Surgical treatment of broken ribs uses plates to stabilize fractured ribs while they heal and hold the ribs in their correct anatomic location.
Fractured ribs, also referred to as broken or cracked ribs, are common in blunt chest wall trauma and active lifestyle injuries from cycling to football. The fractured ribs usually heal on their own without specific treatment, but a subset of patients have fractures that produce overlaying bone fragments that may produce symptoms like severe rib pain, respiratory compromise, chest wall deformity, and/or a clicking sensation. The pain/rib soreness with rib fractures can make coughing and sleeping uncomfortable and difficult.
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Surgical stabilization of rib fractures (aka rib plating) is underutilized, partly due to a perceived lack of evidence of benefit and unfamiliarity with the operation.
Recent meta-analyses and prior trials have provided evidence that rib fixation in flail chest injuries decreases the need for mechanical ventilation, decreases risk of pneumonia, and decreases mortality. Additionally, the Eastern Association for the Surgery of Trauma and the Rib Fracture Colloquium have provided statements supporting rib fixation in flail injuries. The role of rib plating for patients with non-flail rib fractures remains controversial and requires further study.
Rib fractures are common injuries associated with high energy chest wall trauma and carry with them significant morbidity and mortality .
Surgical stabilization of rib fractures (SSRF or “rib plating”) has gained increasing popularity in recent years with the development of new and improved rib fixation systems, growing interest in post-SSRF outcomes, and formation of chest wall injury consortiums including the Chest Wall Injury Society. Concomitantly, short-term data have consistently demonstrated improved outcomes in patients with flail chest injuries including earlier liberation from mechanical ventilation, decreased rates of pneumonia, decreased duration of hospitalization, decreased need for tracheostomy, and improved mortality.
While multiple studies including several randomized clinical trials and meta-analyses have demonstrated that patients with flail injuries suffering from respiratory failure likely stand to benefit from SSRF, there is little consensus on SSRF use in non-flail injury patterns . Yet, despite the proven benefit of SSRF for patients with flail chest, a recent National Trauma Database analysis demonstrated less than 1% utilization of SSRF for flail injuries.
Indications for SSRF remain a source of contention and are dependent on the patient’s injury pattern, physiology at presentation or time of consultation, and the potential for decompensation. Broadly speaking, SSRF in patients with flail chest leads to decreased pain, decreased duration of mechanical ventilation, decreased need for tracheostomy, shorter hospitalizations, and fewer days in the intensive care unit .
Contraindications for operative rib fixation largely follow the rule that if the primary driver of a patient’s clinical course is not related to the degree or extent of chest wall trauma, then they are likely to not benefit from SSRF. Common examples include those with underlying pulmonary contusion or severe traumatic brain injury (TBI). Pulmonary contusions can lead to hypoxic pulmonary vasoconstriction, subsequent ventilation–perfusion mismatching, and potentiate acute respiratory failure. In these cases, the underlying parenchymal pathology may drive clinical outcomes to a greater degree than chest wall instability, and therefore SSRF may not significantly impact a patient’s short-term recovery .