Surgical Stabilization of Rib Fractures

Abstract

Background: Rib fractures are a common thoracic injury that is encountered in 20% to 39% of patients with blunt chest trauma and is associated with substantial morbidity and mortality 1 , 2 . Traditionally, the majority of patient with rib fractures have been managed nonoperatively. Recently, the utilization of surgical stabilization of rib fractures has increased considerably because the procedure has shown improved outcomes 3 - 5 . Description: Surgical stabilization should be considered in cases of multiple bicortically displaced rib fractures, especially in those with a flail chest and/or a concomitant ipsilateral displaced midshaft clavicular fracture or sternal fracture, as such cases may result in thoracic wall instability. For surgical stabilization of rib fractures, we classify rib fractures by location, type of fracture, and degree of displacement after obtaining thin-sliced chest computed tomography (CT) scans. The incision is selected depending on the fracture location, and the surgical technique is chosen relevant to the type of fracture. Single-lung intubation is preferred if there is no severe contralateral pulmonary contusion. We favor performing video-assisted thoracoscopy if possible to control bleeding, evacuate hematomas, repair a lung, and perform cryoablation of the intercostal nerves. A lateral approach is considered to be the main surgical approach because it allows access to the majority of rib fractures. A curvilinear skin incision is made overlying the fractured ribs. Posterior rib fractures are exposed through a vertical incision within the triangle of auscultation, and anterior fractures, through a transverse inframammary incision. The muscle-sparing technique, splitting alongside fibers without transection, should be utilized if possible and supplemented by muscle retraction. For surgical stabilization of rib fractures, we currently prefer precontoured side and rib-specific plates with threaded holes and self-tapping locking screws. Polymer cable cerclage is used to enhance plating of longitudinal fractures, rib fractures near the spine, osteoporotic ribs, and injuries of rib cartilage. The third to eighth ribs are plated most often. Intercostal muscle deficit, if present, is repaired with a xenograft patch. In comminuted rib fractures, the bone gap is bridged with bone graft. Surgical stabilization of rib fractures is recommended within the first 7 days after trauma, preferably within the first 3 days 6 - 8 . Alternatives: Nonoperative treatment alternatives include (1) epidural analgesia when not contraindicated because of anticoagulant venous thromboembolism prophylaxis 9 , 10 ; (2) thoracic paravertebral blockage, e.g., serratus anterior or erector spinae plane nerve block ...

Negative Pressure Wound Therapy Can Prevent Surgical Site Infections Following Sternal and Rib Fixation in Trauma Patients: Experience From a Single-Institution Cohort Study

“…As part of their work-up and pre-operative planning, all patients underwent a computer tomography scan of the chest with threedimensional reconstruction (Figure 1). The chest wall reconstruction method detailed by Fokin et al was utilized, using the DePuy Synthes Matrix rib and sternal plating systems (DePuy Synthes, West Chester, PA) [8]. For rib fixation, video-assisted thoracoscopic surgery (VATS) was used to identify and verify the areas of chest wall weakness before making the chest wall incision and placing fixation plates and screws.…”

Flail Chest: A Literature Review

“…Treatment for most patients with rib fractures is supportive care, consisting of aggressive pain control and pulmonary rehabilitation. (18) Based on (Fokin et al, 2020), there are indications for surgical stabilization for ribs fracture:…”

“…There are no clear guidelines which delineates indications for osteosynthesis in order to restore chest wall stability. It is justified for flail chest which causes severe deformity, and exceptionally for intractable pain (Townsend et al, 2016) In meta-analysis study, rib fixation for patient with flail chest had found to decrease mortality, shorten days on mechanical ventilation, hospital and intensive cate length of stay, decrease incidence of pneumonia and need for tracheostomy (Kasotakis et al, 2017) Surgical stabilization of rib fractures has shown success in managing flail chest (Yahn et al, 2021) Key steps for surgical stabilization of rib fractures include CT imaging (Figure 6) to choose the exact ribs for fixation, selection of optimal incision based on the fracture location, and selection of appropriate technique relevant to the type of fracture (Fokin et al, 2020).…”

Surgical stabilization of rib fracture patients versus nonoperative controls treated by a multidisciplinary team in a single institution

“…Stabilization of the chest wall, particularly when a flail segment is present, has been associated with reduced rates of pneumonia, number of days in the ICU, and in mortality [ 4 , 9 , 10 ]. Cohort studies and meta-analyses have revealed positive outcomes [ 7 , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] ].…”