What is the optimal timing to perform surgical stabilization of rib fractures?

Abstract

The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.

Keywords: Rib fracture; early fixation; surgical stabilization of rib fractures (SSRF); timing.

Figure 1

Initial chest radiography (A) of a 55-year-old male who sustained left 4–9 rib fractures which were nondisplaced. Chest radiography of the same patient 24 hours after ICU admission (B) showing interval rib fracture displacement. Chest radiography after SSRF (C) during which this patient received 11 plates to restore chest wall stability. ICU, intensive care unit; SSRF, surgical stabilization of rib fractures.

Figure 2

Initial chest CT displaying two offset posterior fractures of rib six and seven (A). After two days, a repeat chest CT showed interval rib fracture displacement of these same fractures (B). CT, computed tomography.