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World Journal of Surgery

, Volume 33, Issue 1, pp 14–22 | Cite as

Rib Fracture Repair: Indications, Technical Issues, and Future Directions

  • Raminder Nirula
  • Jose J. DiazJr.
  • Donald D. Trunkey
  • John C. MayberryEmail author
Article

Abstract

Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib’s relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

Keywords

Chest Wall Intercostal Nerve Absorbable Plate Pulmonary Contusion Surgical Fixation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Hurt R (1996) The management of fractured ribs and wounds of the chest. In: The history of cardiothoracic surgery from early times. Parthenon Publishing Group, New York, pp 231–265Google Scholar
  2. 2.
    Pare A (1634) The works of the famous chirurgion, Ambrose Pare (translated by Johnson). Cotes and Young, LondonGoogle Scholar
  3. 3.
    DeBakey M (1942) Management of chest wounds: collective review. Int Abstract Surg 74:203–237Google Scholar
  4. 4.
    Elkin DC, Cooper FW (1943) Thoracic injuries: review of cases. Surg Gynecol Obstet 77:271–278Google Scholar
  5. 5.
    Valle AR (1952) Management of war wounds of the chest. J Thorac Surg 24:457–481PubMedGoogle Scholar
  6. 6.
    Tagawa T, Itoh S, Ide S, Tanaka K, Yoshida K, Ohe H (1998) Repair of intrathoracic visceral damage using video-assisted thoracoscopic surgery for blunt chest trauma and rib fixation at the site of mini-thoracotomy. Jpn J Thorac Cardiovasc Surg 46:121–126PubMedCrossRefGoogle Scholar
  7. 7.
    Sing RF, Mostafa G, Matthews BD, Kercher KW, Heniford BT (2002) Thoracoscopic resection of painful multiple rib fractures: case report. J Trauma 52:391–392PubMedCrossRefGoogle Scholar
  8. 8.
    Jones TB, Richardson EP (1926) Traction on the sternum in the treatment of multiple fractured ribs. Surg Gynecol Obstet 42:283–285Google Scholar
  9. 9.
    Jaslow IA (1946) Skeletal traction in the treatment of multiple fractures of the thoracic cage. Am J Surg 72:753–755CrossRefGoogle Scholar
  10. 10.
    Hudson TR, McElvenny RT, Head JR (1954) Chest wall stabilization by soft tissue traction: a new method. JAMA 156:768–769Google Scholar
  11. 11.
    Cohen EA (1955) Treatment of the flail chest by towel clip traction. Am J Surg 90:517–521PubMedCrossRefGoogle Scholar
  12. 12.
    Coleman FP, Coleman CL (1950) Fracture of ribs: a logical treatment. Surg Gynecol Obstet 90:129–134PubMedGoogle Scholar
  13. 13.
    Crutcher RR, Nolen TM (1956) Multiple rib fracture with instability of chest wall. J Thorac Surg 32:15–21PubMedGoogle Scholar
  14. 14.
    Gray HR (1942) War injuries of the chest. Proc Mayo Clinic 17:566–572Google Scholar
  15. 15.
    Hagen K (1945) Multiple rib fractures treated with a drinker respirator. J Bone Joint Surg 27:330–334Google Scholar
  16. 16.
    Avery EE, Morch ET, Benson DW (1956) Critically crushed chests: a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization. J Thoracic Surg 32:291–311Google Scholar
  17. 17.
    Gordon IJ, Jones ES (2001) Intermittent positive pressure ventilation for the crushed chest: an epic in intensive care. Intensive Care Med 27:32–35PubMedCrossRefGoogle Scholar
  18. 18.
    Trinkle JK, Richardson JD, Franz JL, Grover FL, Arom KV, Holmstrom FM (1975) Management of flail chest without mechanical ventilation. Ann Thorac Surg 19:355–363PubMedGoogle Scholar
  19. 19.
    Richardson JD, Adams L, Flint LM (1982) Selective management of flail chest and pulmonary contusion. Ann Surg 196:481–487PubMedCrossRefGoogle Scholar
  20. 20.
    Freedland M, Wilson RF, Bender JS, Levison MA (1990) The management of flail chest injury: factors affecting outcome. J Trauma 30:1460–1468PubMedCrossRefGoogle Scholar
  21. 21.
    Simon BJ, Cushman J, Barraco R et al (2005) Pain management guidelines for blunt thoracic trauma. J Trauma 59:1256–1267PubMedCrossRefGoogle Scholar
  22. 22.
    Todd SR, McNally MM, Holcomb JB et al (2006) A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg 192:806–811PubMedCrossRefGoogle Scholar
  23. 23.
    McDowell A, Dykes J, Paulsen GA (1962) Early reconstruction of the crushed chest. Dis Chest 41:618–623CrossRefGoogle Scholar
  24. 24.
    Carlisle BB, Sutton JP, Stephenson SE Jr (1966) New technic for stabilization of the flail chest. Am J Surg 112:133–135PubMedCrossRefGoogle Scholar
  25. 25.
    Judet R (1973) Osteosynthese costale. Rev Chir Orthop Reparatrice Appar Mot 59(Suppl 1):334–335PubMedGoogle Scholar
  26. 26.
    Moore BP (1975) Operative stabilization of nonpenetrating chest injuries. J Thorac Cardiovasc Surg 70:619–630PubMedGoogle Scholar
  27. 27.
    Paris F, Tarazona V, Blasco E et al (1975) Surgical stabilization of traumatic flail chest. Thorax 30:521–527PubMedGoogle Scholar
  28. 28.
    Thomas AN, Blaisdell FW, Lewis FR Jr, Schlobohm RM (1978) Operative stabilization for flail chest after blunt trauma. J Thorac Cardiovasc Surg 75:793–801PubMedGoogle Scholar
  29. 29.
    Meier P, Schupbach P (1978) Therapy of the unstable thorax in serial fractures of the ribs. Schweiz Med Wochenschr 108:608–613PubMedGoogle Scholar
  30. 30.
    Albrecht F, Brug E (1979) Stabilization of the flail chest with tension band wires of ribs and sternum (author’s transl). Zentralbl Chir 104:770–776PubMedGoogle Scholar
  31. 31.
    Vecsei V, Frenzel I, Plenk H Jr (1979) A new rib plate for the stabilization of multiple rib fractures and thoracic wall fracture with paradoxical respiration. Hefte Unfallheilkd 138:279–282PubMedGoogle Scholar
  32. 32.
    Brunner L, Hoffmeister HE, Koncz J (1964) Stabilizing Surgical Interventions on the thorax in funnel chest corrections and injuries of the bony thorax. Med Klin 59:515–518PubMedGoogle Scholar
  33. 33.
    Tanaka H, Yukioka T, Yamaguti Y et al (2002) Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 52:727–732, discussion 32PubMedCrossRefGoogle Scholar
  34. 34.
    Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A (2005) Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 4:583–587PubMedCrossRefGoogle Scholar
  35. 35.
    Ahmed Z, Mohyuddin Z (1995) Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 110:1676–1680PubMedCrossRefGoogle Scholar
  36. 36.
    Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP (1998) Operative chest wall stabilization in flail chest: outcomes of patients with or without pulmonary contusion. J Am Coll Surg 187:130–138PubMedCrossRefGoogle Scholar
  37. 37.
    EAST Practice Management Workgroup for Pulmonary Contusion—Flail Chest (2006) Available at http://www.east.org/tpg.asp. Accessed 2 November 2007
  38. 38.
    Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB (2006) Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg 72:307–309PubMedGoogle Scholar
  39. 39.
    Hauser CJ, Livingston DH (2008) Pulmonary contusion and flail chest. In: Asensio JA, Trunkey DD (eds) Current therapy of trauma and surgical critical care. Mosby, Inc., pp 269–277Google Scholar
  40. 40.
    Easter A (2001) Management of patients with multiple rib fractures. Am J Crit Care 10:320–327, quiz 8–9PubMedGoogle Scholar
  41. 41.
    Landercasper J, Cogbill TH, Lindesmith LA (1984) Long-term disability after flail chest injury. J Trauma 24:410–414PubMedCrossRefGoogle Scholar
  42. 42.
    Beal SL, Oreskovich MR (1985) Long-term disability associated with flail chest injury. Am J Surg 150:324–326PubMedCrossRefGoogle Scholar
  43. 43.
    Livingston DH, Richardson JD (1990) Pulmonary disability after severe blunt chest trauma. J Trauma 30:562–566, discussion 6–7PubMedGoogle Scholar
  44. 44.
    Kishikawa M, Yoshioka T, Shimazu T, Sugimoto H, Yoshioka T, Sugimoto T (1991) Pulmonary contusion causes long-term respiratory dysfunction with decreased functional residual capacity. J Trauma 31:1203–1208, discussion 8–10PubMedCrossRefGoogle Scholar
  45. 45.
    Mouton W, Lardinois D, Furrer M, Regli B, Ris HB (1997) Long-term follow-up of patients with operative stabilisation of a flail chest. Thorac Cardiovasc Surg 45:242–244PubMedCrossRefGoogle Scholar
  46. 46.
    Lardinois D, Krueger T, Dusmet M, Ghisletta N, Gugger M, Ris HB (2001) Pulmonary function testing after operative stabilisation of the chest wall for flail chest. Eur J Cardiothorac Surg 20:496–501PubMedCrossRefGoogle Scholar
  47. 47.
    Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib fractures. Chest 124:295SGoogle Scholar
  48. 48.
    Kroeker A, Hoke N, Peck E, Mullins R, Ham B, Mayberry J (2008) Long-term morbidity, pain and disability following repair of severe chest wall injury. J Invest Med 56:210Google Scholar
  49. 49.
    Lang-Lazdunski L, Bonnet PM, Pons F, Brinquin L, Jancovici R (2002) Traumatic extrathoracic lung herniation. Ann Thorac Surg 74:927–929PubMedCrossRefGoogle Scholar
  50. 50.
    Croce EJ, Mehta VA (1979) Intercostal pleuroperitoneal hernia. J Thorac Cardiovasc Surg 77:856–857PubMedGoogle Scholar
  51. 51.
    Mayberry JC, Terhes JT, Ellis TJ, Wanek S, Mullins RJ (2003) Absorbable plates for rib fracture repair: preliminary experience. J Trauma 55:835–839PubMedCrossRefGoogle Scholar
  52. 52.
    Carrasquilla C, Watts J, Ledgerwood A, Lucas CE (1971) Management of massive thoraco-abdominal wall defect from close-range shotgun blast. J Trauma 11:715–717PubMedCrossRefGoogle Scholar
  53. 53.
    Bender JS, Lucas CE (1990) Management of close-range shotgun injuries to the chest by diaphragmatic transposition: case reports. J Trauma 30:1581–1584PubMedCrossRefGoogle Scholar
  54. 54.
    Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC (2003) Rib fracture pain and disability: can we do better? J Trauma 54:1058–1063, discussion 63–64PubMedCrossRefGoogle Scholar
  55. 55.
    Quell M, Vecsei V (1991) Zur Operativen Stabilisierung von Thoraxwandbruchen. Unfllchirurg 94:129–133Google Scholar
  56. 56.
    Cacchione RN, Richardson JD, Seligson D (2000) Painful nonunion of multiple rib fractures managed by operative stabilization. J Trauma 48:319–321PubMedCrossRefGoogle Scholar
  57. 57.
    Ng AB, Giannoudis PV, Bismil Q, Hinsche AF, Smith RM (2001) Operative stabilisation of painful non-united multiple rib fractures. Injury 32:637–639PubMedCrossRefGoogle Scholar
  58. 58.
    Iwasaki A, Hamatake D, Shirakusa T (2004) Biosorbable poly-L-lactide rib-connecting pins may reduce acute pain after thoracotomy. Thorac Cardiovasc Surg 52:49–53PubMedCrossRefGoogle Scholar
  59. 59.
    Slater MS, Mayberry JC, Trunkey DD (2001) Operative stabilization of a flail chest six years after injury. Ann Thorac Surg 72:600–601PubMedCrossRefGoogle Scholar
  60. 60.
    Richardson JD, Franklin GA, Heffley S, Seligson D (2007) Operative fixation of chest wall fractures: an underused procedure? Am Surg 73:591–596, discussion 6–7PubMedGoogle Scholar
  61. 61.
    Mayberry J, Ham B, Ellis TJ (2006) Thorascopic-assisted rib fracture repair: Trauma Surgery Video Session. Am Col SurgGoogle Scholar
  62. 62.
    Mayberry J, Peck E, Hoke N, Ham B (2007) Rib fracture non-union with intercostal nerve entrapment treated by thorascopic-assisted reduction and repair. Western Trauma Association, Steamboat Springs, CO Google Scholar
  63. 63.
    Sales JR, Ellis TJ, Gillard J et al (2008) Biomechanical testing of a novel, minimally invasive rib fracture plating system. J Trauma 64:1270–1274PubMedCrossRefGoogle Scholar
  64. 64.
    Rogers ML, Duffy JP (2000) Surgical aspects of chronic post-thoracotomy pain. Eur J Cardiothorac Surg 18:711–716PubMedCrossRefGoogle Scholar
  65. 65.
    Menard A, Testart J, Philippe JM, Grise P (1983) Treatment of flail chest with Judet’s struts. J Thorac Cardiovasc Surg 86:300–305PubMedGoogle Scholar
  66. 66.
    Reber P, Ris HB, Inderbitzi R, Stark B, Nachbur B (1993) Osteosynthesis of the injured chest wall. Use of the AO (Arbeitsgemeinschaft fur Osteosynthese) technique. Scand J Thorac Cardiovasc Surg 27:137–142PubMedGoogle Scholar
  67. 67.
    Oyarzun J, Bush A, McCormick J, Bolanowski P (1998) Use of 3.5-mm acetabular reconstruction plates for internal fixationof flail chest injuries. Ann Thorac Surg 65:1471–1474PubMedCrossRefGoogle Scholar
  68. 68.
    Actis Dato GM, Aidala E, Ruffini E (1999) Surgical management of flail chest. Ann Thorac Surg 67:1826–1827PubMedCrossRefGoogle Scholar
  69. 69.
    Engel C, Krieg JC, Madey SM, Long WB, Bottlang M (2005) Operative chest wall fixation with osteosynthesis plates. J Trauma 58:181–186PubMedCrossRefGoogle Scholar
  70. 70.
    Hellberg K, de Vivie ER, Fuchs K et al (1981) Stabilization of flail chest by compression osteosynthesis—experimental and clinical results. Thorac Cardiovasc Surg 29:275–281PubMedCrossRefGoogle Scholar
  71. 71.
    Bellezzo F, Hunt RJ, Provost R, Bain FT, Kirker-Head C (2004) Surgical repair of rib fractures in 14 neonatal foals: case selection, surgical technique and results. Equine Vet J 36:557–562PubMedCrossRefGoogle Scholar
  72. 72.
    Labitzke R (1981) Early thoracotomy and chest wall stabilization with elastic rib clamps (author’s translation). Zentralbl Chir 106:1351–1359PubMedGoogle Scholar
  73. 73.
    Tormala P, Rokkanen P (2001) Bioabsorbable implants in the fixation of fractures. Ann Chir Gynaecol 90:81–85PubMedGoogle Scholar
  74. 74.
    Ambrose CG, Clanton TO (2004) Bioabsorbable implants: review of clinical experience in orthopedic surgery. Ann Biomed Eng 32:171–177PubMedCrossRefGoogle Scholar
  75. 75.
    Laine P, Kontio R, Lindqvist C, Suuronen R (2004) Are there any complications with bioabsorbable fixation devices? A 10 year review in orthognathic surgery. Int J Oral Maxillofac Surg 33:240–244PubMedCrossRefGoogle Scholar
  76. 76.
    Bell RB, Kindsfater CS (2006) The use of biodegradable plates and screws to stabilize facial fractures. J Oral Maxillofac Surg 64:31–39PubMedGoogle Scholar
  77. 77.
    Laughlin RM, Block MS, Wilk R, Malloy RB, Kent JN (2007) Resorbable plates for the fixation of mandibular fractures: a prospective study. J Oral Maxillofac Surg 65:89–96PubMedCrossRefGoogle Scholar
  78. 78.
    Matsui T, Kitano M, Nakamura T, Shimizu Y, Hyon SH, Ikada Y (1994) Bioabsorbable struts made from poly-L-lactide and their application for treatment of chest deformity. J Thorac Cardiovasc Surg 108:162–168PubMedGoogle Scholar
  79. 79.
    Puma F, Ragusa M, Santoprete S et al (1999) As originally published in 1992: Chest wall stabilization with synthetic reabsorbable material. Updated in 1999. Ann Thorac Surg 67:1823–1824PubMedCrossRefGoogle Scholar
  80. 80.
    Tatsumi A, Kanemitsu N, Nakamura T, Shimizu Y (1999) Bioabsorbable poly-L-lactide costal coaptation pins and their clinical application in thoracotomy. Ann Thorac Surg 67:765–768PubMedCrossRefGoogle Scholar
  81. 81.
    Paavolainen P, Karaharju E, Slatis P, Ahonen J, Holmstrom T (1978) Effect of rigid plate fixation on structure and mineral content of cortical bone. Clin Orthop Relat Res 136:287–293PubMedGoogle Scholar
  82. 82.
    Tayton K, Bradley J (1983) How stiff should semi-rigid fixation of the human tibia be? A clue to the answer. J Bone Joint Surg Br 65:312–315PubMedGoogle Scholar
  83. 83.
    Hanafusa S, Matsusue Y, Yasunaga T et al (1995) Biodegradable plate fixation of rabbit femoral shaft osteotomies. A comparative study. Clin Orthop 315:262–271PubMedGoogle Scholar
  84. 84.
    Viljanen J, Pihlajamaki H, Kinnunen J, Bondestam S, Rokkanen P (2001) Comparison of absorbable poly-L-lactide and metallic intramedullary rods in the fixation of femoral shaft osteotomies: an experimental study in rabbits. J Orthop Sci 6:160–166PubMedCrossRefGoogle Scholar
  85. 85.
    Vu KC, Skourtis ME, Gong X, Zhou M, Ozaki WH, Winn SR (2008) Reduction of rib fractures with a bioresorbable plating system: preliminary observations. J Trauma 64:1264–1269PubMedCrossRefGoogle Scholar
  86. 86.
    Mitchell DE, Sewell D, Mayberry J (2003) Absorbable polylactide fracture repair prostheses may inhibit adherence and growth of Staphylococcus epidermidis. J Am Coll Surg 197:S45CrossRefGoogle Scholar
  87. 87.
    Mitchell DE, Mayberry JC (2007) In vitro staphylococcal adherence and growth on polylactide prostheses (unpublished data)Google Scholar
  88. 88.
    Tiainen J, Veiranto M, Suokas E et al (2002) Bioabsorbable ciprofloxacin-containing and plain self-reinforced polylactide-polyglycolide 80/20 screws: pullout strength properties in human cadaver parietal bones. J Craniofac Surg 13:427–433PubMedCrossRefGoogle Scholar
  89. 89.
    Makinen TJ, Veiranto M, Knuuti J, Jalava J, Tormala P, Aro HT (2005) Efficacy of bioabsorbable antibiotic containing bone screw in the prevention of biomaterial-related infection due to Staphylococcus aureus. Bone 36:292–299PubMedCrossRefGoogle Scholar
  90. 90.
    Schmit-Neuerburg KP, Weiss H, Labitzke R (1982) Indication for thoracotomy and chest wall stabilization. Injury 14:26–34PubMedCrossRefGoogle Scholar
  91. 91.
    Haasler GB (1990) Open fixation of flail chest after blunt trauma. Ann Thorac Surg 49:993–995PubMedGoogle Scholar
  92. 92.
    Landreneau RJ, Hinson JM Jr, Hazelrigg SR, Johnson JA, Boley TM, Curtis JJ (1991) Strut fixation of an extensive flail chest. Ann Thorac Surg 51:473–475PubMedCrossRefGoogle Scholar
  93. 93.
    Di Fabio D, Benetti D, Benvenuti M, Mombelloni G (1995) Surgical stabilization of post-traumatic flail chest. Our experience with 116 cases treated. Minerva Chir 50:227–233PubMedGoogle Scholar
  94. 94.
    Balci AE, Eren S, Cakir O, Eren MN (2004) Open fixation in flail chest: review of 64 patients. Asian Cardiovasc Thorac Ann 12:11–15PubMedGoogle Scholar
  95. 95.
    Beelen R, Rumbaut J, De Geest R (2007) Surgical stabilization of a rib fracture using an angle stable plate. J Trauma 63:1159–1160PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Raminder Nirula
    • 1
  • Jose J. DiazJr.
    • 2
  • Donald D. Trunkey
    • 3
  • John C. Mayberry
    • 3
    Email author
  1. 1.Surgery, Burns/Trauma/Critical Care SectionUniversity of UtahSaltlake CityUSA
  2. 2.Surgery, Division of Trauma, Emergency General Surgery, and Surgical Critical CareVanderbilt UniversityNashvilleUSA
  3. 3.Department of SurgeryOregon Health & Science UniversityPortlandUSA

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