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Current Surgery Reports

, 7:18 | Cite as

Timing of Surgical Stabilization of Rib Fractures

  • Michal RadomskiEmail author
  • Fredric Pieracci
Trauma Surgery (J. Diaz, Section Editor)
  • 25 Downloads
Part of the following topical collections:
  1. Trauma Surgery

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.

Keywords

Surgical stabilization of rib fractures Rib plating Rib fixation Flail chest Chest wall trauma 

Notes

Compliance with Ethical Guidelines

Conflict of interest

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

Human and Animal Rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

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

  1. 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.PubMedCrossRefGoogle Scholar
  2. 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.PubMedCrossRefGoogle Scholar
  3. 3.
    Vana PG, Neubauer DC, Luchette FA. Contemporary management of flail chest. Am Surg. 2014;80(6):527–35.PubMedGoogle Scholar
  4. 4.
    Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040–46; discussion 6–7.CrossRefGoogle Scholar
  5. 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.PubMedCrossRefGoogle Scholar
  6. 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.PubMedCrossRefGoogle Scholar
  7. 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. 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.PubMedCrossRefGoogle Scholar
  9. 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.PubMedCrossRefGoogle Scholar
  10. 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. PubMedCrossRefGoogle Scholar
  11. 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.PubMedCrossRefGoogle Scholar
  12. 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.PubMedCrossRefGoogle Scholar
  13. 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.PubMedCrossRefGoogle Scholar
  14. 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.PubMedCrossRefGoogle Scholar
  15. 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.PubMedCrossRefGoogle Scholar
  16. 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.PubMedCrossRefGoogle Scholar
  17. 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.PubMedCrossRefGoogle Scholar
  18. 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.PubMedCrossRefGoogle Scholar
  19. 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.PubMedCrossRefGoogle Scholar
  20. 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. 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.Google Scholar
  22. 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.PubMedCrossRefGoogle Scholar
  23. 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.PubMedGoogle Scholar
  24. 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.PubMedCrossRefGoogle Scholar
  25. 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.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Majercik S, Pieracci FM. Chest wall trauma. Thorac Surg Clin. 2017;27(2):113–21.PubMedCrossRefGoogle Scholar
  27. 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.PubMedCrossRefGoogle Scholar
  28. 28.
    Dabezies EJ, D’Ambrosia R. Fracture treatment for the multiply injured patient. Instr Course Lect. 1986;35:13–21.PubMedGoogle Scholar
  29. 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.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 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.PubMedCrossRefGoogle Scholar
  31. 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.CrossRefGoogle Scholar
  32. 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.PubMedCrossRefGoogle Scholar
  33. 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. PubMedCrossRefGoogle Scholar
  34. 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. PubMedCrossRefGoogle Scholar
  35. 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. PubMedCrossRefGoogle Scholar
  36. 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. 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.PubMedCrossRefGoogle Scholar
  38. 38.
    Cacchione RN, Richardson JD, Seligson D. Painful nonunion of multiple rib fractures managed by operative stabilization. J Trauma. 2000;48(2):319–21.PubMedCrossRefGoogle Scholar
  39. 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.PubMedCrossRefGoogle Scholar
  40. 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.Google Scholar
  41. 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.PubMedCrossRefGoogle Scholar
  42. 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.PubMedCrossRefGoogle Scholar
  43. 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.PubMedCrossRefGoogle Scholar
  44. 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.PubMedGoogle Scholar
  45. 45.
    Leavitt D. Non-union of three ribs. J Bone Joint Surg Am. 1942;24:932–6.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryDenver Health Medical Center and the University of Colorado School of MedicineDenverUSA

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