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

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.

[1]  F. Puma,et al.  Chest wall stabilization with synthetic reabsorbable materials as originally published in 1992: Updated in 1999 by , 1999 .

[2]  J. Kent,et al.  Resorbable plates for the fixation of mandibular fractures: a prospective study. , 2007, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons.

[3]  A. Iwasaki,et al.  Biosorbable poly-L-lactide rib-connecting pins may reduce acute pain after thoracotomy. , 2004, The Thoracic and cardiovascular surgeon.

[4]  J. R. Oyarzun,et al.  Use of 3.5-mm acetabular reconstruction plates for internal fixation of flail chest injuries. , 1998, The Annals of thoracic surgery.

[5]  N. Ashammakhi,et al.  Bioabsorbable Ciprofloxacin-Containing and Plain Self-Reinforced Polylactide-Polyglycolide 80/20 Screws: Pullout Strength Properties in Human Cadaver Parietal Bones , 2002, The Journal of craniofacial surgery.

[6]  K. Hagen MULTIPLE RIB FRACTURES TREATED WITH A DRINKER RESPIRATOR , 1945 .

[7]  J. Testart,et al.  Treatment of flail chest with Judet's struts. , 1983, The Journal of thoracic and cardiovascular surgery.

[8]  D. Trunkey,et al.  Operative stabilization of a flail chest six years after injury. , 2001, The Annals of thoracic surgery.

[9]  J. Richardson,et al.  Pulmonary disability after severe blunt chest trauma. , 1990, The Journal of trauma.

[10]  Coleman Fp,et al.  Fracture of ribs; a logical treatment. , 1950 .

[11]  T Sugimoto,et al.  Pulmonary contusion causes long-term respiratory dysfunction with decreased functional residual capacity. , 1991, The Journal of trauma.

[12]  E. Croce,et al.  Intercostal pleuroperitoneal hernia. , 1979, The Journal of thoracic and cardiovascular surgery.

[13]  C. Cocanour,et al.  A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. , 2006, American journal of surgery.

[14]  R. de Geest,et al.  Surgical stabilization of a rib fracture using an angle stable plate. , 2007, The Journal of trauma.

[15]  M. Eren,et al.  Open Fixation in Flail Chest: Review of 64 Patients , 2004, Asian cardiovascular & thoracic annals.

[16]  M. Fuenfer Chest wall stabilization with synthetic reabsorbable material , 2000 .

[17]  E. S. Jones,et al.  Intermittent positive pressure ventilation for the crushed chest: an epic in intensive care , 2001, Intensive Care Medicine.

[18]  K. Tayton,et al.  How stiff should semi-rigid fixation of the human tibia be? A clue to the answer. , 1983, The Journal of bone and joint surgery. British volume.

[19]  R. Wilson,et al.  The management of flail chest injury: factors affecting outcome. , 1990, The Journal of trauma.

[20]  E. A. Cohen Treatment of the flail chest by towel clip traction. , 1955, American journal of surgery.

[21]  V. Vécsei,et al.  [Surgical stabilization of thoracic wall fractures]. , 1991, Der Unfallchirurg.

[22]  P. Paavolainen,et al.  Effect of rigid plate fixation on structure and mineral content of cortical bone. , 1978, Clinical orthopaedics and related research.

[23]  I. A. Jaslow Skeletal traction in the treatment of multiple fractures of the thoracic cage. , 1946, American journal of surgery.

[24]  J. Landercasper,et al.  Long-term disability after flail chest injury. , 1983, The Journal of trauma.

[25]  F. Grover,et al.  Management of flail chest without mechanical ventilation. , 1975, The Annals of thoracic surgery.

[26]  Z. Ahmed,et al.  Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. , 1995, The Journal of thoracic and cardiovascular surgery.

[27]  R. T. McElvenny,et al.  Chest wall stabilization by soft tissue traction: a new method. , 1954, Journal of the American Medical Association.

[28]  R. Labitzke [Early thoracotomy and chest wall stabilization with elastic rib clamps (author's transl)]. , 1981, Zentralblatt fur Chirurgie.

[29]  J. Richardson,et al.  Operative Fixation of Chest Wall Fractures: An Underused Procedure? , 2007, The American surgeon.

[30]  S. Stephenson,et al.  New technic for stabilization of the flail chest. , 1966, American journal of surgery.

[31]  B. Regli,et al.  Long-Term Follow-up of Patients with Operative Stabilisation of a Flail Chest , 1997, The Thoracic and cardiovascular surgeon.

[32]  Y Ikada,et al.  Biodegradable plate fixation of rabbit femoral shaft osteotomies. A comparative study. , 1995, Clinical orthopaedics and related research.

[33]  K. Schmit-Neuerburg,et al.  Indication for thoracotomy and chest wall stabilization. , 1982, Injury.

[34]  G. Haasler Open fixation of flail chest after blunt trauma. , 1990, The Annals of thoracic surgery.

[35]  Benson Dw,et al.  Critically crushed chests; a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization. , 1956 .

[36]  M. Gugger,et al.  Pulmonary function testing after operative stabilisation of the chest wall for flail chest. , 2001, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[37]  Y. Ikada,et al.  Bioabsorbable struts made from poly-L-lactide and their application for treatment of chest deformity. , 1994, The Journal of thoracic and cardiovascular surgery.

[38]  J. Richardson,et al.  Painful nonunion of multiple rib fractures managed by operative stabilization. , 2000, The Journal of trauma.

[39]  Crutcher Rr,et al.  Multiple rib fracture with instability of chest wall. , 1956 .

[40]  C. Kirker-Head,et al.  Surgical repair of rib fractures in 14 neonatal foals: case selection, surgical technique and results. , 2010, Equine veterinary journal.

[41]  Valle Ar Management of war wounds of the chest. , 1952 .

[42]  E. Ruffini,et al.  Surgical management of flail chest. , 1999, The Annals of thoracic surgery.

[43]  A. Iwasaki,et al.  Results of surgical treatment for non-small cell lung cancer of 20 mm or less in diameter. , 2004, The Thoracic and cardiovascular surgeon.

[44]  P. Törmälä,et al.  Bioabsorbable implants in the fixation of fractures. , 2001, Annales chirurgiae et gynaecologiae.

[45]  R. Landreneau,et al.  Strut fixation of an extensive flail chest. , 1991, The Annals of thoracic surgery.

[46]  B. Heniford,et al.  Thoracoscopic resection of painful multiple rib fractures: case report. , 2002, The Journal of trauma.

[47]  F. W. Blaisdell,et al.  Operative stabilization for flail chest after blunt trauma. , 1978, The Journal of thoracic and cardiovascular surgery.

[48]  H. Plenk,et al.  [A new rib plate for the stabilization of multiple rib fractures and thoracic wall fracture with paradoxical respiration]. , 1979, Hefte zur Unfallheilkunde.

[49]  P. Schüpbach,et al.  [Therapy of the unstable thorax in serial fractures of the ribs]. , 1978, Schweizerische medizinische Wochenschrift.

[50]  R. Mullins,et al.  Absorbable plates for rib fracture repair: preliminary experience. , 2003, The Journal of trauma.

[51]  A. Granetzny,et al.  Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. , 2005, Interactive cardiovascular and thoracic surgery.

[52]  J. Richardson,et al.  Selective Management of Flail Chest and Pulmonary Contusion , 1982, Annals of surgery.

[53]  J. Bender,et al.  Management of close-range shotgun injuries to the chest by diaphragmatic transposition: case reports. , 1990, The Journal of trauma.

[54]  W. Ruschewski,et al.  Stabilization of Flail Chest by Compression Osteosynthesis - Experimental and Clinical Results , 1981, The Thoracic and cardiovascular surgeon.

[55]  J. Dykes,et al.  Early Reconstruction of the Crushed Chest , 1962 .

[56]  G. Almassi,et al.  Surgical Management of Multiple Rib Fracture , 2003 .

[57]  E. Brug,et al.  [Stabilization of the flail chest with tension band wires of ribs and sternum (author's transl)]. , 1979, Zentralblatt fur Chirurgie.

[58]  H. Ris,et al.  Osteosynthesis of the injured chest wall. Use of the AO (Arbeitsgemeinschaft für Osteosynthese) technique. , 1993, Scandinavian journal of thoracic and cardiovascular surgery.

[59]  M. Aufmkolk,et al.  Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion. , 1998, Journal of the American College of Surgeons.

[60]  J. Pastor,et al.  Surgical stabilization of traumatic flail chest. , 1975, Thorax.

[61]  Raymond Hurt The History of Cardiothoracic Surgery: From Early Times , 1996 .

[62]  P. Giannoudis,et al.  Operative stabilisation of painful non-united multiple rib fractures. , 2001, Injury.

[63]  C Lindqvist,et al.  Are there any complications with bioabsorbable fixation devices? A 10 year review in orthognathic surgery. , 2003, International journal of oral and maxillofacial surgery.

[64]  P. Bonnet,et al.  Traumatic extrathoracic lung herniation. , 2002, The Annals of thoracic surgery.

[65]  H. Matsuda,et al.  Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. , 2002, The Journal of trauma.

[66]  J. Roberts War Injuries of the Chest , 1940, Postgraduate medical journal.

[67]  M. Debakey The Management of Chest Wounds (Collective Review) , 1942 .

[68]  D. Benetti,et al.  [Surgical stabilization of post-traumatic flail chest. Our experience with 116 cases treated]. , 1995, Minerva chirurgica.

[69]  D. Livingston,et al.  CHAPTER 36 – PULMONARY CONTUSION AND FLAIL CHEST , 2008 .

[70]  D. Benson,et al.  Critically crushed chests; a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization. , 1957, The Journal of thoracic surgery.

[71]  H. Hoffmeister,et al.  [STABILIZING SURGICAL INTERVENTIONS ON THE THORAX IN FUNNEL CHEST CORRECTIONS AND INJURIES OF THE BONY THORAX]. , 1964, Medizinische Klinik.

[72]  N. Suleman,et al.  War injuries of the chest. , 1985, Injury.

[73]  J. Knuuti,et al.  Efficacy of bioabsorbable antibiotic containing bone screw in the prevention of biomaterial-related infection due to Staphylococcus aureus. , 2005, Bone.

[74]  W. Long,et al.  Operative chest wall fixation with osteosynthesis plates. , 2005, The Journal of trauma.

[75]  T. Tagawa,et al.  [Repair of intrathoracic visceral damage using video-assisted thoracoscopic surgery for blunt chest trauma and rib fixation at the site of mini-thoracotomy]. , 1998, The Japanese journal of thoracic and cardiovascular surgery : official publication of the Japanese Association for Thoracic Surgery = Nihon Kyobu Geka Gakkai zasshi.

[76]  R. Mullins,et al.  Rib fracture pain and disability: can we do better? , 2003, The Journal of trauma.

[77]  M. Oreskovich,et al.  Long-term disability associated with flail chest injury. , 1985, American journal of surgery.

[78]  R. Nirula,et al.  Rib Fracture Stabilization in Patients Sustaining Blunt Chest Injury , 2006, The American surgeon.

[79]  A Easter,et al.  Management of patients with multiple rib fractures. , 2001, American journal of critical care : an official publication, American Association of Critical-Care Nurses.

[80]  F. Luchette,et al.  Pain management guidelines for blunt thoracic trauma. , 2005, The Journal of trauma.

[81]  B. Moore,et al.  Operative stabilization of nonpenetrating chest injuries. , 1975, The Journal of thoracic and cardiovascular surgery.

[82]  R. Bell,et al.  The use of biodegradable plates and screws to stabilize facial fractures. , 2006, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons.

[83]  T. Nakamura,et al.  Bioabsorbable poly-L-lactide costal coaptation pins and their clinical application in thoracotomy. , 1999, The Annals of thoracic surgery.

[84]  J. Duffy,et al.  Review article Surgical aspects of chronic post-thoracotomy pain , 2000 .

[85]  Catherine G. Ambrose,et al.  Bioabsorbable Implants: Review of Clinical Experience in Orthopedic Surgery , 2004, Annals of Biomedical Engineering.

[86]  F. Coleman,et al.  Fracture of ribs; a logical treatment. , 1950, Surgery, gynecology & obstetrics.

[87]  S. Winn,et al.  Reduction of rib fractures with a bioresorbable plating system: preliminary observations. , 2008, The Journal of trauma.

[88]  A. Ledgerwood,et al.  Management of massive thoraco-abdominal wall defect from close-range shotgun blast. , 1971, The Journal of trauma.

[89]  T. Ellis,et al.  Biomechanical testing of a novel, minimally invasive rib fracture plating system , 2005 .

[90]  M. Longaker,et al.  Re: Bioabsorbable Ciprofloxacin-Containing and Plain Self-Reinforced Polylactide-Polyglycolide 80/20 Screws: Pullout Strength Properties in Human Cadaver Parietal Bones. Johanna Tiainen; Minna Veiranto; Esa Suokas; Pertti Törmälä, Timo Waris, Milomir Ninkovic, Nureddin Ashammakhi, J Craniofacial Sur , 2002 .