Surgical Repair Benefits For Rib Fractures

Because rib fractures are common, it may surprise you to learn that there is substantial controversy about how they should be managed. Although surgical stabilization of rib fracture (SSRF) has become more widespread in recent years, it is usually reserved for patients with multiple, severe fractures (called, flail chest). Evert Eriksson, M.D., Associate Professor of Surgery at MUSC explains, "Medical students learn very little about managing rib fractures in training because, traditionally, nothing is done about broken ribs. They're taught that rib fractures get pain control and, if the patient can't breathe, they may need ventilator support." However, mounting evidence indicates that many more patients may benefit from SSRF, which is a sea-change in clinical thinking.

As often happens, this shift has been largely driven by advances in technology and surgical techniques. "A lot of physicians don't consider SSRF because they still think of it as a big, open surgery that requires a 12-15 inch incision. But, we have better devices now, like self-tapping screws, and right-angle drills and screw drivers, that let us do the whole fixation procedure through a 4-6 inch incision. We can repair the same ribs and types of fractures with a much less invasive procedure, so it can be applied in a broader patient population. But, old ideas die hard," says Eriksson.

Since SSRF became accepted for the most severe cases (i.e., flail chest), Eriksson and his colleagues have published several studies to clarify exactly which patients may benefit from the procedure. "We knew there was reliable evidence that, if we fix the fractures early (within a couple of days) in ventilated patients with multiple broken ribs, they recover quicker and have fewer complications–less pneumonia, less time on the ventilator, and less time in the ICU. So, next, we looked at patients with impending respiratory failure and found that, if we did an SSRF when they were declining and about to need mechanical ventilation, they started getting better. We were one of the early groups to look at fixing ribs in people who were not already on a ventilator."

In December 2019, the Journal of Trauma and Acute Care Surgery published findings from a new study by a team of researchers from the Chest Wall Injury Society, that further supports SSRF in patients without flail chest. This is the first prospective, multicenter trial of SSRF specifically conducted in patients without flail chest. Because of a lack of published evidence and wide ranging clinical practice patterns, the team needed help determining which population to study. "The research committee sent out a survey asking, theoretically, which patients should or should not get SSRF. We wanted to identify the group of patients with clinical equipoise–that would split surgeons 50/50 about whether to offer SSRF or not. It turned out to be patients with three or more partially displaced rib fractures and at least two parameters suggesting pulmonary or respiratory compromise. About half of surgeons we surveyed said they would offer SSRF and half said they wouldn't. Basically, these patients have a 50/50 chance of getting their ribs fixed, based almost entirely on the intrinsic bias of who they saw," Eriksson explains.

The study enrolled 110 patients without flail chest at 12 US academic trauma centers to compare SSRF outcomes to best medical management. The findings were striking. Numeric pain scores were significantly lower in the SSRF group versus the non-operative group (mean score 2.9 vs. 4.5, p less than 0.01). Respiratory disability related quality-of-life was significantly improved in SSRF patients (mean disability score 21 vs. 25, p=0.03). In addition, pleural space complications (common in these patients) were significantly lower in SSRF patients compared to non-operative patients (0% vs. 10.2%, p=0.02). "That's one of our most important findings," says Eriksson. "Over 10% of the non-operative group required additional procedures to evacuate air, blood, or fluid from around their lungs. We think the thoracic cavity irrigation and wash out, which is an important part of the procedure, is what led to reducing the plural space complication rates." There was also a non-significant trend (0.5 vs. 1.2 narcotic equivalents, p=0.05) toward lower narcotic use in the SSRF group that may be clinically important.

Overall, the study results support a moderate benefit for SSRF in non-flail chest patients with respiratory compromise. Eriksson says, "For those of us who've been doing this surgery and seeing the benefits, this study was the next logical step. It made sense to us that we would look at non-flail fracture patterns next. But, for people who are slower to adopt new technologies or who haven't absorbed the evidence that SSRF improves patients' physiology, these data will be extremely surprising."

The findings may also raise interest in investigating the potential benefits of surgical fracture repair in other populations. For example, isolated sternal fractures do not usually receive surgical fixation, but outcome data on these patients is sparse. Eriksson asks, "Would they get back to their lives quicker with less narcotic use? Would they have better respiratory quality-of-life?" Similarly, patients who have clavicle and scapular fractures with associated rib fractures, do not generally receive SSRF. "Scapular repair studies haven't paid much attention to the interaction of the scapula with the chest wall, but all of the muscles for the arm attach to the chest. So, of course, fixing one fracture without also fixing the ribs, won't help much. Patients will still have ongoing pain and disability in that arm. We should look at whether fixing both fractures at the same time gets patients into recovery and rehabilitation faster," says Eriksson.

The new study also highlights the importance of referring patients with three or more rib fractures to a thoracic trauma center for evaluation and treatment. Eriksson emphasizes that SSRF procedures should be done in centers that specialize in chest wall repairs. "It's not simply fixing the ribs that makes patients do better," says Eriksson. "Fixing the ribs in a trauma center where there's expertise and all of the components to support their recovery is what really benefits patients."