From the Guidelines
For a non-union right rib fracture involving ribs 6,7, and 8, surgical stabilization of rib fractures (SSRF) should be considered as a treatment option to improve outcomes and reduce morbidity, mortality, and healthcare resource utilization, as suggested by the recent position paper by the World Journal of Emergency Surgery 1.
Background and Rationale
The management of rib fractures, especially non-unions, is crucial due to the associated risks of respiratory compromise, chronic pain, and significant loss of work days, ultimately affecting the quality of life (QoL) 1. The standard treatment includes nonoperative management (NOM) via multimodal analgesia, pulmonary hygiene, and chest physiotherapy. However, in cases of non-union, especially with multiple and displaced rib fractures, the duration of mechanical ventilation may be prolonged, leading to increased rates of pneumonia, sepsis, and tracheostomy 1.
Treatment Approach
Given the potential benefits of surgical fixation in appropriate cases, SSRF should be considered for non-union right rib fracture involving ribs 6,7, and 8, to reduce the risk of respiratory complications and improve QoL 1. The treatment approach should include:
- Multimodal analgesia with NSAIDs like ibuprofen or naproxen, along with acetaminophen for pain management
- Gentle breathing exercises and gradual mobility through physical therapy
- Avoidance of strenuous activities and heavy lifting for at least 6-8 weeks
- Consideration of surgical intervention if pain persists beyond 6 months or if there's significant displacement affecting lung function
Importance of Specialist Follow-up
Follow-up with a thoracic surgeon or orthopedic specialist within 2-4 weeks is crucial for clinical evaluation and repeat imaging to assess the fracture site and overall patient condition 1. This specialist follow-up will help determine the best course of treatment, including the potential need for SSRF, and ensure optimal management of the non-union rib fracture.
Additional Considerations
Smoking cessation and adequate calcium and vitamin D intake are essential for optimal healing and should be emphasized to the patient 1. Furthermore, addressing underlying conditions like osteoporosis or nutritional deficiencies is vital to promote proper fracture healing and prevent future complications.
From the Research
Appropriate Follow-up for Non-union of a Right Rib Fracture
- The appropriate follow-up for non-union of a right rib fracture (ribs 6,7, and 8) involves surgical management, specifically operative fixation of the symptomatic rib fracture nonunion 2, 3, 4.
- Studies have shown that surgical stabilization of rib fracture nonunions using locking plates and screws with or without a graft can be an effective treatment with acceptable implant failure and complication rates 3, 4.
- The use of bone grafting is common in the treatment of symptomatic rib fracture nonunions, with eight out of nine studies mentioning the benefits of grafting 4.
- Surgical management of rib fracture nonunions has been shown to decrease pain, reduce opiate use, and improve patient-reported outcomes in patients with rib fracture nonunion after trauma 5.
- However, the benefits of surgical stabilization of nonunited rib fractures (SSNURF) should be balanced against the risk of symptomatic hardware failure and infection 5.
Surgical Techniques and Outcomes
- Operative fixation of symptomatic rib fracture nonunion has demonstrated favorable outcomes, including reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union 2.
- The reported outcomes of surgical management of rib fracture nonunions are inconsistent between studies, but show high rates of union (>94%), reduction in reported VAS scores, and improved return to work when included 3.
- Implant failure occurred in 10% of the total patients reported in the studies, the re-operation rate was 13%, and the overall complication rate was 27% 3.