Injury, Int. J. Care Injured 46 (2015) 929–932
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical note
Surgical rib fixation – Technical aspects Silvana Marasco *, Pankaj Saxena CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 December 2014
Surgical rib fixation (SRF) for severe rib fracture injuries is increasingly becoming an accepted treatment modality. There is now adequate evidence in randomised controlled trials that rib fixation in flail chest patients reduces ventilator times, intensive care stay and costs of treatment in ventilator dependent patients [1–3]. Despite this, rib fixation has not become standard of care for these patients and remains a treatment modality practised by few centres, usually those with large trauma loads who see high volumes of severe rib fracture injury patients. The purpose of this article is to outline the available prostheses, indications, operative planning and techniques of rib fixation. Surgical approaches to rib fractures in anterior, lateral and posterior positions are described as are the use of currently available cortical and medullary fixation prostheses. Crown Copyright ß 2015 Published by Elsevier Ltd. All rights reserved.
Introduction
Patient selection
Surgical rib fixation (SRF) for severe rib fracture injuries is increasingly becoming an accepted treatment modality. There is now adequate evidence in randomised controlled trials that rib fixation in flail chest patients reduces ventilator times, intensive care stay and costs of treatment in ventilator dependent patients [1–3]. It is well documented that poorly healed fractured ribs can lead to chronic pain, disability, and deformity [4]. Despite this, the use of rib fixation has failed to achieve standard of care in many hospitals because of lack of awareness of the evidence for rib fixation, available prostheses and lack of knowledge of techniques for rib fixation [5]. Lack of specific rib fixation prostheses led to the use of alternatives such as K wires, cerclage sutures, and off label absorbable prostheses which have all been associated with hardware failures [6,7]. The development and availability of specific rib fixation prostheses in recent years such as the MatrixRib (DePuy Synthes, West Chester, PA, USA), RibLoc (Acute Innovations, Hillsboro, OR) and Stratos (Strasbourg Thoracic Osteosyntheses System – STRATOSTM; MedXpert GmbH, Heitersheim, Germany) has addressed this deficiency.
We commenced our rib fixation programme enrolling ventilator dependent patients only. These patients had significant flail chest injury, and often had other injuries [3,8]. Patients between the ages of 18 and 80 were considered for fixation. We were concerned about osteoporosis and risk of screw pull out in older patients early in our experience but now recognise that this does not seem to be a significant issue, and these older patients may well have more to benefit, particularly if ventilator dependent. We have excluded patients with severe head injury (as this will dictate their invasive ventilator time and prognosis), spinal injury (that precludes positioning on the operating table for the rib fixation surgery), open and soiled wounds, and sepsis. As our experience has grown, we now also consider non ventilator dependent patients with multiple displaced rib fractures for rib fixation, particularly if pain is not well controlled, and have commenced a randomised trial comparing operative management to best practice conservative management in this subset of patients (NCT pending clinical trials.gov).
* Corresponding author at: CJOB Cardiothoracic Department, The Alfred Hospital, Commercial Road, Prahran 3181, Australia. Tel.: +61 3 9076 2558. E-mail addresses: [email protected] (S. Marasco), [email protected] (P. Saxena). http://dx.doi.org/10.1016/j.injury.2014.12.021 0020–1383/Crown Copyright ß 2015 Published by Elsevier Ltd. All rights reserved.
Operative planning We perform 3D computed tomography reconstructions of the ribs on all patients before considering them for surgery. We aim to fix only ribs between level 3 and 10 as ribs 1 and 2 are difficult to access and ribs 11 and 12 do not contribute to breathing. Displaced ribs are given priority in our operative planning and fractured nondisplaced ribs are often not fixed at all. In the past we aimed to
930
S. Marasco, P. Saxena / Injury, Int. J. Care Injured 46 (2015) 929–932
convert fail chest injury to simple fractured ribs by fixing one fracture per rib, rather than both ends of the flail segment. However, we have recently recognised that posterior fractures tend to continue to displace and overlap over time, even when more anterior fractures on the same ribs have been fixed [9]. Therefore it seems that fixation of all accessible fractures should be performed if possible. Position on the table is dictated by the position of the fractures and may be supine, lateral or prone. If a concomitant thoracotomy is not required, we use a single lumen tube only. This is also useful in the ventilator dependent patients who may not tolerate single lung ventilation due to underlying contusions. It is worth considering reducing positive end expiratory pressure and/or tidal volumes during the surgery (if possible) as it is easy to puncture the lung with the drill when predrilling the screw holes. However, even if this occurs, in our experience formal repair is never required, even if a small air leak becomes apparent. An intercostal catheter is always placed at the end of the procedure, as well as a Redivac drain in the chest wall layers to reduce haematoma formation. In thinner patients, it is easy to locate the fractures prior to making the incision either by direct palpation or by landmarks using the preoperative computed tomography imaging as a guide. In larger patients, ultrasound can be useful to identify the exact site of the fractures and guide your skin incision. Available prostheses The three rib fixation systems described here are titanium. MatrixRib plates sit on the outer cortex of the rib and are precontoured to fit the various curvatures of ribs 4 through to 8. The plates can be further bent to ensure perfect apposition of the plate to the bone. The titanium screws are designed for bicortical fixation as well as locking to the plate, with a recommendation that three screws on either side of the fracture be used. The plates are quite long and can be cut to length. Acute Innovations RibLoc plates are a titanium plate with a U shape at either end designed to sit over the rib. The primary locking screws at either end go through the anterior U plate then through rib, then lock into the posterior part of the U plate, making a very strong construct. Intermediate screws are also placed through the plate which lies between the two U shaped ends locking the plate to the rib. The U shaped ends of the plates come in different sizes to accommodate different thickness ribs and the plates can be bent to further contour them to the rib. The Stratos system relies on crimping clips onto the rib on either side of the fracture. It is essential that the clips are firmly applied to the superior and inferior border of the rib to ensure that there is no slippage. A connecting bar is then cut to length, contoured to the rib and then crimped to the clips. Surgical approach Anterior fractures These are probably the easiest fractures to access and the trickiest to fix. Generally an inframammary crease incision will give good access to ribs 4–6. The incision can be extended superiorly up the sternum to allow higher ribs to be accessed. If lower ribs need to be accessed, either a minimally invasive approach via the inframammary crease incision or a second lower incision can be made over the ribs. The main muscle encountered will be pectoralis major, and minor over the upper ribs and these can both be reflected off the ribs without problem. Lower down serratus anterior is encountered and can easily be split along the length of its fibres to achieve access to each rib.
Fig. 1. Anterior rib fracture fixation to sternum.
Once the rib fracture is identified, care must be taken not to unnecessarily strip off the intercostal attachments or the periosteum. Intact periosteum is essential for the ribs blood supply and healing. If there is concern about rib fragments protruding into the pleura or difficultly reducing overlapping ribs, we do not hesitate to open a 2 cm section of intercostal muscle and put a finger into the pleural space to palpate the rib fracture ends and assist in their reduction. This is also useful to identify where the fracture is in the rib above or below your position, as it is not always immediately evident in patients with a lot of chest wall tissue covering their ribs. Once reduction of the rib fracture is achieved, the appropriate prosthesis is chosen and fitted onto the rib. Although many of the available rib prostheses are pre-contoured, further contouring is often required to ensure a flush alignment with the rib. Particular care is required with the tight curvature of the costal cartilages anteriorly. Furthermore, fixation of most prostheses into cartilage is not recommended so use of a longer plate and fixation to the sternum is prudent. This can only really be done with the MatrixRib system as the other systems described here anchor over the superior cortex of the rib and cannot be fixed flush with the outer cortex of the sternum (Fig. 1). Lateral fractures Access to lateral fractures can be achieved in several ways. We suggest approaching them through a standard posterolateral thoracotomy incision to start with, as this is an incision that all cardiothoracic and many general trauma surgeons would be familiar with. The patient is laid in a lateral decubitus position and the thoracotomy incision can be positioned anywhere from the
S. Marasco, P. Saxena / Injury, Int. J. Care Injured 46 (2015) 929–932
931
Fig. 3. Anatomy and exposure for posterior rib fixation.
Posterior fractures
Fig. 2. Thoracoscopic port assisted rib fixation.
fourth to the seventh intercostal space, depending on the levels of the fractures. Latissium dorsi is divided and serratus anterior retracted anteriorly by dividing its posterior fascia. The thorax can be entered if required. Once familiarity with the procedure develops, smaller lateral transverse incisions can be performed, sparing latissimus dorsi by retracting it posteriorly, and splitting serratus anterior along the length of its fibres. Using this smaller incision of 6–8 cm, three rib levels can easily be reached through the incision. Any ribs higher or lower than this can usually be reached well enough to reduce them, but it is impossible to get perpendicular access to place the screws. We then use a thoracoscopic port placed through the chest wall muscles, but not past the ribs to allow access to the reduced rib and plate in order to perform the drill holes and place the screws (Fig. 2). Right angle drills and screw drivers do exist for some of the systems (such as MatrixRib), although they are not available in all countries. If there are a lot of sequential ribs fractured laterally, then a vertical incision in the mid axillary line is another alternative which gives excellent access. This is also muscle sparing in that latissimus dorsi which lies posteriorly and pectoralis major which lies anteriorly do not have to be incised at all. Serratus anterior muscle fibres are again split along their length over each rib as necessary. Care must be taken not to divide too much tissue under the anterior border of latissimus dorsi where the long thoracic nerve runs, particularly above the level of the fifth rib. Laterally, the ribs follow their straightest course both in terms of ‘in plane’ curvature and out of plane curvature. This makes them the easiest to fix in many ways, and little extra contouring of available plates is required.
These are the most difficult to access. We define posterior fractures as anything posterior to the posterior axillary line. Usually the patient will need to be placed prone, although some of the more lateral fractures can be accessed with the patient in a lateral position. Fractures in the lower ribs, where the scapula does not interfere are the easiest. Either a vertical (longitudinal) or horizontal (transverse) incision can be made, depending on how many levels need to be reached. Over the lower ribs, latissimus dorsi fibres will be encountered and can be divided. Over ribs 6 and 7. There is a triangular area bound superiorly and medially by trapezius, laterally by the medial border of scapula and inferiorly by latissimus dorsi that is relatively free of muscle. Erector spinae runs along the spine and can be retracted medially to reach the neck of the ribs. Care must be taken not to overbend then correct the curvature of the metal implants in order to avoid metal fatigue and fracture. Between the medial border of the scapula and the spine, a longitudinal incision is advised [10]. Trapezius then the rhomboids can be divided, or taken down from their attachment to the scapula (Fig. 3). This allows dislocation of the scapula laterally and access to rib fractures under the scapula body. Care must be taken here though to ensure the rib prostheses are as flush as possible, as contact between the scapula and any prosthesis on the outer cortex of the rib is very painful. Use of the intramedullary splint (DePuy Synthes) may be useful here to prevent this complication (Fig. 4). However, these are quite tricky to implant and are probably best tried after gaining some familiarity with the rib fixation procedure. Interestingly, these splints have only one point of fixation, with no distal fixation. However they seem to achieve stability by providing a stiff ‘rod’ within the intramedullary canal and although they would provide no counterforce to prevent rib fracture distraction, they do prevent overlapping dislocation, presumably by friction within the intramedullary canal. These splints can be implanted via this posterior approach (Fig. 4C) or via a lateral approach, in which case the point of fixation on the rib is anterolateral with the splint pointing posteriorly (Fig. 4D).
S. Marasco, P. Saxena / Injury, Int. J. Care Injured 46 (2015) 929–932
932
Fig. 4. (A and B) Insertion of intramedullary splint. (C and D) Radiological appearance following the insertion of intramedullary splints and plates.
Pitfalls It is essential to achieve the correct contouring on the rib prostheses. The plates need to sit flush on the outer cortex of the rib. If the plates are sitting proud of the bone, then it is likely that optimal stabilisation has not been achieved, allowing excessive movement and poor healing at the fracture site. The plate may also be palpable and uncomfortable particularly in the thin patient. Both the RibLoc and the MatrixRib systems rely on screws traversing both the outer and inner cortex. The outer cortex is thinner than the inner cortex and alone provides insufficient contact area for the screws [11]. Thus bicortical fixation is essential. Both of these prostheses also require a minimum of three screws on either side of the fracture. Conflicts of interest statement
[2]
[3]
[4] [5]
[6]
[7] [8]
[9]
No conflicts of interest to declare. [10]
References [11] [1] Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized
study of management of severe flail chest patients. J Trauma 2002;52(4): 727–32. Granetzny A, El-Aal MA, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4:583–7. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013;216(5):924–32. Gordy S, Fabricant L, Ham B, Mullins R, Mayberry J. The contribution of rib fractures to chronic pain and disability. Am J Surg 2014;207(5):659–62. Mayberry JC, Ham LB, Schipper PH, Ellis TJ, Mullins RJ. Surveyed opinion of American trauma, orthopaedic and thoracic surgeons on rib and sternal fracture repair. J Trauma 2009;66(March (3)):875–9. Nirula R, Diaz Jr JJ, Trunkey DD, Mayberry JC. Rib fracture repair; indications, technical issues and future directions. World J Surg 2009;33(January (1)): 14–22. Marasco SF, Sutalo ID, Bui AV. Mode of failure of rib fixation with absorbable plates: a clinical and numerical modelling study. J Trauma 2010;68:1225–33. Marasco S, Cooper J, Pick A, Kossmann T. Pilot study of operative fixation of fractured ribs in patients with flail chest. ANZ J Surg 2009;79(November (11)):804–8. Marasco S, Liew S, Edwards E, Varma D, Summerhayes R. Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib? J Trauma Acute Care Surg 2014;77(September (3)):452–8. Solberg BD, Moon CN, Nissim AA, Wilson MT, Marguiles DR. Treatment of chest wall implosion injuries without thoracotomy: technique and clinical outcomes. J Trauma 2009;67:8–13. Bottlang M, Walleser S, Noll M, Honold S, Madey SM, Fitzpatrick D, et al. Biomechanical rationale and evaluation of an implant system for rib fracture fixation. Eur J Trauma Emerg Surg 2010;36:417–26.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Technical note
Surgical rib fixation – Technical aspects Silvana Marasco *, Pankaj Saxena CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 December 2014
Surgical rib fixation (SRF) for severe rib fracture injuries is increasingly becoming an accepted treatment modality. There is now adequate evidence in randomised controlled trials that rib fixation in flail chest patients reduces ventilator times, intensive care stay and costs of treatment in ventilator dependent patients [1–3]. Despite this, rib fixation has not become standard of care for these patients and remains a treatment modality practised by few centres, usually those with large trauma loads who see high volumes of severe rib fracture injury patients. The purpose of this article is to outline the available prostheses, indications, operative planning and techniques of rib fixation. Surgical approaches to rib fractures in anterior, lateral and posterior positions are described as are the use of currently available cortical and medullary fixation prostheses. Crown Copyright ß 2015 Published by Elsevier Ltd. All rights reserved.
Introduction
Patient selection
Surgical rib fixation (SRF) for severe rib fracture injuries is increasingly becoming an accepted treatment modality. There is now adequate evidence in randomised controlled trials that rib fixation in flail chest patients reduces ventilator times, intensive care stay and costs of treatment in ventilator dependent patients [1–3]. It is well documented that poorly healed fractured ribs can lead to chronic pain, disability, and deformity [4]. Despite this, the use of rib fixation has failed to achieve standard of care in many hospitals because of lack of awareness of the evidence for rib fixation, available prostheses and lack of knowledge of techniques for rib fixation [5]. Lack of specific rib fixation prostheses led to the use of alternatives such as K wires, cerclage sutures, and off label absorbable prostheses which have all been associated with hardware failures [6,7]. The development and availability of specific rib fixation prostheses in recent years such as the MatrixRib (DePuy Synthes, West Chester, PA, USA), RibLoc (Acute Innovations, Hillsboro, OR) and Stratos (Strasbourg Thoracic Osteosyntheses System – STRATOSTM; MedXpert GmbH, Heitersheim, Germany) has addressed this deficiency.
We commenced our rib fixation programme enrolling ventilator dependent patients only. These patients had significant flail chest injury, and often had other injuries [3,8]. Patients between the ages of 18 and 80 were considered for fixation. We were concerned about osteoporosis and risk of screw pull out in older patients early in our experience but now recognise that this does not seem to be a significant issue, and these older patients may well have more to benefit, particularly if ventilator dependent. We have excluded patients with severe head injury (as this will dictate their invasive ventilator time and prognosis), spinal injury (that precludes positioning on the operating table for the rib fixation surgery), open and soiled wounds, and sepsis. As our experience has grown, we now also consider non ventilator dependent patients with multiple displaced rib fractures for rib fixation, particularly if pain is not well controlled, and have commenced a randomised trial comparing operative management to best practice conservative management in this subset of patients (NCT pending clinical trials.gov).
* Corresponding author at: CJOB Cardiothoracic Department, The Alfred Hospital, Commercial Road, Prahran 3181, Australia. Tel.: +61 3 9076 2558. E-mail addresses: [email protected] (S. Marasco), [email protected] (P. Saxena). http://dx.doi.org/10.1016/j.injury.2014.12.021 0020–1383/Crown Copyright ß 2015 Published by Elsevier Ltd. All rights reserved.
Operative planning We perform 3D computed tomography reconstructions of the ribs on all patients before considering them for surgery. We aim to fix only ribs between level 3 and 10 as ribs 1 and 2 are difficult to access and ribs 11 and 12 do not contribute to breathing. Displaced ribs are given priority in our operative planning and fractured nondisplaced ribs are often not fixed at all. In the past we aimed to
930
S. Marasco, P. Saxena / Injury, Int. J. Care Injured 46 (2015) 929–932
convert fail chest injury to simple fractured ribs by fixing one fracture per rib, rather than both ends of the flail segment. However, we have recently recognised that posterior fractures tend to continue to displace and overlap over time, even when more anterior fractures on the same ribs have been fixed [9]. Therefore it seems that fixation of all accessible fractures should be performed if possible. Position on the table is dictated by the position of the fractures and may be supine, lateral or prone. If a concomitant thoracotomy is not required, we use a single lumen tube only. This is also useful in the ventilator dependent patients who may not tolerate single lung ventilation due to underlying contusions. It is worth considering reducing positive end expiratory pressure and/or tidal volumes during the surgery (if possible) as it is easy to puncture the lung with the drill when predrilling the screw holes. However, even if this occurs, in our experience formal repair is never required, even if a small air leak becomes apparent. An intercostal catheter is always placed at the end of the procedure, as well as a Redivac drain in the chest wall layers to reduce haematoma formation. In thinner patients, it is easy to locate the fractures prior to making the incision either by direct palpation or by landmarks using the preoperative computed tomography imaging as a guide. In larger patients, ultrasound can be useful to identify the exact site of the fractures and guide your skin incision. Available prostheses The three rib fixation systems described here are titanium. MatrixRib plates sit on the outer cortex of the rib and are precontoured to fit the various curvatures of ribs 4 through to 8. The plates can be further bent to ensure perfect apposition of the plate to the bone. The titanium screws are designed for bicortical fixation as well as locking to the plate, with a recommendation that three screws on either side of the fracture be used. The plates are quite long and can be cut to length. Acute Innovations RibLoc plates are a titanium plate with a U shape at either end designed to sit over the rib. The primary locking screws at either end go through the anterior U plate then through rib, then lock into the posterior part of the U plate, making a very strong construct. Intermediate screws are also placed through the plate which lies between the two U shaped ends locking the plate to the rib. The U shaped ends of the plates come in different sizes to accommodate different thickness ribs and the plates can be bent to further contour them to the rib. The Stratos system relies on crimping clips onto the rib on either side of the fracture. It is essential that the clips are firmly applied to the superior and inferior border of the rib to ensure that there is no slippage. A connecting bar is then cut to length, contoured to the rib and then crimped to the clips. Surgical approach Anterior fractures These are probably the easiest fractures to access and the trickiest to fix. Generally an inframammary crease incision will give good access to ribs 4–6. The incision can be extended superiorly up the sternum to allow higher ribs to be accessed. If lower ribs need to be accessed, either a minimally invasive approach via the inframammary crease incision or a second lower incision can be made over the ribs. The main muscle encountered will be pectoralis major, and minor over the upper ribs and these can both be reflected off the ribs without problem. Lower down serratus anterior is encountered and can easily be split along the length of its fibres to achieve access to each rib.
Fig. 1. Anterior rib fracture fixation to sternum.
Once the rib fracture is identified, care must be taken not to unnecessarily strip off the intercostal attachments or the periosteum. Intact periosteum is essential for the ribs blood supply and healing. If there is concern about rib fragments protruding into the pleura or difficultly reducing overlapping ribs, we do not hesitate to open a 2 cm section of intercostal muscle and put a finger into the pleural space to palpate the rib fracture ends and assist in their reduction. This is also useful to identify where the fracture is in the rib above or below your position, as it is not always immediately evident in patients with a lot of chest wall tissue covering their ribs. Once reduction of the rib fracture is achieved, the appropriate prosthesis is chosen and fitted onto the rib. Although many of the available rib prostheses are pre-contoured, further contouring is often required to ensure a flush alignment with the rib. Particular care is required with the tight curvature of the costal cartilages anteriorly. Furthermore, fixation of most prostheses into cartilage is not recommended so use of a longer plate and fixation to the sternum is prudent. This can only really be done with the MatrixRib system as the other systems described here anchor over the superior cortex of the rib and cannot be fixed flush with the outer cortex of the sternum (Fig. 1). Lateral fractures Access to lateral fractures can be achieved in several ways. We suggest approaching them through a standard posterolateral thoracotomy incision to start with, as this is an incision that all cardiothoracic and many general trauma surgeons would be familiar with. The patient is laid in a lateral decubitus position and the thoracotomy incision can be positioned anywhere from the
S. Marasco, P. Saxena / Injury, Int. J. Care Injured 46 (2015) 929–932
931
Fig. 3. Anatomy and exposure for posterior rib fixation.
Posterior fractures
Fig. 2. Thoracoscopic port assisted rib fixation.
fourth to the seventh intercostal space, depending on the levels of the fractures. Latissium dorsi is divided and serratus anterior retracted anteriorly by dividing its posterior fascia. The thorax can be entered if required. Once familiarity with the procedure develops, smaller lateral transverse incisions can be performed, sparing latissimus dorsi by retracting it posteriorly, and splitting serratus anterior along the length of its fibres. Using this smaller incision of 6–8 cm, three rib levels can easily be reached through the incision. Any ribs higher or lower than this can usually be reached well enough to reduce them, but it is impossible to get perpendicular access to place the screws. We then use a thoracoscopic port placed through the chest wall muscles, but not past the ribs to allow access to the reduced rib and plate in order to perform the drill holes and place the screws (Fig. 2). Right angle drills and screw drivers do exist for some of the systems (such as MatrixRib), although they are not available in all countries. If there are a lot of sequential ribs fractured laterally, then a vertical incision in the mid axillary line is another alternative which gives excellent access. This is also muscle sparing in that latissimus dorsi which lies posteriorly and pectoralis major which lies anteriorly do not have to be incised at all. Serratus anterior muscle fibres are again split along their length over each rib as necessary. Care must be taken not to divide too much tissue under the anterior border of latissimus dorsi where the long thoracic nerve runs, particularly above the level of the fifth rib. Laterally, the ribs follow their straightest course both in terms of ‘in plane’ curvature and out of plane curvature. This makes them the easiest to fix in many ways, and little extra contouring of available plates is required.
These are the most difficult to access. We define posterior fractures as anything posterior to the posterior axillary line. Usually the patient will need to be placed prone, although some of the more lateral fractures can be accessed with the patient in a lateral position. Fractures in the lower ribs, where the scapula does not interfere are the easiest. Either a vertical (longitudinal) or horizontal (transverse) incision can be made, depending on how many levels need to be reached. Over the lower ribs, latissimus dorsi fibres will be encountered and can be divided. Over ribs 6 and 7. There is a triangular area bound superiorly and medially by trapezius, laterally by the medial border of scapula and inferiorly by latissimus dorsi that is relatively free of muscle. Erector spinae runs along the spine and can be retracted medially to reach the neck of the ribs. Care must be taken not to overbend then correct the curvature of the metal implants in order to avoid metal fatigue and fracture. Between the medial border of the scapula and the spine, a longitudinal incision is advised [10]. Trapezius then the rhomboids can be divided, or taken down from their attachment to the scapula (Fig. 3). This allows dislocation of the scapula laterally and access to rib fractures under the scapula body. Care must be taken here though to ensure the rib prostheses are as flush as possible, as contact between the scapula and any prosthesis on the outer cortex of the rib is very painful. Use of the intramedullary splint (DePuy Synthes) may be useful here to prevent this complication (Fig. 4). However, these are quite tricky to implant and are probably best tried after gaining some familiarity with the rib fixation procedure. Interestingly, these splints have only one point of fixation, with no distal fixation. However they seem to achieve stability by providing a stiff ‘rod’ within the intramedullary canal and although they would provide no counterforce to prevent rib fracture distraction, they do prevent overlapping dislocation, presumably by friction within the intramedullary canal. These splints can be implanted via this posterior approach (Fig. 4C) or via a lateral approach, in which case the point of fixation on the rib is anterolateral with the splint pointing posteriorly (Fig. 4D).
S. Marasco, P. Saxena / Injury, Int. J. Care Injured 46 (2015) 929–932
932
Fig. 4. (A and B) Insertion of intramedullary splint. (C and D) Radiological appearance following the insertion of intramedullary splints and plates.
Pitfalls It is essential to achieve the correct contouring on the rib prostheses. The plates need to sit flush on the outer cortex of the rib. If the plates are sitting proud of the bone, then it is likely that optimal stabilisation has not been achieved, allowing excessive movement and poor healing at the fracture site. The plate may also be palpable and uncomfortable particularly in the thin patient. Both the RibLoc and the MatrixRib systems rely on screws traversing both the outer and inner cortex. The outer cortex is thinner than the inner cortex and alone provides insufficient contact area for the screws [11]. Thus bicortical fixation is essential. Both of these prostheses also require a minimum of three screws on either side of the fracture. Conflicts of interest statement
[2]
[3]
[4] [5]
[6]
[7] [8]
[9]
No conflicts of interest to declare. [10]
References [11] [1] Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized
study of management of severe flail chest patients. J Trauma 2002;52(4): 727–32. Granetzny A, El-Aal MA, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4:583–7. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013;216(5):924–32. Gordy S, Fabricant L, Ham B, Mullins R, Mayberry J. The contribution of rib fractures to chronic pain and disability. Am J Surg 2014;207(5):659–62. Mayberry JC, Ham LB, Schipper PH, Ellis TJ, Mullins RJ. Surveyed opinion of American trauma, orthopaedic and thoracic surgeons on rib and sternal fracture repair. J Trauma 2009;66(March (3)):875–9. Nirula R, Diaz Jr JJ, Trunkey DD, Mayberry JC. Rib fracture repair; indications, technical issues and future directions. World J Surg 2009;33(January (1)): 14–22. Marasco SF, Sutalo ID, Bui AV. Mode of failure of rib fixation with absorbable plates: a clinical and numerical modelling study. J Trauma 2010;68:1225–33. Marasco S, Cooper J, Pick A, Kossmann T. Pilot study of operative fixation of fractured ribs in patients with flail chest. ANZ J Surg 2009;79(November (11)):804–8. Marasco S, Liew S, Edwards E, Varma D, Summerhayes R. Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib? J Trauma Acute Care Surg 2014;77(September (3)):452–8. Solberg BD, Moon CN, Nissim AA, Wilson MT, Marguiles DR. Treatment of chest wall implosion injuries without thoracotomy: technique and clinical outcomes. J Trauma 2009;67:8–13. Bottlang M, Walleser S, Noll M, Honold S, Madey SM, Fitzpatrick D, et al. Biomechanical rationale and evaluation of an implant system for rib fracture fixation. Eur J Trauma Emerg Surg 2010;36:417–26.
