Association of Early Rib Plating on Clinical and Financial Outcomes: A National Analysis

BACKGROUND

With reported improvements in patient outcomes, surgical stabilization of rib fractures (SSRF) has been increasingly adopted. While institutional series have sought to define the role of early SSRF, large scale analysis remains lacking. The present study evaluated clinical and financial outcomes of SSRF in a nationally representative cohort.

METHODS

Patients (≥16 years) admitted with multiple rib fractures were identified using the 2016-2020 National Inpatient Sample. Those who underwent rib plating >14 days following admission were omitted. Using restricted cubic spline analysis, patients who underwent SSRF within 2 days of hospitalization were classified as Expedited while fixation >2 days were deemed Routine. Multivariable regressions were used to evaluate the association of operative timing on outcomes of interest.

RESULTS

Of 8150 patients meeting final inclusion criteria, 4090 (50.2%) were Expedited. Compared to Routine, Expedited tended to be older but were of comparable race, primary payer, and income quartile. Traumatic mechanism was also similar but rates of concomitant sternal fracture as well as intra-abdominal and cardiac injuries were higher in Routine. After adjustment, Expedited was associated with lower odds of respiratory complications, which included need for mechanical ventilation, prolonged mechanical ventilation, and pneumonia, compared to Routine. Expedited was associated with similar hospitalization duration but had lower incremental costs (β: -$19.1 K, 95% CI: -24.1 to -14.2).

DISCUSSION

Early SSRF was associated with lower likelihood of a number of respiratory complications and in-hospital costs. While patient selection criteria may limit our findings, expeditious fixation may limit morbidity while enhancing value of care.

Attempted repair of chest wall injury following penetrating injury with surgical stabilization rib and autologous bone graft: A case report

Rib fractures are one of the most common injuries following blunt trauma. When associated with penetrating trauma, the projectile velocity and immense energy transfer cause significant rib fracture displacement and fragmentation. As a result, these patients are potentially exposed to an even higher risk of complications compared to those seen in more simple rib fractures. Unfortunately, there is limited research regarding technical considerations for surgical stabilization of rib fractures (SSRF) in severely displaced rib fractures with bone loss following penetrating injury. We present the case of a 21-year-old male gunshot wound victim with severely displaced and comminuted rib fractures in which we utilized an autologous bone graft bridge during SSRF to enhance fracture unionization, chest wall stability, and cosmesis. Unfortunately, the bone graft failed to incorporate into surrounding tissue.

Delayed rib plating and lung herniation repair in a traumatic chest injury after thoracotomy: A case report

INTRODUCTION AND IMPORTANCE

Lung herniation following trauma is a rare occurrence, and consensus on optimal surgical repair techniques remains limited. While small herniations may resolve without surgery, intervention becomes necessary in cases of unsuccessful non-operative management or concurrent rib fracture stabilization. Mesh application in repair poses a dilemma, often providing physical support but raising infection concerns, particularly in trauma scenarios with delayed closure. Surgical stabilization of rib fractures, employing hardware similar to orthopedic procedures, may necessitate prophylactic antibiotics, though empirical evidence supporting routine use is scant. Polytrauma patients often resort to delayed chest closure techniques during methodical surgical planning, but these carry potential consequences compared to immediate closure.

CASE PRESENTATION

Presented is a case involving a patient in a motorcycle collision sustaining multiple injuries, necessitating a massive transfusion protocol, multiple surgeries, including delayed chest closure, and eventual surgical rib fixation four days post-injury. During rib stabilization, exacerbation of traumatic lung herniation mandated mesh repair, prompting the cautious use of prophylactic vancomycin powder to mitigate infection risks.

DISCUSSION

A review of the literature revealed a scarcity of similar cases, particularly those involving lung herniation with delayed chest closure, the use of prophylactic antibiotics and mesh in polytrauma.

CONCLUSION

This case underscores the lack of depth of comprehensive research guiding surgical decisions concerning lung herniation and the prophylactic use of vancomycin powder in trauma patients.

Is There a Role for Rib Plating in Thoracic Trauma?

Rib fractures are a morbid consequence of blunt trauma and are associated with a highly variable clinical presentation ranging from nondisplaced rib fractures causing limited, manageable pain to severely displaced rib fractures with concomitant thoracic injuries leading to respiratory failure. Due to an evolution of techniques, hardware technology, and general acceptance, rib plating has increased substantially at trauma centers all throughout the United States over the past decade. This article aims to review the most recent and current reports for rib plating with respect to indications, preoperative evaluation and imaging, approaches, timing for intervention, outcomes in patients with flail chest and nonflail injuries, and the management of complications. From these data, it becomes clear that the surgical stabilization of rib fractures (SSRF) has a firm place in the management of thoracic trauma.

Operative fixation of rib fracture nonunions

INTRODUCTION

Rib fractures are common injuries in trauma patients that often heal without intervention. Infrequently, symptomatic rib fracture nonunions are a complication after rib fractures. There is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe the efficacy of rib fracture nonunion operative fixation with particular focus on surgical technique, healing rates, and complications.

MATERIALS AND METHODS

Patients aged ≥ 18 years with symptomatic rib fracture nonunions treated with open reduction and internal fixation (ORIF) with locking plates at a single urban level 1 trauma center were retrospectively reviewed. Pertinent demographic, clinical, radiographic, and surgical data were collected and analyzed.

RESULTS

A total of 18 patients met inclusion criteria. The mean time from injury to undergoing ORIF for rib fracture nonunion was just under a year and the number of ribs plated was 2.95 ± 1.16 (1-5 ribs) with bone grafting used in six cases. All patients (100%) showed evidence of healing at an average of 2.65 ± 1.50 months (2-8 months). All patients reported a decrease in pain. No narcotic pain medication was used at an average of 3.88 ± 3.76 weeks (0-10 weeks) post-operatively. Intraoperative and postoperative complications were found in 4 (22.2%) patients.

CONCLUSION

This study concluded that operative fixation of symptomatic rib fracture nonunion demonstrated favorable outcomes with reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union. This described method provides symptomatic relief, reduction in pain, and promotes bony healing of the fracture nonunion without development of major complications. We suggest that operative fixation should be considered as the primary method of treatment of symptomatic rib nonunions.

Far posterior rib plating: Preliminary results of a retrospective case series

INTRODUCTION

Far posterior, or paraspinal rib fractures, defined as fractures that are medial to the medial border of the scapula (and may involve the costovertebral articulation), are often treated nonoperatively. However, in certain cases, including severe displacement, persistent pain, nonunion, or persistent respiratory distress, stabilization with open reduction and internal fixation (ORIF) may be warranted. There is a paucity of literature regarding the surgical approach and clinical outcomes following ORIF for far posterior rib fractures and fracture-dislocations. The purpose of this paper is to describe the surgical approach and to report the first collection of clinical outcomes for patients undergoing paraspinal rib ORIF.

PATIENTS AND METHODS

A retrospective case series was performed at a single urban level 1 trauma center. Patients 18 years of age or older who underwent ORIF of far posterior rib fractures were included in this study. Far posterior rib fractures were defined as fractures that occurred medial to the medial border of the scapula underneath the paraspinal musculature. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed.

RESULTS

Twenty-six patients, with a mean age of 50.7 years, who underwent paraspinal rib ORIF were included in this study. The mean follow-up was 12.1 months. 80.8% of patients had a flail chest injury. On average, 3.4 ribs were instrumented posteriorly with 22.8% of patients requiring fixation spanning the costotransverse articulation. No intraoperative complications occurred. Only one patient required a repeat procedure. Total hospital length of stay averaged 17.3 days with an intensive care unit stay averaging 6.2 days. Total ventilator time averaged 4 days. 7 patients were diagnosed with postoperative pneumonia and 6 patients required tracheostomy.

CONCLUSION

Open reduction and internal fixation for far posterior, or paraspinal rib fractures and fracture-dislocations is a safe procedure with low complications rates and favorable postoperative outcomes including hospital length of stay, ICU length of stay, need for tracheostomy, postoperative pneumonia, and mechanical ventilation time.

A model for evaluating the biomechanics of rib fracture fixation

INTRODUCTION

High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation.

METHODS

One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes.

FINDINGS

Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating.

INTERPRETATION

This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.

Clinical management of rib fractures and methods for prevention of pulmonary complications: A review

Rib fractures are common injuries associated with significant morbidity and mortality, largely due to pulmonary complications. Despite equivocal effectiveness data, incentive spirometers are widely utilized to reduce pulmonary complications in the postoperative setting. Few studies have evaluated the effectiveness of incentive spirometry after rib fracture. Multiple investigations have demonstrated incentive spirometry to be an important screening tool to identify high-risk rib fracture patients who could benefit from aggressive, multidisciplinary pulmonary complication prevention strategies. This review evaluates the epidemiology of rib fractures, their associated pulmonary complications, along with the evidence for optimizing their clinical management through the use of incentive spirometry, multimodal analgesia, and surgical fixation.

Geriatric chest wall injury: is it time for a new sense of urgency?

Geriatric trauma has become an increasingly recognized management concern for trauma centers, and hospitals alike, on a national scale. The population of the United States is aging, as life expectancy rates have demonstrated a steady climb to an average of 78.8 years of expected life. With pervasive efforts of medical screening, prevention and chronic medical condition management, more elderly people will lead more active lifestyles and will be more predisposed to injury. As best practice guidelines specific for the geriatric trauma population have yet to be developed, many researchers have identified management strategies that have offset complications and mortality rates inherent to this patient population after injury. The impact of rib fractures in the 65-year and older patient population has been well documented, as have the mortality and pneumonia rates yet, historically, little attention has been directed to curtailing these adverse outcomes with more advanced treatment options. With the advent of rib plating for rib fracture fixation and chest wall stabilization, the practice paradigm for rib fracture management is shifting, as a viable operative intervention now exists. In this review, we focus on the characteristics of the geriatric trauma patient, areas of management where improvement opportunities have been identified, chest wall injury in the elderly patient, rib plating as a treatment option and offer our data to facilitate a better understanding of rib plating's impact in the geriatric trauma patient.

Using electromagnetic navigation for intraoperative rib fracture localization during rib plating: A case report

INTRODUCTION

The precise localization of fractured ribs represents one of the primary challenges of surgical rib fixation. Computed tomography (CT) provides the facture's general location, but it is difficult to use the imaging alone to properly place a surgical incision. We used electromagnetic navigation to identify the exact location of the fracture on the patient's skin.

PRESENTATION OF CASE

A 64-year-old man fell and suffered multiple left-sided nonunion rib fractures (4th to 9th). He was initially treated with a chest tube and analgesia, but he developed chronic pain from the injury. On the CT scan of the chest, the rib fractures were displaced and on exam, the ribs were mobile with reproducible pain and clicks on palpation. We used electromagnetic navigation to determine the fracture's exact location on the skin during the operation, which aided in the location of the incision. The patient had open reduction and internal fixation of the broken ribs using rib plates. The patient had relief from his chronic pain after the surgery.

DISCUSSION

The localization of the rib fracture on a patient's skin can be performed using a physical exam, landmarks from the CT scan, or video-assisted thoracic surgery (VATS) procedure. Each of the techniques sacrifices either time or accuracy during the operation. The electromagnetic navigation can provide precise localization of the fracture without sacrificing too much time during the operation.

CONCLUSION

The use of electromagnetic navigation to identify the fracture on a patient's skin provides quick and accurate intraoperative localization for surgical rib fixation.

Comparative studies of different types of osteosynthesis on the human corpse preparation in bilateral antero-lateral flail chest

INTRODUCTION

Bilateral flail chest injuries are challenging in treatment and comparatively often require an operative stabilization of the anterior chest wall to re-establish normal physiological conditions of the chest wall in shape and statics. Various procedures have been described which are technically sophisticated for the surgeon. Consequently there is an increasing interest in potentials of operative care and their effectiveness on the anterolateral chest wall.

MATERIALS AND METHODS

12 Human cadavers were prepared and the natural Sternum Position (NP) was marked. A digital probe was fixed to the sternum at the height of the 4th intercostal space in order to measure and compare the stability of the thorax. Readings were taken of the sternal displacement at 1-5cm sagittal distance from NP in starting conditions and from every combination of materials. Serial osteotomies were performed on 2 locations on ribs 2-8 to induce bilateral flail chest. Afterwards the stabilization was achieved with different implants: RESULTS: The osteotomies lead to a subsidence of the sternum occurred to almost 75 mm from NP which corresponds to a maximal unstable situation. The unstable chest wall showed substantially more stabilization through the use of locking plates. Our materialcombinations showed a stability of up to 60% of normal. The more ribs were treated osteosynthetically, the higher the stability of the chest wall.

DISCUSSION AND CONCLUSIONS

Locking plate fixation offers anatomically realignment of the ribs whereas metal strut support only lifts up the chest wall, but could not provide realignment of the dislocated ribs.

Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer

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Long thoracic nerve injury is a potential complication of rib fracture fixation.

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Long thoracic nerve injury from rib fracture fixation has not been reported.

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Long thoracic nerve injury can be corrected surgically by pectoralis major transfer.

INTRODUCTION

Rib plating is becoming increasingly common as a method for stabilizing a flail chest resulting from multiple rib fractures. Recent guidelines recommend surgical stabilization of a flail chest based on consistent evidence of its efficacy and lack of major safety concerns. But complications of this procedure can occur and are wide ranging.

PRESENTATION OF CASE

We report an interesting case of a 58-year-old male patient that worked as a long-distance truck driver and had a flail chest from multiple bilateral rib fractures that occurred when his vehicle was blown over in a wind storm. He underwent open reduction with internal fixation (ORIF) of the bilateral rib fractures and they successfully healed. However, he had permanent long thoracic nerve injury on the side with the most severe trauma. This resulted in symptomatic scapular winging that impeded him from long-distance truck driving. The scapular winging was surgically corrected nearly two years later with a pectoralis major transfer augmented with fascia lata graft. The patient had an excellent final result.

DISCUSSION

We report this case to alert surgeons who perform rib fracture ORIF that long thoracic nerve injury is a potential iatrogenic complication of that procedure or might be a result of the chest wall trauma.

CONCLUSION

Although the specific cause of the long thoracic nerve injury could not be determined in our patient, it was associated with chest wall trauma in the setting of rib fracture ORIF. The scapular winging was surgically corrected with a pectoralis major transfer.