Surgical Management of Multiple Rib Fractures
Primary Recommendation
Surgical stabilization of rib fractures (SSRF) should be strongly considered for all patients with flail chest and for non-flail chest patients with ≥3 severely displaced rib fractures, particularly when performed within 48-72 hours of injury, as this approach reduces mortality, ventilator days, and improves long-term quality of life. 1
Clear Indications for SSRF
Absolute Indications
- Flail chest (≥3 consecutive ribs each fractured in ≥2 places with paradoxical chest wall movement) 1, 2
Strong Indications for Non-Flail Chest Patients
- ≥3 ipsilateral severely displaced rib fractures (>50% rib width displacement on CT, or no cross-sectional overlap) in ribs 3-10 1
- ≥3 displaced rib fractures (ribs 3-10) PLUS ≥2 of the following pulmonary derangements despite optimal loco-regional anesthesia and multimodal analgesia: 1
- Respiratory rate >20 breaths/minute
- Incentive spirometry <50% predicted
- Numeric pain score >5/10
- Poor cough
Additional Indications
- Chest wall deformity causing significant lung impairment or mechanical instability on palpation ("Stoved-in Chest") 1
- Respiratory failure requiring mechanical ventilation or weaning failure 1
- Severe pain non-responsive to multimodal analgesia and regional blocks 1, 2
Critical Timing Considerations
SSRF must be performed within 48-72 hours of injury for optimal outcomes. 2, 3 Delaying beyond this window significantly reduces the mortality and morbidity benefits. 3 The strongest evidence supports intervention within the first 72 hours, with some data suggesting even earlier (within 48 hours) is preferable. 4
Technical Surgical Approach
Preoperative Planning
- CT imaging with 3D reconstruction is mandatory before SSRF for surgical planning 2
- Target ribs 2-10 for fixation; ribs 1,11, and 12 should only be repaired in highly selected circumstances 2
- Ribs 3-8 are most commonly plated 3
Surgical Techniques
- Titanium plates and screws are the standard fixation method 5, 6
- Muscle-sparing approaches with precontoured locking plate technology provide stable fixation 6
- Video-assisted thoracoscopic surgery (VATS) with titanium elastic nails (2.0-2.5mm intramedullary) offers a less invasive alternative with shorter surgical wounds 7
- Pelvic fixation plates should be avoided (outdated technique) 1
Expected Outcomes with SSRF
Mortality and Major Morbidity
- Reduced mortality in mechanically ventilated patients (0% vs 6%) 1
- Decreased pneumonia rates compared to non-operative management 1, 4
- Lower pleural space complication rates 1
Functional Outcomes
- Shorter ventilator duration and faster weaning 1, 7, 4
- Reduced ICU and hospital length of stay 7, 6, 4
- Improved pain scores and respiratory disability at 2-week follow-up 1
- Better return-to-work rates at 3-6 months 1, 3
- Reduced long-term complications including chronic pain and chest wall deformity 1, 3
Special Population: Elderly Patients (>60 Years)
Elderly patients warrant particularly aggressive consideration for early SSRF as they deteriorate faster and are less likely to tolerate rib fractures. 3 Several retrospective studies demonstrate that SSRF in elderly patients may reduce mortality compared to non-operative management. 3 However, one meta-analysis showed mixed results, with some benefit favoring conservative management in hospital stay and ventilation duration. 4 Given the high morbidity and mortality risk in this population, early SSRF within 48-72 hours should be strongly considered for elderly patients meeting surgical criteria. 2, 3
Non-Operative Management Considerations
For patients who do not meet surgical criteria, the evidence shows only small benefits from SSRF in non-ventilated patients without the specific indications listed above. 1 One RCT (Marasco et al.) failed to demonstrate improvements in pain or quality of life at 3-6 months in non-ventilated patients with ≥3 painful or displaced fractures, though return-to-work rates improved. 1
Optimal Care Setting
SSRF should be performed in dedicated centers with multidisciplinary teams that have developed protocols for both non-operative management and SSRF. 1 This ensures appropriate patient selection, surgical expertise, and comprehensive perioperative care including multimodal analgesia and respiratory support. 2
Common Pitfalls to Avoid
- Delaying surgical decision beyond 72 hours in appropriate candidates significantly reduces benefits 3, 4
- Failing to obtain CT with 3D reconstruction before surgery compromises surgical planning 2
- Underestimating severity in elderly patients who require more aggressive early intervention 2, 3
- Operating on non-ventilated patients without clear pulmonary derangements may not provide meaningful benefit 1
- Using outdated fixation techniques (e.g., pelvic plates) instead of modern rib-specific plating systems 1