Rib fracture fixation in a South African public trauma service.
Nonoperative management strategies have been suggested for the management of flail chest since the 1950s and most trauma surgeons still follow this approach today. (1-4) However, follow-up studies on patients with rib fractures which have been managed nonoperatively have demostrated a significant incidence of chronic pain and disability. (5) This results in a significantly decreased quality of life with only 71% of victims ever returning to any form of work. (6) Dating back to the 1960s, various authors have attempted operative management of flail chest using a variety of techniques such as curved struts, intramedullary nails, wires, Kirschner wires, staples, and bone grafts. (7-8) More recent literature has confirmed the safety and efficacy of modern rib fracture fixation techniques. (9-12) In our unit (Pietermaritzburg Metropolitan Trauma Service), we admit approximately 2 500 trauma patients annually, among whom only approximately 10 present with flail chests or severely displaced rib fractures and associated mechanical breathing difficulties. In response to the growing body of evidence showing safety and benefit of modern rib fracture fixation, we adopted the technique in 2014. This retrospective audit reviews our experience with the technique over the last three years and goes on to demonstrate the feasibility of rib fracture fixation in the South African public sector.
A retrospective audit was performed of all cases of rib fracture fixation performed between April 2014 and March 2017.
We adopted rib fracture fixation in 2014. The first author was formally trained to perform the procedure by an experienced team based in Sweden. Further practice was guided by literature. (13) Our initial indication for rib fracture fixation was major rib cage deformity with anticipated difficulty in mechanical breathing.
Currently our indications are in line with those suggested by Pieracci et al from Denver (14) and essentially encompass three categories: acute respiratory insufficiency despite optimal medical therapy, uncontrolled pain despite optimal medical therapy, and anticipated chronic pain or impaired pulmonary mechanics. The same Denver group performed a randomised controlled trial (RCT) in 2015 (12) in which they showed that patients with the mentioned indications undergoing rib fracture fixation within 3 days had significant decreases in respiratory failure, duration of mechanical ventilation, and need for tracheostomy, as well as significantly better daily incentive spirometry readings.
In our unit, all patients with multiple rib fractures and/or flail chest undergo CT of the chest with 3D reconstruction, (15) followed by multidisciplinary discussion between trauma surgery, orthopaedics and intensive care. When all are in agreement for the need of the procedure and the patient is agreeable, cash flow approval is secured, the relevant company representative is contacted to provide the plating set, and the 3D reconstructed CT is used for planning the incisions (Figure 1).
Most patients tend to have a combination of anterior and posterior fractures, so that the lateral position is sufficient for most, with a curvilinear incision similar to that used for posterolateral thoracotomy. Skin and subcutaneous tissue flaps are raised and a minimally invasive/muscle-splitting technique is employed to access the rib fractures (Figure 2). For securing plates deep to the scapula, we employ either a trans-scapular or a subscapular technique. We have used two different sets (Matrix Rib Fixation System, DePuy Synthes, and Ribfix Blu, Zimmer Biomet)--there is little to choose between the sets in terms of ease of use and results. We use prophylactic cefazolin and leave a suction drain in the vicinity of the plates for two to three days postoperatively. Patients tend to be mobile from day one, if they are not ventilated. Potential complications include wound infection, osteomyelitis, plate migration, and nerve injury. (16) While we believe that this procedure should form part of every trauma surgeon's armamentarium, it is probably advisable to seek the assistance of an experienced orthopaedic surgeon for every procedure.
Nine patients underwent surgical rib fracture fixation, of which seven were male. Patient profiles and outcomes are tabulated in Table 1. The age range was 29 to 67 years. All patients had multiple rib fractures with severe displacement; one had bilateral flail segments and one had severely displaced unilateral single fractures without flail; all others had unilateral flail chests. Six patients were ventilator dependent. Time from injury to operation ranged from 3 to 20 days. We used the following rib fixation sets: Matrix Rib Fixation System, DePuy Synthes (3 patients), and Ribfix Blu, Zimmer Biomet (6 patients). All displaced rib fractures were plated; on flail segments both anterior and posterior fractures were plated, most commonly with one long plate, less commonly with two separate plates. Initially muscle cutting, but later muscle sparing techniques were employed.
Of the six ventilator dependent patients, all but one were extubated within 3 days. The remaining patient remained ventilator dependent for 10 days whilst recovering from a traumatic brain injury. This patient remained in ICU for 15 days, while the others were all discharged from ICU within 5 days. Postoperative length of stay ranged from 7 to 23 days. Five patients with no other significant injuries were discharged within five to eight days, all having been mobile within five days. Procedure-related complications included accidental pleural breach during rib mobilsation necessitating intercostal drain placement (2 patients) and superficial wound infection (1 patient; successfully treated with VAC dressing). All patients were discharged well.
Just under a decade ago in 2009 a survey undertaken among trauma surgeons, orthopaedic surgeons, and thoracic surgeons (17) found that most of these professionals believed that nonoperative management was sufficient for flail chest. Since then that attitude seems to have changed towards a more operative approach and this has been supported by a number of RCTs. An RCT from 2002 (9) found that patients with flail chests, intubated and ventilated in the emergency department and undergoing rib fracture fixation within 14 days had a significantly decreased duration of mechanical ventilation, incidence of pneumonia, need for tracheotomy, length of ICU stay, and total medical expense. In addition, a year after repair, respiratory functions were superior in the group that underwent fixation, and symptoms such as chest tightness, chest cage pain, and dyspnoea on effort were significantly decreased as compared to the nonoperatively managed group. Furthermore, return to normal employment was significantly higher in the operative group. A further RCT from 200510 found that patients with flail chest undergoing operative repair within 24-36 hours had significantly decreased duration of mechanical ventilation, incidence of pneumonia, length of ICU stay, length of hospital stay, and chest wall deformity. In addition, respiratory functions were superior to nonoperatively managed patients at 2 months follow-up. A third RCT published in 2013 (11) showed that patients with a flail chest and who were being ventilated with no prospect of weaning within 48 hours, who underwent rib fracture fixation, had significant decreases in duration of mechanical ventilation, incidence of pneumonia, need for tracheostomy, length of ICU stay, and hospital costs. Several systematic reviews and meta-analyses have confirmed superior outcomes for operatively treated patients. (18-23)
Our experience with this procedure is in agreement with the findings of the abovementioned RCTs. Rib fracture fixation is technically easy to perform and results in dramatic improvement of respiratory function. This is evidenced by the expeditious weaning and extubation of almost all the patients in this series. Our overall impressions are that early operation is ideal, patient selection is critical, and that patients should be fit for discharge within one week of operation, unless there are other reasons for ongoing hospitalisation.
It costs in the order of 10 000 ZAR to plate each rib (cost of plates and screws), and generally each patient requires between 4 to 10 rib fixations. This is a major limitation especially in a resource constrained environment. The cost of the procedure needs to be weighed against the cost saved in terms of ICU occupancy and hospital stay, and detailed cost analyses must be undertaken.
Conflict of interest
We have no conflicts of interest.
This was an audit conducted from data captured in our Hybrid Electronic Medical Registry (HEMR). Ethics approval for this study and for maintenance of the registry was obtained from the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu-Natal (reference: BE 207/09).
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G V Oosthuizen , J De Wet , J L Bruce , D L Clarke 
 Pietermaritzburg Metropolitan Trauma Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
 Department of Orthopaedics, Edendale Hospital, University of KwaZulu Natal, Pietermaritzburg, South Africa
Corresponding author: G VOosthuizen (email@example.com)
Caption: Figure 1: Three dimensional reconstruction of chest CT
Caption: Figure 2: Rib fracture fixation in progress
Table 1: Patient profiles and outcomes Patient Injury pattern Ventilated? 65y old Flail chest right, humerus Yes male fracture right, mild traumatic brain injury, mild dementia. 48y old Bilateral flail chest, C2 Yes female teardrop fracture, mandible fracture, acetabular fracture, femur fracture. 52y old Severely displaced multiple No female right-sided single rib fractures, lung contusion. 29y old Flail chest right. Yes male 39y old Bilateral flail chest, old Yes male underlying PTB. 32y old Single rib fractures Yes male 5-10 left. Splenic injury (splenectomy). Distal humerus fracture. 67y old Flail chest left, single Yes male undisplaced rib fractures right. Grade 3 liver injury (nonoperative management). Left humeral head fracture/ disclocation. Bilateral haemopneumothorax. 49y old Multiple right-sided rib No male fractures, right humerus fracture, right 5th metatarsal fracture. 62y old Multiple right sided rib No male fractures, flail and stove-in chest Patient Time from Indication Ribs injury to rib plated fixation 65y old 5 days Ventilator dependence; Ribs 5-10 male suspected mechanical right breathing difficulty. 48y old 20 days Ventilator dependence; Ribs 5-10 female failed weaning on two left, 5-9 occasions. right 52y old 5 days Intractable pain, oxygen Ribs 4-7 female dependence, anticipated right respiratory failure/ pulmonary infection. 29y old 7 days Ventilator dependence; Ribs 5-10 male suspected mechanical right breathing difficulty. 39y old 3 days Ventilator dependence; Ribs 5-9 male suspected mechanical left, 4-7 breathing difficulty. right 32y old 3 days Ventilator dependence; Ribs 6,7,9 male suspected mechanical left breathing difficulty. 67y old 14 days Pneumonia, then Ribs 7,8,9 male ventilator dependence left (fully treated with Tazocin before surgery). 49y old 14 days Oxygen dependence Ribs 5-8 male beyond day 10 post right. injury. 62y old 7 days Intractable pain, 4 male protracted oxygen dependence Patient Post-op Post-op Post-op ventilator ICU stay hospital dependence stay 65y old 10 days 15 days 23 days male 48y old 2 days 5 days 5 days female 52y old Nil 3 days 11 days female 29y old 2 days 3 days 8 days male 39y old 3 days 4 days 8 days male 32y old 2 days 3 days 7 days male 67y old Nil 3 days 21 days. male Prolonged stay because developed biloma and GI bleed. 49y old Nil 1 day 7 days male (High Care) 62y old Nil 1 day 10 days male (High Care) Patient Complications 65y old Prolonged ventilator male dependence due to brain injury with mild dementia. Two episodes of ventilator associated pneumonia. 48y old AKI requiring dialysis-- female not related to rib fixation. 52y old Pleural breach during female surgery; ICD inserted. 29y old Nil male 39y old Nil male 32y old Pleural breach during male surgery; ICD inserted. 67y old Superficial wound male infection. Treated with VAC. Fully resolved. 49y old Nil male 62y old Delirium tremens male
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|Author:||Oosthuizen, G.V.; De Wet, J.; Bruce, J.L.; Clarke, D.L.|
|Publication:||South African Journal of Surgery|
|Date:||Nov 1, 2017|
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