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 Table of Contents  
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 11-15

Surgical stabilization of rib fractures after penetrating thoracic injury: A chest wall injury society multicenter study

1 Division of Thoracic Surgery, Department of Surgery; Albert Einstein College of Medicine, Bronx, NY, 10467, USA
2 Division of Thoracic Surgery, Department of Surgery, Bronx, NY, 10467, USA
3 Center for Trauma and Critical Care, Department of Surgery, Washington, DC, 20037, USA
4 Division of Thoracic Surgery, Department of Surgery, Cali, Valle Del Cauca, Colombia

Date of Web Publication24-Dec-2020

Correspondence Address:
Jody M Kaban
1400 Pelham Parkway S Jacobi Medical Center Department of Surgery, Rm 510 Bronx, NY
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jctt.jctt_5_20

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Introduction: Surgical stabilization of rib fractures (SSRF) has emerged as an acceptable modality to manage chest wall injuries in select patients after blunt thoracic injury; however, its use in penetrating trauma has not been described.
Materials and Methods: An international, retrospective study was carried out in two centers who reported experience with SSRF following penetrating chest wall trauma. All adult patients (≥18 years) who underwent SSRF after penetrating thoracic trauma between January 1, 2008, and December 13, 2017 were included.
Results: Thirteen patients were enrolled in the study. The entire cohort was male with a median age of 28 years (interquartile range [IQR] 22, 33). Chest wall injury was due to firearm and impalement injuries in 10 (77%) and 3 (23%) patients, respectively. Indications for SSRF included chest wall instability (n = 8), mechanical ventilation or impending respiratory failure (n = 7), and pain (n = 4). Median time to SSRF was 24 h (IQR 20, 48). A median of 3 rib fracture lines (IQR 2, 4) were identified on imaging, and a median of 3 plates (IQR 2, 4) were placed in each patient. Six patients (46%) were extubated immediately after SSRF and the remainder required 3 (IQR 2, 6) days of mechanical ventilation. No patient required a tracheostomy. There were no cases of hardware failure, empyema, hemothorax, or death during hospitalization.
Conclusion: In this series, 13 patients with penetrating thoracic injuries underwent SSRF with improved clinical outcomes. These data demonstrate that SSRF can be safely and effectively utilized in patients with penetrating chest wall injuries.

Keywords: Chest wall injury, penetrating injury, penetrating thoracic injury, rib plating, surgical stabilization of rib fracture

How to cite this article:
Skendelas JP, Lewis ER, Sarani B, Galvis MV, Rojas MA, Kaban JM. Surgical stabilization of rib fractures after penetrating thoracic injury: A chest wall injury society multicenter study. J Cardiothorac Trauma 2020;5:11-5

How to cite this URL:
Skendelas JP, Lewis ER, Sarani B, Galvis MV, Rojas MA, Kaban JM. Surgical stabilization of rib fractures after penetrating thoracic injury: A chest wall injury society multicenter study. J Cardiothorac Trauma [serial online] 2020 [cited 2023 Jun 1];5:11-5. Available from: https://www.jctt.org/text.asp?2020/5/1/11/304867

  Introduction Top

Traumatic thoracic injuries affect all age groups with significant morbidity and mortality despite aggressive medical and surgical management and expeditious modern pre-hospital emergency care. Blunt and penetrating trauma to the thorax may result in a multitude of chest wall and underlying visceral injuries, some of which mandate intervention.[1],[2] Surgical stabilization of rib fractures (SSRF) has emerged as an acceptable modality to improve ventilation,[3],[4],[5],[6],[7] prevent pneumonia,[3],[4],[5],[6],[7] shorten intensive care unit and overall length of stay,[3],[4],[5],[6],[7] reduce cost,[7] avoid tracheostomy,[6] and decrease hospital mortality[4],[6] in patients with flail chest. More recently, a prospective study suggested that SSRF may also be useful in patients with displaced, non-flail pattern fractures.[8] Each patient in that study sustained rib fractures from blunt force trauma.

The most conservative SSRF consensus guidelines are defined by the Eastern Association for Surgery of Trauma (EAST); these guidelines recommended use only for the management of flail chest due to limited supportive evidence for pain control or repair of non-flail segments.[9] Recommendations for wider use were adopted by the Western Trauma Association (WTA), and provided a management algorithm for patients with more than 2 rib fractures whereby early fixation was recommended if a patient were greater than or equal to 65 years with “severe rib fractures,” as determined by a fracture pattern causing respiratory compromise or otherwise based on clinical judgment.[10] In addition, the Chest Wall Injury Society have released a broader but more refined approach for SSRF patient selection including presence of a flail segment, contiguous bicortical fractures, or failure of nonoperative treatment.[11] However, all of these guidelines are predicated on blunt force injury to the chest wall. To date, there are no reports regarding the use of SSRF for patients with rib fractures due to penetrating trauma. The aim of this study was to describe the use of SSRF and report short-term, hospital outcomes.

  Materials and Methods Top

A descriptive, retrospective, two-center study of all adult patients who underwent SSRF following penetrating chest wall trauma was performed. All patients age 18 years old and older who were injured between January 1, 2008, and December 31, 2017, were included. No patients were excluded during the report period. The baseline characteristics and short-term outcomes were provided by each institution for review and analysis. Medians (interquartile range, [IQR], 25th and 75th percentile) were used for all continuous and ordinal variables. No univariate or multivariate analysis was performed due to limited sample size. The study was approved by the institutional review board, or equivalent, at the participating institutions.

  Results Top

Thirteen SSRF patients were identified and enrolled. Baseline characteristics and injuries are summarized in [Table 1]. The entire cohort was male with a median age of 28 years (IQR 22, 33). Ten patients (77%) sustained firearm injuries due to unspecified weapon (n = 6), handgun (n = 3), or rifle (n = 1). No other ballistics data were available. Impalement during motor vehicle collision caused injury in the remaining three patients. Overall, the cohort had a median injury severity score (ISS) of 16 (IQR 9, 16), and an abbreviated chest injury score (ACIS) of either 3 (n = 5) or 4 (n = 8). A median of 3 rib fracture lines (IQR 2, 4) were identified on imaging and 3 total plates (IQR 2, 4) were placed in each patient. Fractures of ribs 4, 6, and 7 were the most common and accounted for 47% of all fractures. Most rib fracture lines were identified in either the posterolateral (44%) or lateral (22%) segment. The most common associated injury was hemo/pneumothorax (n = 10) and unspecified lung injury or pulmonary contusion (n = 6). Other associated injuries were less common and included the shoulder or scapula (n = 3), sternum (n = 2), heart (n = 1), thoracic aorta (n = 1), diaphragm (n = 1), liver (n = 1), or caused an open wound (n = 1). Most patients (n = 9) had multiple indications for SSRF including chest wall instability (n = 8), mechanical ventilation or impending respiratory failure (n = 7), and pain (n = 4). Patients with only one indication for SSRF (n = 4) all underwent the procedure for pain relief. Twelve patients (92%) had plating in the acute setting with a median time to SSRF of 24 h (IQR 20, 48). The decision was made to proceed with rib fixation in the remaining patient after a prolonged hospital course and failure for pain to improve. The composite frequency and rib fracture locations are described in [Table 2].
Table 1: Baseline characteristics

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Table 2: Frequency of fracture lines by location

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In total, 7 patients (54%) remained intubated after the procedure and received a median of 3 days of mechanical ventilation (IQR 2, 6). No patients required tracheostomy placement. Overall hospital length of stay was 6 days (IQR 5, 12). One patient developed a surgical site infection and acute respiratory distress syndrome. There were no cases of screw migration, plate fracture, empyema, or hemothorax during hospitalization. There were no cases of hospital death. Outcomes are summarized in [Table 3].
Table 3: Outcomes

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  Discussion Top

In this case series, 13 male patients underwent SSRF due to predominately firearm-related thoracic trauma. To the best of our knowledge, this is the first case series to characterize SSRF in patients with penetrating thoracic injury. The median ISS and ACIS were 16 and 4, respectively, which suggests that patients in our series often had severe yet isolated thoracic injuries. Only two patients had injuries to the heart, great vessels, or major aerodigestive tract structures. As in patients who sustain rib fractures following blunt force trauma, the majority of rib fractures in this study occurred in the posterolateral segment and affected ribs 4–7. Most patients recovered quickly following SSRF. No patient required tracheostomy placement and no significant complications were reported. Although we cannot determine an association between SSRF and postoperative outcomes since there are no other reports of penetrating trauma with or without SSRF to which we can compare our findings.

The results of this study are difficult to compare in the context of blunt thoracic trauma and SSRF literature. Arguably, none of the patients who underwent SSRF in this study met anatomic criteria for SSRF as established by EAST or WTA; however, that assessment is limited based on the data available for this series. A blunt thoracic trauma mechanism is much more likely to produce rib fracture patterns which meet these strict criteria compared to those with penetrating injuries. Forensic studies of autopsy specimens have demonstrated that missiles, from firearm-related injuries, may pass through intercostal spaces without evidence of rib injury, cause small defects without clinically significant fracture, or cause comminuted displaced fractures.[12] Injury to underlying thoracic structures may result in the absence of rib fracture or confer prohibitively high mortality before criteria for SSRF is considered.

There has been a recent trend in the SSRF literature to better describe the nonflail blunt thoracic injury patient population to move toward better understanding of who may benefit from SSRF. The Chest Wall Injury Society taxonomy consensus guidelines identified varying degrees of fracture displacement as well as individual fracture types as important factors in assessing degree of chest wall injury.[13] Fracture types were defined as simple (single fracture line without fragmentation), wedge (a second fracture line that does not span the entire rib), or complex (at least two fracture lines with fragmentation). In a subsequent study, patients with complex fractures were more likely to have pulmonary complications or adverse outcomes compared to other fracture types.[14] These patterns have been prospectively studied patients with 3 or more displaced rib fractures but without flail to assess the efficacy of SSRF in the nonflail population. Numeric pain scores were significantly lower and narcotic usage had a trend to being less in the operative group.[8] These studies in conjunction with the data here lead to the possibility that SSRF may have a role to play in the penetrating trauma population even without flail segments. Studies focusing on characterizing rib fracture patterns secondary to penetrating thoracic injury are now needed to determine the utility of SSRF in this population.

The use of SSRF in patients with non-anatomic criteria (e.g., respiratory failure) cannot be determined from this study alone and remains unclear in the blunt injury population as well.[15] Nevertheless, SSRF was performed within 2 days of injury in 11 patients (85%) and led to a favorable outcome with a median of 2 days of mechanical ventilation and no cases of tracheostomy placement. In larger studies in the blunt injury population, SSRF within 2–3 days of injury has been associated with decreased duration of mechanical ventilation and reduced hospital length of stay.[16],[17]

Given that this is the sole report of SSRF following penetrating chest wall trauma, it has limitations that we acknowledge. First, it consists of a small sample size. Second, there was no appropriate control or propensity matched group available for comparison with the SSRF cohort. Even if such a comparator group existed, the small sample size of this study precludes the ability to carry out meaningful statistical analysis. The decision to proceed with SSRF was made at the discretion of each surgeon. Unfortunately, due to the large number of gunshot wounds seen at each institution, we cannot evaluate the nature of the chest wall injuries in gunshot victims who did not undergo SSRF. Finally, patient outcomes were limited to observations upon hospital discharge. Additional studies will need to be performed to assess long-term recovery and associated functional outcomes in this population.

  Conclusion Top

SSRF is used in patients with severe blunt chest wall trauma but has not been described in patients with penetrating injuries. In this series, 13 patients underwent operative fixation for pain, respiratory failure, or chest wall instability without tracheostomy placement or hospital mortality. Although limited, this study has demonstrated that SSRF can be safely performed in patients with penetrating chest wall injuries without overt complications. Additional studies and prospective trials studies are required to further expand use of SSRF in patients with penetrating thoracic trauma.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

1. Cheema FA, Chao E, Buchsbaum J, Giarra K, Parsikia A, Stone ME, et al. State of Rib Fracture Care: A NTDB Review of Analgesic Management and Surgical Stabilization. Am Surg 2019;85:474-8.  Back to cited text no. 1
2. Majerick S, Pieracci FM. Chest wall trauma. Thorac Surg Clin 2017;27:113-21.  Back to cited text no. 2
3. Coughlin TA, Ng JW, Rollins KE, Forward DP, Ollivere BJ. Management of rib fractures in traumatic flail chest: A meta-analysis of randomised controlled trials. Bone Joint J 2016;98-B: 1119-25.  Back to cited text no. 3
4. 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;258:914-21.  Back to cited text no. 4
5. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013;216:924-32.  Back to cited text no. 5
6. Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: A meta-analysis. J Am Coll Surg 2013;216:302-110.  Back to cited text no. 6
7. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52:727-32.  Back to cited text no. 7
8. Pieracci FM, Leasia K, Bauman Z, Eriksson EA, Lottenberg L, Majercik S, et al. A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma Acute Care Surg 2020;88:249-57.  Back to cited text no. 8
9. Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, 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;82:618-26.  Back to cited text no. 9
10. Brasel KJ, Moore EE, Albrecht RA, deMoya M, Schreiber M, Karmy-Jones R, et al. Western trauma association critical decisions in trauma: Management of rib fractures. J Trauma Acute Care Surg 2017;82:200-3.  Back to cited text no. 10
11. Pieracci FM, Majercik S, Ali-Osman F, Ang D, Doben A, Edwards JG, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury 2017;48:307-21.  Back to cited text no. 11
12. Langley NR. An anthropological analysis of gunshot wounds to the chest. J Forensic Sci 2007;52:532-7.  Back to cited text no. 12
13. Edwards JG, Clarke P, Pieracci FM, Bemelman M, Black EA, Doben A, et al. Taxonomy of multiple rib fractures: Results of the chest wall injury society international consensus survey. J Trauma Acute Care Surg 2020;88:e40-e45.  Back to cited text no. 13
14. Clarke PT, Simpson RB, Dorman JR, Hunt WJ, Edwards JG. Determining the clinical significance of the Chest Wall Injury Society taxonomy for multiple rib fractures. J Trauma Acute Care Surg 2019;87:1282-8.  Back to cited text no. 14
15. Beks RB, Peek J, de Jong MB, Wessem KJP, Öner CF, Hietbrink F, et al. Fixation of flail chest or multiple rib fractures: Current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg 2019;45:631-44.  Back to cited text no. 15
16. Iqbal HJ, Alsousou J, Shah S, Jayatilaka L, Scott S, Scott S, et al. Early Surgical stabilization of complex chest wall injuries improves short-term patient outcomes. J Bone Joint Surg Am 2018;100:1298-308.  Back to cited text no. 16
17. Su YH, Yang SM, Huang CH, Ko HJ. Early versus late surgical stabilization of severe rib fractures in patients with respiratory failure: A retrospective study. PLoS One 2019;14:e0216170.  Back to cited text no. 17


  [Table 1], [Table 2], [Table 3]


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