Operative Management of Rib Synostosis and Malunion: A Case Report

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.

[Treatment strategy for severe implosion injuries of the lateral chest wall]

In the majority of cases implosion injuries to the thoracic wall are caused by blunt, massive force acting on the thorax. Basically, different regions and directions of the acting energy have to be taken into account. In common usage, the term implosion injury has become established, especially for the sequelae of lateral energy impact. Particular attention should be paid to the stability of the shoulder girdle, the underlying hemithorax and its intrathoracic organs.

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.

Resection of Posttraumatic Rib Synostoses Resolves Pulmonary Insufficiency: A Case Report

CASE

A 30-year-old woman underwent open reduction and internal fixation for multiple segmental rib fractures status post a motor vehicle collision. A year later, the patient presented with extensive intercostal heterotopic ossification associated with multilevel, hemithoracic, rib synostoses compromising her ventilation. The patient subsequently underwent synostoses excision and hardware removal. Pulmonary function tests (PFT), imaging, and patient-reported outcome scores demonstrate resolution of impairment.

CONCLUSION

Resection of multilevel, intercostal, rib synostoses provided an effective treatment for pulmonary restrictive disorder secondary to traumatic rib synostosis. This is the first patient with documentation of prereconstructive and postreconstructive PFTs for chest wall synostosis excision.

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.

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.