INDICATIONS/CONTRAINDICATIONS

Indications

Annually, 350,000 people in the United States suffer from rib or sternal fractures. These injuries are associated with a lot of morbidity and mortality. Chest wall fractures result in severe pain, which results in shallow breathing and ineffective coughing, which in turn leads to sputum retention, atelectasis, pneumonia, and respiratory failure. Severe pain in the chest also affects the function of the whole body. The sharp edges of fracture can lacerate thoracic and abdominal organs and cause bleeding and pneumothorax. Displaced chest wall fractures result in chest wall deformities causing compromised lung function and unsightly cosmetic result. The severe physiologic compromise due to flail chest has been well established in literature.

Flail chest is established when two or more ribs are fractured at two places on each rib. It results in paradoxical movement of the flail segment and ineffective respiration. There are long-term consequences. Twenty five percent of these patients are permanently disabled. Only 40% eventually return to work. Forty nine percent have chronic pain, 63% dyspnea, and 57% abnormal spirometry.

Traditionally, chest wall fractures have been treated conservatively with the use of analgesics (oral, parenteral, intercostal nerve block, or epidural) or traditional stabilization methods (chest wall binder, Kirschner wire, Judet staple, or internal pneumatic stabilization with the use of the ventilator and positive pressure ventilation). However, these methods are slow in pain control and not very effective in addressing the residual deformity. The use of ventilator increases the risk of pneumonia and prolongs ICU and hospital stay. Return to work or normal life is delayed or denied.

In recent years, open reduction and internal fixation (ORIF) of chest wall fractures have evolved into a good strategy to treat chest wall fractures when indicated. ORIF of chest wall fractures results in rapid pain relief, correction of chest wall deformity, preservation of lung function, shortened ICU and hospital stay, and rapid return of body function and rapid return to work.

Althausen et al. (2011) compared 22 operatively managed patients and 28 case-matched controls. Patients who had undergone ORIF of rib fractures had shorter ICU stays, decreased ventilator requirements, shorter hospital stays, fewer tracheostomies, less pneumonia, less need for re-intubation, and decreased home oxygen requirements. In a “Best Evidence Topic” review article, Girsowicz et al. (2011) concluded that surgical stabilization improved outcomes in patients with isolated multiple distracted and painful nonflail rib fractures by reducing pain, improving respiratory function, improving quality of life, and reducing socio-professional disability.

ORIF of chest wall fractures can be carried out during the acute trauma phase or in the latent phase when patients present with symptomatic fracture nonunion.

Current indications for ORIF of chest wall fractures include:

1. Severe pain not relieved by traditional analgesic approaches.

2. Fractures resulting in ineffective respiratory physiology.

3. Chest wall deformity.

4. Fracture nonunion especially with pain.

Contraindications

ORIF of chest wall fractures is contraindicated when the patient is unstable, involved in other more severe life-threatening injuries, or when the patient is septic.

PREOPERATIVE PLANNING

In the evaluation of the trauma patient, basic ATLS principles should be followed. When the patient is stabilized, priority in the management of the multiple-trauma patient is established. The patient is carefully examined and the CT chest of the patient is thoroughly studied to identify the number and sites of chest wall fractures and plan is made regarding how many and which fractures to fix. In the presence of multiple chest wall fractures, ORIF of different fractures can be staged.

Not all fractures require ORIF. In general, the most painful or displaced fractures require ORIF. The less painful and nondisplaced fractures can heal conservatively once the major ones are fixed.

SURGERY

The author has experience in the use of MatrixRIB system and sternal fixation system from Synthes. The systems use titanium locking plates.

Advantages of titanium include:

1. Very stable and can remain in the body indefinitely

2. Good pliability allows precise adaptation to the contour of the chest wall

3. Minimal rebound after bending

4. Rare allergic reaction

5. Minimal interference with CT or MRI

The locking rib plates come precontoured to fit an average rib shape and minimize intraoperative bending. They are also color coded to distinguish left and right designs (Fig. 15.1). However, the eight-hole universal plate featured in the operative photos of this chapter is the author’s favorite. It can be bent to fit almost any fracture anywhere.

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