介绍 — 
多发性肋骨骨折是大力撞击胸壁的结果，最常见的原因是钝器伤（如机动车碰撞、跌倒、殴打），但穿透伤（如枪击）也可导致肋骨骨折。非手术治疗基于疼痛控制和积极的支持性肺部护理，主要目的是避免插管的需要，这与肺炎和死亡率的增加有关。对于持续出现急性疼痛或固有胸壁不稳定（如连枷胸）的患者，尽管进行了最大程度的药物治疗，但其中任何一种都会阻碍肺功能，或者肋骨骨折不愈合（不愈合）并引起持续疼痛和功能障碍的患者，可能需要手术稳定肋骨（也称为骨合成）。

本文将总结肋骨骨折的适应证、准备、稳定技术以及结局。创伤性肋骨骨折的初始处理详见其他专题。（参见 “成人胸部钝挫伤的初始评估和治疗”和 “成人创伤性肋骨骨折和连枷胸的住院治疗”）

 迹象 — 
虽然大多数患者会通过保守治疗治愈肋骨骨折，但部分患者可能受益于手术肋骨骨折固定[ 1-4]。连枷胸伴有需要机械通气的呼吸衰竭是肋骨骨折固定的唯一指征，有高质量的证据证明。支持连枷胸患者肋骨骨折固定的随机试验见下文[ 5-9]。许多中心使用更广泛的标准来治疗没有连枷胸但因严重移位的肋骨骨折而出现呼吸衰竭的患者（流程图 1）[ 4,10]。一项多中心前瞻性研究还评估了3例或3例以上严重移位的非连枷型肋骨骨折患者手术稳定肋骨骨折是否有任何益处[ 11]。（参见下文'连枷胸'和'非连枷肋骨骨折'）

适应证总结 — 以下一般公认的肋骨手术固定标准：

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由于疼痛管理策略难治的疼痛、可移动的肋骨（即，不是由于肺挫伤）导致的即将发生或实际的呼吸衰竭。这包括连枷胸部或多发性严重移位的非连枷型骨折患者。（参见 “成人创伤性肋骨骨折和连枷胸的住院治疗”，关于'疼痛控制'一节和 “成人创伤性肋骨骨折和连枷胸的住院治疗”，关于'支持性治疗'一节）

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明显的胸壁畸形。

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机械通气失败（与肺挫伤无关）。

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由于其他原因（例如，开放性气胸、肺撕裂伤、血胸滞留、膈疝、血管损伤）进行开胸手术时发现肋骨明显移位。这被称为“出路固定”。

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由于肋骨骨折不愈合或不愈合而导致的持续胸壁不稳定/畸形或疼痛。

目前尚无前瞻性验证或可推广的评分系统可用于预测哪些患者将失败保守疼痛管理策略。床旁诱导肺活量测定可用于评估肺活量和呼吸衰竭的可能性，但没有循证指南可用于确定在什么阈值下应将患者视为手术肋骨固定的候选者。肋骨骨折移位程度越严重，阿片类药物需求增加，手术肋骨固定术可能会减少镇痛药的使用。然而，尚无研究证明手术肋骨固定对单独控制疼痛有益[ 12]。因此，许多外科医生建议将手术稳定作为避免医疗管理失败患者插管的一种手段，或作为促进因胸壁不稳定或疼痛而依赖呼吸机的患者拔管的一种手段。

一项针对美国创伤和胸外科医生的调查发现，尽管大多数人认为肋骨骨折固定术适合特定患者，但只有26%的外科医生真正参与了此类病例[ 13]。国家创伤数据库的结果表明，只有1%的连枷胸患者接受了肋骨手术固定[14]。造成这种情况的原因包括不熟悉操作;缺乏可用于制定具体的、基于证据的指南的统一分类法;并且缺乏对这种疾病过程的专业所有权。

稳定肋骨的疗效 — 手术治疗似乎可有效减轻疼痛、改善肺功能，并通过减少运动和使肋骨末端紧密贴合来促进骨愈合[ 15]。大多数评估手术肋骨骨折固定有效性的研究都是在急性期进行的，尤其是在连枷胸患者中。

连枷胸 — 对于连枷胸患者，早期手术治疗可减少肺部并发症，促进呼吸机脱机，并缩短机械通气时间[16-22]。然而，有连枷胸和相关严重肺挫伤的患者获益的可能性较小[23-26]。（参见上文'适应证'）

几项系统评价和meta分析，包括东部创伤外科协会（Eastern Association for the Surgery of Trauma， EAST）发表的22项研究（包括988例患者）[ 4]，发现接受手术稳定连枷胸的患者肺部结局有所改善[ 4,9,22,27,28]。在过去五年中，评估手术肋骨稳定后结局的单中心研究数量迅速增加，大多数研究还发现手术组的死亡率获益、机械通气需求和住院时间减少。一项纳入了超过600,000例肋骨骨折患者的美国国家创伤数据库（National Trauma Data Bank）的综述显示，手术肋骨骨折固定可降低死亡率（比值比0.13,95%CI 0.01-0.18）[ 29]。

系统评价纳入了3项小型试验[5-7]，比较了连枷胸手术稳定与非手术治疗的有效性[28]。对于随机接受手术的患者，肺炎和胸部畸形的发生率显著降低（肺炎相对危险度 [RR] 0.36,95% CI 0.15-0.85;胸部畸形 RR 0.13,95% CI 0.03-0.67），并且气管切开术的需求有减少的趋势（RR 0.38,95% CI 0.14-1.02）。治疗组之间的死亡率没有明显差异，但死亡人数很少（123人中有6人）。由于报告的差异，无法比较机械通气持续时间、重症监护病房 （ICU） 住院时间和住院时间。各项试验总结如下。

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一项试验将37例连枷胸患者随机分配至手术稳定组或非手术治疗组[5]。所有患者均需机械通气。与非手术组相比，手术治疗的患者使用呼吸机的天数明显减少，ICU住院时间更短，肺炎发病率更低，一个月时肺功能更好，六个月时重返工作岗位的患者比例更高。

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另一项试验将40例连枷胸患者随机分配至手术固定或外部粘性膏药组[6]。与保守治疗组相比，手术组需要机械通气的患者明显减少，ICU天数减少，住院时间更短，肺炎发病率更低。

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一项试验纳入了46例呼吸机依赖的连枷胸患者，结果显示，与保守治疗相比，随机分配至肋骨固定组的患者ICU住院时间显著缩短（324小时 vs 448小时）[7]。与保守治疗相比，肋骨固定术的拔管后无创通气持续时间显著缩短（3 小时 vs 50 小时）。在机械通气持续时间或长期结局（包括3个月的肺功能检查和6个月的生活质量评估）方面没有发现差异。

非连枷肋骨骨折 — 如果肋骨骨折因难治性疼痛或重度胸壁畸形导致实际或即将发生呼吸衰竭，则重度肋骨骨折但无连枷胸的患者可能受益[2]。其他患者亚组，如老年患者[30,31]，或未导致呼吸衰竭的严重移位、非连枷骨折患者，也可能受益于手术稳定，但针对这些组的任何推荐仅基于这些人群的有限数据[ 11]。（参见上文'适应证'）

一项多中心试验（美国、加拿大）将211例有连枷或非连枷胸部损伤模式的患者随机分配至肋骨骨折的手术或非手术治疗组[ 32]。在接受手术稳定的患者中，无呼吸机天数总体上有改善的趋势（23天 vs 21天;平均差2.1,95%CI -0.2至4.5）。在预先指定的亚组分析中，随机分组时插管并接受手术稳定肋骨骨折的患者的总住院时间显著改善（32日 vs 30日）。对于随机分组时未通气且接受手术稳定肋骨骨折的患者，住院时间相似。

另一项多中心研究重点关注，对于3个或3个或更多严重移位的非连枷型肋骨骨折患者，与标准治疗相比，早期手术稳定肋骨骨折是否有任何益处[11]。患者需要表现出一定程度的呼吸紊乱，但急性呼吸机依赖性呼吸衰竭的患者被排除在外。该研究将同意随机分组的患者（n = 23）与在知情讨论后选择首选治疗方案的患者（n = 87）的结果相结合。在指数住院期间，手术组的胸膜腔并发症发生率显著降低（0% vs 10.2%）。胸膜间隙并发症定义为入院后24小时以上需要干预（如胸腔引流管造口术、视频辅助胸腔镜手术）的血胸滞留或脓胸。手术组在1周、2周、4周和8周随访时的疼痛评分略有改善（平均差异1.5分），但两周后阿片类药物的使用相似。其他并发症发生率（如肺炎、再入院）和结局（如肺功能、住院时间）以及生活质量指标相似。这项研究的结果表明，肋骨骨折的早期手术稳定可能有助于减轻疼痛并可能减少活动肋骨的出血，如胸膜腔并发症所证明的那样。然而，手术稳定肋骨骨折的总体影响仍然存在争议，因为在麻醉需求或生活质量方面没有观察到差异。 因此，我们继续保留对疼痛管理难治性肋骨骨折的手术，这些骨折是即将发生或实际呼吸衰竭的原因。

对于在急性期接受手术肋骨骨折固定的患者，手术固定可能更具成本效益[2,3]。评估成本的研究报告称，尽管与手术相关的费用（包括植入物的成本）仍为接受手术的组节省了 2000 至 14,000 美元。在后来的一项研究中，对于65岁以下的连枷胸部损伤患者来说，这种手术是最具成本效益的，其次是65岁以上的连枷胸部损伤患者。手术成本效益最低的人群是65岁以上且无连枷胸损伤的患者[33]。较高的初始成本被更长的机械通气时间、ICU住院时间和住院时间的较高成本以及药物治疗组的肺炎发病率较高所抵消。

骨折不愈合/畸形愈合 — 也有一些小型病例系列研究评估了慢性肋骨骨折不愈合或畸形愈合患者的手术[ 34,35]。

肋骨愈合不良可导致两根独立肋骨之间形成骨折胼胝样，这是严重移位肋骨骨折非手术治疗的后遗症。真实发病率尚不清楚。畸形愈合可导致持续的疼痛，这是由于神经瘤的形成或肋骨本身的不适当配置。在这种情况下，手术干预需要取下骨化囊，用截骨器连接两根肋骨，并将肋骨重置为解剖学上正确的方向。然后使用如下所述的钛板/螺钉系统进行接骨。在这种情况下，尚无研究评估手术肋骨固定治疗缓解疼痛的疗效。

在评估手术固定治疗骨折肋骨不愈合或畸形愈合的研究中[ 34,35]，这些研究联合使用了自体骨移植物和钛/网片固定系统，发现固定后客观疼痛评分和生活质量指标有所改善。有动物研究表明，在骨折部位应用富含血小板的血浆可能会促进愈合，但这尚未在人类中得到验证，并且尚未确定使用适应症[ 36]。

 禁忌 — 
当重度肺挫伤是呼吸功能不全的原因时，手术稳定不起作用[10,25,37,38]。因此，如果患者有严重的潜在肺挫伤，由于氧交换受损而无法在合理的时间内脱机，则手术几乎没有益处。然而，轻至中度肺挫伤患者不会妨碍呼吸机的解放，其优势与无肺挫伤的患者相同，包括更短的重症监护病房住院时间和肋骨骨折固定机械通气时间[ 39]。（参见 “成人肺挫伤”）

大多数人认为，对于伴有颅脑损伤的患者，手术稳定肋骨也没有任何作用，无法脱离机械通气。

肋骨骨折稳定

早期手术的时机 — 早期手术而不是手术后，旨在减轻疼痛，避免或解决机械通气（即呼吸衰竭）的需求[ 10,11,19,23,40]。我们努力在受伤后 72 小时内进行手术，前 24 小时用于确保仅使用医疗措施无法充分控制患者的疼痛和肺功能。如果患者因其他原因需要胸外科手术（例如，视频辅助胸腔镜手术 [VATS] 治疗滞留血胸），则尽早进行肋骨固定是合理的。（参见上文'适应证'）

●A multicenter study that included 731 patients found that each additional day to operative intervention compared with operation on the day of admission following acute injury was associated with a 27 percent increased risk of need for intubation, a 26 percent increased risk of tracheostomy, and 31 percent increased risk of pneumonia. Given these results, it is not surprising that the study also found that early operation was associated with a decreased hospital and intensive care unit (ICU) length of stay [41].

●A review of nine studies evaluating the impact of timing to surgical stabilization of rib fractures found that surgical stabilization of rib fractures within 72 hours of injury was associated with significantly shorter ICU and hospital lengths of stay, duration of mechanical ventilation, incidence of pneumonia, and need for tracheostomy [42].

There are few data evaluating whether recent infection, particularly pneumonia or empyema, increases the risk of infection of the plates; thus, it seems prudent to delay surgical stabilization until all infection has been appropriately managed. Case studies have reported successful outcomes for surgical stabilization of rib fractures in patients with known sources of infection (eg, fungal colonization of the mediastinum [43], empyema [44]). Weighing the potential benefit of surgical stabilization of rib fractures against the possibility and ramifications of hardware infection is important for determining whether to pursue operative rib fracture stabilization in such patients. There are no studies upon which evidence-based recommendations can be made regarding type or duration of antibiotic therapy in these patients [45].

Imaging — The imaging study of choice to evaluate the characteristics of rib fractures is two-dimensional computed tomography (CT) of the chest. Three-dimensional CT scan may be more useful in terms of operative planning (image 1), such as determining the exact location of the fractures to help determine optimal patient positioning and the location of incisions [46]. (See 'Positioning and incisions' below.)

The curvature of the ribs must be accounted for when measuring the distance from a fixed landmark to the fracture site on the CT scan. It is easiest to measure distance from the edge of the sternum to the fracture site for anterior fractures and distance from the spinous process of the vertebra to the fracture site for posterior fractures. Using the scapula as a point of reference can be misleading as the position of the scapula changes with movement of the upper extremity. If the scapula is to be used, it is important to know how the arms were positioned when the CT scan of the chest was obtained and also to account for the position of the arms when the patient is positioned on the operating table.

Approach — All but one of the commercially available rib plating systems require open operative repair; however, the plating systems used today have a smaller profile and less need for dissection compared with those used in the past [10]. Nevertheless, VATS has been used to aid localization of fractures, evacuate retained hemothorax, and perform repair of some associated injuries (eg, diaphragm rupture) [47]. (See "Overview of minimally invasive thoracic surgery".)

Positioning and incisions — Most rib fractures are located in the mid- to posterior axillary line, thereby requiring the patient to be placed in a lateral decubitus position. Patients can be positioned supine if the fractures are anteriorly located (ie, anterior to the anterior axillary line). Posterior fractures (ie, posterior to the posterior axillary line) can be approached with the patient in the prone or lateral decubitus positions.

Because operative rib fixation does not necessitate a thoracotomy, there is no need to follow the course of the ribs. More often than not, the fracture line on multiple rib fractures is straight, thereby allowing excellent exposure using a vertical incision centered on the fracture line itself [40]. Conversely, flail segments that are in relative proximity may be best exposed using a horizontal incision with raised myocutaneous flaps. However, muscle-sparing techniques should be used to mitigate postoperative pain to the extent that is possible [19,48]. In instances where the fracture lines of a flail segment are far apart, two incisions may be less morbid than a single large incision with raised flaps to minimize postoperative pain, seroma formation, and the potential for subsequent infection. In addition, an intrathoracic approach may allow for a minimally invasive method to address such distant fractures.

Number of fractures to repair — The actual number of ribs to be repaired should be determined by weighing the length and number of incisions needed to expose the fracture, the degree of displacement of each fracture, the presence of a flail segment, and the location of the patient's pain with deep breathing. Based on chest physiology and the available evidence, fixation of all fractures is usually not necessary [49-51]. In cases where all fractures cannot be fixed, most authors recommend operative fixation of ribs 4 to 9 [52].

The majority of chest wall movement occurs in the region of ribs 4 to 9, and therefore operative fixation of these ribs results in the greatest improvement in overall respiratory function and relief of pain [19]. Ribs 1 and 2 demonstrate little movement with breathing and therefore rarely have to be surgically stabilized. Similarly, ribs 10 to 12 contribute little to chest wall stability and do not require operative repair. Furthermore, osteosynthesis of posterior fractures along ribs 1 to 3 may not be technically possible due to the location of the scapula. Most commercially available rib plating systems now have right angle tools that allow for fixation of fractures located behind the scapula, as may be the case with ribs 3 to 5.

One study has suggested that partial surgical stabilization of flail chest was acceptable [50]. However, a review of 3D chest CT three months after rib fixation found that fixing only one fracture per rib in a flail segment did not avoid deformity and displacement, particularly in posterior rib fractures [49]. It is important to note that this study used absorbable plates, which are no longer used or recommended by most surgeons. Only 50 percent of fractured ribs were surgically fixed in another study that found a significant reduction in respiratory failure and need for tracheostomy tube placement following rib plating [17].

Plating types and techniques — The standard approach to operative fixation of the ribs uses titanium plates placed from the outside of the chest wall and secured into place using locking screws. To minimize the risk of hardware failure, it is important to ensure that screws are locked to the plate, the plate is securely apposed to the rib surface, and there is minimal, if any, gap that the plate traverses. A plating system that uses reverse-contoured plates to reduce and fix the fracture from within the chest cavity using a VATS approach has been approved for use. In the past, absorbable plates were used for rib fracture fixation; however, the incidence of non- or partial healing was between 11 and 56 percent, and this type of plate should no longer used [49]. In a small trial, at any of the time intervals studied, significantly more patients assigned to absorbable plates had plate displacement compared with patients assigned to metal plates, for which there were no plate displacement events [53]

All dissection and manipulation of the rib should occur from the anterior and superior aspects to avoid injury to the neurovascular bundle, which is located inferior and slightly posterior to each rib. Rib fixation plates are contoured for the curvature of the rib (image 2). Because the cortex is very thin (measuring 0.5 to 1.5 mm), it cannot be used as a lever to reduce a fracture [54]. This is the main reason for the differing plating systems, but there are no comparative studies upon which to base a recommendation to use one system over the other. Some plating systems are based on bicortical fixation of the plate (eg, MatrixRIB, RibFix Blu, Advantage Rib), while another (RibLoc) uses a U-plate design that provides fixation to both sides of the cortex as well as to both the anterior and posterior aspects of the titanium plate (picture 1 and image 3). Another system (Level One) is based upon fixation to the anterior cortex only using screws that are placed at an angle. Anterior and intrathoracic plates should be positioned in the midportion of the rib. Anterior plates require a minimum of three points of fixation on each side of a fracture while intrathoracic plates require one point of fixation on each side of the fracture line. U-plates should be wrapped around the superior portion of the rib to minimize risk of injury to these neurovascular bundles and require two points of fixation. A system that also involves an anterior plate (StraTos) is unique in that it does not use screws to fix the plate in place but rather uses a series of wrap-around clips to secure the plate to both the superior and inferior aspects of the rib. This system is not commonly used in the United States.

Furthermore, some plating systems require drilling holes into the rib prior to insertion of screws, whereas others use self-tapping screws, thereby saving a step. All systems (except Level One; anterior fixation using 1.5-mm screw) require the surgeon to measure the thickness of the rib to determine the proper screw length. This is done using a caliper that is unique to each rib plating system. The soft tissues on the anterior surface of the rib and the parietal pleura on the undersurface of the rib must be dissected away to make this measurement. Use of screws that are too short can result in displacement of the plates due to poor fixation while use of screws that are too long can result in injury to the lung.

Regardless of the type of plating system that is used, it is vital that plates are secured to healthy bone at least 2 to 3 cm away from the fracture line. A longer landing zone is needed if the fracture involves an oblique angle or has a high degree of comminution. This can be problematic in instances where the fracture line is close to the spine. When this occurs, there are commercially available intramedullary splints that can be used to traverse a fracture and provide stability. A six-month follow-up study of patients who underwent fixation of a total of 35 rib fractures using intramedullary splints found complete healing in 94 percent of patients as assessed by 3D CT scanning [55]. However, computer modeling finds significant shear stress on splints placed across posterior fracture lines, thereby raising concern for structural fatigue and failure of the device [56]. There have also been reports of the splint piercing the rib cortex, which could be dangerous if it were to occur close to the spinal column. As a result, use of intramedullary splints has not gained popularity overall.

Need for thoracostomy tube — There are no absolute indications for placement of a thoracostomy tube, since operative rib fixation with any system other than Advantage Rib does not require violation of the pleural space. However, injuries that involve severely displaced rib fractures or reduction of displaced rib fractures intraoperatively often result in tears in the pleura. Furthermore, implantation of U-plates is associated with a higher likelihood of pleural violation than placement of anterior plates due to the need to dissect behind the rib and wrap the plate around the superior portion of the rib. In addition, using a caliper to measure rib thickness for plate/screw sizing can result in perforation of the parietal pleura. Given the lack of evidence-based guidelines regarding tube thoracostomy following operative rib fixation, some authors recommend routine placement of a thoracostomy tube whereas others use a selective approach in determining the need for chest tube placement. When placed, the tube should be placed well away from the plates to decrease the probability of infection and removed as soon as possible.

PERIOPERATIVE CARE — The general postoperative management of patients following rib fixation is centered on timely extubation, pain control, and thoracostomy tube management if such a tube was placed. Because the operation does not necessitate thoracotomy, patients usually do not experience the pulmonary inflammatory effects and fluid shifts associated with thoracic operations. Furthermore, fixation of the ribs usually results in immediate relief of pain, which, in turn, allows for extubation either on the day of or the day following operation. Medical measures for pain relief instituted prior to operation (eg, pharmacologic analgesia, regional analgesia) should be continued in the immediate perioperative period but can be weaned over time based on the patient's condition. (See "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)

There is no need for prolonged prophylactic perioperative antibiotics [57]. A first-generation cephalosporin antibiotic or its equivalent should be administered prior to the start of operation, and antibiotic prophylaxis should be discontinued within 24 hours of operation when there is no pre-existing infection or pneumonia [45]. There is insufficient evidence to guide antibiotic therapy in patients who have pneumonia or other infection and are undergoing surgical stabilization of rib fractures [45].

Management of a thoracostomy tube postoperatively follows the same principles as in general thoracic surgery. Namely, when the output from the chest tube is less than approximately 200 mL in 24 hours, there is no air leak noted in the collection system, and there is no evidence of a pneumothorax on chest radiograph, the tube should be removed. In instances where a chest tube has been inserted solely for pleural violation before or during rib fixation, the tube can usually be removed within 48 hours of operation. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)

ADJUNCTIVE TECHNIQUES

Iliac bone graft — An autograft from the iliac crest is the preferred graft for filling in significant defects that can result from a severely comminuted or avulsed fracture pattern. This option is the most effective for producing successful arthrodesis (or bone healing) across the fracture. However, it requires that bone be harvested from the iliac crest with the associated risk for wound complications and other morbidity.

Demineralized bone matrix — Demineralized bone matrix is a collagen allograft that serves as a scaffold to encourage ingrowth of osteoblasts from osteoprogenitor cells. It is a commercially prepared product that can be applied to fill in small gaps in cases with significant comminution. However, it has no mechanical integrity and is expensive.

SURGICAL COMPLICATIONS — Complications specifically related to the surgical technique of rib fracture fixation are overall uncommon [40].

Surgical site infection — Infection is the most clinically important complication because it may necessitate hardware removal and is associated with a significant rate of nonunion. The reported rate of hardware infection varies between 0 and 10 percent, but all reports are single center and consist of small numbers of patients [23,58]. In a report of five patients who developed a hardware infection following rib plating, three patients required removal of the plates. Treatment with antibiotics suppressed the infection, allowing the underlying fracture to heal. The mean time to plate removal was 174 days following operation. None had long-term sequelae of the infection. A later review of patients receiving rib fracture stabilization included nine patients who had systemic antibiotic therapy and vancomycin/gentamicin antibiotic beads placed for wound infection and eight patients who had antibiotic beads placed prophylactically due to high risk of developing a wound infection [59]. There was no benefit for prophylactic treatment. Seventy-eight percent of infected hardware was removed six months following implantation. However, the study also found 100 percent healing in the infected group, suggesting that antibiotic treatment without or perhaps without plate removal may be an option in these patients. The authors did not comment on what factors lead to removal of hardware. A separate report that included the bacterial isolate in patients who developed a surgical site infection reported that all infections were due to methicillin-sensitive Staphylococcus aureus [60].

Other hardware complications — Other complications include those specific to the hardware system. A systematic review of 24 observational studies evaluating hardware failure after surgical stabilization of rib fractures reported a 4 percent prevalence of hardware failures [61]. Hardware failure was less for repair of acute compared with chronic fractures. Sixty percent of patients required hardware removal, but only 10 percent of these required restabilization. Mechanisms of failure included mechanical failures (60 percent), infection (22 percent), persistent pain (16 percent), and nonunion (3 percent). The included studies did not allow for further evaluation of patient-specific risk factors for any one outcome. In one review that included over 1200 rib fracture stabilization procedures, hardware failure, which occurred in 38 (3 percent), was most common in the anterolateral/lateral region [62].

Among reported hardware failures [61-64], it is somewhat surprising that they are often related to screw/plate migration since all plating systems used locking screws that lock the screw to the plate itself. Such displacement suggests that the screw was not sufficiently tightened to lock it to the plate at the time of insertion or that the plate/screw construct pulled away from the bone due to poor overall fixation to the cortex.

Aside from screw displacement, there are isolated reports of plates fracturing over time [65,66]. There are no systematic reviews or large case series to describe risk factors for this, but all manufacturers recommend against using the plates to traverse a gap longer than 1 to 1.5 cm as repetitive movement of the plates will result in metal fatigue and fracture.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Thoracic trauma".)

SUMMARY AND RECOMMENDATIONS

●Rib fracture stabilization – Rib fractures are the consequence of significant forces impacting the chest wall. Surgical stabilization of rib fractures (ie, osteosynthesis) may be indicated in the following circumstances (see 'Indications' above):

•Indications

-Impending or actual respiratory failure due to painful, movable ribs refractory to pain management strategies. This includes patients with flail chest or with multiple, severely displaced non-flail pattern fractures.

-Significant chest wall deformity.

-Failure to wean from mechanical ventilation (not due to pulmonary contusion).

-Significantly displaced ribs found at thoracotomy being performed for other reasons (eg, open pneumothorax, pulmonary laceration, retained hemothorax, diaphragm hernia, vascular injury). This is referred to as "on-the-way-out fixation."

-Ongoing chest wall instability/deformity or pain due to nonunion or malunion of rib fractures.

•Contraindications – Rib fracture stabilization should not be performed in patients with severe pulmonary contusion as the cause for respiratory insufficiency or in patients with other concomitant injury (eg, head injury) that precludes separation from mechanical ventilation. (See 'Contraindications' above.)

●Timing of surgery – For patients with indications for rib fracture stabilization, we perform the procedure once it becomes apparent that the patient's pain cannot be adequately controlled (typically 24 to 48 hours), and we try to perform the procedure within 48 hours of injury. For patients who require a thoracic procedure for other reasons, it is reasonable to carry out rib fixation earlier. (See 'Timing of early surgery' above.)

●Efficacy of surgery – For patients with flail chest, early rib fracture stabilization helps to avoid the need for intubation and reduces the incidence of pneumonia and other pulmonary complications. (See 'Efficacy of rib stabilization' above.)

●Surgical techniques

•Plate systems and placement – Several types of plate fixation systems are available. Anterior or intrathoracic plates are positioned in the midportion of the rib, while U-plates are wrapped around the superior portion of the rib to minimize risk of injury to the neurovascular bundle. Two to three points of screw fixation are needed (depending on the type of plate) on each side of the fracture. Longer plates are needed if the fracture is oblique or comminuted to assure adequate fixation on either side of the fracture line. Fractures that are within 2 cm of the spine may not be amenable to operative fixation using standard plating systems. (See 'Plating types and techniques' above.)

•Number of ribs to stabilize – Fixation of all ribs is usually not necessary, but in general, ribs 4 to 9 should be repaired because these ribs provide most of the stability to the chest wall. The actual number is determined by weighing the length and number of incisions needed to expose the fractures, the degree of displacement of each fracture, the presence of a flail segment, and the location of the patient's pain with deep breathing. (See 'Number of fractures to repair' above.)

•Thoracostomy tube placement –A chest tube may be needed if the pleura is violated during rib fracture fixation. This is more likely to occur for reduction of severely displaced rib fractures. Implantation of U-plates (compared with anterior plates) may increase the likelihood due to the need to dissect behind the rib. When needed, the thoracostomy tube should be placed well away from the plates to decrease the likelihood of hardware infection. (See 'Rib fracture stabilization' above.)

●Perioperative care – Pain control measures are reinstituted postoperatively (acetaminophen, COX-2 inhibitors, regional anesthesia) and weaned as tolerated. Fracture fixation typically reduces pain to the extent that extubation can be accomplished either on the day of or the day following the surgery. (See 'Perioperative care' above and "Inpatient management of traumatic rib fractures and flail chest in adults", section on 'Pain control'.)

●Surgical complications – Other than pneumothorax, which can occur in the postoperative period if a chest tube was not initially placed, there are few complications specific to the surgical technique. Infection is a serious problem when it occurs and may require removal of the plates. A trial of antibiotic treatment without plate removal may be an option. To minimize the risk of hardware failure, it is important to ensure that screws are locked to the plate, the plate is securely apposed to the rib surface, and there is minimal, if any, gap that the plate traverses. (See 'Surgical complications' above.)