Ortho/Pain Management question

[rev ronin]

Colleagues,

I have a 44 YOM patient with chronic/ongoing nonunion of single, unilateral fractures of ribs 7-10. University of Washington thoracic surgery at Harborview looked at him, and after shared decision making discussion, recommended he go to pain management.

Has anyone dealt with this as a permanent/chronic problem in one of your patients before?  I'm looking at the literature and not seeing a whole lot to love there.

My goal as an occ med PA is to get this gentleman back to work... but effectively managing the pain from this condition long term is going to make that a challenge.

ETA: injury date was this year, but >6m ago.  Nonunion is proven on CT, so everyone is relatively sure this isn't changing.

Edited December 19, 2023 by rev ronin
more info

[Reality Check 2]

Nonunion as in soft tissue interposed between bone ends or the two ends aren’t in the same room or chronic bone marrow non healing on MRI?

if not healing, are there metabolic reasons for nonunion? Lab work up, PTH, calcium, etc or smoker or maybe a Bone stimulator?

if interposed tissue entrapping nerves then maybe nerve block, radio frequency ablation?

Topical lidocaine patches, acupuncture.

Historically, I have seen maybe one surgery to move trapped soft tissue and put bone ends in the same room for healing.

A PMR colleague did an alcohol injection to kill a tiny nerve trapped in bone. A numb spot the size of a silver dollar was way better than the pain.

Nerve pain or bone pain? What generates the pain? That will give the best path to any improvement, in my experience.

Sorry, late at night and random flow of thoughts.

[SedRate]

Chronic pain management for this is a crappy option, IMO... 

Agree with a nonunion workup. 

I would recommend referring to someone who can repair and plate rib nonunions, but I'm guessing those fractures aren't in a spot amenable to fixation if the Uni folks don't want to do it... Maybe a referral for a second opinion is prudent. 

Edited December 19, 2023 by SedRate

[rev ronin]

9 hours ago, Reality Check 2 said:

Nonunion as in soft tissue interposed between bone ends or the two ends aren’t in the same room or chronic bone marrow non healing on MRI?

if not healing, are there metabolic reasons for nonunion? Lab work up, PTH, calcium, etc or smoker or maybe a Bone stimulator?

if interposed tissue entrapping nerves then maybe nerve block, radio frequency ablation?

Topical lidocaine patches, acupuncture.

Historically, I have seen maybe one surgery to move trapped soft tissue and put bone ends in the same room for healing.

A PMR colleague did an alcohol injection to kill a tiny nerve trapped in bone. A numb spot the size of a silver dollar was way better than the pain.

Nerve pain or bone pain? What generates the pain? That will give the best path to any improvement, in my experience.

Sorry, late at night and random flow of thoughts.

No, this is good. I wasn't even thinking about metabolic factors and the possibility of further healing. He came to me >3m after the injury, and it took another 3m to get the CT scan to settle the question of whether the ribs were healing or not and then get him into the thoracic surgeon for a consult. I just assumed that the die was cast, or if not, the thoracic surgeon would know best.

Have already been thinking along the lines of nerve ablation, but I didn't see much in last night's cursory literature search. Sending him to PMR instead of pain management sounds like a much better plan.

[rev ronin]

5 hours ago, SedRate said:

I would recommend referring to someone who can repair and plate rib nonunions, but I'm guessing those fractures aren't in a spot amenable to fixation if the Uni folks don't want to do it... Maybe a referral for a second opinion is prudent. 

Per the patient, the surgeon said the plates would have to be in a place where constant motion would eventually cause them to break and possibly puncture a lobe.

Second opinion would be either someone else in the same academic department, or out of state.

[ventana]

10 years ago bone stim, but the data did not support them...

 

smoker?  if so he gotta quit

 

I am amazed ortho doesn't want to slap some plates on for  a few months then remove....

 

yup work up.......  but if he has an attorney he might well be milking it...

[SedRate]

7 hours ago, rev ronin said:

Per the patient, the surgeon said the plates would have to be in a place where constant motion would eventually cause them to break and possibly puncture a lobe.

Second opinion would be either someone else in the same academic department, or out of state.

Um, yeah... Don't all ribs constantly move? Lol. Refer for a second opinion. 

According to The George Washington University Hospital they plate symptomatic nonunion rib fxs to reduce pain, so it sounds like a reasonable option. https://www.gwhospital.com/services/rib-plating

Looks like these authors in the Thoracic Dept would be an option for your patient in WA:

Rib Plating Offers Favorable Outcomes in ... - The Annals of Thoracic Surgery https://www.annalsthoracicsurgery.org/article/S0003-4975(20)30615-9/pdf

Edited December 20, 2023 by SedRate