Surgical Stabilization of Rib Fractures: Emerging Indications

Rib fractures are one of the most common injuries after road traffic accidents. Most simple rib fractures heal well with minimum intervention. But multiple rib fractures may require use of mechanical ventilation and sometimes surgical management [1]. Thoracic trauma comprises 10-15 % of all trauma and are the causes of death in 25 % of all fatalities due to trauma [2]. We present a case of multiple rib fractures and chest deformity and present the outcome of surgical fixation and its significance.


Introduction
Rib fractures are one of the most common injuries after road traffic accidents. Most simple rib fractures heal well with minimum intervention. But multiple rib fractures may require use of mechanical ventilation and sometimes surgical management [1]. Thoracic trauma comprises 10-15 % of all trauma and are the causes of death in 25 % of all fatalities due to trauma [2]. We present a case of multiple rib fractures and chest deformity and present the outcome of surgical fixation and its significance.

Case Summary
A 34 year male, a bus conductor, was brought to our hospital in the emergency room with an alleged history of road traffic accident.
He sustained mild head injury with a history of loss of consciousness and there were multiple abrasions all over his body. He complained of severe excruciating pain during breathing and movements of left arm, with a pain score in VAS scale at 8-9(0-10). Pain was nonresponsive to analgesics. He had significant depression of the chest wall on the left side; chest wall movements were equal bilaterally.
Computed tomography of the brain showed no parenchymal injury.     There were no signs of pleural tear after fixation, as clinically confirmed by positive pressure ventilation. The wound was closed in layers with a vacuum drain in-situ. He made a rapid recovery with marked reduction in his pain and discomfort (VAS score of 5) on post-operative day 1. The chest wall deformity was fully corrected. He was discharged on the 3rd post-operative day. Patient was last followed-up at 7months. The fractures had united ( Figure  5) and recovery was uneventful. He had returned to work 3weeks following surgery.

Discussion
Incidence of rib fracture reported by various studies ranges between 7 -40 %. Most commonly 4 th -9 th ribs are fractured.
Fractures of upper ribs (1st & 2nd) usually signify severe trauma with increased risk of great vessel injuries [2]. Recently there has been a resurgence of interest in the surgical management of rib fractures [3,4]. Indications for surgical fixation of rib fractures include flail chest, severe chest wall deformity, failure to wean from mechanical ventilation, chronic pain or disability, pulmonary herniation, nonunion and "on the way out" after thoracotomy [5]. Initial research suggests that in select patients, operative management of chest wall injuries is a promising treatment option. Granetzy et al. [4] in 2005 randomised 40 patients who experienced fractures of 3 or more ribs to receive either conservative or surgical treatment and the results showed that patients in the surgical group experienced significantly fewer days on mechanical ventilation, decreased stay in the Intensive Care Unit and hospital stay and less restrictive pattern on pulmonary function tests 2 months after treatment [6]. Similar results were found by Nirula et al. [5] in 2006 where they treated 60 patients with rib fractures [7]. Favourable long term outcomes of patients undergoing surgical chest wall stabilization was documented from a prospective study by Lardinois et al. [8], who had done surgical stabilization of 60 patients of chest wall injuries from 1990-1999.
Rib fractures have been associated with significant disability and loss of work [9]. Hence selected patients with multiple rib fractures but without flail chest have been hypothesized to benefit better from open reduction with internal fixation than from nonoperative treatment [10,11]. All existing surgical indications are relative. Surgical repair has been attributed to possible sooner return to work and usual activities [5,12]. In a retrospective study by Solberg et al on 16 patients of unilateral rib fracture and chest wall deformity, the overall recovery of the surgically treated patient was much earlier than that of those who were treated conservatively [13]. However, no cohort study is available to confirm the beneficial effects of surgical fixation for multiple rib fractures without flail chest [5,12]. Treatment must be individualized on the basis of the patient's fracture pattern, overall medical condition, and functional status [12]. This patient presents an ideal scenario where a surgical fixation of the rib fracture would result in better clinical outcomes and reduce the morbidity of prolonged pain and disability and loss of work.

Conclusion
The most preferred modality of treatment of rib fractures is non-operative, with analgesics and active chest physiotherapy.