From the Guidelines
Surgical rib fixation is indicated for all flail chest patients and non-flail chest patients with specific severe rib fracture patterns, as it improves morbidity, mortality, and quality of life outcomes. The indications for trauma surgical rib fixation include flail chest patients, as well as non-flail chest patients with multiple (≥ 3) ipsilateral severely displaced rib fractures or multiple (≥ 3) ipsilateral displaced rib fractures in ribs 3–10 with respiratory failure or other pulmonary derangements despite optimal medical management 1.
Key Indications
- Flail chest patients
- Non-flail chest patients with:
- Multiple (≥ 3) ipsilateral severely displaced rib fractures
- Multiple (≥ 3) ipsilateral displaced rib fractures in ribs 3–10 with:
- Respiratory failure despite mechanical ventilation
- Weaning failure
- At least two pulmonary derangements in non-ventilated patients, including:
- Respiratory rate > 20 breaths per minute
- Incentive spirometry < 50% predicted
- Numeric pain score (NPS) > 5/10
- Poor cough
Optimal Timing
The optimal timing for surgical rib fixation is within 48-72 hours from the traumatic injury, as it minimizes the incidence of unfavorable outcomes and reduces the technical complexity of the surgical procedure 1. Early surgical rib fixation (within 72 hours) has been shown to decrease the need for prolonged mechanical ventilation, ICU stay, and hospitalization costs, as well as reduce the risk of pneumonia and tracheostomy 1. However, in cases where early surgery is not possible, the decision to perform late surgery (7-14 days from injury) should be made on a case-by-case basis, as there is currently limited evidence to support its benefits over non-operative management 1.
From the Research
Indications for Trauma Surgical Rib Fixation
The indications for trauma surgical rib fixation include:
- Flail chest, which is a life-threatening condition that can lead to high mortality and morbidity 2, 3, 4, 5
- Multiple rib fractures, which can result in significant morbidity and mortality 3, 6
- Severe polytrauma patients with rib fractures, who may benefit from surgical fixation to reduce medical resource use and lower risk of complications 2
- Patients with pulmonary contusion, although the benefits of surgical fixation may be limited in this subgroup 2
- Patients with serious chest injury (thoracic Abbreviated Injury Scale (AIS) ≥ 3), who may benefit from surgical fixation to reduce mortality and need for tracheostomy 6
- Isolated flail chest, where surgical fixation has been shown to improve survival 4
Benefits of Surgical Rib Fixation
The benefits of surgical rib fixation include:
- Reduced duration of mechanical ventilation 2, 3, 4
- Shorter ICU stay 2, 3
- Lower risk of adult respiratory distress syndrome, pneumonia, and thoracic deformity 2
- Less pain while coughing and deep breathing 2
- Improved survival 6, 4
- Reduced need for tracheostomy 6
- Faster return to work 5
Patient Selection
Patient selection is crucial for the appropriate application of surgical rib fixation. Factors to consider include:
- Type of rib fracture (flail chest, multiple rib fractures) 3
- Age of the patient (patients over 60 years may have a statistical benefit of conservative management on length of hospital stay and mechanical ventilation) 3
- Timing of fixation (early fixation may be associated with a reduced need for prolonged mechanical ventilation) 4
- Presence of pulmonary contusion or other associated injuries 2