Outcomes after operative management of symptomatic rib nonunion

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

BACKGROUND

Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements.

RESULTS

A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection.

CONCLUSION

This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Conservative Treatment of Empyema Formation Following Intrathoracic Rib Fixation With Antibiotics and Tissue Plasminogen Activator/Dornase

Rib plating is a recommended intervention for patients with multiple rib fractures or flail chest to improve shortness of breath, significantly reduce pain, and shorten the length of hospital stay. Here, we report a unique and extremely rare finding in a patient with empyema following intrathoracic rib fixation. A 32-year-old male with a history of alcohol use disorder presented to the emergency department trauma bay after a motor vehicle accident. Computed tomography (CT) showed right hemopneumothorax and fourth to ninth rib fractures with displacement. The right fifth and sixth ribs were then plated using a titanium RibFix bridge, implanted intrathoracically along the posterior surface of the ribs. On postoperative day 11, the patient developed an empyema and a CT-guided drainage catheter was placed into the collection. The patient was given a 3-day course of tissue plasminogen activator (tPA) and DNase for the treatment of his empyema. On postoperative day 15, a repeat CT scan demonstrated significant improvement in the empyema with evidence of abscess resolution. Antibiotics were discontinued after a total of 7 days and the patient was discharged on postoperative day 20. This case report contributes information to the management of complications in intrathoracic rib fixation.

Management of non-union of rib fractures secondary to trauma: A scoping review

OBJECTIVE

Rib fracture non-union is an uncommon complication of traumatic rib fractures. Our objective was to perform a scoping review of the literature for the management of rib fracture non-union. This included analysis of the variations in surgical technique, complications experienced, and reported outcomes.

METHODS

We conducted a scoping review and searched databases (MEDLINE, CINAHL, and Embase). We performed abstract and full-text screening, and abstracted data related to pre-operative assessment, surgical technique, complications, and reported outcome measures.

RESULTS

We included 29 articles of which 19 were case reports and 10 were case series. The data quality was generally heterogeneous. The studies included 229 patients and the commonest symptoms of rib fracture non-union included chest pain, clicking, dyspnea and deformities. The patients underwent surgical management of rib fracture non-union (excluding first rib fractures) using various techniques. The majority used surgical stabilization of rib fracture with or without a graft. The reported outcomes were inconsistent between studies, but showed high rates of union (>94 %), reduction in reported VAS scores, and improved return to work when included. Implant failure occurred in 10 % of the 229 total patients reported in our studies, the re-operation rate was 13 %, and the overall complication rate was 27 %.

CONCLUSION

Surgical management of rib fracture non-union often involving locking plates and screws with or without a graft has been shown in several case reports and series as an effective treatment with acceptable implant failure and complication rates. Surgical management is therefore a viable option for symptomatic patients. Further research is required to determine optimal management strategies that further reduce surgical complications for these patients.

Symptomatic rib fracture nonunion: a systematic review of the literature

INTRODUCTION

Rib fractures commonly occur in trauma patients with varying presentations. Though the literature in recent years has moved toward favoring more early intervention of acute rib fractures, little has been reported on the matter of surgical fixation for symptomatic rib fracture nonunions.

MATERIALS AND METHODS

We performed a review of PubMed and Cochrane databases for articles published since 2000. Inclusion criteria were studies with greater than six months of follow-up, while case studies were excluded. A thorough analysis was performed on patient outcomes, complications reported, operative techniques utilized, and fixation systems used, among other parameters reported by the articles.

RESULTS

One hundred and thirty-nine studies resulted from our review, and a total of nine studies met our inclusion criteria with a combined total of 182 patients who underwent open reduction and internal fixation for symptomatic rib fracture nonunions. All studies reported a significant reduction of pain with increased satisfaction in the majority of patients. There were a total of 71 postoperative complications, the most common of which included surgical site infections, hardware failure, and hematoma. The most serious complications were insulting injury to the lung parenchyma or pleura; however, these were extremely rare based off the current literature. The use of bone grafting was common with eight of the nine studies mentioning the benefits of grafting.

CONCLUSION

Surgical stabilization of rib fracture nonunions appears to be an appropriate treatment alternative, and various techniques and approaches may be used with similar success. Further studies with higher level of evidence are recommended on the subject.

Radiographic rib fracture nonunion and association with fracture classification in adults with multiple rib fractures without flail segment: A multicenter prospective cohort study

BACKGROUND

Rib fracture nonunion is a probable cause of chronic pain following chest trauma, although its prevalence remains unknown. The aims of this study were to determine rib fracture nonunion prevalence following nonoperative management and to determine if presence of nonunion was associated with the number of rib fractures, or the rib fracture classification of anatomical location, type, and displacement.

METHODS

This multicenter prospective cohort study included trauma patients with three or more fractured ribs but without a flail segment, who participated in the nonoperative management group of the FixCon trial between January 2019 and June 2022. The number and classification of rib fractures were assessed on trauma chest CT. Chest CTs conducted six months post-trauma were evaluated for the presence of nonunion. Radiological characteristics of nonunions were compared with normally healed rib fractures using the Mann-Whitney U, χ2 test, and Fisher's exact test as appropriate. A generalized linear model adjusted for multiple observations per patient when assessing the associations between nonunion and fracture characteristics.

RESULTS

A total of 68 patients were included with 561 post-traumatic fractures in 429 ribs. Chest CT after six months revealed nonunions in 67 (12 %) rib fractures in 29 (43 %) patients with a median of 2 (P25-P75 1-3) nonunions per patient. Nonunion was most commonly observed in ribs seven to 10 (20-23 %, p < 0.001, adjusted p = 0.006). Nonunion occurred in 14 (5 %) undisplaced, 22 (19 %) offset, and 20 (23 %) displaced rib fractures (p < 0.001). No statistically significant association between rib fracture type and nonunion was found.

CONCLUSIONS

Forty-three percent of patients with multiple rib fractures had radiographic nonunion six months after trauma. Fractures in ribs seven to 10 and dislocated fractures had an increased risk of rib fracture nonunion.

Better late than never-a single-center review of delayed rib fixation for symptomatic rib fractures and nonunions

BACKGROUND

Surgical stabilization of rib fractures (SSRFs) has become an emerging therapy for treatment of patients with rib fractures. More commonly, it is used in the acute setting; however, delayed SSRF can be utilized for symptomatic rib fracture nonunions. Here, we describe our institution's experience with delayed SSRF, hypothesizing it is safe and resolves patient symptoms.

METHODS

This is a retrospective review of patients presenting to our Level I trauma center to undergo delayed SSRF for symptomatic nonunions from January 2017 to September 2022. Delayed SSRF was defined as SSRF over 2 weeks in the outpatient setting. Basic demographics were obtained. Outcomes of interest included mean pain score (preoperatively and postoperatively), intensive care unit (ICU) and hospital length of stay (LOS), and resolution of preoperative symptoms, specifically chest wall instability, with return to activities of daily living (ADLs).

RESULTS

Forty-four patients met inclusion criteria with a total of 156 symptomatic nonunion rib fractures that received delayed SSRF. The average age was 59.2 ± 11.9 years and median number of days from injury to SSRF was 172.5 (interquartile range, 27.5-200). The average number rib fractures plated per patient 3.5 ± 1.8. Only three patients required ICU admission postoperatively for no longer than 2 days. Median hospital LOS was 2 days (interquartile range 1-3 days). Average preoperative and postoperative pain score was 6.8 ± 1.9 and 2.02 ± 1.5, respectively ( p < 0.001). Chest wall instability and preoperative symptoms resolved in 93.2% of patients postoperatively ( p < 0.001). Two patients (4.5%) had postoperative complications that resolved after additional surgical intervention. Rib fracture healing was demonstrated on radiographic imaging during postoperative follow-up.

CONCLUSION

Delayed SSRF is safe and demonstrates significant resolution of preoperative symptoms by decreasing pain, improving chest wall stability, and allowing patients to return to activities of daily living.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Surgical strategy for treating multiple symptomatic rib fracture malunions with bridging heterotopic ossifications: A case report

Rib fractures are common and serious injuries, which can negatively impact long-term quality of life. Here we present a woman in her early twenties who was referred to our trauma surgery outpatient clinic five years after a motor vehicle collision in which she sustained upper extremity injury and multiple displaced rib fractures. The rib fractures were initially managed non-operatively. At the time of the outpatient consultation, she endured persistent severe pain located between the left scapula and the thoracic spine. The pain worsened on repetitive motion and deep respiration. A new chest CT revealed left-sided posterior rib fracture malunions of ribs 4 to 8 with heterotopic ossifications (HO) that formed an osseous bridge between these ribs. Surgical excision of the bridging HO and remodeling of the angulated rib malunions resulted in significant alleviation of symptoms, which allowed her to return to work and other activities. Given the dramatic improvement after surgery, we suggest considering surgical remodeling and excision for rib fracture malunions and associated HO that cause local mechanical symptoms.

Outpatient Surgery for Rib Fracture Fixation: A Report of Three Cases

Rib fractures are common injuries observed in trauma patients that will often heal without operative intervention. However, patients can infrequently have continued pain. Operative fixation of these symptomatic rib fractures has traditionally led to the patient requiring hospital admission for observation and pain control. The purpose of this study was to review three cases of outpatient rib fracture, open reduction and internal fixation (ORIF) surgery. Three patients with symptomatic rib fractures treated with ORIF at a single urban level one trauma center underwent outpatient same-day surgery. Pertinent demographic, clinical, radiographic, and surgical data were collected. All patients had decreased preoperative pain and no complications. This case series demonstrates that outpatient surgery for rib fracture ORIF can be performed safely in a select patient population. Additionally, it has similar efficacy as inpatient operative fixation with the main added benefit being decreased costs to both the patient and the healthcare system. We suggest that outpatient operative fixation of rib fractures should be considered for select patients.

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.

Outcomes After Operative Reconstruction of Symptomatic Rib Nonunions

OBJECTIVE

To assess the outcomes of patients after rib nonunion reconstruction.

DESIGN

Retrospective case series.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Between January 2007 and August 2019, 25 consecutive patients with 51 nonunions with disabling pain or chronic instability were treated for nonunited rib fractures.

INTERVENTION

Rib nonunion reconstructions performed using plate and screw fixation, recannalizing the medullary canal and augmented with autogenous iliac crest bone graft.

MAIN OUTCOME MEASUREMENTS

Patient demographics, mechanism of injury, number of rib nonunions, and postoperative radiographs were assessed. Satisfaction, patient-reported complications, return to occupation and activity, and general health measures were captured using patient questionnaires.

RESULTS

In 25 patients, 51 painful rib nonunions were surgically treated. The average length from injury to surgical rib reconstruction was 25.1 months (range = 3-118 months; median = 12 months). Follow-up was obtained in 18 of 25 patients (72%) with a mean of 46.1 months (range = 13-139 months). All ribs achieved radiographic union at an average of 12.3 weeks (range = 8-24 weeks) after surgery. Sixteen of 18 patients (89%) reported satisfaction with surgery and 15 patients (83%) reported mild to no pain at final follow-up. Five patients had complications that all resolved after subsequent treatment.

CONCLUSIONS

Successful treatment of symptomatic rib nonunion is possible using rib plates in conjunction with bone grafting and has high union rates, satisfactory results, and limited complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome after surgical stabilization of symptomatic rib fracture nonunion: a multicenter retrospective case series

Purpose

This study aimed to determine the long-term level of pain after surgical treatment of one or more symptomatic rib fracture nonunions. Secondary aims were to evaluate the occurrence of adverse events, satisfaction, and activity resumption. The final aim was to assess the association between pain and the presence of bridging callus at the nonunified fracture. Hypothesized was that thoracic pain would diminish after surgery.

Methods

This retrospective case series included adults who underwent surgery for a symptomatic rib fracture nonunion from three hospitals. Symptomatic nonunion was defined as persistent pain associated with nonbridging callus of ≥1 rib fractures on a chest CT scan at ≥3 months after the initial injury. Patients completed questionnaires about pain, satisfaction, and activity resumption ≥3 months postoperatively.

Results

Thirty-six patients (26 men, 10 women), with a median age of 55 (P₂₅–P₇₅ 49–62) years and 169 acute rib fractures were included. Nonunion occurred in 98 (58%) fractures of which 70 (71%) were treated surgically. After a median of 11 months (P₂₅–P₇₅ 7–21), 13 (36%) patients reported severe pain, in contrast to 26 (72%) preoperatively. Patients who underwent intercostal neurectomy or neurolysis in addition to surgical stabilization less often reported pain reduction. Twenty-six (72%) had postoperative complications, for which 12 (33%) underwent additional surgery, mostly for persistent pain. The majority (n = 27; 75%) was satisfied with their functional recovery. Of patients who had paid work pre-trauma, 65% had resumed working.

Conclusion

Most patients reported less pain and better daily functioning after surgical stabilization of symptomatic rib fracture nonunions, although causality cannot be proven with this retrospective case series. Additional intercostal nerve treatment was not associated with pain relief. Despite surgery-related complications being common, patient satisfaction was high.

Level of evidence: Level V.

Study type: Therapeutic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01867-x.

Mapping of common rib fracture patterns and the subscapular flail chest associated with operative scapula fractures

BACKGROUND

Rib fractures occur in approximately 10% of trauma patients and are associated with more than 50% of patients with scapula fractures. This study investigates the location and patterns of rib fractures and flail chest occurring in patients with operatively treated scapula fractures. Novel frequency mapping techniques of rib fracture patterns in patients who also injure the closely associated scapula can yield insight into surgical approaches and fixation strategies for complex, multiple injuries patients. We hypothesize that rib fractures have locations of common occurrence when presenting with concomitant scapula fracture that requires operative treatment.

METHODS

Patients with one or more rib fractures and a chest computed tomography scan between 2004 and 2018 were identified from a registry of patients having operatively treated scapula fractures. Unfurled rib images were created using Syngo-CT Bone Reading software (Siemens Inc., Munich, Germany). Rib fracture and flail segment locations were marked and measured for standardized placement on a two-dimensional chest wall template. Location and frequency were then used to create a gradient heat map.

RESULTS

A total of 1,062 fractures on 686 ribs were identified in 86 operatively treated scapula fracture patients. The mean ± SD number of ribs fractured per patient was 8.0 ± 4.1 and included a mean ± SD of 12.3 ± 7.2 total fractures. Rib fractures ipsilateral to the scapula fracture occurred in 96.5% of patients. The most common fracture and flail segment location was ipsilateral and subscapular; 51.4% of rib fractures and 95.7% of flail segments involved ribs 3 to 6.

CONCLUSION

Patients indicated for operative treatment of scapula fractures have a substantial number of rib fractures that tend to most commonly occur posteriorly on the rib cage. There is a pattern of subscapular rib fractures and flail chest adjacent to the thick bony borders of the scapula. This study enables clinicians to better evaluate and diagnose scapular fracture patients with concomitant rib fractures.

LEVEL OF EVIDENCE

Diagnostic test, level IV.

Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.

METHODS

Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.

RESULTS

Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.

CONCLUSIONS

SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.

Abdominal flank bulge following intercostal neurectomy for symptomatic rib fracture nonunion

The gold standard for rib fracture nonunion management remains a matter of debate. Operative treatment of rib fracture nonunion has become increasingly popular. A 69-year-old man was operatively treated with intercostal neurectomy of the left eighth rib to resolve chronic thoracic pain following a rib fracture nonunion. After the intervention, the patient developed a flank bulge which was most likely due to the intercostal neurectomy, causing partial denervation of the abdominal musculature. Although the pain at the nonunion site decreased after the operative intervention, the patient still experienced severe pain during daily activities and reported poor quality of life due to the flank bulge. Physiotherapy and an abdominal belt did not improve this flank bulge. When considering operative neurectomy of the intercostal nerves of ribs 7-12 to resolve chronic pain due to rib fracture nonunion, the treating surgeon should be aware of this debilitating complication.

Operative Management of Rib Synostosis and Malunion: A Case Report

CASE

We present a complex case of a 56-year-old man with multiple left-sided rib pathology including nonunion, rib heterotopic ossification (HO) forming a rib-to-rib synostosis, and rib malunion. After a major forequarter trauma and failed conservative management, followed by scapula reconstruction and rib recontouring, the surgical resection of the rib synostosis, reconstruction of a rib nonunion, and contouring of rib malunions are described. The patient was followed up clinically for 1 year after the final procedure and demonstrated marked improvement in functional outcome.

CONCLUSION

In the setting of complex forequarter malunion and nonunion, resolution of painful rib nonunion and synostosis can be effectively managed with HO resection and rib reconstruction.

Case report: The use of three-dimensional biomodels for surgical planning of rib fixation

Background

Prosthetic titanium plates are frequently used in the stabilization of rib fractures and are typically contoured to the patient's anatomy at the time of implant in the operating room. Smith et al. [17] described the use of a 3D prototype biomodel of his patient's skeletal anatomy for preoperative customization of standard titanium plates for rib fractures. This process facilitated the preoperative planning and provided implants appropriate for a patient's unique anatomy. Further, the approach facilitated repair of complex fractures and may decrease operating time. Besides that, it provides idealized conditions for plate shaping and may facilitate implantation.

Methods

We performed rib fixation combined with 3D biomodels for surgical planning for the first time in Brazil, achieving reduced operating time with a good outcome for our patient.

Results

Surgical planning was conducted one day before the surgery using a 3D printer to make a patient-specific model. The printing time of the model was 16 h. The 3D biomodel was used for simulating the surgical procedure, pre-molding the titanium plates, and measuring the screw sizes that would be used in the procedure. All five fractures were fixed on the 3D biomodel and the total simulation time was 58 min. We used four pre-contoured titanium plates of 1.5 mm thickness and one straight 1.5 mm thickness titanium plate. We used the printed model to measure screw size, as we would do in the surgery. After planning, the material was processed and sterilized according to the hospital standards to be implanted in the patient the following day.

Conclusion

This is the second reported case of surgical stabilization of rib fractures using a 3D model. Both cases demonstrated the advantages of this approach. More studies are needed to validate the safety and benefits for the patient, as well as the impact on cost savings.

Rescue Re-Do Inline Osteosynthesis with Wire Cerclage for Failed Rib Plating of Multilevel Rib Nonunion

Rib nonunion is a rare occurrence that requires surgical management and has a high rate of failure that may necessitate repeated intervention. We present the case of successful rescue redo repair of previously failed plating of chronic nonunion for multilevel posterior rib fractures, reinforced by wire cerclage of the osteosynthesis plate. Our objective is to illustrate the feasibility of repeated interventions, and the technique to resolve this challenging problem.

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.

Bone Autograft Coupled with Locking Plates Repairs Symptomatic Rib Fracture Nonunions

Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010–2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (66.1) months. A median of 3 [1–3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.

Surgical treatment of rib fracture nonunion: A single center experience

INTRODUCTION

In contrast to the emerging evidence on the operative treatment of flail chest, there is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe our standardized approach and report the outcome (e.g. patient satisfaction, pain and complications) after surgical treatment of a rib fracture nonunion.

METHODS

A single centre retrospective cohort study was performed at a level 1 trauma centre. Symptomatic rib nonunion was defined as a severe persistent localized pain associated with the nonunion of one or more rib fractures on a chest CT scan at least 3 months after the initial trauma. Patients after initial operative treatment of rib fractures were excluded.

RESULTS

Nineteen patients (11 men, 8 women), with symptomatic nonunions were included. Fourteen patients were referred from other hospitals and 8 patients received treatment from a pain medicine specialist. The mean follow-up was 36 months. No in-hospital complications were observed. In 2 patients, new fractures adjacent to the implant, without new trauma were observed. Furthermore 3 patients requested implant removal with a persistent nonunion in one patient. There was a mean follow-up of 36 months, the majority of patients (n = 13) were satisfied with the results of their surgical treatment and all patients experienced a reduction in the number of complaints. Persisting pain was a common complaint. Three patients reporting severe pain used opioid analgesics on a daily or weekly basis. Only 1 patient needed ongoing treatment by a pain medicine specialist.

CONCLUSION

Surgical fixation of symptomatic rib nonunion is a safe and feasible procedure, with a low perioperative complication rate, and might be beneficial in selected symptomatic patients in the future. In our study, although the majority of patients were satisfied and the pain level subjectively decreases, complaints of persistent pain were common.

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.