Operative treatment of multiple costochondral dislocations in a patient with severe rib fractures and a flail chest following trauma

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.

Hardware failure for anterior chest wall and costal cartilage injuries: A single-center experience

BACKGROUND

Often missed in blunt chest wall injury, costal cartilage injuries can cause chest wall instability, refractory pain, and deformity. Notably, there is only a small amount of evidence regarding hardware performance when applied to costal cartilage. In a prior multicenter study, hardware failure rate was found to be approximately 3% following surgical stabilization of rib fractures (SSRFs) for all fracture locations. The aim of the current study was to evaluate hardware performance for costal cartilage injuries.

METHODS

All patients undergoing SSRF performed at our institution from 2016 to 2022 were queried, including both acute and chronic injuries. Both radiographic and clinical follow-up were retrospectively reviewed to evaluate for hardware failure defined as plate fracture, malposition, or screw migration following cartilage fixation.

RESULTS

After screening 359 patients, 43 were included for analysis. Mean age was 64 years, and 67% of patients were male. Median number of fractures per patient was 7 with 60% of patients sustaining a flail chest injury pattern. Median total plates per operation was 6 and median costal cartilage plates was 3. In total, 144 plates were applied to the costal cartilage for the group. Mean follow-up was as follows: clinical 88 days, two-view plain radiography 164 days, and chest computed tomography 184 days. Hardware failure was observed in 3 of 144 plates (2.1%), in three separate patients. Two cases were asymptomatic and did not require intervention. One patient required revisional operation in the acute setting.

CONCLUSION

In our institution, hardware failure for costal cartilage fractures was observed to be 2.1%. This aligns with prior reports of hardware failure during SSRF for all injury locations. Surgical stabilization of anterior and cartilaginous chest wall injury with appropriate plate contouring and fixation technique appears to provide adequate stabilization with a relatively low rate of hardware malfunction.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level V.

Anatomy of the anterior ribs and the composition of the costal margin: A cadaver study

BACKGROUND

Traditional rib anatomy and costal margin teaching contends that the costal margin consists of a combined costal cartilage made up of ribs 7 to 10. Variations in 9th and 10th rib anatomy have been observed. We sought to evaluate the variability of interchondral joints and the make-up of the costal margin.

METHODS

Cadaveric dissections were performed to evaluate the anatomy of the anterior ribs and the composition of the costal margin. Experienced chest wall surgeons evaluated this anatomy through a standardized dissection and assessment. Dissection videos were performed to allow for further review/assessment.

RESULTS

Bilateral chest wall anatomy of 30 cadavers was evaluated (15 male, 15 female). The average age was 78 ± 12 years, and all patients were Caucasian. In all patients, the first rib attached to the manubrium, the second rib attached to the manubriosternal junction, and ribs 3 to 6 attached directly to the sternum. Interchondral joints were present between ribs 4/5-3%, 5/6-68%, 6/7-83%, 7/8-72%. Ribs combining to form a common costal cartilage via cartilaginous unions were observed between 6/7-3%, 7/8-45%, 8/9-30%, and 9/10-20%.The 8th rib attached directly to the sternum without joining the 7th rib in 10% of cadavers. The 8th and 9th ribs had free tips in 45% and 60% of evaluations, respectively. The 10th rib was found to have a hooked tip in 25% of cases and was a floating rib without attachment to the 9th rib 52% of the time. Rib tip mobility was noted in ribs 8, 9, and 10 in 52%, 70%, and 90%, respectively.

CONCLUSION

Interchondral joints are common between ribs 5 and 8. Significant variability exists in the chest wall and costal margin compared with traditional teaching. It is important for chest wall surgeons treating diseases of the costal margin to appreciate this anatomic variability.

Costal margin injuries and trans-diaphragmatic intercostal hernia: Presentation, management and outcomes according to the Sheffield classification

BACKGROUND

Costal margin rupture (CMR) injuries are under-diagnosed and inconsistently managed, while carrying significant symptomatic burden. We hypothesized that the Sheffield Classification system of CMR injuries would relate to injury patterns and management options.

METHODS

Data were collected prospectively between 2006 and 2023 at a major trauma center in the United Kingdom. Computed tomography scans were interrogated and injuries were categorized according to the Sheffield Classification. Clinical, radiologic, management and outcome variables were assessed.

RESULTS

Fifty-four patients were included in the study. Intercostal hernia (IH) was present in 30 patients and associated with delayed presentation ( p = 0.004), expulsive mechanism of injury (i.e. such as occurs with coughing, sneezing, or retching), higher body mass index ( p < 0.001), and surgical management ( p = 0.02). There was a bimodal distribution of the level of the costal margin rupture, with IH Present and expulsive mechanism injuries occurring predominantly at the ninth costal cartilage, and IH Absent cases and other mechanisms at the seventh costal cartilage ( p < 0.001). There were correlations between the costal cartilage being thin at the site of the CMR and the presence of IH and expulsive etiology ( p < 0.001). Management was conservative in 23 and surgical in 31 cases. Extrathoracic mesh IH repairs were performed in 3, Double Layer Mesh Repairs in 8, Suture IH repairs in 5, CMR plating in 8, CMR sutures in 2, and associated Surgical Stabilization of Rib Fractures in 11 patients. There was one postoperative death. There were seven repeat surgical procedures in five patients.

CONCLUSION

The Sheffield Classification is associated statistically with presentation, related chest wall injury patterns, and type of definitive management. Further collaborative data collection is required to determine the optimal management strategies.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Management of a Flail Chest Caused by Multiple Costosternal Fractures: A Case Report

Costochondral separation is a rare consequence of blunt thoracic trauma and can lead to life-threatening complications such as a flail chest. The diagnosis of costochondral separation remains challenging due to the obscurity of the condition on chest radiographs. Surgical rib fixation is a viable treatment option and research regarding its effectiveness and long-term benefits is promising but still evolving. Here, we discuss a case of flail chest caused by multiple costosternal fractures definitively managed with surgical rib fixation.

Open Reduction and Internal Fixation of a Chronic Precordial Flail Chest Segment: A Case Report

CASE

We report on a 35-year-old man presenting with disabling pain secondary to multiple rib nonunions and a costochondral dislocation 5 months after sustaining a chest wall crush injury. He underwent surgical reconstruction of the chest and was followed for 2 years. Surgical exposure to the heart was necessary during open reduction of the flail segment, followed by costochondral joint fixation with plates and screws. Although he was a workers' compensation patient, he returned to full gainful employment.

CONCLUSION

Open reduction and internal fixation of a symptomatic, chronically displaced, precordial, flail segment can relieve pain and promote return to baseline function.