Introduction

Rib fractures are commonly encountered in polytrauma patients and are often seen in combination with orthopaedic injuries. A wide spectrum of injury can be encountered with rib fractures, ranging from single/nondisplaced rib fractures to multiple fractured/displaced ribs to flail chest injuries with mechanical instability of the chest wall. Increasing severity of rib injury is clearly correlated with increasing levels of morbidity and mortality. The traditional management of these injuries (including severe injuries such as flail chest) has been largely nonoperative with analgesia, supportive care of respiratory function as required, and chest tube placement for the management of associated pneumothorax/hemothorax. Recently, there has been increasing interest in the surgical management of more severe rib fractures and chest injuries (e.g., multiple displaced rib fractures or flail chest injuries).

I. Preoperative

1. 
   

   History and physical exam

   
   
   
   
   1. 
      

      Substantial rib injuries typically occur as a result of high-energy blunt trauma (typically motor vehicle collisions, falls from 10 feet or greater, pedestrian hit by vehicle, etc.).

      
      
   2. 
      

      Patient assessment should proceed following Advanced Trauma Life Support (ATLS) protocol as these patients often suffer from multiple injuries and can present with imminently life-threatening injuries.

      
      
   3. 
      

      Specific physical examination of the chest should include assessment of cardiovascular function (heart rate, blood pressure, cardiac monitoring), respiratory function (tracheal deviation, oxygen saturation, air entry, percussion for dullness or hyper resonance, asymmetric or paradoxical chest movement), and physical findings of chest trauma (ecchymosis, seat-belt sign, open injuries, crepitus, subcutaneous emphysema).

      
      
   4. 
      

      Commonly associated orthopaedic injuries include clavicle and scapula fractures.

      
      
   5. 
      

      Commonly associated nonorthopaedic injuries include head injuries and intra-abdominal injuries such as spleen or liver lacerations.

   
   
2. 
   

   Anatomy—in addition to the anatomy of the thoracic cage and its contribution to respiratory function, it is important to recognize the anatomic structures contained within the thorax and upper abdomen by the ribs, and the associated injuries which can occur to these structures.

   
   
   
   
   1. 
      

      Mediastinal structures including the heart (cardiac tamponade, cardiac contusion, laceration), great vessels (vascular injury), trachea (tracheobronchial injury), and esophagus (esophageal rupture).

      
      
   2. 
      

      Pleural space (tension pneumothorax, sucking chest wound, pneumothorax, and hemothorax).

      
      
   3. 
      

      Lungs (pulmonary contusion, laceration).

      
      
   4. 
      

      The diaphragm, liver, and spleen are contained by the lower ribs (10–12) and injury to these structures can be associated with rib fractures (diaphragmatic rupture, spleen or liver laceration).

      
      
   5. 
      

      Ribs and thoracic cage (increasing severity of rib injuries cause increasing impairments in ventilatory function due to both painful inspiration/expiration and compromised respiratory mechanics).

      
      
   6. 
      

      Intercostal vessels and nerves (neurovascular injury).

   
   
3. 
   

   Imaging

   
   
   
   
   1. 
      

      AP chest X-ray:

      
      
      
      
      1. 
         

         Per ATLS protocol, all patients with suspected chest trauma should undergo expedited imaging with an AP chest X-ray.

         
         
      2. 
         

         This initial investigation is critical for the early detection of injuries representing an immediate threat to life, such as tension pneumothorax (see ▶ Fig. 15.1a,b ), massive hemothorax, or mediastinal injury.

         

         
         
      3. 
         

         Serves as the initial screening test for the identification of rib fractures, pneumo/hemothorax, and diaphragmatic rupture.

      
      
   2. 
      

      Contrast-enhanced thoracic and abdominal computed tomography (CT):

      
      
      
      
      1. 
         

         CT of the chest and abdomen with intravenous contrast is indicated for all patients with suspicion of these injuries based on injury mechanism, physical exam or initial imaging.

         
         
      2. 
         

         CT scanning is the imaging modality of choice for identification and characterization of fractures of the ribs and sternum.

         
         
      3. 
         

         Three-dimensional (3D) reconstructions are helpful for further characterization of fracture pattern and displacement, particularly in those instances where surgical treatment is being considered (see ▶ Fig. 15.2b ). In addition, CT scan is the modality of choice for identifying the associated injuries outlined above.

         

   
   
4. 
   

   Classification

   
   
   
   
   1. 
      

      Although no widely recognized classification system exists for rib fractures or bony injuries to the thoracic cage, it is important to recognize that a wide spectrum of pathology exists.

      
      
   2. 
      

      Injuries range from:

      
      
      
      
      1. 
         

         Single and nondisplaced rib fractures.

         
         
      2. 
         

         Multiple, displaced rib fractures.

         
         
      3. 
         

         Flail chest injuries (an entire segment of the chest wall is free-floating).

      
      
   3. 
      

      The literature has clearly shown that as the severity of these injuries increases, there are substantial increases in both morbidity and mortality.

      
      
   4. 
      

      Flail chest injuries occur when multiple ribs have segmental fractures, creating a “flail segment” which moves paradoxically with respiration (inward during inspiration and outward during respiration). Flail chest injuries have been defined as:

      
      
      
      
      1. 
         

         Three or more unilateral segmental rib fractures.

         
         
      2. 
         

         Three or more bilateral rib fractures.

         
         
      3. 
         

         Three or more unilateral rib fractures combined with sternal fracture or dissociation.