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.