What is the recommended surgical approach for a patient undergoing rib plating?

Operative Report Template for Rib Plating

Preoperative Diagnosis

Multiple displaced rib fractures (specify ribs and locations: anterior/lateral/posterior) with [flail chest/chest wall instability/respiratory compromise/refractory pain] 1

Procedure Performed

Surgical Stabilization of Rib Fractures (SSRF) with open reduction and internal fixation using [titanium/bioabsorbable] plating system 2

Indications for Surgery

• Patient presents with ≥3 ipsilateral displaced rib fractures in ribs 2-10, meeting standard criteria for SSRF 1, 3
• Fractures located in ribs [specify numbers, typically 3-8 are most commonly plated] with [anterior/lateral/posterior] displacement 1, 2
• [If applicable: Flail chest with paradoxical chest wall motion] 4, 2
• [If applicable: Respiratory compromise despite optimal medical management] 4
• [If applicable: Severe refractory pain limiting pulmonary hygiene] 3

Preoperative Planning

• CT scan with thin-slice imaging obtained to determine fracture number, location, type (simple/wedge/complex), and degree of displacement 1
• [If used: 3D reconstruction performed for surgical planning] 1
• [If used: 3D printing technology utilized to pre-contour plates, reducing operative time and incision length] 1
• Fracture classification: [simple/wedge/complex] fractures at [anterior/lateral/posterior] locations 1
• Preoperative planning sheet completed indicating fracture locations on affected side 1

Anesthesia

General anesthesia with single-lung intubation [left/right] to facilitate surgical exposure and allow video-assisted thoracoscopy if needed 2

Patient Positioning

[Lateral decubitus/supine with ipsilateral arm abducted] position with affected side up, ensuring adequate exposure of [anterior/lateral/posterior] chest wall 2

Surgical Approach

For Lateral Fractures (Most Common):

• Curvilinear skin incision made overlying the fractured ribs along the [specify intercostal space] line, providing access to ribs [specify numbers] 2
• Muscle-sparing technique utilized, splitting serratus anterior and latissimus dorsi alongside fibers without transection 2

For Posterior Fractures:

• Vertical incision made within the triangle of auscultation to expose posterior rib segments 2

For Anterior Fractures:

• Transverse inframammary incision performed to access anterior rib segments 2

Intraoperative Findings

• [Describe fracture pattern: simple/wedge/complex displacement]
• [Describe associated injuries: hemothorax/pneumothorax/pulmonary contusion]
• [Describe bone quality: normal/osteoporotic]

Surgical Technique

VATS Component (If Performed):

• Video-assisted thoracoscopy performed to control bleeding, evacuate hematomas, repair lung injuries, and perform cryoablation of intercostal nerves for pain control 2
• [Describe findings and interventions]

Fracture Reduction and Fixation:

• Ribs [specify numbers] exposed through muscle-sparing dissection with careful preservation of neurovascular bundles 2
• Fracture sites identified and reduced anatomically under direct visualization 2
• Precontoured [side-specific/rib-specific] titanium plates with threaded holes applied to ribs [specify numbers] 2
• Self-tapping locking screws placed with [specify number] screws proximal and [specify number] screws distal to each fracture line, achieving bicortical purchase 2

Special Techniques (If Applicable):

• For multiple fracture lines (flail segment): Both fracture lines stabilized with separate plates or spanning plate 1
• For longitudinal fractures: Polymer cable cerclage used to enhance plating stability 2
• For fractures near transverse process: Fixation obtained on proximal fragment with reliable screw purchase 1
• For fractures within 2.5 cm of costal cartilage: Spanning plate extended to sternum outer cortex [or fixation to cartilage] 1
• For comminuted fractures: Bone gap bridged with [autograft/allograft] bone graft 2, 5
• For osteoporotic bone: Polymer cable cerclage supplemented plating 2

VATS Internal Fixation (If Performed):

• Video-assisted thoracoscopic internal rib fixation performed for [posterior/subscapular] fractures difficult to access via traditional approach 6
• Internal plates placed spanning multiple fractures with single post on either side 6

Wound Closure:

• Intercostal muscle deficit [if present] repaired with xenograft patch 2
• Hemostasis achieved and chest tube placed [if indicated] 2
• Muscle layers reapproximated in anatomic fashion 2
• Subcutaneous tissues closed with absorbable suture 2
• Skin closed with [running subcuticular/staples] 2

Hardware Used

• [Number] precontoured titanium rib plates, [side-specific/rib-specific] 2
• [Number] self-tapping locking screws, [specify size] 2
• [If used: Polymer cable cerclage] 2
• [If used: Xenograft patch for muscle repair] 2
• [If used: Bone graft material] 2, 5

Estimated Blood Loss

[Specify volume]

Complications

None/[Specify if any occurred]

Specimens

None

Drains

[Chest tube placed/No drains]

Condition

Patient tolerated procedure well, extubated [in OR/in PACU], transferred to [ICU/floor] in stable condition 2

Postoperative Plan

• Aggressive multimodal pain management including [epidural/paravertebral block/serratus anterior plane block/systemic analgesics] 4, 2
• Aggressive pulmonary hygiene protocol: incentive spirometry, assisted coughing, deep breathing exercises, early mobilization 4
• Serial chest radiographs to monitor for complications 4
• Respiratory parameter monitoring: respiratory rate, oxygen saturation, incentive spirometry volumes, cough effectiveness 4
• Venous thromboembolism prophylaxis 2
• [If smoker: Smoking cessation counseling and close monitoring for wound healing complications] 3

---

Surgeon: [Name]
Assistant: [Name]
Date: [Date]
Time: [Start] - [End]