Hon Chi Suen
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.
These systems employ orthopedic AO principles of anatomic reduction, stable fixation, preservation of blood supply, and early, active mobilization. The locking plate/screw system allows the screw to be fixed to the bone and to the plate so that the whole system will be stable without requiring every bit of the plate touching the bone.
Figure 15.1 Color-coded pre-contoured rib plates. © DePuy Synthes CMF, a division of DOI 2013. All rights reserved.
Technique
ORIF of Fracture Ribs
Patient could lay supine, full lateral or semi-lateral depending on which rib(s) and which part of the rib(s) need to fix. After receiving the preoperative antibiotic, an incision is made over the fractures to be fixed. Muscle division is minimized to preserve respiratory function. The fractures are exposed and nonviable bone removed. The periosteum is left intact. The fractures are reduced and the broken rib segments are re-approximated. The thickness of the rib is measured with a caliper. The length of the screw is chosen by adding 2 mm (accounting for the plate thickness) to the rib thickness. The appropriate rib plate is chosen and bent according to the contour of the rib. The plate is then positioned on the rib straddling the fracture with holes for at least three screws on each side of the fracture. The drill guide is attached to the plate and the appropriate drill bit is used to create holes in the rib. The drill guide is then removed and the appropriate screw is inserted with the help of an electric screwdriver. Preferably, at least three screws are applied on each side of the fracture. Figure 15.2 is a diagrammatic representation of the steps provided by Synthes. Video 15.1 demonstrates the application of drill guide, drilling, and application of a screw.
If the wound does not expose part of the plate well, separate holes may need to be created in the skin to insert the drill or screw to avoid excessively enlarging the incision. The screws are finally hand tightened to ensure secure application.
Other procedures such as bronchoscopy, drainage of pneumothorax, drainage of hemothorax, or decortication may need to be done concomitant with the rib fracture fixation.
Figures 15.3 and 15.4 describe two representative patients and their excellent results.
ORIF of Fracture Sternum
The patient is positioned supine with arms tucked along the sides. The sternum is exposed through a vertical incision. Debridement of necrotic bone is performed. Bone graft may be needed to fill the gap. Bone graft can be obtained from the iliac crest or a rib.
Figure 15.2 Steps of ORIF of rib fracture (A–M). © DePuy Synthes CMF, a division of DOI 2013. All rights reserved.
For transverse fractures, one or two straight plates are used with preferably at least four screws on each side of the fracture.
For vertical fractures (such as repair of median sternotomy dehiscence), an assortment of manubrium plates, sternal body plates or straight plates can be used depending on the circumstances.
After measuring the thickness of the sternum, 3 mm is added to account for the plate thickness and then the appropriate screw is chosen and applied.
Figure 15.5 illustrates ORIF of transverse sternal fracture. Videos 15.2–15.5 demonstrate the trimming of plate, bending of plate, applying the screw, and tightening of the screws. Figure 15.6 showed repair of median sternotomy dehiscence using an assortment of plates.
Figure 15.3 A: A 29-year-old man had displaced fracture of right sixth to tenth ribs after a motor vehicle accident and developed hemopneumothorax. B: There was instability of chest wall and tapes were applied in the emergency room to reduce it. C: The intercostal muscles were also lacerated. D: The fractures were grossly displaced. E: The three most severely displaced rib fractures (seventh to ninth) were fixed by ORIF using the eight-hole universal plates. F: PA and lateral chest x-rays 3 months after ORIF showed absence of deformity and good alignment of all the ribs.
Figure 15.4 A: A 52-year-old man had 10 rib displaced fractures on the right after a motor vehicle accident associated with hemopneumothorax. The right chest cavity had markedly diminished in size due to overlapping of the ribs from severe displacement. There would be severe compromise of respiratory function if the severe deformity was not fixed. B: Severe right chest wall deformity before surgery was corrected after ORIF of 5 of the 10 rib fractures. C: PA and lateral chest x-rays 4 months after ORIF showed re-expansion of right chest cavity, absence of deformity, and good alignment of all the ribs.
Figure 15.5 A: 53-year-old lady presented 14 months after a motor vehicle accident with painful nonunion of sternal fracture. B: The necrotic bone at the site of nonunion was debrided. C: A bone graft harvested from the iliac crest was inserted into the sternal defect. D: Two straight sternal plates were applied for internal fixation.
Figure 15.6 Repair of median sternotomy dehiscence with an assortment of sternal plates.
POSTOPERATIVE MANAGEMENT
Patients in general are extubated in the operating room and they usually feel that the chest wall pain is immediately improved. Postoperative management is according to the routine management of a post-thoracotomy patient: perioperative antibiotic, management of chest tube(s) if present, pain control, incentive spirometry, and early ambulation. In general, they can be discharged home within a few days (range outpatient procedure to 4 days after surgery) unless there are other indications to keep the patient in the hospital.
COMPLICATIONS
Complications in general are uncommon but include bleeding, hardware fracture, hardware infection, and hardware migration. The last three complications are usually treated with hardware removal. In my patient who had hardware fracture 2 years after implantation, the sternal fracture had completely healed and there was no problem in removing the fractured implants.
RESULTS
Almost all patients experienced immediate and dramatic improvement of the pain and their ability of deep breathing and moving around. They are very happy with their cosmetic and functional results and have no trouble recommending the procedure to the next patient.
Videos 15.6 and 15.7 demonstrate the good functional result after two-stage ORIF of multiple right rib fractures.
CONCLUSIONS
In selected patients with chest wall fractures, especially those with severe pain not relieved by conventional analgesic techniques, respiratory compromise, chest wall deformity, or nonunion, ORIF has been proven to dramatically reduce the pain, improve the respiratory physiology, reduce ICU and hospital stay, and result in early return to society and work.
Recommended References and Readings
Althausen PL, Shannon S, Watts C, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011; 25:641–647.
Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: What is the benefit? J Am Coll Surg. 2012;215:201–205.
Bille A, Okiror L, Campbell A, et al. Evaluation of long-term results and quality of life in patients who underwent rib fixation with titanium devices after trauma. Gen Thorac Cardiovasc Surg. 2013; 61:345–349.
Campbell N, Conaglen P, Martin K, et al. Surgical stabilization of rib fractures using inion OTPS wraps-techniques and quality of life follow-up. J Trauma. 2009;67:596–601.
Fabricant L, Ham B, Mullins R, et al. Prolonged pain and disability are common after rib fractures. Am J Surg. 2013;205:511–515.
Girsowicz E, Falcoz P, Santelmo N, et al. Does surgical stabilization improve outcomes in patients with isolated multiple distracted and painful non-flail rib fractures? Interac Cardiovasc Thorac Surg.2012;14:312–315.
Lafferty M, Anavian J, Will RE, et al. Operative treatment of chest wall injuries: Indications, technique, and outcomes. J Bone Joint Surg Am. 2011;93:97–110.
Leinicke JA, Elmore L, Freeman BD, et al. Operative management of rib fractures in the setting of flail chest: A systematic review and meta-analysis. Ann Surg. 2013;258(6):914–921. [Epub ahead of print]
Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216:924–932.
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;66:875–879.
Nirula R, Diaz JJ Jr, Trunkey DD, et al. Rib fracture repair: Indications, technical issues, and future directions. World J Surg. 2009; 33:14–22.
Richardson JD, Franklin GA, Heffley S, et al. Operative fixation of chest wall fractures: An underused procedure? Am Surg. 2007;73: 591–597.
Slobogean GP, MacPherson CA, Sun T, et al. Surgical fixation vs nonoperative management of flail chest: A meta-analysis. J Am Coll Surg. 2013;216:302–311.