Manual techniques with multiple rib fractures??

I keep hearing conflicting views on the application of manual techniques, clapping and vibes etc on patients with multiple rib fractures. Some sources say that they are completely contraindicated whereas other sources say that it is ok the proceed with caution if the fracture is stable and adequate pain control is given?? If anyone could give any input on the subject or even point me in the direction of any relevant research it would be greatly appreciated.

Cheers for your help

:o

don't have any research at hand, and to be honest, i doubt there is much out there.

i think lots of things that we are taught through university to be contraindications should really be regarded as precautions. still, it's probably better to teach the former to students in some ways.

the accepted medical management of rib fractures is adequate analgesia - a nerve block is usually best.

personally i would not do manual techniques over someone's rib fractures unless they had good analgesia onboard. there are usually alternatives that are just as good - ie, do you REALLY need to do manual techniques right THERE.

for one rib fracture, the patient may tolerate it, for multiple ones, who knows? you can always trial it. too much pain will possibly stop them from even taking a deep breath and surely that's more important/effective than manual techniques.

Matin,

Thanks for your reply, It's valuable to hear the opinion of people with experience. I did think that research would be hard to come by, just a shot in the dark really.

I realise that applying manual techniques to a chest could be seen as a slightly sadistic approach! and I would by no means approach this as my first treatment, but you confirmed my thoughts about adequate pain relief.

thanks again

This is a pretty difficult one and while I personally don't like to pummel someone with rib fractures in my experience it comes down to what is going to be MOST harmful - pounding a chest with rib fractures or allowing secretions to remain in the lungs. As a senior once said to me - there's no point saving someone's ribs if they're going to drown in their own secretions.

So ultimately I think it's a personal choice that needs to be backed with sound clinical judgement.

Ray

I think the reply from Ray was right on, provided of course adequate pain control is achieved. If the fractures are unilateral, I have found the technique of manually restricting the ventilation of the good side to be most effective. Not only is ventilation facilitated, but secretions are more easily mobilized and collapse of the area can be minimized if techniques are started early enough.
Susan

Thankyou for your comments,

Susan, what do you mean by manually restricting ventilation to the good lung. I have never come across this technique and was just wondering what it consisted of and how it would be carried out.

Alex

i guess it comes down to... are secretions a problem now, or is potential atelectasis/collapse the bigger problem

if someone doesn't have lots of secretions now, or difficulty clearing, then manual techniques are useless and should be avoided.

if they do have secretion problems, are we doing everything else possible before resorting to manual techniques: mobilising the patient if possible (walking or ex bike), position, humidification/nebs, getting them doing adequate deep breathing themselves etc

By manually restricting the ventilation on the good side I mean this: Stand at the patient's good side, open hand or hands over the lateral thorax. Ask the patient to breathe in while you monitor the lateral costal expansion, then as he exhales follow with your hand on that side assisting his expiration. Maintain that pressure as tolerated when you ask him to inhale again. By restricting that flow into the good side, the bad side is forced to expand. This technique works well in the absence or the presence of secretions, and helps to preven atelectasis.

Susan PT

susan - do you have any references, of any sort, for this technique? i occasionally use it because it makes logical sense, but i've never seen it written about anywhere.

This technique is taught as part of a respiratory physio seminar by a physio in Toronto who is part of the faculty of the University of Toronto. A colleague attended the seminar and gave me an in-service on her return. His first name is Waldemar, but his last name escapes me. I have his name and contact info at work, and will try to have it next work day. It does make sense, and I think those are the most wonderful techniques we have--the ones that just mechanically you know have to work!
Susan PT

I intended to get back to the board with the name of the physio teaching the technique I mentioned, among others. He is Wlademar Kolaczkowski (PhD, MA, RPT), and he is a physio at St.Michael's Hospital in Toronto, as well as a lecturer in the Faculty of Medicine at University of Toronto.

It would be contraindicated to apply manual techniques immed over a fracture. However, for a simple displaced fracture mt's could be used to other areas of affected lung.

If segement is flail, you need to be well away from the whole flail area.

Remember, lung beneath fracture(s) will often be contused, and will usually resolve spontaneously.

Positioning to preferentially ventilate affected lung is crucial.
If the patient is well enough, sit out of bed/ mobilise. This will be as effective, if not more efective than manual techniques alone. It also has the benefit of being functional, and psychologically the patient will be more agreeable to the patient, whilst improving lung ventilation generally and specifically.

Good analgesia is critical to any treatment.

I would also add that you can look at the patient also as a person with a simple rib fracture. Lateral binding, via bandage or tape etc, of a rib fracture to minimize lateral expansion has proved clinically to provide some relief of pain for some fracture sites. So too has adhesive strapping over a flail segment.

Remember the lungs can also expand with simple diaphragm decent and AP rib movements, not just lateral expansion. it would seem therefore appropriate to suggest extended (standing-type) postures would assist the diaphragmatic movement in these patients.

So as Liz has said, get them up if you can, even tilt table them. If not think about postural drainage positions to assist specific targeting perfusion and ventilation, whilst using pain as feedback. in a more difficult case I would contact the pain team to see if they can assist you to do your job the best way possible! 8o