Photos by Peter Hewitt
Injuries to the chest wall are pretty common, and vary in severity from minor bruising or an isolated rib fracture to severe and fatal crush injuries. While chest wall injuries are responsible for, or contribute to, 75 percent of trauma-related deaths, those on the less severe end of the spectrum – rib fractures and bruising – are usually left to heal on their own. Typically, the injuries (severe or not) are caused by an impact such as falling from a height, a car accident, or during contact sports. What doesn’t typically cause a chest wall injury? A sneeze. That is, unless you’re Lou Farrell.
“It’s not entirely unheard of for coughing or sneezing to cause a rib fracture, but usually that happens in the elderly, people with specific medical illnesses, or reduced bone density,” said Adam Shiroff, MD, FACS, director of the Penn Center for Chest Trauma and an associate professor of Surgery. “And typically, a cough- or sneeze-induced rib fracture would be so minor that patients would be sent home with a prescription for a painkiller, and the injury would heal itself in a few weeks. Certainly for someone who is healthy and active, Lou’s injury and subsequent road to recovery, is incredibly rare. I’ve never seen anything like it.”
It was December 2016 – the height of the holiday season. Lou, a 56-year-old, classically-trained French chef turned brewer, had been under the weather with a bad cough, but nothing you’d call extraordinary. It was mid-day and, not unlike most other days, Lou was walking through the brewery, carrying a full keg in each hand (for those of you doing the mental gymnastics, that’s about 150 pounds… in each hand), when it happened.
“It was a monumental sneeze, for sure,” said Lou, who remembers feeling what he describes as, “a twinge in my chest, but no great pain.”
Twelve hours later, that twinge grew into “pain that was through the roof,” and Lou and his wife Cathy headed to the Emergency Room at their local hospital where an x-ray revealed that that “twinge” was due to blood pooling in his chest because of a severed artery.
Lou’s injuries landed him in the ICU for a few days, with a chest tube draining the fluid in his lung. The doctors were unable to determine the cause of the bleeding, and sent him home with a prescription painkiller.
Animated Ribs.
There are 12 pairs of ribs in the human body. The upper seven pairs are directly attached to the sternum. Ribs eight through 10 are attached indirectly to the sternum through pieces of cartilage that make up the costal wall, while ribs 11 and 12 – known as “the floating ribs” – do not attach to the sternum at all.
What Lou’s doctors didn’t know when they sent him home was that in addition to his fracture (which would heal as expected in a few weeks), his injuries had caused the cartilage connecting his tenth rib to tear, separating it from the costal margin and the rest of the rib cage.
A few months after being sent home, Lou’s pain persisted and began taking a toll on his daily life. A long-time brewer, Lou was used to being on the go, lifting 50-pound sacks of grain, filling kegs, and carrying cases.
“I’m used to being able to lift cars if I need to, but I couldn’t do what I needed to – or wanted to – in daily life,” said Lou, adding that the only bright spot was that his son jumped in to help with daily operations at the brewery, giving Lou a chance to work alongside and train his son in the business.
With a worsening pain, Lou paid a visit to a local care provider who advised undergoing surgery to diagnose the cause of his pain. He was able to see the detached rib, and performed a standard and conservative procedure in which stitches were used to try and tie his rib to his sternum until the cartilage could heal. But, cartilage grows slowly, and six weeks later, the stitches gave out, causing the rib to “pop out” again. Over time, as Lou’s muscles stretched and gravity did what gravity does, the lower one-third of his rib cage continued to pull away from the upper two-thirds, creating a growing gap between his ninth and tenth ribs.
For more than a year, Lou suffered through the pain of a rib that never fully healed and a rib cage that was literally falling apart. Fed up with watching her husband live in pain, and not being able to do the things he loved – which, outside of his brewery included yoga – or even drive without pain in his ribs, Lou’s wife Cathy took to Dr. Google.
“She googled ‘best rib doctor,’ and there was Dr. Shiroff and Penn’s trauma center,” Lou said.
While it’s perfectly reasonable and sound for some patients with rib fractures to be given a prescription for pain management and sent home, in some patients, where four or more ribs may be broken or there’s an unusually traumatic injury, Shiroff says the growing body of research suggests sending them home with a prescription – which can easily snowball into addiction – is not the best practice. The alternative is a rib fixation, a relatively uncommon surgical procedure because it represents a dramatic shift in the approach to healing these injuries.
“The literature shows that performing early fixation with surgery can be beneficial for people with extreme injuries or whose lifestyle requires a faster healing,” Shiroff says, noting that for people whose jobs require a certain amount of mobility (such as a pilot or brewer, or athlete), may benefit from a surgical procedure that can get them back to where they need to be without painkillers. “We used to think there was nothing we could do but send people home and tell them to wait for their injury to heal, but technology has developing to a point where we can help these patients heal and get back to work and their daily lives faster.”
Shiroff met Lou and Cathy just days later to come up with a personalized game plan for what he describes as a “tough diagnosis” and “a strange problem.”
“I’d never seen anything like it where the rib cage was literally drifting away from itself,” Shiroff said. Fortunately, Shiroff was also preparing to attend the annual meeting of the Chest Wall Injury Society (of which Shiroff serves as President-Elect). There, he presented Lou’s case to get buy-in from other world experts in the field.
3D Model of Ribs.
Ultimately, Shiroff decided the best way to approach Lou’s injury would be to literally get his hands on it. He teamed up with industry partners to create a custom 3D-printed model of Lou’s ribs – both the bad side, and a mirror image of the good side. The life-size, 3D ribs would allow Shiroff to see what he was working with and come up with a solution before going into surgery.
The surgery was April 19, 2018, almost a full 18 months after “The Sneeze.”
The planned procedure, which would take about two hours, involved titanium plating the cartilage back into its natural position.
However, despite the preparation and 3D print of the rib cage, when Shiroff went in to operate, he noticed the separation was much greater than he had anticipated. Lou’s body weight had been slowly pulling it apart for months.
“We had a game plan to deal with the torn cartilage, but we didn’t know we would have to be as creative and come up with a solution for the dramatic separation,” said Shiroff. “We made up a solution on the fly.”
Their solution? Two plates, used for sternal fixation, were screwed into Lou’s ribs above and below the separation, taking pressure off the cartilage as it finally had the opportunity to heal.
“It was supposed to be a two-hour surgery, but it ended up being over four hours,” said Cathy, remembering that when Shiroff came out of the OR to talk to her, he said, “that was a lot of work!”
Lou’s titanium plates, screws, and suspension bridge are permanent fixtures in his chest, but for him and Cathy, it’s a small price to pay to finally be at the end of a very long and painful journey. Just two weeks after surgery, Lou was off painkillers and starting to get back to the life he’d known and missed for so long. Within six weeks he was back to doing yoga.
“I’m not back at it full bore, but I’m back at it. I’m doing yoga, I’m driving, I’m playing Disc Golf. It’s amazing to be doing all of these things after essentially not moving for 18 months,” said Lou, who also has plans to open his own brewery sometime next year – plans that he and his family are certain might never have seen the light of day. “This doesn’t happen if I’m still in pain. I couldn’t focus on the things I needed to do.”
The 3D model of Lou’s ribs still sit in Shiroff’s office. He’s promised to give them to Lou after his brewery opens. They’ll celebrate with a pint at the brewery’s first Rib Night.