Version May 2024
INTRODUCTION — Multiple rib fractures are the consequence of significant forces impacting the chest wall and are most commonly due to blunt injuries (eg, motor vehicle crash, falls, assault), but penetrating injuries (eg, gunshot) can also fracture ribs. Nonoperative treatment is based on pain control and aggressive supportive pulmonary care primarily aimed at avoiding the need for intubation, which is associated with increased rates of pneumonia and death. For patients who continue to have acute pain or inherent chest wall instability (eg, flail chest), either of which hinders pulmonary function, in spite of maximal medical therapy, or those with rib fractures that do not heal (nonunion) and are causing persistent pain and functional impairment, surgical rib stabilization (also known as osteosynthesis) may be needed.
The indications, preparation, technique for rib fracture stabilization, and outcomes are reviewed here. Initial management of traumatic rib fractures is reviewed elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Inpatient management of traumatic rib fractures and flail chest in adults".)
INDICATIONS — Although the majority of patients will heal their rib fractures with conservative measures, selected patients may benefit from surgical rib fracture fixation [1-4]. Flail chest with resultant respiratory failure requiring mechanical ventilation is the only indication for rib fracture fixation for which good quality evidence is available. Randomized trials supporting rib fracture fixation in patients with flail chest are reviewed below [5-9]. Many centers use broader criteria that address patients who do not have flail chest but do have respiratory failure due to severely displaced rib fractures (algorithm 1) [4,10]. One multicenter, prospective study has also evaluated whether there are any benefits for surgical stabilization of rib fractures in patients with three or more severely displaced, non-flail-type rib fractures [11]. (See 'Flail chest' below and 'Non-flail rib fractures' below.)
Summary of indications — The following are generally accepted as criteria for operative rib fixation:
●Impending or actual respiratory failure due to painful, movable ribs refractory to pain management strategies (ie, not due to pulmonary contusion). This includes patients with flail chest, or multiple, severely displaced non-flail pattern fractures. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control' and "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Supportive care'.)
●Significant chest wall deformity.
●Failure to wean from mechanical ventilation (not related to pulmonary contusion).
●Significantly displaced ribs found at thoracotomy being performed for other reasons (eg, open pneumothorax, pulmonary laceration, retained hemothorax, diaphragm hernia, vascular injury). This is referred to as "on-the-way-out fixation."
●Ongoing chest wall instability/deformity or pain due to nonunion or malunion of rib fractures.
There are no prospectively validated or generalizable scoring systems that can be used to predict which patients will fail conservative pain management strategies. Bedside incentive spirometry can be used to assess vital capacity and likelihood of respiratory failure, but there are no evidence-based guidelines that can be used to determine at what threshold patients should be considered candidates for operative rib fixation. A more severe degree of displacement of rib fractures correlates with increased opioid needs, and it is possible that operative rib fixation may be reduce use of analgesics. However, there are no studies that demonstrate a benefit to operative rib fixation for pain control alone [12]. Therefore, many surgeons recommend surgical stabilization as a means to avoid intubation in patients who are failing medical management or as a means to facilitate extubation in patients who are ventilator dependent due to chest wall instability or pain.
A survey of trauma and thoracic surgeons in the United States found that although the majority felt that rib fracture fixation was appropriate for selected patients, only 26 percent of surgeons who answered the survey had actually been involved in such a case [13]. National Trauma Data Bank results indicate that only 1 percent of patients with flail chest undergo operative fixation of the ribs [14]. Reasons for this include lack of familiarity with the operation; lack of a uniform taxonomy that can be used to develop specific, evidence-based guidelines; and lack of specialty ownership of this disease process.
Efficacy of rib stabilization — Surgical management appears to be effective for reducing pain, improving pulmonary function, and facilitating bony healing by reducing movement and providing close apposition of the ends of the ribs [15]. The majority of studies evaluating the effectiveness of surgical rib fracture fixation have been performed in the acute setting and, in particular, in patients with flail chest.
Flail chest — For patients with flail chest, early operative treatment reduces pulmonary complications, facilitates ventilator weaning, and shortens the duration of mechanical ventilation [16-22]. However, patients with flail chest and associated significant pulmonary contusions are less likely to benefit [23-26]. (See 'Indications' above.)
Several systematic reviews and meta-analyses, including a review of 22 studies including 988 patients published by the Eastern Association for the Surgery of Trauma (EAST) [4], have found improved pulmonary outcomes for patients undergoing surgical stabilization for flail chest [4,9,22,27,28]. There has been a rapid increase in the number of single-center studies evaluating outcomes following surgical rib stabilization over the last five years, with most studies also finding a mortality benefit and decreased need for mechanical ventilation and duration of hospitalization in the operative group. In a review of the National Trauma Data Bank that included over 600,000 patients with rib fractures, surgical rib fracture fixation reduced mortality (odds ratio 0.13, 95% CI 0.01-0.18) [29].
The systematic reviews identified three small trials [5-7] comparing the effectiveness of surgical stabilization for flail chest with nonsurgical management [28]. For those randomized to surgery, significant reductions were seen for the incidence of pneumonia and chest deformity (pneumonia relative risk [RR] 0.36, 95% CI 0.15-0.85; chest deformity RR 0.13, 95% CI 0.03-0.67), and there was a trend toward a decreased need for tracheostomy (RR 0.38, 95% CI 0.14-1.02). No clear difference was apparent for mortality between treatment groups, but the number of deaths was small (6 out of 123). Because of differences in reporting, duration of mechanical ventilation, length of intensive care unit (ICU) stay, and length of hospital stay could not be compared. The individual trials are summarized below.
●One trial randomly assigned 37 flail chest patients to surgical stabilization or nonoperative management [5]. All patients required mechanical ventilation. The surgically managed patients had significantly fewer days on the ventilator, shorter ICU stay, a lower incidence of pneumonia, better pulmonary function at one month, and a higher percentage of patients who returned to work at six months compared with the nonoperative group.
●Another trial randomly assigned 40 patients with flail chest to surgical fixation or an external adhesive plaster [6]. The operative group had significantly fewer patients requiring mechanical ventilation, fewer days in the ICU, shorter hospital stay, and a lower incidence of pneumonia compared with the conservatively managed group.
●In a trial that included 46 patients with flail chest who were ventilator dependent, those randomized to rib fixation compared with conservative management had a significant reduction in the duration of ICU stay (324 versus 448 hours) [7]. A significantly decreased duration of noninvasive ventilation following extubation was found for rib fixation compared with conservative management (3 versus 50 hours). No differences were found for the duration of mechanical ventilation or for long-term outcomes, including three-month pulmonary function testing and six-month quality-of-life assessment.
Non-flail rib fractures — Patients with severe rib fractures but without flail chest may benefit if the rib fractures result in actual or impending respiratory failure due to refractory pain or severe chest wall deformity [2]. Other patient subgroups, such as older patients [30,31], or patients with severely displaced, non-flail fractures not resulting in respiratory failure, may also benefit from surgical stabilization, but any recommendation for these groups is based on only limited data in these populations [11]. (See 'Indications' above.)
A multicenter trial (United States, Canada) randomized 211 patients with flail or non-flail chest injury patterns to operative or nonoperative treatment of rib fractures [32]. There was a trend toward an overall improvement in ventilator-free days for those who underwent surgical stabilization (23 versus 21 days; mean difference 2.1, 95% CI -0.2 to 4.5). In prespecified subgroup analysis, overall length of hospital stay was significantly improved for patients who were intubated at the time of randomization and who underwent surgical stabilization of rib fractures (32 versus 30 days). For patients who were not ventilated at the time of randomization and who underwent surgical stabilization of rib fractures, the length of hospital stay was similar.
Another multicenter study focused on whether early surgical stabilization of rib fractures offered any benefits compared with standard care in patients with three or more severely displaced, non-flail-type rib fractures [11]. Patients were required to exhibit some degree of respiratory derangement, but those with acute ventilator-dependent respiratory failure were excluded. The study combined the outcomes of patients who agreed to randomization (n = 23) with those of patients who selected their preferred treatment course after an informed discussion (n = 87). The incidence of pleural space complications was significantly lower in the operative group during the index hospitalization (0 versus 10.2 percent). A pleural space complication was defined as either retained hemothorax or empyema requiring intervention (eg, tube thoracostomy, video-assisted thoracoscopic surgery) more than 24 hours after admission. Pain scores at one, two, four, and eight weeks follow-up were modestly improved for the operative group (mean differences 1.5 points), but opioid usage was similar after two weeks. Other complication rates (eg, pneumonia, readmission) and outcomes (eg, pulmonary function, hospital length of stay) as well as quality-of-life measures were similar. The results of this study suggest there may be a role for early surgical stabilization of rib fractures to decrease pain and potentially reduce bleeding from mobile ribs as evidenced as pleural space complications. However, the overall impact of surgical stabilization of rib fractures remains controversial, given no observed differences in narcotic requirement or quality-of-life. As such, we continue to reserve surgery for rib fractures that are refractory to pain management and are the cause of impending or actual respiratory failure.
For the subset of patients who benefit from surgical rib fracture fixation in the acute period, surgical fixation may be more cost effective [2,3]. Studies that have evaluated cost report $2000 to $14,000 (USD) of savings for the group that underwent operation in spite of the costs associated with surgery, including the cost of implants. In a later study, this procedure was the most cost effective for patients who sustained a flail chest injury and were younger than 65 years old, followed by those with a flail chest injury who were older than 65 years old. The group in whom the operation was least cost-effective were those older than 65 years of age who did not have flail chest injury [33]. The higher initial cost was offset by the greater cost of longer durations of mechanical ventilation, ICU stay, and hospital length of stay as well as a higher incidence of pneumonia in the medically treated group.
Fracture nonunion/malunion — There are also some small case series evaluating surgery for patients in the chronic setting with chronic nonunion or malunion of fractured ribs [34,35].
Malunion of the rib can result in fracture callous formation between two separate ribs as a sequela of nonoperative management of severely displaced rib fractures. The true incidence is not known. Malunions can result in ongoing pain, either due to formation of a neuroma or inappropriate configuration of the ribs themselves. Operative intervention in such cases requires taking down the ossified capsule connecting the two ribs with an osteotome and resetting the ribs in an anatomically correct orientation. Osteosynthesis is then carried out using a titanium plate/screw system as described below. There are no studies evaluating the efficacy of operative rib fixation for resolution of pain in this setting.
Among studies evaluating surgical fixation for nonunion or malunion of fractured ribs [34,35], the studies used a combination of autologous bone graft as well as titanium/mesh fixation systems and found improvement in objective pain score as well as quality-of-life measures following fixation. There are animal studies that suggest application of platelet-rich plasma at the fracture site may augment healing, but this has yet to be validated in humans, and indications for use have not been established [36].
CONTRAINDICATIONS — There is no role for surgical stabilization when severe pulmonary contusion is the cause for respiratory insufficiency [10,25,37,38]. Thus, if the patient has a significant underlying pulmonary contusion that will prevent weaning within a reasonable period due to impaired oxygen exchange, there would be little benefit to a procedure. However, patients with mild-to-moderate pulmonary contusions that will not impede liberation from the ventilator have the same benefits of shorter intensive care unit length of stay and duration of mechanical ventilation with rib fracture fixation as patients without pulmonary contusion [39]. (See "Pulmonary contusion in adults".)
Most agree that there is also no role for surgical stabilization of fractured ribs in patients with concomitant head injury that precludes separation from mechanical ventilation.
RIB FRACTURE STABILIZATION
Timing of early surgery — Early operation rather than later is aimed at mitigating pain and avoiding or resolving the need for mechanical ventilation (ie, respiratory failure) [10,11,19,23,40]. We strive to carry out the operation within 72 hours of injury, with the first 24 hours being spent assuring that the patient's pain and pulmonary function cannot be adequately managed using medical measures alone. It is reasonable to carry out rib fixation earlier if a patient requires a thoracic procedure for another reason (eg, video-assisted thoracoscopic surgery [VATS] for retained hemothorax). (See 'Indications' above.)
●A multicenter study that included 731 patients found that each additional day to operative intervention compared with operation on the day of admission following acute injury was associated with a 27 percent increased risk of need for intubation, a 26 percent increased risk of tracheostomy, and 31 percent increased risk of pneumonia. Given these results, it is not surprising that the study also found that early operation was associated with a decreased hospital and intensive care unit (ICU) length of stay [41].
●A review of nine studies evaluating the impact of timing to surgical stabilization of rib fractures found that surgical stabilization of rib fractures within 72 hours of injury was associated with significantly shorter ICU and hospital lengths of stay, duration of mechanical ventilation, incidence of pneumonia, and need for tracheostomy [42].
There are few data evaluating whether recent infection, particularly pneumonia or empyema, increases the risk of infection of the plates; thus, it seems prudent to delay surgical stabilization until all infection has been appropriately managed. Case studies have reported successful outcomes for surgical stabilization of rib fractures in patients with known sources of infection (eg, fungal colonization of the mediastinum [43], empyema [44]). Weighing the potential benefit of surgical stabilization of rib fractures against the possibility and ramifications of hardware infection is important for determining whether to pursue operative rib fracture stabilization in such patients. There are no studies upon which evidence-based recommendations can be made regarding type or duration of antibiotic therapy in these patients [45].
Imaging — The imaging study of choice to evaluate the characteristics of rib fractures is two-dimensional computed tomography (CT) of the chest. Three-dimensional CT scan may be more useful in terms of operative planning (image 1), such as determining the exact location of the fractures to help determine optimal patient positioning and the location of incisions [46]. (See 'Positioning and incisions' below.)
The curvature of the ribs must be accounted for when measuring the distance from a fixed landmark to the fracture site on the CT scan. It is easiest to measure distance from the edge of the sternum to the fracture site for anterior fractures and distance from the spinous process of the vertebra to the fracture site for posterior fractures. Using the scapula as a point of reference can be misleading as the position of the scapula changes with movement of the upper extremity. If the scapula is to be used, it is important to know how the arms were positioned when the CT scan of the chest was obtained and also to account for the position of the arms when the patient is positioned on the operating table.
Approach — All but one of the commercially available rib plating systems require open operative repair; however, the plating systems used today have a smaller profile and less need for dissection compared with those used in the past [10]. Nevertheless, VATS has been used to aid localization of fractures, evacuate retained hemothorax, and perform repair of some associated injuries (eg, diaphragm rupture) [47]. (See "Overview of minimally invasive thoracic surgery".)
Positioning and incisions — Most rib fractures are located in the mid- to posterior axillary line, thereby requiring the patient to be placed in a lateral decubitus position. Patients can be positioned supine if the fractures are anteriorly located (ie, anterior to the anterior axillary line). Posterior fractures (ie, posterior to the posterior axillary line) can be approached with the patient in the prone or lateral decubitus positions.
Because operative rib fixation does not necessitate a thoracotomy, there is no need to follow the course of the ribs. More often than not, the fracture line on multiple rib fractures is straight, thereby allowing excellent exposure using a vertical incision centered on the fracture line itself [40]. Conversely, flail segments that are in relative proximity may be best exposed using a horizontal incision with raised myocutaneous flaps. However, muscle-sparing techniques should be used to mitigate postoperative pain to the extent that is possible [19,48]. In instances where the fracture lines of a flail segment are far apart, two incisions may be less morbid than a single large incision with raised flaps to minimize postoperative pain, seroma formation, and the potential for subsequent infection. In addition, an intrathoracic approach may allow for a minimally invasive method to address such distant fractures.
Number of fractures to repair — The actual number of ribs to be repaired should be determined by weighing the length and number of incisions needed to expose the fracture, the degree of displacement of each fracture, the presence of a flail segment, and the location of the patient's pain with deep breathing. Based on chest physiology and the available evidence, fixation of all fractures is usually not necessary [49-51]. In cases where all fractures cannot be fixed, most authors recommend operative fixation of ribs 4 to 9 [52].
The majority of chest wall movement occurs in the region of ribs 4 to 9, and therefore operative fixation of these ribs results in the greatest improvement in overall respiratory function and relief of pain [19]. Ribs 1 and 2 demonstrate little movement with breathing and therefore rarely have to be surgically stabilized. Similarly, ribs 10 to 12 contribute little to chest wall stability and do not require operative repair. Furthermore, osteosynthesis of posterior fractures along ribs 1 to 3 may not be technically possible due to the location of the scapula. Most commercially available rib plating systems now have right angle tools that allow for fixation of fractures located behind the scapula, as may be the case with ribs 3 to 5.
One study has suggested that partial surgical stabilization of flail chest was acceptable [50]. However, a review of 3D chest CT three months after rib fixation found that fixing only one fracture per rib in a flail segment did not avoid deformity and displacement, particularly in posterior rib fractures [49]. It is important to note that this study used absorbable plates, which are no longer used or recommended by most surgeons. Only 50 percent of fractured ribs were surgically fixed in another study that found a significant reduction in respiratory failure and need for tracheostomy tube placement following rib plating [17].
Plating types and techniques — The standard approach to operative fixation of the ribs uses titanium plates placed from the outside of the chest wall and secured into place using locking screws. To minimize the risk of hardware failure, it is important to ensure that screws are locked to the plate, the plate is securely apposed to the rib surface, and there is minimal, if any, gap that the plate traverses. A plating system that uses reverse-contoured plates to reduce and fix the fracture from within the chest cavity using a VATS approach has been approved for use. In the past, absorbable plates were used for rib fracture fixation; however, the incidence of non- or partial healing was between 11 and 56 percent, and this type of plate should no longer used [49]. In a small trial, at any of the time intervals studied, significantly more patients assigned to absorbable plates had plate displacement compared with patients assigned to metal plates, for which there were no plate displacement events [53]
All dissection and manipulation of the rib should occur from the anterior and superior aspects to avoid injury to the neurovascular bundle, which is located inferior and slightly posterior to each rib. Rib fixation plates are contoured for the curvature of the rib (image 2). Because the cortex is very thin (measuring 0.5 to 1.5 mm), it cannot be used as a lever to reduce a fracture [54]. This is the main reason for the differing plating systems, but there are no comparative studies upon which to base a recommendation to use one system over the other. Some plating systems are based on bicortical fixation of the plate (eg, MatrixRIB, RibFix Blu, Advantage Rib), while another (RibLoc) uses a U-plate design that provides fixation to both sides of the cortex as well as to both the anterior and posterior aspects of the titanium plate (picture 1 and image 3). Another system (Level One) is based upon fixation to the anterior cortex only using screws that are placed at an angle. Anterior and intrathoracic plates should be positioned in the midportion of the rib. Anterior plates require a minimum of three points of fixation on each side of a fracture while intrathoracic plates require one point of fixation on each side of the fracture line. U-plates should be wrapped around the superior portion of the rib to minimize risk of injury to these neurovascular bundles and require two points of fixation. A system that also involves an anterior plate (StraTos) is unique in that it does not use screws to fix the plate in place but rather uses a series of wrap-around clips to secure the plate to both the superior and inferior aspects of the rib. This system is not commonly used in the United States.
Furthermore, some plating systems require drilling holes into the rib prior to insertion of screws, whereas others use self-tapping screws, thereby saving a step. All systems (except Level One; anterior fixation using 1.5-mm screw) require the surgeon to measure the thickness of the rib to determine the proper screw length. This is done using a caliper that is unique to each rib plating system. The soft tissues on the anterior surface of the rib and the parietal pleura on the undersurface of the rib must be dissected away to make this measurement. Use of screws that are too short can result in displacement of the plates due to poor fixation while use of screws that are too long can result in injury to the lung.
Regardless of the type of plating system that is used, it is vital that plates are secured to healthy bone at least 2 to 3 cm away from the fracture line. A longer landing zone is needed if the fracture involves an oblique angle or has a high degree of comminution. This can be problematic in instances where the fracture line is close to the spine. When this occurs, there are commercially available intramedullary splints that can be used to traverse a fracture and provide stability. A six-month follow-up study of patients who underwent fixation of a total of 35 rib fractures using intramedullary splints found complete healing in 94 percent of patients as assessed by 3D CT scanning [55]. However, computer modeling finds significant shear stress on splints placed across posterior fracture lines, thereby raising concern for structural fatigue and failure of the device [56]. There have also been reports of the splint piercing the rib cortex, which could be dangerous if it were to occur close to the spinal column. As a result, use of intramedullary splints has not gained popularity overall.
Need for thoracostomy tube — There are no absolute indications for placement of a thoracostomy tube, since operative rib fixation with any system other than Advantage Rib does not require violation of the pleural space. However, injuries that involve severely displaced rib fractures or reduction of displaced rib fractures intraoperatively often result in tears in the pleura. Furthermore, implantation of U-plates is associated with a higher likelihood of pleural violation than placement of anterior plates due to the need to dissect behind the rib and wrap the plate around the superior portion of the rib. In addition, using a caliper to measure rib thickness for plate/screw sizing can result in perforation of the parietal pleura. Given the lack of evidence-based guidelines regarding tube thoracostomy following operative rib fixation, some authors recommend routine placement of a thoracostomy tube whereas others use a selective approach in determining the need for chest tube placement. When placed, the tube should be placed well away from the plates to decrease the probability of infection and removed as soon as possible.
PERIOPERATIVE CARE — The general postoperative management of patients following rib fixation is centered on timely extubation, pain control, and thoracostomy tube management if such a tube was placed. Because the operation does not necessitate thoracotomy, patients usually do not experience the pulmonary inflammatory effects and fluid shifts associated with thoracic operations. Furthermore, fixation of the ribs usually results in immediate relief of pain, which, in turn, allows for extubation either on the day of or the day following operation. Medical measures for pain relief instituted prior to operation (eg, pharmacologic analgesia, regional analgesia) should be continued in the immediate perioperative period but can be weaned over time based on the patient's condition. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)
There is no need for prolonged prophylactic perioperative antibiotics [57]. A first-generation cephalosporin antibiotic or its equivalent should be administered prior to the start of operation, and antibiotic prophylaxis should be discontinued within 24 hours of operation when there is no pre-existing infection or pneumonia [45]. There is insufficient evidence to guide antibiotic therapy in patients who have pneumonia or other infection and are undergoing surgical stabilization of rib fractures [45].
Management of a thoracostomy tube postoperatively follows the same principles as in general thoracic surgery. Namely, when the output from the chest tube is less than approximately 200 mL in 24 hours, there is no air leak noted in the collection system, and there is no evidence of a pneumothorax on chest radiograph, the tube should be removed. In instances where a chest tube has been inserted solely for pleural violation before or during rib fixation, the tube can usually be removed within 48 hours of operation. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)
ADJUNCTIVE TECHNIQUES
Iliac bone graft — An autograft from the iliac crest is the preferred graft for filling in significant defects that can result from a severely comminuted or avulsed fracture pattern. This option is the most effective for producing successful arthrodesis (or bone healing) across the fracture. However, it requires that bone be harvested from the iliac crest with the associated risk for wound complications and other morbidity.
Demineralized bone matrix — Demineralized bone matrix is a collagen allograft that serves as a scaffold to encourage ingrowth of osteoblasts from osteoprogenitor cells. It is a commercially prepared product that can be applied to fill in small gaps in cases with significant comminution. However, it has no mechanical integrity and is expensive.
SURGICAL COMPLICATIONS — Complications specifically related to the surgical technique of rib fracture fixation are overall uncommon [40].
Surgical site infection — Infection is the most clinically important complication because it may necessitate hardware removal and is associated with a significant rate of nonunion. The reported rate of hardware infection varies between 0 and 10 percent, but all reports are single center and consist of small numbers of patients [23,58]. In a report of five patients who developed a hardware infection following rib plating, three patients required removal of the plates. Treatment with antibiotics suppressed the infection, allowing the underlying fracture to heal. The mean time to plate removal was 174 days following operation. None had long-term sequelae of the infection. A later review of patients receiving rib fracture stabilization included nine patients who had systemic antibiotic therapy and vancomycin/gentamicin antibiotic beads placed for wound infection and eight patients who had antibiotic beads placed prophylactically due to high risk of developing a wound infection [59]. There was no benefit for prophylactic treatment. Seventy-eight percent of infected hardware was removed six months following implantation. However, the study also found 100 percent healing in the infected group, suggesting that antibiotic treatment without or perhaps without plate removal may be an option in these patients. The authors did not comment on what factors lead to removal of hardware. A separate report that included the bacterial isolate in patients who developed a surgical site infection reported that all infections were due to methicillin-sensitive Staphylococcus aureus [60].
Other hardware complications — Other complications include those specific to the hardware system. A systematic review of 24 observational studies evaluating hardware failure after surgical stabilization of rib fractures reported a 4 percent prevalence of hardware failures [61]. Hardware failure was less for repair of acute compared with chronic fractures. Sixty percent of patients required hardware removal, but only 10 percent of these required restabilization. Mechanisms of failure included mechanical failures (60 percent), infection (22 percent), persistent pain (16 percent), and nonunion (3 percent). The included studies did not allow for further evaluation of patient-specific risk factors for any one outcome. In one review that included over 1200 rib fracture stabilization procedures, hardware failure, which occurred in 38 (3 percent), was most common in the anterolateral/lateral region [62].
Among reported hardware failures [61-64], it is somewhat surprising that they are often related to screw/plate migration since all plating systems used locking screws that lock the screw to the plate itself. Such displacement suggests that the screw was not sufficiently tightened to lock it to the plate at the time of insertion or that the plate/screw construct pulled away from the bone due to poor overall fixation to the cortex.
Aside from screw displacement, there are isolated reports of plates fracturing over time [65,66]. There are no systematic reviews or large case series to describe risk factors for this, but all manufacturers recommend against using the plates to traverse a gap longer than 1 to 1.5 cm as repetitive movement of the plates will result in metal fatigue and fracture.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Thoracic trauma".)
SUMMARY AND RECOMMENDATIONS
●Rib fracture stabilization – Rib fractures are the consequence of significant forces impacting the chest wall. Surgical stabilization of rib fractures (ie, osteosynthesis) may be indicated in the following circumstances (see 'Indications' above):
•Indications
-Impending or actual respiratory failure due to painful, movable ribs refractory to pain management strategies. This includes patients with flail chest or with multiple, severely displaced non-flail pattern fractures.
-Significant chest wall deformity.
-Failure to wean from mechanical ventilation (not due to pulmonary contusion).
-Significantly displaced ribs found at thoracotomy being performed for other reasons (eg, open pneumothorax, pulmonary laceration, retained hemothorax, diaphragm hernia, vascular injury). This is referred to as "on-the-way-out fixation."
-Ongoing chest wall instability/deformity or pain due to nonunion or malunion of rib fractures.
•Contraindications – Rib fracture stabilization should not be performed in patients with severe pulmonary contusion as the cause for respiratory insufficiency or in patients with other concomitant injury (eg, head injury) that precludes separation from mechanical ventilation. (See 'Contraindications' above.)
●Timing of surgery – For patients with indications for rib fracture stabilization, we perform the procedure once it becomes apparent that the patient's pain cannot be adequately controlled (typically 24 to 48 hours), and we try to perform the procedure within 48 hours of injury. For patients who require a thoracic procedure for other reasons, it is reasonable to carry out rib fixation earlier. (See 'Timing of early surgery' above.)
●Efficacy of surgery – For patients with flail chest, early rib fracture stabilization helps to avoid the need for intubation and reduces the incidence of pneumonia and other pulmonary complications. (See 'Efficacy of rib stabilization' above.)
●Surgical techniques
•Plate systems and placement – Several types of plate fixation systems are available. Anterior or intrathoracic plates are positioned in the midportion of the rib, while U-plates are wrapped around the superior portion of the rib to minimize risk of injury to the neurovascular bundle. Two to three points of screw fixation are needed (depending on the type of plate) on each side of the fracture. Longer plates are needed if the fracture is oblique or comminuted to assure adequate fixation on either side of the fracture line. Fractures that are within 2 cm of the spine may not be amenable to operative fixation using standard plating systems. (See 'Plating types and techniques' above.)
•Number of ribs to stabilize – Fixation of all ribs is usually not necessary, but in general, ribs 4 to 9 should be repaired because these ribs provide most of the stability to the chest wall. The actual number is determined by weighing the length and number of incisions needed to expose the fractures, the degree of displacement of each fracture, the presence of a flail segment, and the location of the patient's pain with deep breathing. (See 'Number of fractures to repair' above.)
•Thoracostomy tube placement –A chest tube may be needed if the pleura is violated during rib fracture fixation. This is more likely to occur for reduction of severely displaced rib fractures. Implantation of U-plates (compared with anterior plates) may increase the likelihood due to the need to dissect behind the rib. When needed, the thoracostomy tube should be placed well away from the plates to decrease the likelihood of hardware infection. (See 'Rib fracture stabilization' above.)
●Perioperative care – Pain control measures are reinstituted postoperatively (acetaminophen, COX-2 inhibitors, regional anesthesia) and weaned as tolerated. Fracture fixation typically reduces pain to the extent that extubation can be accomplished either on the day of or the day following the surgery. (See 'Perioperative care' above and "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)
●Surgical complications – Other than pneumothorax, which can occur in the postoperative period if a chest tube was not initially placed, there are few complications specific to the surgical technique. Infection is a serious problem when it occurs and may require removal of the plates. A trial of antibiotic treatment without plate removal may be an option. To minimize the risk of hardware failure, it is important to ensure that screws are locked to the plate, the plate is securely apposed to the rib surface, and there is minimal, if any, gap that the plate traverses. (See 'Surgical complications' above.)
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