Rib Fracture Repair: Indications, Technical Issues, and Future Directions

Abstract

Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib's relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

Risk factors for prolonged mechanical ventilation in patients with severe multiple injuries and blunt chest trauma: a single center retrospective case–control study

“…Despite progress in intensive care for severe trauma, blunt chest trauma frequently requires some ventilatory assist and is associated with significant mortality and morbidity 3, 4, 5, 6, 7…”

Traumatic flail chest injuries and the benefits of epidural analgesia

“…A flail chest, defined as three or more consecutive rib fractures in two or more locations creating a flail segment, can lead to numerous complications, such as chest wall instability, asynchronous movement of the flail segment, and paradoxical chest motion. It may also cause physical deformity of the chest wall and loss of thoracic volume [11]. These in turn lead to decreased lung volume, atelectasis, chest tightness, dyspnea, and chronic pain [12,20].…”

“…One of the cornerstones of management of multiple rib fractures and flail chest is appropriate analgesia [11,12,21]. We chose to study the benefits of epidural analgesia in patients with flail chest because we believe that this is an understudied topic and we adopt a more aggressive approach at our center with epidural use.…”

“…In a recent review of outcomes and treatment practices from the national trauma databank, Deghan, et al concluded that patients who have sustained a flail chest have significant morbidity (ICU admission, 82%; mechanical ventilation, 59%; need for chest tube, 44%; tracheostomy, 21%; ARDS, 14%; sepsis, 7%) and a high rate of mortality (16%) [10]. In addition, pulmonary contusions, prolonged mechanical ventilation, pneumonia, sepsis and poor pain control are common among patients sustaining flail chest injuries [7,[10][11][12].…”

Repair of flail chest using interfragmentary wiring and stability augmentation with basket-weave fashion sutures in a toy breed dog: a case report

“…This condition is not commonly observed in dogs and cats because of the compliance and anatomical shape of the thoracic cage, but the paradoxical movement accompanying pulmonary contusions may be life-threatening (Craven et al 1979;Orton 2003). Human medicine has introduced several methods including plates with wire cerclage (Moore 1975), intramedullary fixation (Moore 1975), Judet strut (Judet 1973), U-plate (Sales et al 2008) and absorbable plates (Mayberry et al 2003), as surgical techniques for rib fractures and the goal of ongoing research is to develop a minimally invasive form of therapy (Nirula et al 2009). However, in veterinary medicine, especially toy breeds, only a small number of reports are available dealing with the surgical treatment of rib fractures and available surgical techniques are limited because of small rib size (Knecht 1973;Shahar et al 1997;Olsen et al 2002).…”