今天谈谈另一个医学神话：
肋骨骨折的胸带固定
熟悉吗？多头胸腹带，年轻医生可能都没见过了！
胸带固定，至今仍是众多临床医生护士接诊处置胸部创伤肋骨骨折的标准做法！但是，一贯的做法就一定是对的吗？
美国创伤外科协会
肋骨骨折 – 美国创伤外科协会 (aast.org)
https://www.aast.org/resources-detail/rib-fractures
Clinical management of rib fractures and methods for prevention
of pulmonary complications: A review
斯坦福一级创伤中心指南
美国外科学会ATLS
没有一处出现“rib belt”，ATLS第10版通篇474页，“belt”倒是出现很多次，但都是以“seat-belt”和“lap-belt”组合出现。
这些老外指南又没说不能用！况且很多咱们的专著指南共识里面都说要胸带固定啊，你看！中华战创伤学胸部外伤卷里面都说了！就你在这里叽歪！
“指南又没说不能用”，很多临床医生会用这种逻辑来反驳，就像你说急诊室里的发热病人不能都用地塞米松去退烧，他会反驳说：哪个指南说地塞米松不能用于退烧？
指南也没说耗子药不能用于退烧啊！耗子药退烧多简单直接！不处理人的问题，就处理出问题的人，人挂了也就不存在发热问题了
老外的各种创伤指南，确实没明确文字写着反对胸骨骨折胸带固定，因为那在他们看来是根本不需要去回答的临床行为。肋骨骨折处理的关键点在于早期有效的镇痛和配合深呼吸咳嗽训练，目的是维持深呼吸氧合通气功能和有效咳嗽气道廓清能力，特别是老年肋骨骨折，早期管理直接影响并发症和死亡率。
胸带固定最初朴素的想法是通过限制胸廓运动来达到“想当然”的镇痛效果，而肋骨骨折管理的核心就是让胸廓能够有效运动以达到维持通气和廓清能力的目的，二者是完全背道而驰的事情！
实际上，Pubmed检索“rib fracture”和“belt”，几乎没有文献，除了两篇30多年前的文献。
第一篇：1989年
Use of rib belts in acute rib fractures
Am J Emerg Med 1989 Jan;7(1):97-100.
The current treatment for uncomplicated rib fractures is the exclusion of associated injuries followed by symptomatic treatment with analgesics. Encouragement of deep breathing is also recommended to avoid secondary or delayed pulmonary complications. The use of circumferential rib belts in treating patients with acute rib fractures has been discouraged because of possible complications from restricted ventilation. A review of the literature revealed no previous clinical studies to support this view. We designed and conducted a controlled, prospective, randomized pilot study to determine if there was any increased morbidity associated with the use of rib belts in the treatment of patients with acute rib fractures. Twenty-five adult patients with radiographically proven acute rib fractures were randomized into two groups. The first group was treated with analgesics and a standard circumferential rib belt (Zimmer Universal Rib Belt). The second group was treated with oral analgesics alone. Patients were contacted by telephone three days after the initial injury and then reexamined 14 days postinjury. Rates of pain resolution, compliance, and delayed complications were determined. Rib belts were not found to significantly reduce the severity of pain. Four complications (one case of bloody pleural effusion requiring hospitalization, two cases of asymptomatic discoid atelectasis, and one case of allergic contact dermatitis) were identified, all occurring in the group of patients receiving rib belts. This pilot study indicates that while rib belts are widely accepted by patients for control of pain, they appear to be associated with an increased incidence of complications.Clinical studies with larger sample sizes will be needed to confirm these findings.
The authors present a pilot study in which 20 patients with simple rib fractures were randomized prospectively into two treatment groups. One group received ibuprofen and the other group ibuprofen plus a rib belt for analgesia. There were no statistically significant differences observed in pulmonary function testing between the groups at initial visit, 48 hours, or 5 days. Atelectasis developed in four patients, two in each treatment group; there were no cases of pneumonitis. Patients with displaced rib fractures experienced a higher rate of hemo- or pneumothorax than did those with nondisplaced fractures (5/10 v 1/10). Patients with displaced fractures who used rib belts experienced a higher rate of hemothorax than those using oral analgesia alone (4/6 v 1/4). Patients using rib belts uniformly reported a significant amount of additional pain relief. The clinician can use a rib belt to provide additional comfort to the patient with fractured ribs without apparent additional compromise to respiratory parameters. A further study stratifying displaced and nondisplaced fractures has been initiated to clarify the possible contributing roles of displaced rib fractures and the rib belt in patients with displaced fractures.
最后，看看老外的Up主比较温和的观点
Rib fractures and rib belts – YouTube
https://www.youtube.com/watch?v=Y2KgDkzodOU
Are rib belts beneficial for rib fractures?
● Do patients with rib fractures even develop pneumonia?
o A prospective study was performed in four Canadian emergency departments and included patients discharged home with minor thoracic trauma. 347 patients had a least one rib fracture. Only 4 patients (1.1%) with rib fractures developed pneumonia.
o Underlying pulmonary disease may have increased the risk of pneumonia but the study was too small for statistical significance.Use of rib belts in acute rib fractures. Am J Emerg Med. 1989 Jan;7(1):97-100.
▪ 25 patients with radiographically proven rib fractures were randomized to a rib belt versus no rib belt. They were followed-up in 14 days. There was no difference in pain levels but patients with rib belts reported greater comfort.
▪ Complications occurred in 4 patients in the rib belt group and included a hemothorax, asymptomatic discoid atelectasis and contact dermatitis.A randomized clinical trial of rib belts for simple fractures. Am J Emerg Med. 1990 Jul;8(4):277-81.
▪ 20 patients were randomized to a rib belt versus no rib belt. Patients were followed for five days.
▪ What did they find? No difference in pulmonary function testing. A few patients in each group got atelectasis. They did note improvement in pain relief.
▪ Patients with displaced fractures did worse if they had a rib belt with a higher rate of hemothorax (4/6 versus 1/4). Patients with nondisplaced fractures had no major difference in complications.
● The evidence doesn’t support use of rib belts. However, it could be an option in healthy patients with non-displaced fractures and no underlying lung disease. We need more literature.
培训基地：浙大一院急危重医学科（之江院区）
这里有大型三甲教学医院中独有的急重症一体化管理！
这里是浙江省单中心ECMO数量最多的体外生命支持中心！
这里是没有挂牌的事实上的创伤中心！
这里是浙江省ECMO专项人才培训基地！
这里是浙江省急重症超声专项人才培训基地！
欢迎前来交流！
