Rib Fixation Guidelines

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Rib Fixation Guideline


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.  

2.     Evaluate for retained hemothorax.  

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.  

 


References

 

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.