How To Make Repairs To Ribs Vent With

Surgical Technique

Rib fracture repair

Introduction

Edgeless chest wall trauma and the resultant fracture of ribs is exceedingly mutual and is the source of significant morbidity and potential mortality. Surgical repair for markedly displaced rib fractures, particularly in the setting of flail chest has been attempted sporadically for over fifty years. In the last decade, rib-specific plating systems have been introduced. These have helped to usher in the era of modern rib repair and have fabricated surgical stabilization of rib fractures (SSRF) technically easier, safer, and arguably more than effective. In the United states, the process is increasingly utilized by trauma, orthopedic, and thoracic surgeons.

2 recently published consensus statements accept attempted to codify the indications, contra-indications, timing, and technical aspects of SSRF (1,2). In brief, patients with 3 or more severely displaced rib fractures or flail breast (two or more contiguous ribs fractured in two or more places) should exist considered for repair whether they require mechanical ventilation or not. Other candidates may include patients who neglect optimal not-operative management regardless of fracture pattern, and patients with rib fractures who require thoracotomy for another reason. Severe traumatic brain injury and unstable spine fracture are absolute contraindications to immediate SSRF. The role of pulmonary contusion in the decision to repair the unstable chest wall remains controversial, but in full general is not a contraindication.

Operative techniques

Preparation

One time the trauma patient has been satisfactorily resuscitated, hemodynamic stability has been achieved, and a thorough evaluation of all injuries completed, a decision to proceed with operative fixation of rib fractures can be made. 3-dimensional reformatted images of the breast CT scan (Figure 1), while not mandatory, are extremely helpful in delineating the true extent of fractures, chest wall deformity/instability, and in incision planning. Pre-operative patient optimization must include aggressive multi-modal pain control, pulmonary hygiene, and an assessment of pulmonary function, i.e., spirometry. Pre-operative bronchoscopy can articulate bronchial secretions and blood, and assist in placement of a double-lumen endotracheal tube, if necessary. Many surgeons utilize VATS routinely (3). These authors do so selectively to assist in evacuation of hemothorax, localize fractures, and to dominion-out diaphragm laceration.

Click on image to zoom

Effigy 1 3D rendering of chest CT scan.

Performance

Lateral decubitus positioning provides admission to the majority of rib fractures. Supine position with a crash-land will provide ideal exposure for anterior and antero-lateral fractures. Many patients volition have multiple fracture lines and may do good from dual incisions. Prone positioning with 90-degree abduction of the ipsilateral arm volition rotate the scapula laterally and optimize exposure to posterior and subscapular fractures (Figure 2).

Click on image to zoom

Figure ii Common musculus sparing incisions (subscapular, inframammary and posterior vertical).

Proper placement of the surgical incision(southward) should minimize incision length and soft–tissue trauma. We take increasingly adopted non-traditional incisions, such as oblique or vertical, and avert musculus transection whenever feasible. "Splitting" (without dividing) the latissimus dorsi is routine and provides fantabulous exposure to most lateral and posterior fractures. The triangle of auscultation affords the surgeon reliable access to the subscapular space (Figure 3).

Click on image to zoom

Figure 3 Subscapular exposure through the triangle of auscultation.

Following skin incision, sub-cutaneous flap development will allow admission to multiple fractures through the same incision. Fractures are generally easily palpable through the musculature and should exist exposed individually. Self-retaining retractors such as the Bookwalter or Thompson blazon retractor can aid in this exposure. Fracture reduction is ordinarily quite simply accomplished with lifting of the depressed rib segment with a right-angle clamp or finger and the fracture ends can be "perched" in proper reduction. Reduction of multiple adjacent fractures in sequence prior to fixation will assistance maintain breast wall contour and help in hardware placement.

Clearing the rib of its anterior soft tissue envelope is necessary for 3 centimeters on either side of the fracture to facilitate precise matching of rib prosthesis to the rib surface. Ambitious exposure of the fractured rib ends is unnecessary and undesirable.

Several rib-specific plating systems are now commercially bachelor. They share multiple design features; notably, semi-rigid fixation with anterior plate positioning and locking screws. The flexible nature of ribs makes locking screws critical to minimize failure. Additionally, these systems are low profile, fabricated from titanium, and hands shapeable (Figure iv).

Click on image to zoom

Effigy 4 Bi-cortical fixation with locking spiral construct.

Rib thickness is variable. Thus, prior to plating, in nigh systems, rib thickness is measured with a caliper to determine optimal screw length. Bi-cortical screw purchase of the rib is considered the standard at this time, but one commercially-available organisation utilizes shorter uni-cortical screws with non-parallel orientation. The surgeon volition assess the obliqueness of the fracture line to determine how many screw holes to leave open in the centre of the plate. One should strive for a minimum of 3 cm of plate fixation on each side of the fracture (Figure five). The plate should exist shaped to the precise contour of the anterior rib surface with no gaps and with minimal tension. Plate holding forceps or right angle clamps will hold the plate in position and the rib in reduction for screw placement. Current systems utilize either pre-drilling or cocky-borer screws.

Click on image to zoom

Figure 5 Fracture reduction and plate application.

Ribs accept circuitous shapes and precise matching of plates to ribs will often require bending and twisting in two or more planes. All of the available systems accept "low profile" or right angled drill and screwdriver instruments to accommodate fixation at the extremes of exposure, i.due east. underneath the scapula or close to the spine.

It is unnecessary to repair every cleaved rib. In general, ribs 1,2,eleven, and 12 should be avoided. Chest wall stability increases with each rib stabilized and it is reasonable to prepare all rib fractures that are readily approachable through the index incision. One should make a concerted attempt to repair both fracture lines in the setting of flail (Figure 6).

Click on image to zoom

Figure 6 Various fracture and plate configurations.

Completion

Closure is made easier with muscle sparing approaches. Absorbable sutures in a running or interrupted fashion, are used to close muscular "windows". The decision to place a airtight suction drain in the sub-cutaneous space is based on host factors and surgeon preference. Chest tube placement is optional but strongly suggested by these authors. We employ soft, fluted tubes of 24Fr bore. This is an excellent opportunity to lavage the pleural space with 1 or 2 liters of warm saline. These authors utilize this blind lavage technique and have had fantabulous results with minimal incidence of retained hemothorax (4). Placement of a regional analgesia catheter or intercostal rib blocks consummate the procedure (Figure 7).

Click on image to zoom

Effigy 7 Bilateral fracture repair and costo-sternal bridging.

Rib fracture repair, like any other process, has a definite learning bend. Those new to SSRF should select patients with lateral fracture patterns, avoiding the more than difficult fractures at the extremes of exposure. Length of incision will naturally diminish every bit one gains feel and confidence in adequate exposure and reduction of fractures. Most rib repairs in the Us are performed past trauma or thoracic surgeons, although this varies from heart to center. Surgeons new to the principles of osteosynthesis may wish to enlist the help of an orthopedist colleague equally they navigate their early on experience.

Acknowledgments

We would similar to thank Jill Rhead as our talented and generous Medical Illustrator for the affiliate.

Funding: None.

Provenance and Peer Review: This article was commissioned by the Invitee Editors (Marco Scarci, Alan D.L. Sihoe and Benedetta Bedetti) for the series "Open up Thoracic Surgery" published in Shanghai Breast. The article has undergone external peer review.

Conflicts of Interest: Both authors take completed the ICMJE uniform disclosure class (available at http://dx.doi.org/10.21037/shc.2017.05.07). The series "Open Thoracic Surgery" was deputed past the editorial office without whatever funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Argument: This is an Open Admission article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs iv.0 International License (CC Past-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/iv.0/.

References

Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical do guidelines. Injury 2022;48:307-21. [Crossref] [PubMed]
Kasotakis G, Hasenboehler EA, Streib EW, et al. Operative fixation of rib fractures after blunt trauma: A practice direction guideline from the Eastern Association for the Surgery of Trauma. J Trauma Astute Care Surg 2022;82:618-26. [Crossref] [PubMed]
Pieracci FM, Lin Y, Rodil G, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2022;80:187-94. [Crossref] [PubMed]
Majercik S, Vijayakumar Southward, Olsen G, et al. Surgical stabilization of astringent rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg 2022;210:1112-6; discussion 1116-7. [Crossref] [PubMed]

doi: 10.21037/shc.2017.05.07
Cite this article as: White TW, Majercik S. Rib fracture repair. Shanghai Chest 2022;1:11.