Rib Fixation

            Normally rib fractures are managed non-operatively using pain control and aggressive pulmonary hygiene.  However, patients with rib fractures are at risk for developing complications such as atelectasis, pneumonia, and respiratory failure because of poor chest wall mechanics and decreased ability to cough and clear secretions.  There are certain instances when the severity of these rib fractures may require surgical intervention with rib fixation.

Indications:

1.       Flail Chest

This is defined as fracture of four or more consecutive ribs in two or more places resulting in paradoxical movement of the chest wall during respiration.  Studies have shown that patients who undergo surgical stabilization versus conservative management tend to demonstrate a decreased incidence of pneumonia, fewer days on mechanical ventilation, shorter duration in the trauma ICU, reduced mortality rates, less chest wall deformity, improved pulmonary function status with less restrictive pattern, and even lower medical costs.

2.       Severe chest wall deformity

In a retrospective study by Soberg et al. of patients with severe chest wall deformity from blunt trauma, patients undergoing surgical stabilization versus those who were managed non-operatively showed significant benefits with less total intubation time (1.9 vs 13.3 days), less ICU length of stay (5.4 vs 21 days), and less chest tube duration (5.6 vs 16.8 days).

3.       Chronic pain, disability, or non-union

Malunion or nonunion of fractured rib segments can result in severe irritation that causes chronic pain, thus preventing patients from any significant movement.  Several case reports have shown success with surgical fixation of these rib fractures and only minor complications such as a postoperative hematoma and a subsequent wound infection that both resolved with medical management. 

4.       Pulmonary herniation

This is a rare injury where the lung parenchyma and pleura membranes protrude through a weakness in the thoracic cage.  Treatment with surgical fixation has not been assessed in a prospective randomized controlled trial but it was a popular choice among practitioners when surveyed about indications for surgical rib fixation (58% of trauma, orthopedic, and thoracic surgeons).      

  

5.       On retreat after thoracotomy

There are Level III recommendations from the Eastern Association for the Surgery of Trauma that supports surgical fixation “in severe unilateral flail chest or in patients requiring mechanical ventilation when thoracotomy is otherwise required”.  The indications for thoracotomy included retained hemothorax, intercostal artery hemorrhage, pulmonary laceration with persistent air leak and hemorrhage, pulmonary hematocele with hemoptysis, open pneumothorax, and diaphragm laceration.

6.       Failure to wean from mechanical ventilation

7.       Symptomatic fractures of 3 or more consecutive ribs

Operative Technique:

Like any surgery, rib fixation presents difficulties and obstacles which continue to be addressed with the advancement of newer techniques and equipment.  Some of these challenges are due to the unique shape and thin cortex of the rib which do not provide a lot of surface area for securing the cortical srews.  Problems can also arise if the intercostal neurovascular bundle that runs along the inferior border of the rib is impinged upon by the fixation hardware resulting in chronic pain.  Other various complications have been noted by Nirula and Mayberry in a review of the literature which included 704 patients who underwent surgical rib fixation after 1975.  The complications that were reported included 14 superficial wound infections, 9 patients with fixation failure, removal of hardware in 9 patients due to discomfort, 2 pleural empyemas, one persistent pleural effusion, one wound hematoma, and one case of osteomyelitis secondary to a contaminated chest tube. 

There are several different types of plates and fixation devices that have been used in order to try to overcome some of these technical challenges and avoid these complications.  The various types of hardware have included securing metal plates with wire cerclage, a Judet strut with crimps along the edges to secure it to the borders of the rib, the U-plate that only attaches to the superior aspect of the rib, 3.5mm reconstruction plates that require intraoperative contouring, and more recently introduced, anatomic, pre-contoured rib plates.   Preliminary trials have shown that biodegradable polymer materials may be safe and effective for fixation of rib fractures, except in the case of the stabilization of posterior rib fractures.  Some studies have shown high rates of fixation failure using absorbable plates in these instances.  Other devices, however, such as intra-medullary hardware with a pre-contoured rib splint using a locking screw for fixation may be especially useful for posterior rib fractures where extensive dissection is required to get adequate exposure for plate fixation.

Various Device Implants:

                       

Summary:

Surgical fixation of rib fractures has been a controversial mode of treatment in the past that is now gaining more support.  Anatomically contoured rib plates and intramedullary splints are helping to simplify the procedure and improve the success rates.  Further studies and research with rib fixation will help to expand the accepted indications and advance the technology used for this surgical procedure.

Sources:

·         Lube, MW. “Surgical Fixation of Rib Fractures”. Surgical Critical Care Evidence-Based Medicine Guidelines Committee. http://www.surgicalcriticalcare.net. February 6, 2013.

·         Fitzpatrick DC, Denard PJ, Phelan D, Long WB, et al. Operative stabilization of flail chest injuries: review of literature and fixation options. Eur J Trauma Emerg Surg. 2010; 36: 427-433.

from Jennifer Jolley, MD