Chest Wall Reconstruction & Surgery with Evert Eriksson, M.D.

MUSC Health is a leader in treating chest wall injuries, including rib fracture care. People come to the MUSC Chest Wall Injury and Reconstruction Center from all over the Southeast and beyond for innovative treatments after traumatic accidents, falls and other cases involving rib and chest wall injuries. Dr. Evert Eriksson is a general surgeon who specializes in injuries to the chest wall. He explains what sets MUSC apart in this area and the hope he offers to so many patients.

“The debilitating effect of rib fractures is the thing that can't be understated. … If you break your ribs, chances are you're not going back to work again if you have a flail chest. If you have multiple rib fractures, 66% of patients who have manual labor type jobs don't go back to work again. That statistic improves significantly with rib fixation and restoring the chest wall and making it work properly again. And that's really what we're trying to do is we're trying to get people back to their normal life.”

- Evert Eriksson, M.D.

Topics covered in this show

• Rib injuries can happen at any time, from almost any type of fall and to people of any age.
• Pain from rib injuries can be quite debilitating and last over a sustained period of time.
• Standard medical care for rib fractures and injuries involves a lot of waiting for things to heal on their own. Eriksson’s team takes a proactive approach, using pain medications and surgery to help patients feel better much more quickly.
• A decade ago, technology advancements allowed surgeons to have plates specific to the ribs and revolutionized the care of rib fracture patients. This has accelerated the rate of recovery and improved pain control for rib fracture patients.
• Early intervention through rib surgery has been most beneficial for elderly patients, decreasing mortality rates, and younger patients who are able to return to their normal way of life much more quickly.
• It is ideal to treat a patient within 48 to 72 hours of sustaining a rib injury.
• The MUSC Chest Wall Injury and Reconstruction Center was developed to expedite care for patients with chest wall injuries through telehealth visits, and quick in-person and surgical follow-up if needed.
• Telehealth has revolutionized chest wall injury care, allowing patients to have a consultation from home, even if they live 2 to 3 hours away from the clinic. Then, they can come in for the surgery. The telehealth program grew by over 300% in 2021, and has included patients from all over the U.S. seeking care.
• Slipped Rib and Rib Tips syndromes are rare and not well-known ailments that can cause severe nerve pain that won’t be picked up with traditional imaging. Many patients suffer from this, but their care providers don’t pick up on the problem. Eriksson can identify this quickly and solve the problem with surgery.
• Some chest wall injury patients may suffer from pain medication overdoses and suicidal tendencies, so the treatment offered for chest wall reconstruction at MUSC Health is crucial to helping these patients get back to a better quality of life.
• Surgery is not always the answer to chest wall injuries. MUSC Health uses innovative pain medication regimens, as well as physical, occupational, and ultrasonic therapy to help patients, as well as chronic pain management services.
• Rib plating allows for minimally invasive surgery that helps stabilize the ribs that need to heal, which really helps a lot of patients recover.
• The Chest Wall Injury Society works to promote the benefit of rib stabilization for rib fractures through regular meetings and collaborative studies.

Read the show transcript below

Erin Spain: [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. MUSC Health is a leader in treating chest wall injuries, including rib fracture care. People come here from all over the southeast and beyond for innovative treatments after traumatic accidents, falls and other cases involving rib and chest wall injuries. Dr. Evert Eriksson is a general surgeon who specializes in injuries to the chest wall. He's here to explain what sets MUSC apart in this area and the hope he offers to so many patients. Thank you so much for being here.

Evert Eriksson: [00:00:49] Thank you, Erin. It's great to be here.

Erin Spain: [00:00:50] Tell me about rib injuries. How do they typically happen and what's recovery like?

Evert Eriksson: [00:00:55] So rib injuries can really occur to almost anyone any day. You know, the typical injuries that we see at a level one trauma center are people who have fallen off of roofs, fallen off of ladders. But we also see people who are in car wrecks, motorcycle wrecks, and even people who fall from standing if they fall on to a banister or fall on to a bathtub or something like that can sustain rib injuries. So we really see quite a few of them in our patients who come in through the trauma program.

Erin Spain: [00:01:21] Are these people of all ages?

Evert Eriksson: [00:01:23] It is. We really see it across the board. We see young people getting injured. We see people working every day doing their job. And then we see elderly patients falling down and breaking ribs. And those because of the osteoporosis that they have and the more brittle bones can even be some of our more injured patients with our elderlies.

Erin Spain: [00:01:40] Tell me about the pain that is associated with these injuries.

Evert Eriksson: [00:01:44] The pain with rib fractures can be quite crippling. It spans anywhere from a kind of a nuisance pain that people can deal with if they only have one or two broken ribs up to something so debilitating that they really can't even breathe on their own, and we have to place them on a ventilator to support their breathing and support their pain control. And the pain doesn't end quickly. This is something that persists for quite a long time. Many of these patients still have pain, 1, 2, 3 months out and even up to a year. Some of these patients still have often debilitating pain if they have multiple, multiple rib fractures.

Erin Spain: [00:02:16] And a lot of people do think of rib injuries as something that's almost untreatable. What is the current standard of care in places that don't have a specialized center like MUSC Health?

Evert Eriksson: [00:02:28] You know, as a medical community, we've really ignored rib fractures for a very, very long time. When I went through medical school, we were taught if you have broken ribs, we give you pain medicine, we support you, tell you to breathe deep, and that it's going to be a rough couple of months to get over this. Some patients can't do that and we have to place them on a ventilator. And unfortunately, that remains the standard of care at a lot of hospitals across the nation. Now, here in Charleston at MUSC, we have a very innovative program where we are treating these patients with a very progressive, multimodal pain medication regimen that gets a lot of them feeling better much quicker as soon as we get all those pain medicines started. And then for those that that's not enough for, we have a surgical rib fixation program where we go in and surgically repair those broken ribs and allow those patients to breathe better. And it's remarkable how many of my patients, when they wake up in the recovery room or the next morning when I go visit with them, tell me they feel so much better after having that big operation than they did the day before. And that's really the change that I'd like to see happen more across the nation, and the benefit of surgical rib fixation has seen.

Erin Spain: [00:03:36] You started this process of transforming rib injury care at MUSC Health about a decade ago. Tell me, what motivated you to do this?

Evert Eriksson: [00:03:44] Yeah. So about a decade ago, there were some advancements in the technology available to us where we could finally have plates that were specific to the ribs and acted like ribs in their interaction with the human body. And that change really revolutionized the care of rib fracture patients. And we saw that when we fix these fractures with these specialized plates, we could get patients off the ventilator quicker. And finally, we had a therapy to offer these patients to improve their outcome. And really, I got into this as a critical care doctor and as a trauma doctor, trying to help people who had such severe injuries, they couldn't breathe on their own. Now, that care has evolved over the years, over that decade, you talk about where it used to be, only a procedure we talked about for the intensive care unit, to now, where we've seen that patients with three or more partially displaced rib fractures and uncontrolled pain or a little bit of difficulty breathing benefit greatly from surgery as well, where we can actually accelerate their recovery and not weeks off of their recovery from a breathing perspective and also improve their pain control with doing the surgery.

Erin Spain: [00:04:51] Share with me some of the success stories recently from patients and how you've been able to really transform their lives.

Evert Eriksson: [00:04:57] Sure. So really, two types of patients come to mind. One are my elderly patients. And, you know, a lot of people would say, "Oh, you know, I'm 70, I'm 80 years old. I've had this big trauma. Am I strong enough to undergo this big operation?" And what we found is that if we operate on those patients before they get sick, before they get their pneumonia, before they really splint a lot and get a lot of lung collapse, we can actually turn that course around, prevent them from getting pneumonia and actually decrease the mortality rate. Multiple rib fractures in a 70 or 80 year old can be a death sentence. The other patient that we really see a huge benefit from is our younger patients who we intervene early on and operate on them. We can get them to turn around and really get back to work, get back to life, get back to everything they enjoy doing much quicker than having to convalesce at home for multiple weeks or months on pain medication. So it really is a life changing operation for a lot of these patients after they have a really severe trauma.

Erin Spain: [00:05:58] Ideally, how soon would you like to see a patient after they've sustained the injury?

Evert Eriksson: [00:06:02] Well, that's the thing. Time is somewhat of the essence in this, in that we want to restore their physiology back to normal breathing as quick as we can. So ideally, we like to operate as soon as possible. And as soon as possible for us is really within 48 to 72 hours of the injury is ideal. Now we can operate at any time and sometimes we go beyond that window and that's okay. But the greatest benefit is found with early intervention. [00:06:28][26.0]

Erin Spain: [00:06:29] A lot of the treatments you've been talking about are housed within the chest wall injury center. This is a fairly unique center. Tell me about the concept.

Evert Eriksson: [00:06:38] Yeah. So this came about two years ago when we finished the Chest Wall Injury Society Non Flail study, which was a study looking at patients with three or more partially displaced rib fractures and some respiratory issues. And we found that fixing those patients accelerated their recovery. And what I had seen in my clinic was multiple patients coming to see me two, three, four weeks out from their injury who had been seen at other local emergency rooms. And these patients clearly would have benefited from early surgical intervention. So the idea of the Chest Wall Injury and Reconstruction Center came out of the idea that through telehealth and through expedited clinic visits, we could take patients who were seen one day in a emergency room somewhere in the low country, see them the follow up day, and either optimize their medical management and keep them at home, or if they were struggling with their rib fractures, bring them into the hospital and get them operated on quickly in order to provide the advancements in care that we've seen at MUSC really to the broader low country area and try and help people, you know, from state line to state line.

Erin Spain: [00:07:43] 2021 was pretty incredible as far as telehealth care goes for your clinic. Tell me how extraordinary this has been to be able to use telehealth to see patients?

Evert Eriksson: [00:07:53] Yeah, the telehealth expansion and the ability to provide telehealth has been awesome for the chest injury program. You can imagine if you have three or four or five broken ribs, the last thing you want to do is get in a car and drive two or 3 hours to see a doctor for 15 or 20 minutes and then have to drive two more hours back home again. What telehealth has allowed me to do is to see the imaging that's taken at any of the hospitals across the low country area. Talk to the patient at home via telehealth. They can stay at home where they're comfortable. We can have a very similar type visit over the Internet. I can provide them medical management over the Internet. And if we need to have surgical management, we already know that we're going to operate on them by the time they take that two hour drive to come see me. So it's really optimized the patient care and the patient experience with their injuries and not inconvenience them with the need to get out of their house, drive all the way to Charleston from wherever they're living, and then have to drive back home again. So it's really been a very patient centric expansion and has been a great thing for the chest wall program and allowed us to really expand the care of these patients beyond the Charleston area.

Erin Spain: [00:09:01] Yeah. In 2021, the rib clinic visits increased 320%, with more than 58% of those through telehealth. That's a pretty incredible statistic.

Evert Eriksson: [00:09:11] It's been an amazing expansion and we're seeing a whole lot of patients. And it was one of those things, you have this vision of something you want to build and you think it'll take off, but you underestimate how big it could really be. And this has really exploded for me to the point where I don't do regular general surgery all that much anymore. I do almost purely rib based surgery.

Erin Spain: [00:09:32] And you have people coming in from the East Coast, West Coast, Midwest to see you in the clinic.

Evert Eriksson: [00:09:36] Yeah, we do. For post traumatic injuries. We've had patients come from almost every state around us: Florida, Georgia, North Carolina, Tennessee and Kentucky. I can think of particular patients who have come from all those states to be seen after they've had acute chest wall injuries, whether that's flail chest or surgical abdominal hernias or that type of thing. And then the reaches become even larger when you look at the other rib conditions that we treat through the chest. All centers such as slipped rib and rib tips syndrome, we've had patients come from as far as California and Washington State, as well as New York and Florida for that treatment.

Erin Spain: [00:10:13] What are those conditions? Tell me a bit more about Rib Tips syndrome.

Evert Eriksson: [00:10:17] Slipped rib and Rib Tips syndrome are these entities that are not well known by the medical community. It isn't traditionally taught in medical school. And these are conditions where you have, in the case of slipped rib syndrome, you have a hypermobility or an increased mobility of the edge of the chest wall where your chest meets your belly. And if those ribs can move more than the normal person's ribs move, they can actually come up and impinge on nerves. There's a nerve that runs on the bottom of every rib and it can actually come up and pinch that nerve on the underside of the rib above it. And when that happens, those patients have exquisite pain, and that pain can extend onto their abdomen. It can extend back to their back, and it can be quite debilitating. And for a lot of these patients, it's an extremely frustrating condition to have because they're told by a lot of medical professionals, there's nothing wrong with you. You do traditional imaging and nothing shows up. They say, you know what? There's nothing there. You need to be on antidepressants, some nerve problem. It's in your head. And they're told this over and over again. And it's not uncommon for patients to have had surgeries done for different things that they think this may be, whether it's gallbladder disease or reflux disease or something like that, have multiple imaging done and seen tons of practitioners who don't diagnose them with this. And then eventually they finally find their way to someone who knows what it is. And they see me in clinic. And it is just crystal clear this is the problem. We take them to surgery and a few months later they feel considerably better.

Erin Spain: [00:11:44] You talked a lot about the pain involved with this, and I'm sure a lot of people are just using narcotics and trying to get through the day. Is that something that's a concern for some of these patients before they're able to find an expert like you?

Evert Eriksson: [00:11:56] Oh, absolutely. And many of them have histories of being suicidal, having overdoses, taking too much pain medicine. All those types of things are very common symptoms that we see with these patients with chronic pain, be it from either nonunion rib fractures or slipped rib syndrome, some of the other rib syndromes that can cause considerable pain. And these patients are just trying to find the right person who knows about these diseases to treat them. And that's why the Rib Center so important at MUSC is we've seen all these different diseases and we know how to treat them.

Erin Spain: [00:12:29] And not only are you performing surgeries there, there's some wraparound care that happens with all of these patients. Tell me about some of the other treatments that are offered that really helps them make a full recovery.

Evert Eriksson: [00:12:40] There are. So surgeries are not the complete answer to any of this. We have a great pain medication regimen that we put people on as well as we have a lot of specialists that help us out with this and part of its physical therapy, occupational therapy. There's ultrasonic therapy that can help with bone healing and bone remodeling. We also have interventional radiologists and physiatrists that can provide nerve injections and or other injections to mediate the pain that comes from some of these nonunion fractures. And some of these fractures, like when I talked about the nerve that runs with every rib, when you break that rib, sometimes you injure that nerve, too, and that can set up a situation for chronic pain. So we have a chronic pain management group that can also help optimize these patients so they live a better life.

Erin Spain: [00:13:28] Explain what rib plating is and what innovations are taking place at MUSC Health to offer these types of surgeries.

Evert Eriksson: [00:13:35] Yeah, we've done a couple innovative things here with respect to rib plating. There is a way to suture repair some of the cost of cartilage that really provides a nice construct there that's very, very stable. We use that quite a bit in the slipped rib syndrome, but I also use it in some of my trauma patients. We've also innovated in the way that we fix sternal fractures and reduce the sternal fractures with using some specialized instruments. And then the opportunity to place plates both intra-thoracic and extra-thoracic along the rib cage is a very unique surgical technique that's only available a few places, and we've been pioneering that here at MUSC. Rib plating itself is a surgery where we go in in a minimally invasive way. So we try and minimize the size of our incisions. We try to not cut any muscles or split the muscles in a way that the recovery is accelerated by that. And then we place titanium plates across the fractures and then hold them in place with specialized screws that screw down into the bone and hold the plate in the fracture in good position so that they don't move. And you can get normal bone healing if you break your arm, the orthopedic surgeons will put you in a cast to keep it from moving. We can't put a cast on the chest wall, so we need to go in and put some plates on there to stabilize those ribs. And that's really what helps them recover. Fortunately, we have some very advanced surgical techniques and surgical instruments that allow us to do this through very small incisions.

Erin Spain: [00:15:03] How are you able to share your knowledge with other surgeons, not only at MUSC Health, but around the country?

Evert Eriksson: [00:15:09] Well, I see we have a fairly robust research program here regarding chest wall injuries and chest wall reconstruction and recovery. And we try to publish those results and talk about those results at national meetings. The other area that's really been revolutionary for the chest wall injury community was the development of the Chest Wall Injury Society, and that started about six years ago. And it's a group of international thought leaders from really everywhere who get together, present their data, do collaborative studies, where we do international studies on chest wall reconstruction and have really tried to move the needle and prove the benefit of surgical stabilization of rib fractures. And that group's done a phenomenal job of that. And really, a lot of the big thought leaders have accelerated each other's thoughts through that collaboration.

Erin Spain: [00:16:00] Why would you encourage caregivers listening in to look into bringing their loved one to MUSC Health if they have a rib fracture or chest wall injury?

Evert Eriksson: [00:16:09] I think that's a great point. You know, the vast majority of trauma patients are men. And let's face it, a lot of guys don't tend to look for health care. They tend to want to deal with that at home. And that may or may not be the best decision. Really, the debilitating effect of rib fractures is the thing that can't be understated. It's not something that goes away if you are someone who uses your hands to work, if you're a carpenter, if you're a mechanic, even a surgeon such as myself, if you break your ribs, chances are you're not going back to work again if you have a flail chest, If you have multiple rib fractures, 66% of patients who have manual labor type jobs don't go back to work again. Now, that statistic improves significantly with rib fixation and restoring the chest wall and making it work properly again. And that's really what we're trying to do is we're trying to get people back to their normal life.

Erin Spain: [00:17:03] Is there anything else that we didn't get to that you'd like to reiterate or share?

Evert Eriksson: [00:17:08] Yeah, I think the rib fractures are not just pain medicine and conservative treatment anymore. Rib fractures require a multidisciplinary team to optimally care for those patients. Not everybody gets a surgery. Very, very few patients ultimately transition on to surgery. But the kind of multidimensional treatment that comes from a Chest Walls program is important for the optimal care of patients with rib fractures. And I think that's an important point to make that we've had so many advances since many of us went to medical school. The general community and the general medical group really need to be reeducated on what the optimal care is for this injury.

Erin Spain: [00:17:46] How long does it take from the point of someone reaching out to the center after an injury to be able to see you and your team?

Evert Eriksson: [00:17:52] So we have telehealth available five days a week, weekends access is a little bit more limited. And then we have a clinic one day a week and that's likely expanding to two days a week soon.

Erin Spain: [00:18:03] What do you do to optimize your health and live well?

Evert Eriksson: [00:18:06] I try to eat well, try to exercise. My wife would probably tell you I don't do a good job of either one of those on a regular basis, but try to be healthy. And then, you know, we live in the low country, so going to the beach, going out on the boat, going fishing and walking around and playing with the dog and the kids keeps me busy.

Erin Spain: [00:18:22] Thank you so much for coming on the show and sharing these great improvements that have been made in recent years. And we look forward to seeing what happens next with the expansion of the center.

Evert Eriksson: [00:18:31] Well, thank you very much. Thanks for having me. And I'm excited to see where all this leads as well.

Erin Spain: [00:18:39] For more information on this podcast, check out at advance.muschealth.org.