Rib fracture repair

Blunt chest wall trauma and the resultant fracture of ribs is exceedingly common 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 50 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 made surgical stabilization of rib fractures (SSRF) technically easier, safer, and arguably more effective. Recently published consensus statements have attempted to codify the indications, contra-indications, timing, and technical aspects of SSRF. Patients with three or more severely displaced rib fractures or flail chest should be considered for repair whether they require mechanical ventilation or not. Other candidates may include patients who fail optimal nonoperative 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 general is not a contraindication. Several rib-specific plating systems are now commercially available. 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. These systems are low profile, made from titanium, and easily shapeable. Most rib repairs in the United States are performed by trauma or thoracic surgeons, although this varies from by center. Surgeons new to the principles of osteosynthesis may wish to enlist the help of an orthopedist colleague as they navigate their early experience.