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Invited Commentary
Rib Fracture Fixation: Controversies
and Technical Challenges
RAMINDER NIRULA, MD,* JOHN C. MAYBERRY, MD†

From the *Department of Surgery, Burns/Trauma/Critical Care Section, University of Utah, Salt
Lake City, Utah and the †Department of Surgery, Trauma/Critical Care/Acute Care Surgery,
Oregon Health and Science University, Portland, Oregon

Rib fractures are a common injury affecting more than 350,000 people each year in the United States and are
associated with respiratory complications, prolonged hospitalization, prolonged pain, long-term disability, and
mortality. The social and economic costs that rib fractures contribute to the health care burden of the United
States are therefore significant. But despite this measurable impact on patients' quality of life, current treatment
of the majority of patients in the United States with rib fracture syndromes is supportive only. Even the most
severe of chest wall injuries have historically been treated non-operatively. Recently, however, several reports
from American centers support an increased application of operative fixation. With this resurgent in-terest of
American surgeons in mind, we review the clinical presentations, potential indications, controversies, and
technical challenges unique to rib fracture fixation.

trauma centers, were treated nonoperatively. In fact,

R IB more
FRACTURES ARE people
than 350,000 A common
eachinjury
year affecting more
in the United
States.1 At least a third of patients with rib fractures will
require hospital admission and a third of these will suffer
nosocomial pneumonia, prolonged respiratory failure,
prolonged hospitalization, or death depending on their
associated injuries, age , and comorbidities.2–4 In
addition, patients with rib fractures are significantly more
disabled at 30 days postinjury when compared with
patients with chronic medical illness and lose an average
of 70 days of work or usual activity during their acute
recovery.5 Long- Term outcome studies of patients with
flail chest indicate that 50 to 60 per cent of patients
develop long-term morbidity, the most common problem
being persistent chest wall pain or deformity. Furthermore,
20 to 60 per cent of patients do not return to full-time
employment.6, 7 The social and economic costs that rib
fractures contribute to the health care burden of the
United States are therefore significant.
Despite this measurable impact on patients' quality of
life, current treatment of the majority of patients in the
United States with rib fracture syndromes is sup-portive
only.8, 9 Even the most severe of chest wall injuries
have historically, in the majority of American
Address correspondence and reprint requests to John C. Mayberry,
MD, Department of Surgery/L611, Oregon Health & Science Uni-
versity, 3181 SW Sam Jackson Park Road, Portland, OR 97239. E-
mail: mayberrj@ohsu.edu.
most active academic trauma surgeons in the United
States have neither performed nor observed a rib
fracture operative procedure and are unfamiliar with the
literature on surgical indications.9 The majority of
published experience with rib fracture fixation, in-cluding
two randomized trials, has come from centers outside
the United States.10–15 Recently, however, several
reports from American centers support an in-creased
application of operative rib fracture fixa- tion.16–20 With
this resurgent interest of American surgeons in mind, we
review the clinical presentations, potential indications,
controversies, and technical challenges unique to rib
fracture fixation.
Rib Fracture Syndromes
Flail chest is radiographically defined by at least three
consecutive ribs fractured in two or more places.
Clinically, a flail chest is diagnosed when the para-
doxical motion of an incompetent segment of chest wall
is visible with the patient's respiration. Flail chest can
occur laterally or anteriorly and the most common causes
are motor vehicle crash or fall from a height (Fig. 1). In a
sternal flail the sternum is dissociated from the
hemithoraces because of bilateral, multiple anterior
cartilage or rib fractures. This injury was in the past most
commonly seen from contact of the motor vehicle driver
with the rigid steering wheel,21 but with the advent of
seatbelts and airbags, the risk of serious

793
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794 THE AMERICAN SURGEON August 2010 Vol. 76

weeks duration and manifestation as multiple fractures in

half the patients. Serious complications associated with
cough fractures include chest wall hematoma, hemothorax,
pneumomediastinum, and pulmonary herniation.30–33
Rib fracture nonunions occur in an unknown but small
percentage of patients.34–36 Although a fibrous capsule
may envelope the fracture, bony union has not occurred
more than 3 months after injury (Fig. 2).
Nonunions may result in pain associated with move-ment
of the fracture and can be quite disabling for the patient.
Additionally, anterior chest trauma (eg, chest compressions
during cardio-pulmonary resuscitation),37 may fracture or
dislocate the cartilaginous segment bridging the gap from
the anterior rib to the sternum. A minority of these
cartilaginous injuries may also be-come nonunions.

Fracture Morphology
Rib fractures are either complete or incomplete
FIG. 1. Three-dimensional reconstruction of chest CT scan (''hairline'') and may be in near perfect alignment or have
demonstrate flail chest in a patient kicked by a horse. varying degrees of displacement (overlap). The fracture
line may be perpendicular or oblique to the rib body and
will occasionally ''spiral''. If the fracture ends are
thoracic injury during motor vehicle crash has dra- overlapping, the fracture is described as dis-placed (Fig.
matically decreased.22, 23 3a). The fracture ends may be displaced up to several
Chest wall implosion is a unique injury caused by centimeters depending on the location and severity of
posterolateral impact to the shoulder and upper thorax injury, the number of adjacent rib fractures, and the
and is characterized by multiple, displaced rib frac-tures degree of comminution. Distracted fractures occur in more
creating a fixed chest wall deformity behind the scapula, severe cases where the fracture ends are separated, in
a clavicle fracture or dislocation, and variably a scapular some cases by a significant distance (Fig. 3b). If the
fracture. 20 Paradoxical motion of the chest wall is not separation is more than 1 to 2 centimeters, the likelihood
present but the majority of patients with chest wall of primary fracture healing is diminished. Comminuted
implosion will require mechanical ventila-tion for fractures are those with multiple fracture lines within the
respiratory failure. Clinically these patients have acute same rib resulting in one or more bone fragments.
sequelae and long-term outcomes similar to patients with
flail chest.
Open chest wall defects occur after penetrating mis-
sile trauma, explosions, or blunt trauma where there is an
impalement.24 These patients are expected to have
displaced rib fractures, which may be comminuted and
may also have a portion of the chest wall missing with
exposed lung.
Pulmonary herniation (without an open wound) can
appear acutely, subacutely (within several weeks), or
chronically (several years) after injury.24–29 The
herniation of lung between fractured ribs is secondary to
damaged intercostal muscles. An anterior herniation due
to severe costochondral separation at the sternum usually
due to seatbelt trauma has also been described.
Cough fractures can be as debilitating as traumatic
fractures and although they more commonly occur in
patients with osteopenia, they have also been described
in the young and healthy.30 Cough fractures are more FIG. 2. Right postero-lateral rib fracture nonunion 3 years after
likely to occur in patients with cough of more than 3 motorcycle crash.
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No. 8 RIB FRACTURE FIXATION 795

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Nirula and Mayberry

years of age and progressively increased with in-creasing

age to a mortality rate of 22.5 per cent in those
85 or older. Patients over the age of 65 have almost a 2-
fold increase in mortality compared with younger pat-tients
when more than five ribs are fractured.43 The
risk of pneumonia and effusions as well as resources
utilization are considerably increased among the el-derly
with rib fractures compared with similarly in-jured younger
patients.

Management of Rib Fractures

Acute Pain Control
Few nonsurgical conditions cause more pain than rib
fractures and the pain may be more debilitating and
potentially harmful than the injury itself. Thank you
there are many options for chest wall analgesia.45, 46
Epidural pain control is the cornerstone of acute man-
agement and has been shown to improve pulmonary
mechanics and reduce pneumonia rates and ventilation
days.47, 48 Many trauma patients, however, for a variety
of reasons are not candidates for an epidural catheter.48
Severe rib fractures are thus optimally managed by
a multidisciplinary team including trauma surgeons,
pain management specialists, respiratory therapists, and
physical therapists.8, 46, 49 Patients older than 65 years
with two or more rib fractures or older than 45 years
with four or more rib fractures are optimally managed in
an intermediate or intensive care unit.4, 50–52

External Appliances
Chest wall taping or strapping for the stabilization of
multiple rib fractures and the relief of pain were common
FIG. 3. (A) Displaced left lateral multiple rib fractures in a
patient thrown from a horse. (B) CT scan demonstrating left posterior previously but its effectiveness has not been established.53–
severely distracting rib fracture in a patient involved in a tractor 56 Surgeons of the modern era became reluctant to tape
mishap. the chest wall because of concerns about excessive re-
spiratory restriction, the potential for increasing the
magnitude of rib fracture displacement, and because of
Associated Injuries a perceived lack of efficacy in the reduction of pain and
Half of all patients admitted to a hospital with rib mortality.57, 58 Drewes reported the spirographic com-
fractures have associated injuries that will be significant promise caused by chest wall strapping and recom-mended
impact their recovery.5, 38–40 Pneumothorax and/or its use cautiously and only in ambulatory
hemothorax is found in 30 to 40 per cent of inpatients patients.59 More recently, two small randomized trials
with rib fractures.40, 41 The risk of delayed hemothorax have indicated that commercially available rib belts
occurring more than 24 hours after injury is 4 per cent.42 may be effective in reducing rib fracture pain, but also
increase the risk of hemothorax.60, 61 It is reasonable to
assume that displaced or unstable rib fractures could be
Rib Fractures, Age, and Outcome
further displaced by rib belts and thereby cause iatro-genic
A number of studies have identified the increase bleeding or pulmonary damage.
mortality risk of rib fractures in the elderly.2, 4, 43
According to the 2006 Healthcare Cost and Utilization
Project National Inpatient Sample, 78,856 people were Operative Fixation: Historical Perspective
admitted with multiple rib fractures or flail chest.44 In Flail chest, known historically as ''stoved-in'' or
patients where flail chest was the principal diagnosis, ''crushed'' chest, had a high mortality up until a few
in-hospital mortality was 9.6 per cent for those 18 to 44 decades ago. Unilateral flail chest was treated with
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796 THE AMERICAN SURGEON August 2010
external strapping, the placement of sandbags, or by
positioning the patient laterally with the injured side
down. Bilateral flail or sternal flail could be treated
with external fixation combined with traction.62–65 The
complications of external fixation/traction, the pro-longed
bedrest necessary for fracture union, and the
occasional failure or inapplicability of this technique,
however, led surgeons to consider internal fixation. A
series of patients receiving wire suture fixation of rib
fractures were reported in 195058 and intramedullary
''Rush nail'' fixation was reported in 1956.66 The de-
velopment and success of positive pressure mechanical
ventilation, however, brought investigation of the ef-
ficacy of both external and internal fixation tempo-rarily
to a halt.67–70
In the 1960s and 1970s, a minority of surgeons rec-
ognized that select patients with flail chest might still
benefit from surgical fixation if a trial of ''internal sta-
bilization'' with mechanical ventilation fails. Sporadic
series of rib fracture repair using a variety of plating, wir-
ing, and intramedullary techniques were reported.71–79
Patients with severe deformities were also considered
candidates for fixation if the displaced rib fractures
or chest wall defect was considered too severe to heal
on its own, even with external fixation and traction.74
''On the way out'' or ''thoracotomy for other indication''
was reported as a valid indication for rib fracture re-
pair.71, 74, 75 Applying the used to reconstruction
pectus excavatum with a substernal stainless steel pros-
thesis, Brunner et al. successfully repaired sternal flail.80
Operative Fixation: Current Indications
and Controls
Flail Chest
Two small, single-center randomized trials suggested
that select patients with flail chest will benefit from
operative fixation. Tanaka et al.14 randomized 37 flail
chest patients require mechanical ventilation to sur-gical
stabilization or nonoperative management. The
surgically repaired group demonstrated significantly
Fewer days on the ventilator and in the intensive care
unit (ICU), had a lower incidence of pneumonia, had
better pulmonary function at 1 month, and had a higher
return to work percentage at 6 months than the non-
operative group. Granetzny et al.15 reported a ran-
domized trial of 40 patients in which the operative
group demonstrated significantly less mechanical ven-
tilation, ICU and inpatient days, and pneumonia
compared with a group of patients treated with an
external adhesive plaster. Visual chest wall deformity
or persistent flail chest were less in the operative group
whereas forced vital capacity and total lung capacity
were significantly higher at 2 months. Criticism of
these centers test on the small numbers of patients,
Vol. 76
the uncontrolled selection of patients for fixation,
and the lack of comparison to patients treated non-
operatively in a modern, tertiary ICU.81 There are also
several nonrandomized, cohort-comparison trials that
have generally confirmed the potential benefit of acute
fixation.12, 17, 82 For example, when preoperative me-
chanical ventilation days were subtracted from both
the operative patient and their case control, operative
patients were weaned from the ventilator on average 6
days sooner.17 Patients with severe associated injuries
and patients with significant pulmonary conditions as
well as elderly patients with significant comorbidities
were, however, in general excluded from the operative
arm of these comparative trials, emphasizing the im-
portance of patient selection for an expectation of a
successful outcome.83
The optimal number of days postinjury at which to
perform repair is not known. In the two randomized
trials mentioned above, one trial randomized patients
at 5 days14 and the other at 36 to 48 hours.15 Only 34
per cent of academic trauma, orthopedic, and thoracic
surgeons, however, chose flail chest with failure to
wean from mechanical ventilation after 7 days as
a valid indication for operative fixation.9 Certainly if
a surgeon waits too long to perform flail chest fixation,
days of potential liberation from mechanical ventila-tion
may be lost, but in our experience it is difficult to
predict early in the patient's hospital course whether
prolonged mechanical ventilation will be necessary.
Several authors have postulated that regardless of
the early benefits of operative fixation, patients with
severe fractures may benefit in the long-term with
lesser degrees of chest wall pain and disability. In one
series of flail chest fixation, 95 per cent of patients
reported 100 per cent working capacity and 86 per cent
had returned to preoperative levels of activities without
chest wall pain in a mean of 28 months.11 In another
series, operative patients reported equivalent or better
physical and mental outcomes than a reference pop-
ulation of comparable adult patients with one or more
chronic medical problems and equivalent health status
with the one exception of role limitations affected by
their physical problems compared with a younger co-
hort of adults reflection of the general population.19 In
contrast, the reported, historical long-term outcome of
a strictly nonoperative approach to severe chest wall
injury is problematic. Fifty to 60 per cent of patients
with severe chest wall fractures treated nonoperatively
develop long-term morbidity, the most common prob-
lems being persistent chest wall pain or deformity.6, 7
These nonoperative results are nearly 25 years out of
date, however, and need to be updated to be compa-
rable to the more modern operative results. Table 1
summarizes the potential benefits of and criticisms
against flail chest operative fixation.
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No. 8 RIB FRACTURE FIXATION
TABLE 1. Potential Benefits and Criticisms of Flail Chest
Fixation
Potential Benefits
1. Less days of mechanical ventilation
2. Less pneumonia
3. Less inpatient hospitalization
4. Less long-term pain and disability
Criticisms
1. Randomized trials are small and not comparable
to current intensive care standards
2. Associated injuries contribute more to disability
than chest injury
3. Current long-term outcome of nonoperative
treatment is unknown
4. Flail chest repair is meddlesome and unnecessary
in most patients
Acute Intractable Pain
The possibility that select patients with displaced and
movable rib fractures who do not require assisted
ventilation, but rather are experiencing persistent pain
with breathing, coughing, or mobilization from re-
cumbency, could have their fractures surgically stabi-
lized and thereby have their pain alleviated and return to
work/usual activity sooner than if the fractures were not
stabilized has been proposed but is unproven.19 Only 10
per cent of academic trauma, orthopedic, and thoracic
surgeons consider this a valid indication for surgical
intervention.9
Open Chest Wall Defect
An open chest wound with exposed and displaced rib
fractures is an obvious indication for operative in-
tervention but these patients are rare.19, 84 Rib frac-
tures in these potentially contaminated wounds can be
repaired with absorbable plates and absorbable suture
cerclage.85 Larger chest wall defects such as those
resulting from close-range shotgun blasts or explosions
are a formidable therapeutic challenge.86 A thorough
debridement of devitalized muscle, bone, skin, and
removal of foreign bodies will result in a large defect over
which soft tissue coverage by rotation of myo-cutaneous
flaps will likely be necessary. A biologic tissue patch may
also be used to bridge the defect.
Pulmonary Herniation
Intercostal muscle defects may be closed by suturing
the surrounding ribs together or by placing an in-
trathoracic biologic tissue patch.19, 25, 31, 32, 87 In
children, repair is not always necessary; spontaneous
resolution has been observed.26, 29 Anterior herniation
has been successfully repaired with wire suture, ab-
sorbable mesh patch, and biologic tissue patch.19, 24,
27, 28, 88 Fifty-eight per cent of academic trauma, or-
thopedic, and thoracic surgeons agree that chest wall
Nirula and Mayberry 797
defect/pulmonary herniation is a valid indication for chest
wall fixation in select patients.9
Non-union
Whether fixation of nonunions will consistently pro-
duce positive outcomes has not been established, but re-
ported experience has been encouraging.18, 34–36, 89, 90
Thoracotomy for Other Indications
The proposal that a patient with multiple rib frac-tures
or a flail chest who needs a thoracotomy for an-other
indication (eg, pulmonary laceration, retained hemothorax,
or diaphragm laceration) is a candidate for rib fracture
fixation has received a mixed review.
Although this indication was supported as a Level III
recommendation by the Eastern Association for the
Surgery of Trauma Practice Management Guidelines,
only 18 per cent of academic trauma, orthopedic, and
thoracic surgeons selected it as a valid indication in select
patients.9, 91 Table
2 summarizes the current status of the poten-tial
indications for rib fracture fixation.
Technical Challenges
Human ribs have a relatively thin (1–2 mm) cortex
surrounding soft marrow and are classified as mem-
branous bone.16 Individual ribs, therefore, do not have
high stress tolerance nor are they expected to hold screw
as well as cortical bone. Many techniques of rib fracture
repair have been described, including using wire sutures,
intramedullary wires, staples, and various plates made of
metal or absorbable materials but none has been proven
proven superior to another.
Anterior Plates with Wire Cerclage
Several series report fixing rib fractures with a va-riety
of malleable, flat plates cerclaged to the anterior surface
of the rib for a distance of several centime-ters.17, 35,
74 Wire cerclage, however, is an imperfect
TABLE 2. Current Status of Potential Indications for Operative
Rib Fracture Fixation
1. Flail chest—supported in select patients but
expert opinion divided
2. Reduction of acute pain and disability—unproven
and controversial
3. Open chest defect—supported by case series
and expert opinion
4. Pulmonary herniation—supported by case series
and expert opinion
5. Non-union—supported by case series but
expert opinion divided
6. Thoracotomy for other indications (ie, ''on the
way out'')—supported by case series but expert
opinion divided
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798 THE AMERICAN SURGEON August 2010 Vol. 76

means of stabilizing the fracture because of the risk of

wire breakage and plate dislodgement. In addition,
cerclaging the rib with a permanent material will po-tentially
impinge the intercostal nerve and lead to
chronic pain. For this reason, in one instance, we have
had to remove plates cerclaged with wire. An alternative
is to drill holes through the rib and anchor the strut to the
rib with interrupted wire suture.17

Anterior Plating with Bicortical Screws

This is the standard, time-tested technique against
which innovations should be compared12, 13, 16, 75, 92–94
(Fig. 4). Dynamic compression osteosynthesis is a variation of
anterior plating where eccentric plate holes and
conical screw heads combine to impact and immobilize
FIG. 4. Multiple rib fracture fixations utilizing standard ante-
the fracture ends.92 Locking screw designs are a rela-tively rior plates with locking bicortical screws.
recent innovation where threads in the screw
head ''lock'' to threads in the plate hole that may im-prove fixation
in softer bone.16

Intramedullary Fixation
Intramedullary wire or plate fixation of rib fractures
with or without subsequent wire/plate removal has been
used successfully.15, 77, 82 This technique, however,
carries a risk of wire dislodgement and is technically possible
demanding. demanding. Internal wire fixation has also been
critical because it does not provide rotational stability.16
Additionally, in a series of rib fracture repair in newborn
foals, migration of an intramedullary Steinmann battery
injured the heart of one pony and resulted in its death.95

Judet Strut
The Judet strut is a bendable metal plate that grasps
the rib with tongues both superiorly and inferiorly
without transfixing screws.12, 14, 73, 96 The fixation of
this plate around the inferior margin of the rib, how-ever, like a
cerclaging wire, could crimp the intercostal
neurovascular bundle and therefore has a potential for
intercostal nerve injury and subsequent chronic pain
(Fig. 5). A variation of the strut that has been used
successfully is a self-gripping, elastic band that enve-lopes the
rib like a ribbon around a maypole.97
RibLoc
The u-shaped design of the RibLoc fixation sys-tem (Acute
Innovations, LLC, Hillsboro, OR) retically overcomes the inherent
softness of the human
rib by grasping the rib over its superior margin and by
securing the plate with anterior to posterior locking
screws that do not rely on screw purchase in bone. Print
a simulation of an unstable rib fracture with a small
bony gap, RibLoc fixation was superior in durability
to anterior plate fixation, despite its reduced length.98
FIG. 5. Multiple Judet struts removed from a patient with
chronic chest wall pain several years after failing chest repair.
The RibLoc may facilitate the application of a lot
less invasive rib fracture fixation than the anterior plate
technique. technique. In this sense, its application is similar to the
Judet strut, but without the potential for crimping of
the intercostal nerve. Both the Judet strut and the
RibLoc plate can be placed with minimal dissection
of the rib in the extrapleural space and with preser-vation of the
periosteum.
Absorbable Plates
Absorbable alpha esters, especially the various pol-ylactide
polymers, have been successfully used in the
fixation of maxillofacial, tibia, and rib fractures.85, 99–102
Polylactide and polydioxanone prostheses have also
been successfully used in the reconstruction of chest
wall deformities and in rib reapproximation after thora-cotomy
for nontraumatic indications.103–106 Absorbable
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No. 8 RIB FRACTURE FIXATION
plates have practical and theoretical advantages over ti-
tanium plates. First, they do not need to be removed, as
may be the case in the minority of metal plates. Addi-
tionally, because metal plates are much stiffer than bone,
''stress-shielding'' of the plated bone is possible.107
''Stress-shielding'' occurs because the plated bone is
protected from normal stress and therefore does not heal
as robustly as nonplated bone. Animal models support
the concept that fractures heal faster and stronger with
absorbable plates as compared with metal.108, 109
Complications
Among 704 rib fracture repairs reported since 1975, 14
superficial wound infections (2%), four cases of wound
drainage without infection (0.6%), two pleural empyemas
(0.3%), one wound hematoma, and one per-sistent
pleural effusion have been reported.9, 11–18, 20, 34–36,
74–76, 82, 85, 92–94, 96, 101, 102, 110–116 Fixation
fail-ure including plate loosening, wire migration, or frac-
ture nonunion occurred in nine patients (1.3%) and
surgical chest wall ''stiffness,'' ''rigidity,'' or ''pain''
necessitating plate removal were reported in nine patients
(1.3%). Rib osteomyelitis was reported in one patient and
was ascribed to operative contamina-tion from a
preoperative chest tube that was colonized
by Staphylococcus aureus. 19
Who Should Perform Rib Fixation?
The knowledge and expertise required for rib fracture
fixation is unfamiliar to all three specialties likely to
encounter a patient with a rib fracture syndrome: trauma
surgeons, orthopedic surgeons, and thoracic surgeons.9
Trauma surgeons lack experience with fracture fixation in
general and rib fracture fixation in particular, but has the
advantage of primary responsibility for the patient and a
wealth of clinical experience with pulmonary critical care.
Orthopedic surgeons understand the principles of fracture
fixation, but lack experience with rib fractures and
managing chest-related complications.
Thoracic surgeons express confidence with their capa-
bility to perform rib fracture fixation, but also lack
experience. Nevertheless, the combined knowledge and
experience of these three specialties is adequate for
surgeons to begin offering repair to select patients.
Because general and trauma surgeons are usually the
admitting physician and have experience with the day to
day care of chest wall trauma patients, they are well-
suited to take the lead on patient selection, but should
liberally involve both orthopedic and/or thoracic sur-
geons until they gain sufficient experience. A coop-erative
approach would benefit the patient, especially because rib
fracture fixation is known to be a technical challenge. The
development of acute care surgeons who
799
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Nirula and Mayberry
have expertise in trauma, orthopedics, and thoracic sur-
gery will address this gap in capability.
Summary
Resurgent interest in the operative fixation of rib
fractures has paralleled technological advances in rib
fracture stabilization hardware. Randomized trials in-
dicate that operative fixation of flail chest is associated
with improved outcomes although these trials consist of
small numbers of patients. Cohort comparisons and
retrospective case series also demonstrate improved short
term outcomes and reduced resource utilization in
surgically managed rib fracture patients.
Given the degree of long-term pain and disability
associated with severe rib fracture syndromes, we believe
clinical trials should include not only tradi-tional outcome
measures such as inpatient morbidity and hospital
resource utilization but also functional outcomes measuring
long-term pain, disability, and quality of life. A multicenter,
randomized, controlled trial in a country developed such
as the United States will be necessary to confirm the short
term benefits of rib fracture fixation as well as to properly
evaluate its potential long term benefits.
REFERENCES
1. National Center for Health Statistics, National Hospital
Ambulatory Medical Care Survey. 2006. Available at: http://
www.cdc.gov/nchs/ahcd.htm (Accessed November, 2009).
2. Holcomb JB, McMullin NR, Kozar RA, et al. Morbidity from
rib fractures increases after age 45. J Am Coll Surg 2003;196:
549–55.
3. Nationwide Inpatient Sample (NIS), Healthcare Cost and
Utilization Project (HCUP), Agency for Healthcare Research and
Quality. 2003. Available at: www.hcup-us.ahrq.gov/nisoverview.
jsp (Accessed May, 2006).
4. Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures:
relationship with pneumonia and mortality. Crit Care Med 2006;
34:1642–6.
5. Kerr-Valentic MA, Arthur M, Mullins RJ, et al. Rib fracture
pain and disability: can we do better? J Trauma 2003;54:1058–63,
discussion 1063–4.
6. Landercasper J, Cogbill TH, Lindesmith LA. Long term
disability after flail chest injury. J Trauma 1984;24:410–4.
7. Beal SL, Oreskovich MR. Long-term disability associated with
flail chest injury. Am J Surg 1985;150:324–6.
8. Todd SR, McNally MM, Holcomb JB, et al. A multidisci-
plinary clinical pathway excluding rib fracture-associated in-
fectious morbidity and mortality in high-risk trauma patients. Am J
Surg 2006;192:806–11.
9. Mayberry JC, Ham LB, Schipper PH, et al. Surveyed opinion
of American trauma, orthopedic, and thoracic surgeons on rib and
sternal fracture repair. J Trauma 2009;66:875–9.
10. Karev DV. Operative management of the flail chest. Wiad
Lek 1997;50(Suppl 1 Pt2):205–8.
Machine Translated by Google
800 THE AMERICAN SURGEON August 2010
11. Mouton W, Lardinois D, Furrer M, et al. Long-term follow-
up of patients with operative stabilization of a flail chest. Thorac
Cardiovasc Surg 1997;45:242–4.
12. Voggenreiter G, Neudeck F, Aufmkolk M, et al. Operative
chest wall stabilization in flail chest–outcomes of patients with or
without pulmonary contusion. J Am Coll Surg 1998;187:130–8.
13. Lardinois D, Krueger T, Dusmet M, et al. Pulmonary function
testing after operative stabilization of the chest wall for flail chest.
Eur J Cardiothorac Surg 2001;20:496–501.
14. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical
stabilization of internal pneumatic stabilization? A prospective ran-
domized study of management of severe flail chest patients.
J Trauma 2002;52:727–32, discussion 732.
15. Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus
conservative treatment of flail chest. Evaluation of the pulmonary
status. Interact Cardiovasc Thorac Surg 2005;4:583–7.
16. Engel C, Krieg JC, Madey SM, et al. Operative chest wall
fixation with osteosynthesis plates. J Trauma 2005;58:181–6.
17. Nirula R, Allen B, Layman R, et al. Rib fracture stabilization
in patients sustaining blunt chest injury. Am Surg 2006;72: 307–9.
18. Richardson JD, Franklin GA, Heffley S, Seligson D. Op-
erative fixation of chest wall fractures: an underused procedure?
Am Surg 2007;73:591–6, discussion 596–7.
19. Mayberry JC, Kroeker AD, Ham LB, et al. Long-term
morbidity, pain, and disability after repair of severe chest wall
injuries. Am Surg 2009;75:389–94.
20. Solberg BD, Moon CN, Nissim AA, et al. Treatment of chest
wall implosion injuries without thoracotomy: technique and clinical
outcomes. J Trauma 2009;67:8–13, discussion.
21. Virshup M. The anteriorly crushed chest or ''steering wheel
injury''. An improved method for sternal traction. J Thorac Car-
diovasc Surg 1960;39:579–85.
22. Cummings P, Wells JD, Rivara FP. Estimating seat belt
efficiency using matched-pair cohort methods. Accid Anal Prev
2003;35:143–9.
23. McGwin G Jr, Metzger J, Rue LW III. The influence of side
airbags on the risk of head and thoracic injury after motor vehicle
collisions. J Trauma 2004;56:512–6, discussion 516–7.
24. Lang-Lazdunski L, Bonnet PM, Pons F, et al. Traumatic
extrathoracic lung herniation. Ann Thorac Surg 2002;74:927–9.
25. Forty J, Wells FC. Traumatic intercostal pulmonary hernia.
Ann Thorac Surg 1990;49:670–1.
26. Fiane AE, Nordstrand K. Intercostal pulmonary hernia after
blunt thoracic injury. Eur J Surg 1993;159:379–81.
27. May AK, Chan B, Daniel TM, Young JS. Anterior lung
herniation: another aspect of the seatbelt syndrome. J Trauma
1995;38:587–9.
28. Francois B, Desachy A, Cornu E, et al. Traumatic pulmo-
nary hernia: surgical versus conservative management. J Trauma
1998;44:217–9.
29. Patel MB, Nathan JD, Frush DP, Rice HE. Nonoperative
management of traumatic pulmonary hernia in a young child. J
Trauma 2007;62:234–5.
30. Hanak V, Hartman TE, Ryu JH. Cough-induced rib frac-
tures. Mayo Clin Proc 2005;80:879–82.
31. Polk HC, Newton WT. Abdominal parietal hernias at the
costal margin. Ann Surg 1963;158:1047–52.
32. Croce EJ, Mehta VA. Intercostal pleuroperitoneal hernia.
J Thorac Cardiovasc Surg 1979;77:856–7.
Vol. 76
33. Hjalmarsson S, Asmundsson T, Sigurdsson J, et al. Major
hemorrhage as a complication of cough fracture. Chest
1993;104:1310.
34. Cacchione RN, Richardson JD, Seligson D. Painful non-
union of multiple rib fractures managed by operative stabilization.
J Trauma 2000;48:319–21.
35. Slater MS, Mayberry JC, Trunkey DD. Operative stabilization
of a flail chest six years after injury. Ann Thorac Surg 2001; 72:600–
1.
36. Ng AB, Giannoudis PV, Bismil Q, et al. Operative
stabilization of painful non-united multiple rib fractures. Injury
2001;32: 637–9.
37. Lederer W, Mair D, Rabl W, Baubin M. Frequency of rib and
sternum fractures associated with out-of-hospital cardiopul-
monary resuscitation is underestimated by conventional chest X-
ray. Resuscitation 2004;60:157–62.
38. Lee RB, Bass SM, Morris JA Jr, MacKenzie EJ. Three or
more rib fractures as an indicator for transfer to a Level I trauma
center: a population-based study. J Trauma 1990;30:689–94.
39. Gaillard M, Herve C, Mandin L, Raynaud P. Mortality
prognostic factors in chest injury. J Trauma 1990;30:93–6.
40. Ziegler DW, Agarwal NN. The morbidity and mortality of rib
fractures. J Trauma 1994;37:975–9.
41. Segers P, Van Schil P, Jorens P, Van Den Brande F.
Thoracic trauma: an analysis of 187 patients. Acta Chir Belg
2001;101: 277–82.
42. Sharma OP, Hagler S, Oswanski MF. Prevalence of delays
hemothorax in blunt thoracic trauma. Am Surg 2005;71:481–6.
43. Stawicki SP, Grossman MD, Hoey BA, et al. Rib fractures in
the elderly: a marker of injury severity. J Am Geriatr Soc
2004;52:805–8.
44. Databases HCUP, Healthcare Cost and Utilization Project
(HCUP). Agency for Healthcare Research and Quality, Rockville,
MD, 2006. Available at www.hcup-us.ahrq.gov/databases.jsp
(Accessed November, 2009).
45. Karmakar MK, Ho AM. Acute pain management of patients
with multiple fractured ribs. J Trauma 2003;54:615–25.
46. Simon BJ, Cushman J, Barraco R, et al. Pain management
guidelines for blunt thoracic trauma. J Trauma 2005;59:1256–67.
47. Mackersie RC, Karagianes TG, Hoyt DB, Davis JW. Pro-
spective evaluation of epidural and intravenous administration of
fentanyl for pain control and restoration of ventilatory function
following multiple rib fractures. J Trauma 1991;31:443–9, dis-
cussion 449–51.
48. Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural
analgesia improves outcome after multiple rib fractures. Surgery
2004;136:426–30.
49. Alexander JQ, Gutierrez CJ, Mariano MC, et al. Blunt chest
trauma in the elderly patient: how cardiopulmonary disease affects
outcomes. Am Surg 2000;66:855–7.
50. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib
fractures in the elderly. J Trauma 2000;48:1040–6, discussion
1046–7.
51. Barnea Y, Kashtan H, Skornick Y, Werbin N. Isolated rib
fractures in elderly patients: mortality and morbidity. Can J Surg
2002;45:43–6.
52. Testerman GM. Adverse outcomes in younger rib fracture
patients. South Med J 2006;99:335–9.
53. Waugh RL. Sam Browne plaster of paris belt for immobi-
lization of the chest. J Bone Joint Surg 1935;17:1067–8.
Machine Translated by Google
No. 8 RIB FRACTURE FIXATION
54. Findlay RT. Fractures of the scapula and ribs. Am J Surg
1937;38:489–94.
55. DeBakey M. Management of chest wounds: collective re-view. Int
Abstr Surg 1942;74:203–37.
56. Norcross K. Strapping up the broken rib. Lancet 1980;1: 589–90.
57. Cameron DA, O'Rourke PV, Burt CW. An analysis of the management
of complications of multiple, three or more, rib fractures. Am J Surg
1949;78(5):668–76.
58. Coleman FP, Coleman CL. Fracture of ribs; a logic
treatment. treatment. Surg Gynecol Obstet 1950;90:129–34, illust.
59. Drewes J. The treatment of multiple rib fractures. Zentralbl Chir
1953;78:683–4 [in German].
60. Lazcano A, Dougherty JM, Kruger M. Use of rib belts in
acute rib fractures. Am J Emerg Med 1989;7:97–100.
61. Quick G. A randomized clinical trial of rib belts for simple fractures. Am
J Emerg Med 1990;8:277–81.
62. Jones TB, Richardson EP. Traction on the sternum in the treatment of
multiple fractured ribs. Surg Gynecol Obstet 1926;42:283–5.
63. Jaslow IA. Skeletal traction in the treatment of multiple diseases
fractures of the thoracic cage. Am J Surg 1946;72:753–5.
64. Hudson TR, McElvenny RT, Head JR. Chest wall stabilization by soft
tissue traction: a new method. JAMA 1954;156:768–9.
65. Cohen EA. Treatment of the flail chest by towel clip trac-tion. Am J
Surg 1955;90:517–21.
66. Crutcher RR, Nolen TM. Multiple rib fracture with in-
stability of chest wall. J Thorac Surg 1956;32:15–21.
67. Gray HR. War injuries of the chest. Proc Mayo Clinic 1942; 17:566–72.
68. Hagen K. Multiple rib fractures treated with a drinker res-
pirate. J Bone Joint Surg 1945;27:330–4.
69. Avery EE, Morch ET, Benson DW. Critically crushed chests: a new
method of treatment with continuous mechanical
hyperventilation to produce alkalotic apnea and internal pneumatic stabilization.
J Thorac Surg 1956;32:291–311.
70. Gordon IJ, Jones ES. Intermittent positive pressure venti-lation for the
crushed chest: an epic in intensive care. Intensive Care Med 2001;27:32–5.
71. McDowell A, Dykes J, Paulsen GA. Early reconstruction of the crushed
chest. Dis Chest 1962;41:618–23.
72. Carlisle BB, Sutton JP, Stephenson SE Jr. New technic for
stabilization of the flail chest. Am J Surg 1966;112:133–5.
73. Judet R. Osteosynthese costale. Rev Chir Orthop Repar Appar Mot
1973;59(Suppl 1):334–5.
74. Moore BP. Operative stabilization of nonpenetrating chest
injuries. J Thorac Cardiovasc Surg 1975;70:619–30.
75. Paris F, Tarazona V, Blasco E, et al. Surgical stabilization of traumatic
flail chest. Thorax 1975;30:521–7.
76. Thomas AN, Blaisdell FW, Lewis FR Jr, Schlobohm RM.
Operative stabilization for flail chest after blunt trauma. J Thorac Cardiovasc
Surg 1978;75:793–801.
77. Meier P, Schupbach P. Therapy of the unstable thorax in serial fractures
of the ribs. Schweiz Med Wochenschr 1978;108:608–13 [in German].
78. Albrecht F, Brug E. Stabilization of the flail chest with tension band
wires of ribs and sternum (author's translation). Zentralbl Chir 1979;104:770–
6 [in German].
79. Vecsei V, Frenzel I, Plenk H Jr. A new rib plate for the stabilization of
multiple rib fractures and thoracic wall fracture
?
Nirula and Mayberry 801
with paradoxical inspiration. Hefte Unfallheilkd 1979;138:279–82 [in German].
80. Brunner L, Hoffmeister HE, Koncz J. Stabilizing surgical interventions
on the thorax in funnel chest corrections and injuries of the bony thorax. Med
Klin 1964;59:515–8 [in German].
81. Wilson RF. Discussion, surgical stabilization or internal pneu-matic
stabilization? A prospective randomized study of management of severe flail
chest patients. J Trauma 2002;52:732.
82. Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal
fixation versus endotracheal intubation and ventilation.
J Thorac Cardiovasc Surg 1995;110:1676–80.
83. Hauser CJ, Livingston DH. Pulmonary contusion and flail chest. In:
Asensio JA, Trunkey DD, eds. Current Therapy of Trauma and Surgical Critical
Care. Philadelphia, PA: Mosby, Inc., 2008, pp 269–77.
84. Quell M, Vecsei V. Surgical stabilization of thoracic wall
fractures. Unfallchirurg 1991;94:129–33 [in German].
85. Mayberry JC, Terhes JT, Ellis TJ, et al. Absorbable plates for rib
fracture repair: preliminary experience. J Trauma 2003;55:835–9.
86. Carrasquilla C, Watts J, Ledgerwood A, Lucas CE. Man-agement of
massive thoraco-abdominal wall defect from close-range shotgun blast. J
Trauma 1971;11:715–7.
87. Khalil MW, Masala N, Waller DA, Cardillo G. Surgical repair of post-
traumatic lung hernia using a video-assisted open technique. Interact
Cardiovasc Thorac Surg 2008;7:506–7.
88. Gross RI, Eversgerd JL. The image of trauma. Transthoracic
lung herniation due to blunt trauma. J Trauma 2006;60:1149.
89. Anavian J, Guthrie ST, Cole PA. Surgical management of multiple
painful rib nonunions in patient with a history of severe shoulder girdle trauma:
a case report and literature review. J Orthop Trauma 2009;23:600–4.
90. Cho YH, Kim HK, Kang DY, Choi YH. Reoperative sur-gical stabilization
of a painful nonunited rib fracture using bone grafting and a metal plate. J
Orthop Trauma 2009;23:605–6.
91. EAST Practice Management Workgroup for Pulmonary Contusion -
Flail Chest, 2006. Available at http://www.east.org/ tpg.asp (Accessed
November 2, 2007).
92. Hellberg K, de Vivie ER, Fuchs K, et al. Stabilization of flail chest by
compression osteosynthesis–experimental and clinical results. Thorac
Cardiovasc Surg 1981;29:275–81.
93. Quell M, Vecsei V. Zur Operativen Stabilisierung von
Thoraxwandbruchen. Unfllchirurg 1991;94:129–33.
94. Oyarzun J, Bush A, McCormick J, Bolanowski P. Use of 3.5-mm
acetabular reconstruction plates for internal fixation of flail chest injuries. Ann
Thorac Surg 1998;65:1471–4.
95. Bellezzo F, Hunt RJ, Provost R, et al. Surgical repair of rib fractures in
14 neonatal foals: case selection, surgical technique and results. Equine Vet
J 2004;36:557–62.
96. Menard A, Testart J, Philippe JM, Grise P. Treatment of flail chest with
Judet's struts. J Thorac Cardiovasc Surg 1983;86:300–5.
97. Labitzke R. Early thoracotomy and chest wall stabilization with elastic
rib clamps (author's translation). Zentralbl Chir 1981;106: 1351–9 [in German].
98. Sales JR, Ellis TJ, Gillard J, et al. Biomechanical testing of a novel,
minimally invasive rib fracture plating system. J Trauma 2008;64:1270–4.
99. Ambrose CG, Clanton TO. Bioabsorbable implants: review of clinical
experience in orthopedic surgery. Ann Biomed Eng 2004;32:171–7.
Machine Translated by Google

802 THE AMERICAN SURGEON August 2010 Vol. 76

100. Laughlin RM, Block MS, Wilk R, et al. Resorbable plates
for the fixation of mandibular fractures: a prospective study. J Oral rabbits. J Orthop Sci 2001;6:160–6.
Maxillofac Surg 2007;65:89–96.
101. Campbell N, Conaglen P, Martin K, Antippa P. Surgical
stabilization of rib fractures using Inion OTPS wraps–techniques
and quality of life follow-up. J Trauma 2009;67:596–601.
102. Marasco S, Cooper J, Pick A, Kossmann T. Pilot study of
operative fixation of fractured ribs in patients with flail chest. ANZ
J Surg 2009;79:804–8.
103. Matsui T, Kitano M, Nakamura T, et al. Bioabsorbable
struts made from poly-L-lactide and their application for treatment
of chest deformity. J Thorac Cardiovasc Surg 1994;108:162–8.
104. Puma F, Ragusa M, Santoprete S, et al. As originally
published in 1992: Chest wall stabilization with synthetic
reabsorbable material. Updated in 1999. Ann Thorac Surg 1999;67:1823–4.Osteosynthese) technique. Scand J Thorac Cardiovasc Surg
105. Tatsumi A, Kanemitsu N, Nakamura T, Shimizu Y. Bio-
absorbable poly-L-lactide costal coaptation pins and their clinical
application in thoracotomy. Ann Thorac Surg 1999;67:765–8.
106. Iwasaki A, Hamatake D, Shirakusa T. Biosorbable poly-L-
lactide rib-connecting pins may reduce acute pain after thora-
cotomy. Thorac Cardiovasc Surg 2004;52:49–53.
107. Tayton K, Bradley J. How stiff should semi-rigid fixation of
the human tibia be? A clue to the answer. J Bone Joint Surg Br
1983;65:312–5.
108. Viljanen J, Pihlajamaki H, Kinnunen J, et al. Comparison
of absorbable poly-L-lactide and metallic intramedullary rods in
the fixation of femoral shaft osteotomies: an experimental study in
109. Vu KC, Skourtis ME, Gong X, et al. Reduction of rib
fractures with a bioresorbable plating system: preliminary obser-
vations. J Trauma 2008;64:1264–9.
110. Schmit-Neuerburg KP, Weiss H, Labitzke R. Indication for
thoracotomy and chest wall stabilization. Injury 1982;14:26–34.
111. Haasler GB. Open fixation of flail chest after blunt trauma.
Ann Thorac Surg 1990;49:993–5.
112. Landreneau RJ, Hinson JM Jr, Hazelrigg SR, et al. Strut
fixation of an extensive flail chest. Ann Thorac Surg 1991;51: 473–
5.
113. Reber P, Ris HB, Inderbitzi R, et al. Osteosynthesis of the
injured chest wall. Use of the AO (Arbeitsgemeinschaft fur
1993; 27:137–42.
114. Di Fabio D, Benetti D, Benvenuti M, Mombelloni G.
Surgical stabilization of post-traumatic flail chest. Our experience
with 116 cases treated. Minerva Chir 1995;50:227–33 [in Italian].
115. Balci AE, Eren S, Cakir O, Eren MN. Open fixation in flail
chest: review of 64 patients. Asian Cardiovasc Thorac Ann 2004;
12:11–5.
116. Beelen R, Rumbaut J, De Geest R. Surgical stabilization
of a rib fracture using an angle stable plate. J Trauma 2007;63:
1159–60.