Prospective Clinical Trial of Surgical Intervention for Painful Rib Fracture Nonunion

Abstract

We performed a prospective clinical trial of resection with or without plate fixation for symptomatic rib fracture nonunion three or more months postinjury with 6-month postoperative followup. The McGill Pain Questionnaire (MPQ) and RAND 36 Health Survey were administered and activity level (sedentary, ambulatory, moderately active, vigorous), functional status (disabled, nonphysical labor, physical labor), and work status (employed, unemployed, retired, student) were queried pre- and postoperatively. Twenty-four patients 4 to 197 months (median, 16 months) postinjury underwent surgical intervention for one to four rib fracture nonunions (median, two nonunions). Evidence of intercostal nerve entrapment was present in nine patients (38%). MPQ Present Pain Intensity and Pain Rating Index and RAND 36 Physical Functioning, Role Physical, Social Functioning, Role Social, Bodily Pain, Vitality, Mental Health, and General Health were significantly improved at six months compared with study entry ( P < 0.05). Activity levels significantly improved ( P < 0.0001) but functional and work status did not change. Twenty-four-hour morphine equivalent dosage of opioids at study entry was 20.3 ± 30.8 (mean ± standard deviation) and at study completion was 9.4 ± 17.5 ( P = 0.054). Complications included one wound infection, two partial screw backouts, and one chest wall hernia at one year after resection of adjacent nonunions with significant gaps repaired with absorbable plates. Surgical intervention for rib fracture nonunion may improve chronic pain and disability but without change in functional or work status. Resection of adjacent nonunions with significant gaps may lead to chest wall hernia.

Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and Treatment

“…It has been suggested that all patients with flail chest or more than four rib fractures who are 45 years of age or older should be treated surgically (107). Intercostal nerve entrapment can lead to chronic pain due to fracture nonunion and can be treated with resection with or without plate fixation (108). A detailed discussion of surgical stabilization is beyond the scope of this article.…”

Surgical Treatment of Flail Chest and Rib Fractures: A Systematic Review of the Literature

“…However, there was no change in functional or work status overall. They did find that patients treated with resection and plating had superior results to resection alone with statistically significant subjective improvement in chronic pain and activity tolerance [30] . Additionally, Gauger et al performed a retrospective study that evaluated the outcomes of 10 patients with 16 symptomatic rib nonunions treated with reconstruction using iliac crest autograft and tension band plate with a locked precontoured plating system [31] .…”

“…This pain can be debilitating and may decrease respiratory effort resulting in atelectasis and pneumonia. Fabricant et al and Gauger et al have recently shown surgical fixation of symptomatic nonunion is a viable option for management [30,31] .…”

“…Pain also disturbs eating habits, sleeping habits, and can affect activities of daily living and ability to work. There are multiple reported methods of management of rib nonunions in literature [30,31] .…”

“…In a prospective review of 24 patients with rib nonunions, Fabricant et al performed resection of callous with or without rib plating, depending on the size of the gap [30] . < 1 cm led to plating or absorbable suture fixation while > 2 cm did not receive SSRF.…”