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Timing of Surgical Stabilization of Rib Fractures

  • Trauma Surgery (J. Diaz, Section Editor)
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Abstract

Purpose of Review

Surgical stabilization of rib fractures (SSRF) has a proven benefit in patients with flail chest. However, the timing of intervention is currently unclear. We aim to evaluate and summarize current evidence related to the time interval for the surgical stabilization of rib fractures.

Recent Findings

Retrospective studies specifically addressing when to perform SSRF in patients with severely displaced rib fractures have reported a benefit for patients who underwent the procedure within 72 h of injury. There are currently no prospective trials specifically addressing timing of rib fixation. Delayed (i.e., months to years) SSRF may be indicated in highly select cases with both physical exam findings of “clicking” or instability and radiographic evidence of nonunion.

Summary

For patients in whom there are no contra-indications, current evidence suggests that surgical stabilization of rib fractures should occur as early as possible, and ideally within 72 h of injury. The decision to perform delayed SSRF should be undertaken cautiously and on a case-by-case basis.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Cameron P, Dziukas L, Hadj A, Clark P, Hooper S. Rib fractures in major trauma. Aust N Z J Surg. 1996;66(8):530–4.

    Article  CAS  PubMed  Google Scholar 

  2. Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011;93(1):97–110.

    Article  PubMed  Google Scholar 

  3. Vana PG, Neubauer DC, Luchette FA. Contemporary management of flail chest. Am Surg. 2014;80(6):527–35.

    PubMed  Google Scholar 

  4. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040–46; discussion 6–7.

    Article  CAS  Google Scholar 

  5. Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76(2):462–8.

    Article  PubMed  Google Scholar 

  6. Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest–outcomes of patients with or without pulmonary contusion. J Am Coll Surg. 1998;187(2):130–8.

    Article  CAS  PubMed  Google Scholar 

  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(4):727–32; discussion 32.

    Google Scholar 

  8. 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(5):924–32.

    Article  PubMed  Google Scholar 

  9. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4(6):583–7.

    Article  PubMed  Google Scholar 

  10. • Pieracci FM, Lin Y, Rodil M, Synder M, Herbert B, Tran DK, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg. 2016;80(2):187–94. This large, prospective study showed that SSRF was superior to medical management in severe rib fractures and fail chest.

    Article  PubMed  Google Scholar 

  11. 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(2):302–11.

    Article  PubMed  Google Scholar 

  12. 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(6):914–21.

    Article  PubMed  Google Scholar 

  13. Liang YS, Yu KC, Wong CS, Kao Y, Tiong TY, Tam KW. Does surgery reduce the risk of complications among patients with multiple rib fractures? A Meta-analysis. Clin Orthop Relat Res. 2019;477(1):193–205.

    Article  PubMed  Google Scholar 

  14. Swart E, Laratta J, Slobogean G, Mehta S. Operative treatment of rib fractures in flail chest injuries: a meta-analysis and cost-effectiveness analysis. J Orthop Trauma. 2017;31(2):64–70.

    Article  PubMed  Google Scholar 

  15. Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg. 2017;43(2):163–8.

    Article  PubMed  Google Scholar 

  16. 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(8):1119–25.

    Article  CAS  PubMed  Google Scholar 

  17. Schulte K, Whitaker D, Attia R. In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality? Interact Cardiovasc Thorac Surg. 2016;23(2):314–9.

    Article  PubMed  Google Scholar 

  18. 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(3):618–26.

    Article  PubMed  Google Scholar 

  19. 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(2):307–21.

    Article  PubMed  Google Scholar 

  20. National Institute for Health and Care Excellence. Insertion of metal rib reinforcements to stabilise a flail chest wall. London: NICE; 2010.

    Google Scholar 

  21. Cataneo AJ, Cataneo DC, de Oliveira FH, Arruda KA, El Dib R, de Oliveira Carvalho PE. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev. 2015(7):CD009919.

  22. Gauger EM, Hill BW, Lafferty PM, Cole PA. Outcomes after operative management of symptomatic rib nonunion. J Orthop Trauma. 2015;29(6):283–9.

    Article  PubMed  Google Scholar 

  23. Fabricant L, Ham B, Mullins R, Mayberry J. Prospective clinical trial of surgical intervention for painful rib fracture nonunion. Am Surg. 2014;80(6):580–6.

    PubMed  Google Scholar 

  24. Kane ED, Jeremitsky E, Pieracci FM, Majercik S, Doben AR. Quantifying and exploring the recent national increase in surgical stabilization of rib fractures. J Trauma Acute Care Surg. 2017;83(6):1047–52.

    Article  PubMed  Google Scholar 

  25. Bemelman M, de Kruijf MW, van Baal M, Leenen L. Rib fractures: to fix or not to fix? An evidence-based algorithm. Korean J Thorac Cardiovasc Surg. 2017;50(4):229–34.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Majercik S, Pieracci FM. Chest wall trauma. Thorac Surg Clin. 2017;27(2):113–21.

    Article  PubMed  Google Scholar 

  27. Gandhi RR, Overton TL, Haut ER, Lau B, Vallier HA, Rohs T, et al. Optimal timing of femur fracture stabilization in polytrauma patients: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2014;77(5):787–95.

    Article  PubMed  Google Scholar 

  28. Dabezies EJ, D’Ambrosia R. Fracture treatment for the multiply injured patient. Instr Course Lect. 1986;35:13–21.

    CAS  PubMed  Google Scholar 

  29. Chou YP, Lin HL, Wu TC. Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma. Curr Opin Pulm Med. 2015;21(4):393–8.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Chou YP, Kuo LC, Soo KM, Tarng YW, Chiang HI, Huang FD, et al. The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma. Eur J Cardiothorac Surg. 2014;46(1):107–11.

    Article  PubMed  Google Scholar 

  31. Smith JW, Franklin GA, Harbrecht BG, Richardson JD. Early VATS for blunt chest trauma: a management technique underutilized by acute care surgeons. J Trauma. 2011;71(1):102–5; discussion 5–7.

    Article  Google Scholar 

  32. Majercik S, Vijayakumar S, Olsen G, Wilson E, Gardner S, Granger SR, et al. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg. 2015;210(6):1112–16; discussion 6–7.

    Article  PubMed  Google Scholar 

  33. •• Pieracci FM, Coleman J, Ali-Osman F, Mangram A, Majercik S, White TW, et al. A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures. J Trauma Acute Care Surg. 2018;84(1):1–10. Largest study to date looking at compared outcomes of SSRF among three groups (< 24 hrs, 24-48 hrs, > 48 hrs). Found that earlier SSRF was of most benefit to the patient.

    Article  PubMed  Google Scholar 

  34. ••• Althausen PL, Shannon S, Watts C, Thomas K, Bain MA, Coll D, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011;25(11):641–7. Study found that earlier SSRF correlated with decreased ventilatory days, decreased ICU and hospital length of stay.

    Article  PubMed  Google Scholar 

  35. •••• 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(15):1298–308. This study compared the outcomes of SSRF in two groups, those with SSRF earlier than 48 hrs and those with SSRF after 48 hrs. The earlier SSRF had shorter ICU and hospital LOS, decreased ventilator days, less pneumonia, and a decreased tracheostomy rate.

    Article  PubMed  Google Scholar 

  36. Brinker MR, O’Connor DP. Nonunions: Evaluation and Treatment. In: Browner BD, Jupiter JB, Krettek C, Anderson PA, editors. Skeletal trauma: basic science, management, and reconstruction. 5th ed. Philadelphia: Elsevier; 2015. p. 637–718.

    Google Scholar 

  37. Marasco S, Liew S, Edwards E, Varma D, Summerhayes R. Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib? J Trauma Acute Care Surg. 2014;77(3):452–8.

    Article  PubMed  Google Scholar 

  38. Cacchione RN, Richardson JD, Seligson D. Painful nonunion of multiple rib fractures managed by operative stabilization. J Trauma. 2000;48(2):319–21.

    Article  CAS  PubMed  Google Scholar 

  39. Ng AB, Giannoudis PV, Bismil Q, Hinsche AF, Smith RM. Operative stabilisation of painful non-united multiple rib fractures. Injury. 2001;32(8):637–9.

    Article  CAS  PubMed  Google Scholar 

  40. Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: an underused procedure? Am Surg. 2007;73(6):591–6; discussion 6–7.

  41. Gardenbroek TJ, Bemelman M, Leenen LP. Pseudarthrosis of the ribs treated with a locking compression plate. A report of three cases. J Bone Joint Surg Am. 2009;91(6):1477–9.

    Article  CAS  PubMed  Google Scholar 

  42. Anavian J, Guthrie ST, Cole PA. Surgical management of multiple painful rib nonunions in patient with a history of severe shoulder girdle trauma: a case report and literature review. J Orthop Trauma. 2009;23(8):600–4.

    Article  PubMed  Google Scholar 

  43. Cho YH, Kim HK, Kang DY, Choi YH. Reoperative surgical stabilization of a painful nonunited rib fracture using bone grafting and a metal plate. J Orthop Trauma. 2009;23(8):605–6.

    Article  PubMed  Google Scholar 

  44. Beelen R, Rumbaut J, De Geest R. Surgical stabilization of a rib fracture using an angle stable plate. J Trauma. 2007;63(5):1159–60.

    PubMed  Google Scholar 

  45. Leavitt D. Non-union of three ribs. J Bone Joint Surg Am. 1942;24:932–6.

    Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, 777 Bannock St, MC 0206, Denver, CO, 80204, USA

    Michal Radomski & Fredric Pieracci

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  1. Michal Radomski
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  2. Fredric Pieracci
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Correspondence to Michal Radomski.

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Michal Radomski declares no potential conflicts of interest. Fredric Pieracci is a paid educator and has received research funding from DePuy Synthes.

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Radomski, M., Pieracci, F. Timing of Surgical Stabilization of Rib Fractures. Curr Surg Rep 7, 18 (2019). https://doi.org/10.1007/s40137-019-0238-9

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