What is the recommended treatment for patients with severe rib fractures, specifically Surgical Stabilisation of Rib Fractures (SSRF)?

Surgical Stabilization of Rib Fractures (SSRF): Definitive Recommendations

SSRF should be performed in all patients with flail chest and in non-flail chest patients with ≥3 severely displaced rib fractures (no cross-sectional overlap on CT), ideally within 48-72 hours of injury, as this approach significantly reduces mortality, ventilator days, pneumonia rates, and improves long-term quality of life. 1, 2

Clear Indications for SSRF

Absolute Indications

• Flail chest (≥3 consecutive ribs each fractured in ≥2 places with paradoxical chest wall movement) is an absolute indication for SSRF 1, 2
• Randomized controlled trials demonstrate 0% mortality with SSRF versus 6% with non-operative management in mechanically ventilated flail chest patients 2
• Meta-analyses confirm reduced pneumonia, tracheostomy rates, ICU stay, and overall costs compared to non-operative management 1

Strong Indications in Non-Flail Chest Patients

• ≥3 ipsilateral severely displaced rib fractures (no cross-sectional overlap on CT) in ribs 3-10 1
• ≥3 ipsilateral displaced rib fractures (ribs 3-10) PLUS ≥2 of the following pulmonary derangements despite optimal loco-regional anesthesia and multimodal analgesia: 1, 2
  • Respiratory rate >20 breaths/minute
  • Incentive spirometry <50% predicted
  • Numeric pain score >5/10
  • Poor cough
• Chest wall deformity with significant lung function impairment or mechanical instability on palpation 1
• Severe refractory pain non-responsive to other treatments 1

Critical Timing: The 48-72 Hour Window

SSRF must be performed within 48-72 hours of injury for optimal outcomes. 2, 3, 4

• Early callous formation begins within the first week, making surgical fixation technically more difficult after 72 hours 3
• Late SSRF (3-10 days) is associated with longer operative times and increased likelihood of prolonged mechanical ventilation 3
• Delaying surgery beyond 72 hours significantly reduces the benefits of SSRF 1, 2

Expected Outcomes with SSRF

Mortality and Major Morbidity Reduction

• Reduced mortality in mechanically ventilated patients (0% vs 6% with non-operative management) 2
• Decreased pneumonia rates compared to non-operative management 1, 2
• Lower respiratory failure rates (odds ratio 0.24) 5
• Reduced tracheostomy rates (odds ratio 0.18) 5

Functional Outcomes

• Shorter ventilator duration and faster weaning from mechanical ventilation 1, 6
• Improved pain scores and respiratory disability at 2-week follow-up 1, 2
• Better return-to-work rates at 3-6 months 1, 2
• Median daily spirometry values 250 mL higher than non-operative management 5
• Reduced long-term complications including chronic pain and chest wall deformity 1, 2

Technical Surgical Approach

Preoperative Planning

• CT imaging with 3D reconstruction is mandatory before SSRF for surgical planning 2, 4
• Classify fractures by location, type, and degree of displacement using thin-sliced chest CT 4

Surgical Technique

• Target ribs 3-10 for fixation, with ribs 3-8 most commonly plated 2, 4
• First, second, eleventh, and twelfth ribs are typically not fixed unless significantly displaced 4
• Titanium plates and screws are the standard fixation method; avoid pelvic fixation plates 2
• Precontoured side and rib-specific plates with threaded holes and self-tapping locking screws are preferred 4
• Single-lung intubation is preferred if there is no severe contralateral pulmonary contusion 4
• Video-assisted thoracoscopy should be performed when possible to control bleeding, evacuate hematomas, and repair lung injuries 4

Surgical Approaches

• Lateral approach is the main surgical approach, allowing access to the majority of rib fractures 4
• Posterior rib fractures are exposed through a vertical incision within the triangle of auscultation 4
• Anterior fractures are accessed through a transverse inframammary incision 4
• Muscle-sparing technique should be utilized when possible 4

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. 2, 3

• Advanced age should NOT be considered an absolute contraindication to SSRF 1
• Elderly patients should be carefully assessed for SSRF on an individual basis 1
• Recent evidence suggests elderly patients may benefit MORE from SSRF compared to younger patients 3
• Several retrospective studies report that SSRF in the elderly may reduce mortality compared to non-operative management 3
• Early SSRF within 48-72 hours should be strongly considered for elderly patients meeting surgical criteria 2, 3

Relative Contraindications and Special Considerations

Hemodynamic Instability

• Patients who are hemodynamically unstable should not undergo SSRF 1
• However, patients with unstable chest wall injuries on low and unchanging vasopressors may benefit from SSRF if it facilitates weaning of pain medications and sedation 1

Traumatic Brain Injury (TBI)

• TBI should NOT be considered an absolute contraindication to SSRF 1
• Patients with moderate to severe TBI who underwent SSRF had shorter ICU stay, shorter mechanical ventilation time, and reduced mortality compared to non-operative management 1
• SSRF was associated with lower risk of pneumonia and 30-day mortality in patients with moderate to severe TBI 1

Pulmonary Contusion

• Pulmonary contusion should NOT be considered a contraindication to SSRF 1
• Patients with pulmonary contusion should be evaluated for SSRF on an individual basis 1

Other Comorbidities

• Patients with significant cardiopulmonary comorbidities, anticoagulation use/uncorrected coagulopathy, active malignancy, or other terminal illness should be carefully assessed for SSRF on an individual basis 1
• Patients with empyema or history of prior chest radiation should be carefully assessed for SSRF on an individual basis 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, 2

• This ensures appropriate patient selection, surgical expertise, and comprehensive perioperative care 1, 2

Common Pitfalls to Avoid

• Delaying surgical decision beyond 72 hours in appropriate candidates significantly reduces benefits 2, 3
• 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 2
• Under-treatment of pain leads to immobilization, shallow breathing, poor cough, atelectasis, and pneumonia 3
• Late consideration of SSRF in appropriate candidates leads to prolonged pain and respiratory compromise 3

Recovery Timeline with SSRF

• SSRF performed within 48-72 hours can shorten recovery time in selected patients 2, 3
• Better return-to-work rates between 3-6 months compared to non-operative management 2, 3
• Reduced long-term complications including chronic pain and chest wall deformity 2
• Pain scores improve significantly by 4 weeks with appropriate management 3