll be very happy with that. Thank you, everyone. Wonderful. Thank you. Do you want to go uh click on the present now again and you should be able to stop presenting. That is right down the bottom, right? OK. All right. Uh How do I do that? Sorry, stop sharing. Yes, stop sharing. Click on that. Perfect. Perfect. So you can see us now. So we do have some questions. Let me see. And if anyone else has any questions, do put them in the chat and we will add them to the Q and A. I'm gonna start the Q and A and you should at the bottom of your screen. Uh Can you see er, that we have a question that's popped up? Ah, it says till June final result, oxygen and pain management is the mainstay or rib fixation is now an option for better outcome. I'm not sure what that means. I like these questions so I can answer with, with not a real, with a real answer. So the situation is extremely patchy uh across the world. And I'm involved, for example, with setting up a rep fracture fixation services for Africa. And we're starting actually this month with South Africa. So I could answer there's growing interest in fixing rib fractures. The main limitation has been costs and has been evidence there were at congress meeting and thoracic surgeon and trauma surgeon, the one that truly believed in, in the intervention and the one that didn't believe what was lacking was high quality, large randomized control trial for finally settle this debate and that's what we are trying to do. So I could answer this question saying that until we don't have the results of the RF study, it will be always a collaborative discussion with your intensivist and you know, you have to consider duration of mechanical ventilation. How long your patient has been struggling to be extubated with multiple refractures? And in selected cases, they could be still a strong indication to do refracture fixation. Once we'll have finally, the the results, we could probably come out and say that we can pick and choose the patient that benefits the most from refracture fixation. Perfect. Next question uh is blunt trauma. Chest includes all these without any puncture, wound, pneumothorax, hemothorax, cardiac tamponade, lung, and cardiac contusions and rib fractures. Um flail, chest, sternal fracture, and medi meal injuries or only rib fracture. I got, I got so. So, ok. So when asked to do a presentation on blanch chest stroma, I could talk about any is injury that can, you can have inside the chest. But first of all, tampon cardiac tamponades or uh pneumothorax. Uh and all this I they're normally they, they pertain to penetrating chest injuries when looking at like a bco thoracic surgery or trauma surgery, tampon and pneumothorax and hemothorax. They are normally for penetrating uh chest injuries. It is true that in very rare cases, you might have a tamponade in a blunt chest trauma. Actually, more than a tamponade, you can have a, a hard contusion that ends up having the patient with arrest rather than a tampon. And then again, when you have rib fractures, you can have a hemothorax, you can have a pneumothorax but I was trying to give you one, you know, review of in depth of the the most common act aspect of blunt chest trauma, which is the management of the rib, chest wall injuries and the rib fractures. Uh the management of pneumothorax or hemothorax. Firstly is normally discussed on the chapter of penetrating chest injuries. And secondly, is not specific to blunt chest trauma is a very wide topic of thoracic surgery. It doesn't, the management of a pneumothorax of a hemothorax does no change regardless of the cause. It's always the same. Perfect. We've got another question. Can you see that question there? Francesco, yeah, fixing ribs and soft tissue injuries can change this blunt trauma into penetrating trauma. Uh and surgical intervention can lead to more pain and more spiritual complication. Well, I guess that this um uh colleague uh is not a fan of surgical refixation, but no, II wouldn't. I would not agree with this uh um quite dramatic way of interpreting surgical approach to refractures because you have to look at the long term effects of non intervention. Meaning that yes, it's true that you have, you know, a blunt chest trauma and you have multiple refractures and that you do an incision. Uh but surgical incision cannot be considered a uh penetrating chest injury is a intentional incision to the chest wall to fix the refractures. Uh actually respiratory complication are uh uh reduced in all studies where you have done surgical approach of refractures for, for, as I was saying during my presentation, my feeling, although I might be proven wrong, but my feeling I haven't been involved with this in the last 15 years that the medical students, they are listening to this, when they will be doctors, they probably will have as gold standard refixation rather than supportive management. But who knows? OK, next question, next question. Well, this is a very interesting who performs this cardiothoracic or trauma. OK. So it's very, very good question. You have to look at the topography and of your uh geographical area. So and they have availability of the two specialities. If you take for example, United Kingdom where I am working and I live, it's about uh 40% done by trauma surgeon and 60% done by uh thoracic surgeon will, if you go in the US, they have a and then Canada, they have a huge culture from a long time or trauma dedicated. They are orthopedic surgeon. They become trauma surgeon, they do this job. They thoracic cardio, thoracic gets invited only in very selected cases, high difficulty when the chest is destroyed, but not in a normal case. Um And so it would be interesting to look at uh you know, your local area and understanding who would be willing to take it on. Uh every country will have a different scenario. Perfect. Next question, what are the current gaps in this domain that can be answered by budget studies in low income settings. Ok. Yes. Um uh what and in this domain? So really like what research can be done? He does say what can be. Yeah, he does say to give context asking for a study that medical student uh that can d in low country. That can Yeah. So something they could do that costs very little if you think about it. What I was saying before the set up of these studies, they are quality improvement questionnaires. They're actually not that costly. You mean if you set up a study in which you need to do a CT scan or you're doing blood tests, these are quite expensive. But if you set up with your uh local Ethical Committee uh and approved, already approved posttrauma quality of life questionnaire and then even a group of medical students, they share the phone calls and they call the patient at three months, six months, one year, you can do a very large studies of all, all the patients that were not operated for refractures or all the patients that were admitted for blann chest trauma, asking them how they are doing and recording the results. This would only cost the mo you know the the the money of making phone calls from the hospital and the time of the medical students, but it is not an expensive study to run. Perfect. Next question. Can't rib fractures be correct. Use closed reduction corrected. I'm assuming using closed reduction, closed reduction. So, so, oh if it mean internal fixation is not treating them, but refractured um closed reduction. Uh um if it means like minimal invasive uh thos scopic uh fixation uh is something that I am also involved with research but is not utilized that much. I mean, there is one system called refix advantages, but one of the main industries, they use an hybrid open ans system. Um but you know, it's, it's utilized um only in North America and I don't know what else. Um So if that was the question, there's very little utilization right now. If close reduction, meaning internal fixation, well, this is a never ending topic. I mean, people who believe you shouldn't fix refractures are, are, are hoping to convince them we, you know, with the, with the power of evidence. Um because you have to think and this is something I mentioned after my presentation that a co if you go 3040 years back in time, the typical way an elderly individual would die is because they broke their femur, they were breaking their femur, they would be in bed, they would get either pneumonia or a DVT and they would die. That was a very common history that all we saw now, grandmothers or grandfathers or great grandfathers. That's how they happened. Now, it's unthinkable that you admit another individual with broken femur, even if they are 90 years old and you don't try to fix it. I feel that what we will see in the next years is the same um trend in refractures. We now consider normal in the medical community not to fix refractures. Has the doctors of the 19 fifties considered normal not to fix the femur fractures in the patients. Some patients do present late with rib fracture, especially in my country and we see them as late presentation. Yes. So, so late presentation meaning uh seven and plus days, especially if it is more than two weeks uh demands a completely different approach. Uh Because especially if you are in a country with uh you know, with lots of young individual and chest trauma, um they are gonna start to heal as soon as seven days even uh after the traumatic event. And if you have a callous formation, you have to ask yourself, is this patient particularly deformed? Is he experiencing a particular amount of pain because of the of the badly fixed uh fractures? And what am I going to gain? And what I benefit I'm going to give to the patient fixing the rib fractures, but this is not common practice to, to surgical approach. Perfect and a follow up from uh George. Yes. The the questionnaire is the one that I was mentioning here. Let me find it for this. Uh for George, she's very keen to start tomorrow to do this. Ok. Let me find it for you. Yeah, that's very great. Ok, let me find the, or if, when I was talking about or if I had the study here, I can, uh, if you can see here. Let's see. Ok. So it's called EQ dash five D. So Echo Quebec dash five delta. This is a common um, posttrauma study, uh questionnaire quality of life, questionnaire. Perfect. Last question. Yeah, that's good. Uh Do patients need chest drains and postoperative care and itu following the surgery, uh, they need chest drains for sure. Uh but they do not require uh level three care necessarily. Uh the definition of itu across the globe varies a lot. You can have level one, the ward level two HD U level three ITU um most of these patients will not need itu won't be ventilated, won't need an a tropic report, but they often need HD U A level two care. Perfect. I just wanna uh there's a comment in the chat that I just want to say to you. I don't know if you saw it. Uh it was uh Shanawaz. I might have pronounced that wrong. I'm so sorry and they just wanted to say thank you so much as a medical student. It made me really glad that you facilitated the talk. According to my knowledge, I'd like to contribute something to the field of oncology in honor of my mum and seeing the difference you've made has given me hope so. Thank you very much. I think that's just lovely to, to know that. Thank you. Thank you so much for making a difference and there's loads and loads of. Thank you in the chat. So thank you very, very much um to our delegates. I'm gonna say thank you very much for joining us. We do actually have a mobile app now. So if you want to download that, please go to your app store and download your feedback form. Should already be in your inbox. Please fill that out. Please be really helpful with your feedback because I will be passing this on to Francesco. Um Please pop loads of information in there. Um And then once you filled out your feedback form, your attendance certificate will be on your med account and this video will be uploaded in the next couple of days. So, um so that's it, that's, that's it from us. So I we're gonna say if I'm just going, we'll say goodbye to our delegates. So thank you delegates for coming along um and take care and we'll see you at another event. Thank you. Thank you so much and apologies again.