UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Surgical management of severe rib fractures

Author
Babak Sarani, MD, FACS, FCCM
Section Editors
Eileen M Bulger, MD, FACS
Joseph S Friedberg, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Multiple rib fractures are the consequence of significant forces impacting the chest wall and are most commonly due to blunt injuries (eg, motor vehicle crash, falls, assault), but penetrating injuries (eg, gunshot) can also fracture ribs. Conservative treatment includes pain control and aggressive supportive pulmonary care primarily aimed at avoiding the need for intubation, which is associated with increased rates of pneumonia and death. For patients who continue to have acute pain and are experiencing worsening pulmonary function in spite of optimal management (eg, flail chest) or those with rib fractures that do not heal (nonunion) and are causing persistent pain and functional impairment, surgical rib stabilization (also known as osteosynthesis) may be needed.

The indications, preparation, technique for rib fracture stabilization, and outcomes are reviewed here. Initial management of traumatic rib fractures is reviewed elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Inpatient management of traumatic rib fractures".)

INDICATIONS

Generally accepted indications for operative rib fixation include the presence of [1,2]:

Painful, movable ribs refractory to pain management strategies resulting in impending or actual respiratory failure. (See "Inpatient management of traumatic rib fractures", section on 'Pain control'.)

Significant chest wall deformity.

                   

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jul 2017. | This topic last updated: May 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002; 52:727.
  2. Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg 2009; 33:14.
  3. Bugaev N, Breeze JL, Alhazmi M, et al. Magnitude of rib fracture displacement predicts opioid requirements. J Trauma Acute Care Surg 2016; 81:699.
  4. Mayberry JC, Ham LB, Schipper PH, et al. Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. J Trauma 2009; 66:875.
  5. Dehghan N, de Mestral C, McKee MD, et al. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014; 76:462.
  6. http://www.east.org/tpg/pulmcontflailchest.pdf (Accessed on August 05, 2010).
  7. Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin 2007; 17:25.
  8. Voggenreiter G, Neudeck F, Aufmkolk M, et al. Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion. J Am Coll Surg 1998; 187:130.
  9. Majercik S, Cannon Q, Granger SR, et al. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg 2014; 208:88.
  10. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg 2012; 215:201.
  11. Kasotakis G, Hasenboehler EA, Streib EW, et al. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 82:618.
  12. Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017; 48:307.
  13. Simon B, Ebert J, Bokhari F, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73:S351.
  14. Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016; 80:187.
  15. Majercik S, Vijayakumar S, Olsen G, et al. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg 2015; 210:1112.
  16. Pieracci FM, Rodil M, Stovall RT, et al. Surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2015; 78:883.
  17. Majercik S, Wilson E, Gardner S, et al. In-hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures. J Trauma Acute Care Surg 2015; 79:533.
  18. Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg 2013; 258:914.
  19. Slobogean GP, MacPherson CA, Sun T, et al. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg 2013; 216:302.
  20. Nirula R, Allen B, Layman R, et al. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg 2006; 72:307.
  21. Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995; 110:1676.
  22. Althausen PL, Shannon S, Watts C, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma 2011; 25:641.
  23. Coughlin TA, Ng JW, Rollins KE, et al. Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials. Bone Joint J 2016; 98-B:1119.
  24. Cataneo AJ, Cataneo DC, de Oliveira FH, et al. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev 2015; :CD009919.
  25. Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005; 4:583.
  26. Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013; 216:924.
  27. Gauger EM, Hill BW, Lafferty PM, Cole PA. Outcomes after operative management of symptomatic rib nonunion. J Orthop Trauma 2015; 29:283.
  28. Fabricant L, Ham B, Mullins R, Mayberry J. Prospective clinical trial of surgical intervention for painful rib fracture nonunion. Am Surg 2014; 80:580.
  29. Gunay S, Candan H, Yılmaz R, et al. The Efficacy of Platelet-Rich Plasma in the Treatment of Rib Fractures. Thorac Cardiovasc Surg 2016.
  30. Sarani B, Schulte L, Diaz JJ. Pitfalls associated with open reduction and internal fixation of fractured ribs. Injury 2015; 46:2335.
  31. Pulley BR, Taylor BC, Fowler TT, et al. Utility of three-dimensional computed tomography for the surgical management of rib fractures. J Trauma Acute Care Surg 2015; 78:530.
  32. Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: an underused procedure? Am Surg 2007; 73:591.
  33. Hasenboehler EA, Bernard AC, Bottiggi AJ, et al. Treatment of traumatic flail chest with muscular sparing open reduction and internal fixation: description of a surgical technique. J Trauma 2011; 71:494.
  34. Marasco S, Liew S, Edwards E, et al. Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib? J Trauma Acute Care Surg 2014; 77:452.
  35. Nickerson TP, Thiels CA, Kim BD, et al. Outcomes of Complete Versus Partial Surgical Stabilization of Flail Chest. World J Surg 2016; 40:236.
  36. Mayberry J. Surgical stabilization of severe rib fractures: Several caveats. J Trauma Acute Care Surg 2015; 79:515.
  37. Livingston D, Hauser C. Trauma to the chest wall and lung. In: Trauma, 5th ed, Moore EE, Feliciano D, Mattox K. (Eds), McGraw Hill, New York 2004. p.513.
  38. Mohr M, Abrams E, Engel C, et al. Geometry of human ribs pertinent to orthopedic chest-wall reconstruction. J Biomech 2007; 40:1310.
  39. Marasco S, Quayle M, Summerhayes R, et al. An assessment of outcomes with intramedullary fixation of fractured ribs. J Cardiothorac Surg 2016; 11:126.
  40. Marasco SF, Liovic P, Šutalo ID. Structural integrity of intramedullary rib fixation using a single bioresorbable screw. J Trauma Acute Care Surg 2012; 73:668.
  41. Oxman DA, Issa NC, Marty FM, et al. Postoperative antibacterial prophylaxis for the prevention of infectious complications associated with tube thoracostomy in patients undergoing elective general thoracic surgery: a double-blind, placebo-controlled, randomized trial. JAMA Surg 2013; 148:440.
  42. Santana-Rodríguez N, Clavo B, Fernández-Pérez L, et al. Pulsed ultrasounds accelerate healing of rib fractures in an experimental animal model: an effective new thoracic therapy? J Thorac Cardiovasc Surg 2011; 141:1253.
  43. Thiels CA, Aho JM, Naik ND, et al. Infected hardware after surgical stabilization of rib fractures: Outcomes and management experience. J Trauma Acute Care Surg 2016; 80:819.
  44. Caragounis EC, Fagevik Olsén M, Pazooki D, Granhed H. Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study. World J Emerg Surg 2016; 11:27.
  45. Lardinois D, Krueger T, Dusmet M, et al. Pulmonary function testing after operative stabilisation of the chest wall for flail chest. Eur J Cardiothorac Surg 2001; 20:496.
  46. Erkmen CP, Zha M. Limitations of rib fixation for chest wall reconstruction. Insights Chest Dis 2016; 1:15.
  47. Kaplan T, Gulbahar G, Gundogdu AG, Han S. An unexpected complication of titanium rib clips. Ann Thorac Surg 2014; 98:2206.