Rationale:
Blunt thoracic trauma causes pulmonary dysfunction through
three primary mediators: inefficient
ventilation through disruption of pulmonary mechanics, atelectasis due to pain,
and pulmonary contusion.1 Rib
fixation has the potential to improve pulmonary mechanics and reduce pain from
fracture displacement.
Indications for Rib fixation in the acute setting:
1.
True
flail chest – Based on evidence and EAST guidelines2
2.
Severely displaced (bi-cortical) rib fractures
(as judged by admitting physician), generally three or more. –
Based on limited evidence and expert opinion
3.
Refractory pain or respiratory compromise –
Based on limited evidence and expert opinion.
Contraindications:
1.
Patients with severe traumatic brain
injury.
2.
Patients with severe pulmonary contusion as the
major driver of respiratory dysfunction and likely to require long term
positive pressure ventilation. 3,4
Next Steps:
1.
Obtain 3D
reconstructions of chest CT in patients who meet the above criteria. 3D recons are not indicated if not meeting
these criteria unless discussed with trauma attending, including those with
multiple non-displaced rib fractures regardless of the number fractured.
2.
Evaluate for retained hemothorax for potential clearance
at combined operation.
3.
Discuss with candidacy for rib fixation with
Trauma Attending, establish operative plan and positioning.
4.
Contact Jason Gerwe (Synthes representative)
regarding availability of hardware sets.
5.
Contact OR front desk preferably the night
before to discuss timing (<72 hours) and importance of performing operation
during daytime hours.
Rib Fixation Considerations:
1.
Rib fixation is optimally performed within the
first 72 hours after imaging for maximum benefit.
3.
Regional
analgesia should be considered/attempted for all patients undergoing rib
fixation without specific contraindications.
4.
Data are sparse on infection rate of
hardware. Empyema should be considered a
strong but relative contraindication to rib fixation.
5.
Not every level needs to be fixed, the goal is
to restore general chest wall integrity.
Attempt to stabilize both fractures in flail chest, but balance this
with the need for further incisions.
6.
Ribs 3-9 contribute the most to respiratory
function. Avoid plating 1,2, 11, 12.6
7.
Posterior fractures, those well buttressed by
latissimus dorsi and trapezius are generally well tolerated, avoid plating
these and anything within 2.5 cm of the transverse process of the vertebrae.6
8.
Plan incisions for maximal benefit and minimal
morbidity, split muscles instead of dividing, use right angle instruments if
needed.
9.
Consider intra-operative x-ray to rule out
pneumothorax if no current chest tube and no plans to place at time of
surgery.
10. Consider
use of fluoroscopy or intra-operative x-ray to confirm hardware placement when
utilizing intramedullary splinting.
1.
Davignon, et. Al. Patholophysiology and management of the flail
chest, Minerva Anestesiol. 2004 Apr;70(4):193-9
2.
Kasotakis, G. et. al. Operative fixation of rib fractures after
blunt trauma. J Trauma Acute Care
Surg. 2017 Mar;82(3):618-626.
3.
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;187:130–138.
4.
Teng J, Cheng Y, Ni D, et al.
Outcomes of traumatic flail chest treated by operative fixation versus conservative
approach. Journal of Shanghai Jiaotong University.
2009;29:1495–1498.
5.
Brasel, K et. al. Western Trauma
Association Critical Decisions in Trauma:
Management of Rib Fractures. .J Trauma Acute Care Surg. 2017;82:
200–203.
6.
Majercik, S., Pieracci, F. Thorac Surg Clin. 2017
May;27(2):113-121.
7.
Hasenboehler E, et. al. Treatment of traumatic flail chest with
muscular sparing open reduction and internal fixation: description of a
surgical technique.J Trauma. 2011 Aug;71(2):494-501.
