|Year : 2019 | Volume
| Issue : 1 | Page : 41-47
Surgical stabilization of rib fractures
Adam M Shiroff1, Jane Keating1, Jose Ribas Milanez de Campos2, Thomas W White3
1 Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
2 Division of Thoracic Surgery, University of Sao Paulo, Sao Paulo, Brazil
3 Intermountain Medical Center, Salt Lake City, Utah, USA
|Date of Web Publication||30-Dec-2019|
Thomas W White
Intermountain Medical Center, Salt Lake City, Utah
Source of Support: None, Conflict of Interest: None
Multiple rib fractures from trauma are common and nonoperative management, including pain control and aggressive pulmonary care, are the mainstay of treatment. However, patients with hindered pulmonary function despite maximal medical therapy, either from acute pain or chest wall instability (flail chest) should be considered for surgical rib stabilization. Additionally, patients with persistent pain or with rib fractures that do not heal (nonunion) should also be considered for surgery. Indications, contraindications, surgical considerations, complications, and future directions of surgical stabilization of rib fractures are reviewed here.
Keywords: Chest wall injury, flail chest, surgical stabilization of rib fractures
|How to cite this article:|
Shiroff AM, Keating J, Milanez de Campos JR, White TW. Surgical stabilization of rib fractures. J Cardiothorac Trauma 2019;4:41-7
|How to cite this URL:|
Shiroff AM, Keating J, Milanez de Campos JR, White TW. Surgical stabilization of rib fractures. J Cardiothorac Trauma [serial online] 2019 [cited 2020 Jul 5];4:41-7. Available from: http://www.jctt.org/text.asp?2019/4/1/35/274205
| Introduction|| |
Chest wall trauma resulting in multiple rib fractures is common. In the United States, approximately half a million patients present to the emergency room with injuries to their chest wall each year, and one-third of these patients will be admitted to the hospital. This injury typically results from blunt mechanisms of injury (motor vehicle collisions, falls, and assaults), but can occasionally occur from penetrating injuries, such as gunshot wounds. The morbidity from chest wall injuries increases with age, number of rib fractures present, and flail chest, which has traditionally been defined as patients who have three or more contiguous ribs fractured in two or more places.
In patients not requiring mechanical ventilation, the tenants of nonoperative management include multimodal pain control and incentive spirometry in order to avoid the complications of progressive atelectasis and pneumonia. In a study of over 3000 blunt trauma patients, the most significant predictor for developing pulmonary complications was the presence of three or more rib fractures. Alternatively, patients with fewer than three rib fractures, no displacement, and no initial lung or other organ injuries, could be managed as outpatients. In the last two decades, surgical stabilization of rib fractures (SSRF) has become much more common. Many studies have shown improved outcomes with surgery compared to nonoperative management alone. In the USA, SSRF is performed by thoracic, trauma, and orthopedic surgeons. There is little established consensus over which patients should undergo SSRF; however, patients who have three or more acutely displaced rib fractures or patients with a flail chest should be considered for a repair regardless of whether they are requiring mechanical ventilation. Additional operative candidates include patients who “fail” optimal nonoperative management and patients with rib fractures undergoing thoracic surgery for an additional reason. The Chest Wall Injury Society (CWIS), established in 2016, is committed to improving the care of patients with chest wall injury and is attempting to understand and study the patterns of chest wall injury as well as optimal treatment of these patients.
Indications for SSRF, efficacy of the procedure, an overview of the operation, as well as complications of the surgery and future directions will be reviewed here.
| Indications for Surgical Stabilization of Rib Fractures|| |
Flail chest resulting in respiratory failure and mechanical ventilation is the strongest indication for SSRF. Traumatic flail chest injuries can be life-threatening and frequently involve admission to the intensive care unit (ICU) and prolonged invasive mechanical ventilation. As mentioned previously, flail chest is defined as two fractures in each of the three or more consecutive ribs. Patients with flail chest often suffer from the underlying pulmonary contusions and have inefficient pulmonary mechanisms, leading to respiratory failure. Furthermore, even if a patient does not require mechanical ventilation, in the long term, he/she may suffer from prolonged pain and chest wall deformity, leading to poor quality of life and inability to work.
An additional, commonly agreed-upon indication for SSRF is severely displaced rib fractures, with respiratory failure, with or without flail chest.
A third indication for SSRF is the patient who suffers from delayed and chronic nonunion as a result of previous rib fractures. The definition of a delayed nonunion fracture is one that has not healed within 3 months of injury. Chronic nonunion is defined as lack of bone healing 9 months following injury. These patients remain symptomatic, with the predominant symptom being persistent pain, which worsens with physical movement. Risk factors for chronic nonunion include smoking, alcohol use, malnutrition, use of steroids, nonsteroidal anti-inflammatory drug, diabetes, and Vitamin D deficiency. Similarly, patients undergoing thoracotomy for a reason other than rib fracture may also make good candidates for SSRF.
Elderly patients with rib fractures are increasingly encountered. These patients carry a significant increase of morbidity and mortality following chest wall injury. It has been shown that in patients >65 years old, SSRF decreases mortality and respiratory complications while improving respiratory mechanics and allowing for a quicker return to functional state. According to Fitzgerald et al., rib plating in the older trauma population results in decreased mortality and respiratory complications, improves respiratory mechanics, and allows for an accelerated return to function. It has also been shown that SSRF is safe and effective in elderly patients with osteoporosis.
There are several scoring systems available to help the physician assess the severity of rib injury following trauma. Most often, they utilize the number of rib fractures, fracture pattern, laterality, presence of flail segment, and presence of the underlying pulmonary contusions. There is no commonly agreed-upon scoring system that predicts the need for future SSRF. In general, the higher the score, the worse the outcome following injury, and all patients should be initially managed with pain control, pulmonary hygiene, and ventilation strategies, regardless of whether they are being treated with surgery.
| Contraindications to Surgical Stabilization of Rib Fractures|| |
Patients who are being actively resuscitated should not undergo SSRF. In addition, it is not known whether it is safe to perform SSRF in the setting of severe pulmonary contusion requiring advanced mechanical ventilation. Unstable spine fractures preclude safe SSRF, but there are anecdotal reports of concomitant spinal and chest wall repairs. There are some centers who suggest that performing SSRF early in patients with pulmonary contusions is desirable, whereas others perceive severe underlying pulmonary contusion as a contraindication to surgery. Certainly, patients with severe traumatic brain injury should not undergo immediate SSRF.
| Efficacy of Surgical Stabilization of Rib Fractures|| |
When indicated, SSRF reduces pain, improves pulmonary mechanics and function, and facilitates the healing of fractured bone. In patients undergoing surgery for flail chest, early operation is shown to reduce pulmonary complications, facilitate ventilator weaning, and shorten the duration of time of mechanical ventilation. A review published by the Eastern Association for the Surgery of Trauma including 22 studies and 988 patients with flail chest found that patients who underwent SSRF had improved pulmonary outcomes when compared to patients managed nonoperatively.
In a meta-analysis of available randomized controlled trials, Coughlin et al. compared the efficacy of nonoperative management to patients undergoing SSRF for flail chest. Three randomized controlled trials reported the results of 123 patients with flail chest. SSRF was associated with reduced pneumonia, reduced time on mechanical ventilation, reduced ICU, and total length of stay.,,,, The number of deaths was small, and there was no significant difference in mortality. Similarly, similar studies have shown that patients with displaced ribs with respiratory failure may also benefit from SSRF.
Fagevik Olsén et al. studied the respiratory and physical function, pain, range of movement, and kinesiophobia in patients with multiple rib fractures who had undergone stabilizing surgery and compared results with nonoperative patients. Although the study was small, they noticed a tendency for decreased pain and improved thoracic range of motion and physical function in the group that underwent SSRF. That same year, Pieracci et al. carried out a prospective, controlled evaluation of SSRF compared with medical management for severe rib fracture patterns in a 2-year clinical evaluation. These patients had one or more of the following rib fracture patterns: flail chest, 30% or greater hemithorax volume loss, and three or more fractures with displacement and experienced severe pain or respiratory failure even with optimal medical management. The authors concluded that compared with optimal medical management, operative patients had improved outcomes. In 2017, Uchida et al. evaluated the efficacy and indications of rib stabilization using a propensity score analysis of 187 patients with significant rib fractures. The surgically treated patients spent less time intubated, experienced a shorter duration of continuous intravenous narcotic, and had a shorter length of ICU stay. The nonoperatively managed patients had a significantly increased incidence of pneumonia. These authors concluded that early rib fixation is appropriate not only for patients with flail chest but also for repair of severe multiple rib fractures.
There have been a few small case series examining the role of surgery for patients with chronic nonunion of fractured ribs resulting in ongoing pain. Chronic nonunion occurs because of the unique characteristics of the fracture and/or because of poor healing factors of the patient. Isolated resection of the fibrous scar tissue from the nonunion site with or without formal plating may be utilized in surgical repair. The pain is thought to be the result of either the formation of an intercostal neuroma or from undue traction of the nerve. In this scenario, an operation serves to remove the capsule, or pseudo joint and resetting the ribs in a more anatomical orientation, and to allow for bony union. In two studies, the researchers found an improvement in objective pain score as well as quality-of-life measures following fixation.
In a retrospective study, Kocher et al. evaluated the cost-effectiveness of SSRF in patients with flail chest requiring mechanical ventilation. Sixty-one consecutive patients with flail chest underwent stabilization with a locking titanium plate fixation system. Sixty-two percent (n = 38) of the patients were free of mechanical ventilation within the first 3 days of surgery. A cost study showed that a reduction in ICU stay by 2 days would offset the cost of the SSRF. The authors concluded, therefore, that SSRF may reduce ventilator days, length of ICU stay, and therefore hospital costs for select patients with flail chest requiring mechanical ventilation.
Even though patient selection and timing of surgery appear to be important to a successful outcome, there is no consensus on the ideal timing of surgery. The timing of surgery should be made in the context of the patient's overall clinical status. Following acute trauma, early operation is aimed at resolving respiratory failure and the need for mechanical ventilation as well as mitigating pain. In a large multicentric trial with 731 patients, the investigators found that when compared to operation at the day of admission, each additional day to operative intervention was associated with a 27% increased risk of intubation, a 26% increased risk of tracheostomy, and a 31% increased risk of pneumonia. Therefore, it seems that earlier surgery, within 72 h of injury (and ideally within 24 h of injury), may be associated with better outcomes. Little is known regarding the safety of SSRF in the setting of known infection, particularly pneumonia or empyema. Two case studies have demonstrated the successful outcome of SSRF in patients with known sources of infection (fungal colonization of the mediastinum and empyema); however, because it is conceivable that ongoing infection may lead to hardware infection, it is reasonable to wait until the infection has been adequately treated.
| Preoperative Imaging|| |
A two-dimensional (2D) or three-dimensional (3D) computed tomography (CT) of the chest is the imaging study of choice to diagnose and characterize rib fractures following trauma. In addition, CT scan will aid in preoperative planning by allowing the measurement of the distance from a fixed landmark (the sternum for anterior fractures and the spinous process for posterior fractures) to the fracture in the rib. In addition, the curvature of the rib may be taken into account and easily identified on CT scan. Postoperative CT scans have also been used to show improved lung volumes following SSRF when compared to CT scans obtained preoperatively.
| Surgical Stabilization of Rib Fractures Technique|| |
With recent improvements of the materials and technique of SSRF, most rib fractures are amenable to fixation. Fractures in ribs 1 or 2 are extremely challenging to expose. These ribs have little contribution to respiratory physiology, and repair is usually avoided. Ribs 11 and 12 (the floating ribs) are also not critical to respiration. For these reasons, the target operative ribs are 3 through 10. Every reasonable attempt at minimizing muscle division using muscle sparing techniques is made. The posterior and lateral rib fractures are readily exposed through the auscultatory triangle (described by the medial scapula, latissimus dorsi, and trapezius muscle borders). Additional techniques which allow access to difficult-to-reach fractures have been described. These include percutaneous trocar access, hanging scapula retractors, stepladder incisions, and the use of 90° “low-profile” screwdrivers and drills.
Many surgeons routinely use video-assisted thoracoscopic surgery (VATS) in conjunction with rib fixation. VATS is safe and may add value by allowing the precise identification of fractures. VATS may allow for optimal incision placement to minimize length and muscle division, as well as facilitate total evacuation of hemothorax, optimize chest tube position, aid in fracture reduction, and rule out and repair pulmonary and diaphragm injuries. A totally thoracoscopic approach to SSRF has been described., A hybrid system, utilizing intrathoracic plates and percutaneous access, is now commercially available, but limited published data exist and the practical and the widespread application of this technique remains to be seen.
| Surgical Preparation|| |
Following adequate resuscitation of the traumatized patient with achievement of hemodynamic stability, as well as a thorough investigation of all injuries, a decision can then be made to undergo SSRF, preferably within the first 72 h from injury. As mentioned previously, 2D or 3D CT scanning can be of help in defining fracture extent, deformity, and instability of the chest wall; it may also help with incision planning; however, it is not absolutely necessary.
The patient should be optimized preoperatively with multimodal pain control, pulmonary hygiene, and pulmonary function evaluation. Often, a perioperative bronchoscopy is performed in order to clear secretions and assist in the placement of a double-lumen endotracheal tube if VATS is planned.
| Operation|| |
Most rib fractures are approached in a lateral or posterior decubitus positioning. For anterior or antero–lateral fractures, a supine position is optimal. Prone positioning with abduction of the ipsilateral arm rotates the scapula out of the way and allows exposure for posterior and subscapular fractures [Figure 1], [Figure 2], [Figure 3], [Figure 4].
|Figure 1: Preoperative three-dimensional chest computed tomography scan and postoperative chest X-ray|
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|Figure 4: Fracture reduction and plate application: Inset. Cross section of locking bicortical screw|
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Prior to incision, a first-generation cephalosporin antibiotic or its equivalent should be administered. Typically, one well-placed incision is used to expose all relevant fractures. Accurate incision placement will keep incision length and soft-tissue trauma to a minimum. Nontraditional skin incisions, such as oblique and vertical incisions, can be extremely useful in exposing specific fracture patterns and allowing for muscle splitting or sparing approaches. Opening of the triangle of auscultation can provide widespread exposure to posterior, lateral, and subscapular fractures. A second incision may be necessary if there are multiple distinct fracture lines.
After skin incision, a subcutaneous flap is developed in order to expose the multiple rib fractures. The fractures are reduced by lifting the depressed rib segment with a right-angled clamp or a finger. The ends of the fracture are then placed or “perched” in proper reduction. Clearing the rib of the anterior soft-tissue envelope while maintaining the periosteum is required for 2.5 cm on both sides of the fracture to allow for accurate placement of the prosthesis to the rib surface. There are several commercially available systems for SSRF, and each system is associated with both advantages and disadvantages. These systems utilize plates secured to the outer rib surface utilizing bicortical screws. Current systems have several design features in common, including semi-rigid fixation with anterior plate positioning and locking screws. The systems are low profile, are made up of titanium, and are malleable to fit the shape of the rib.
Because rib thickness is variable (8–12 mm), the ribs should be measured with a caliper prior to plating in order to determine the optimal bicortical screw length. One system incorporates a unicortical screw, and another popular system uses a u-plate design allowing for screw purchase of the plate in the front and back of the rib. Again, there should be at least 2.5 cm of plate fixation on both sides of the fracture. All systems use low-profile or right-angled drill and screwdriver instruments for fixing. In addition, trocar systems are available to minimize the length of incisions when direct 90° access to the plates with standard instruments is required. Although the stability of the chest wall increases with every rib fracture repair, it is not necessary to repair every rib fracture. When technically feasible, both fracture lines in a flail segment should be repaired.
Following fixation, absorbable sutures are used to close muscular spaces in the muscle-sparing incision in either an interrupted or running pattern. Closed suction drains in the subcutaneous space are at the discretion of the surgeon. A soft fluted 24 Fr thoracostomy tube allows for lavage of the pleural space with 1–2 L of warm saline, either blindly or video assisted. This virtually eliminates the troublesome retained hemothorax. The interoperative placement of a regional anesthesia catheter or intercostal block for postoperative pain control has become routine.
| Postoperative Care|| |
Postoperative care following SSRF involves timely extubation, pain control, early mobilization, and thoracostomy tube management. The procedure typically results in immediate pain relief, which allows for extubation either on the day of or the day following surgery. In the immediate postoperative period, pharmacologic anesthesia and/or regional analgesia should be continued and weaned over time. There is no need for prolonged prophylactic antibiotics, and they should be discontinued within 24 h of operation. Chest tube management is highly variable from institution to institution without obvious differences in outcomes or complications.
| Complications of Surgical Stabilization of Rib Fractures|| |
Overall, complications following SSRF are uncommon., The most clinically important complication is hardware infection because it may require hardware removal and the potential for nonunion. Some centers utilize systemic antibiotic therapy and vancomycin/gentamicin antibiotic beads for wound infection. In addition, patients who are considered high risk for wound infection may have beads placed prophylactically. There are limited single-center studies with small numbers of patients which report the rate of hardware infection between 0% and 10%.
Complications may be specific to the plating system itself, including reports of screw displacement. The displacement is likely a result of insufficient tightening, or “locking” of the screw at the time of plate insertion. In all cases, the displaced screws were asymptomatic., In addition, plates may fracture. To minimize the risk of this complication, manufacturers recommend against using plates to traverse gaps longer than 1–1.5 cm which can produce metal fatigue and plate fracture over time.
| Future Directions|| |
SSRF is increasing in popularity but is clearly underutilized, being performed in <1% of flail chest traumas. Conservative treatment, consisting of respiratory assistance and pain control, remains the preferred treatment in most patients with rib fractures. The relative infrequency of operative management is related to the lack of familiarity with the technique and possibly due to lack of subspecialty ownership of the procedure. Several subspecialties are involved in rib fixation, including orthopedic surgeons, trauma surgeons, and thoracic surgeons, all of which have demonstrated aptitude for SSRF. For those new to SSRF, there is a specific learning curve to the procedure. Novices should select patients with lateral fracture patterns and avoid the more difficult fractures at the extremes of exposure. Incision length will be reduced with experience. Surgeons who are new to osteosynthesis should consider seeking the help of an orthopedist.
As previously discussed, a number of studies have shown a shorter length of mechanical ventilation, ICU stay, hospital length of stay, in addition to reduced rates of pneumonia, improved pain, reduced need for tracheostomy. Mortality reduction has only been shown in a small number of studies. Although appropriate patient selection and timing are considered to be critically important, there is no consensus at this time. More randomized controlled trials are necessary to better determine which patients benefit from surgical fixation and the optimal timing for surgery.
The use of SSRF in nonflail rib fracture patients has recently being investigated by the CWIS nonflail trial. This is a multicentric trial comparing the outcomes of patients with three or more displaced rib fractures who were randomized to rib fracture repair or nonoperative management. We await the results in an upcoming publication. Another population of patients that has not been adequately studied are those with less impressive radiographic fracture patterns, refractory pain, and an uncomfortable “clicking” sensation at the site of injury. SSRF in patients with less dramatic fracture patterns remains unstudied and unclear.
New areas of research related to SSRF are emerging. Animal studies have shown that pulsed ultrasound may augment the healing of fractured ribs. This technique may be beneficial for patients with rib fractures; however, it would not serve as a replacement to surgical fixation, as surgical fixation facilitates pain control and resolves respiratory failure. As mentioned previously, large rib defects resulting from injury cannot be bridged using plates due to concern for plate fracture. In these cases, an autograft from the iliac crest may be used. Another option for bridging rib defects is the use of demineralized bone matrix. This is a collagen allograft that creates a scaffold to encourage the ingrowth of osteoblasts from osteoprogenitor cells. The role of bioabsorbable plates has yet to be fully elucidated.
As discussed in this review, SSRF has gained popularity in recent years. It is a promising treatment for patients with severe chest wall injury. As technology and technique continue to improve, an increasing number of surgeons are expected to gain the experience necessary to offer this important procedure to patients with severe rib fractures. Continued research is necessary to further illustrate additional indications, optimal timing of surgery, as well as the appropriate management of complications.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]