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Surgical Management of Multiple Rib Fractures

Medical College of Wisconsin, Milwaukee, WI

INTRODUCTION: Multiple rib fractures remain life-threatening injuries with considerable morbidity in survivors. There has been renewed enthusiasm for surgical fixation of rib fractures as reports suggest improved short and long-term outcomes. This case report illustrates the Medical College of Wisconsin approach to these injuries using plates to internally fixate the fractures.

CASE PRESENTATIONS: 49 year-old white male involved in motorcycle accident. Seen at outside institution, found to have multiple rib fractures, and discharged with Oxycontin. Represented within 24 hours with pain and shortness of breath.

Taken to operating room for rib stabilization. Via left thoracotomy, left ribs 3-9 were stabilized using plates.

Patient discharged home post-operative day (POD) 4, back to work POD 10, and off all pain medications POD 14.

DISCUSSION: The current standard treatment for multiple rib fractures consists of aggressive pulmonary toilet, vigorous pain control, cautious fluid administration, and selective intubation. Despite this approach, these injuries remain lethal with in-hospital mortalities of roughly 15%12 and pulmonary morbidities (pneumonia, empyema, ARDS) of roughly 25%34. Additionally, in survivors, long-term morbidity is significant with 30-50% complaining of chronic pain and dyspnea and 25-35% remaining permanently disabled56. Studies have suggested that surgical fixation of rib fractures rapidly restores normal chest wall dynamics and decreases pain resulting in decreased mortality, decreased need for mechanical ventilation, acceleration of in-hospital recovery, and decreased long term morbidity78. Also, current surgical techniques and innavative hardware have allowed this procedure to be performed safely with minimal surgical morbidity9. This case illustrates these points as fixation of the patient’s rib fractures allowed rapid recovery with early normalization of pulmonary function tests and resumption of normal activity.

CONCLUSIONS: Multiple rib fractures carry with them high morbidity and mortality rates and in survivors, long-term morbidity is significant. Operative rib stabilization has a role in treatment and studies suggest improved short and long-term outcomes. Further studies are required to better delineate treatment effects and allow optimal patient selection.
Pulmonary Function Tests

PFTs Preoperative Postop Day 11 Postop Day 30 FVC 57% 94% 96% FEV1 63% 87% 90% DLCO 58% 55% 98%

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