BEST EVIDENCE TOPIC

Interactive CardioVascular and Thoracic Surgery 14 (2012) 312315

doi:10.1093/icvts/ivr028 Advance Access publication 21 December 2011

Does surgical stabilization improve outcomes in patients with isolated

multiple distracted and painful non-ail rib fractures?
Elie Girsowicz, Pierre-Emmanuel Falcoz*, Nicola Santelmo and Gilbert Massard
Department of Thoracic Surgery, University Hospital, 1 place de lHpital, BP 426, 67091 Strasbourg Cedex, France
* Corresponding author. Tel: +33-3-69551134; fax: +33-3-69551895; e-mail: pierre-emmanuel.falcoz@wanadoo.fr (P.-E. Falcoz).
Received 28 March 2011; received in revised form 5 September 2011; accepted 12 September 2011

Abstract
A best evidence topic was constructed according to a structured protocol. The question addressed was whether surgical stabilization is
effective in improving the outcomes of patients with isolated multiple distracted and painful non-ail rib fractures. Of the 356 papers
found using a report search, nine presented the best evidence to answer the clinical question. The authors, journal, date and country of
publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that, on the whole, the
nine retrieved studies clearly support the use of surgical stabilization in the management of isolated multiple non-ail and painful rib
fractures for improving patient outcomes. The interest and benet was shown not only in terms of pain (McGill pain questionnaire) and
respiratory function (forced vital capacity, forced expiratory volume in 1 s and carbon monoxide diffusing capacity), but also in
improved quality of life (RAND 36-Item Health Survey) and reduced socio-professional disability. Indeed, most of the authors justied
surgical management based on the fact that the results of surgical stabilization showed improvement in short- and long-term patient
outcomes, with fast reduction in pain and disability, as well as lower average wait before recommencing normal activities. Hence, the
current evidence shows surgical stabilization to be safe and effective in alleviating post-operative pain and in improving patient
recovery, thus enhancing the outcome after isolated multiple rib fractures. However, given the little published evidence, prospective
trials are necessary to conrm these encouraging results.
Keywords: Chest wall Trauma Rib fractures Surgical stabilization Pain Disability

INTRODUCTION
A best evidence topic was constructed according to a structured
protocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION
In [ patients over 45 years old with isolated, movable and painful
rib fractures without true ail chest] is [surgical stabilization] superior to [non-operative management] in improving outcomes
[ pain, disability, respiratory function, number of days lost from
work]?

CLINICAL SCENARIO
A 52-year-old man involved in a motor vehicle accident is transferred to your department. He complains of shortness of breath
and spontaneous right chest wall pain. Clinical examination
reveals 92% of oxygen saturation in free air, a right chest wall
haematoma and aggravated pain on deep palpation over the
lateral aspect of the fth to seventh ribs. There is discernible
mobility of the fractured ribs but no true ail chest or other
extra-thoracic injury. Chest radiograph reveals obvious displaced

fractures of said ribs. As an active businessman, the patient asks

for the best available treatment in order to return to work as
soon as possible with no pain or disability. Since you have just
read two randomized studies [2, 3], indicating that surgical stabilization improved outcomes in patients with severe ail chest injuries, you wonder if surgical stabilization of multiple isolated
non-ail, painful and movable rib fractures is superior to nonoperative management in improving outcomes. You, therefore,
decide to look up the evidence in the literature.

SEARCH STRATEGY
Medline 1948June 2011, using the OVID interface, with results
limited to human subjects and English language articles:
(surgery.mp. or exp General Surgery/ OR (stabilization or xation
or repair).mp.) AND (rib fractures or exp Rib Fractures/). Finally,
a manual searchfrom which ail chest injury was excluded
was used to follow up the references from the retrieved studies.

SEARCH OUTCOME
A total of 356 abstracts were found, from which nine papers
were selected for providing the best evidence on the topic.
These papers are documented in Table 1.

The Author 2011. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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313

Author, date and

country;
study type
(level of evidence)

Patient group

Outcomes

Key results

Comments/weaknesses

Nirula and
Mayberry, 2010,
USA [4]

Identifying surgical indications

and quantifying the potential
short- and long-term individual
benefits of repair

Potential indications for

operative stabilization

(1) Reduction of pain and disability

(2) Chest wall deformity/defect
(3) Symptomatic rib fracture
non-union
(4) Thoracotomy for other
indication (on the way out)

Non-systematic review with

no further statistical analysis

Mayberry et al.,
2009, USA [5]

46 patients with severe chest

wall injury:

Retrospective study
(19962005)
(level 3)

Long-term pain assessed

by the MPQ
Long-term disability
assessed by RAND-36
survey

Mean long-term MPQ pain rating

index was 6.7 2.1
RAND-36 indices indicated
equivalent or better health status
compared with the general
population

Low response rate to the

survey, lack of control group,
small population size, variety
of surgical techniques and
indications used

Acute pain
Weaning from the
ventilator (if respiratory
failure)
Long-term disability
Chronic pain

Excellent pain relief

Fast weaning
No disability
No cases of non-union

Small population size

Mean hospital stay: 8 days

Excellent pain relief
Total socioprofessional
rehabilitation
FVC% at 3 months: 78
FEV1% at 3 months: 77

Unknown preoperative
respiratory function, unknown
tool for pain assessment and
small population size

Non-systematic
review
(level 5)

Richardson et al.,
2007, USA [6]

18 flail chest with failure to

wean from the ventilator
15 intractable pain associated
with severely displaced rib
fractures
5 acute chest wall deformity/
defect
3 acute pulmonary herniation
5 thoracotomy for other
indication

3844 patients with rib fractures

7 surgical stabilization

Retrospective study
(19962005)
(level 3)
Moreno De La
Santa Barajas
et al., 2010,
Spain [7]
Retrospective study
(200809)
(level 3)
Nirula et al., 2006,
USA [8]

22 patients with rib fractures:

-

Length of hospitalization
Long-term disability
13 flail chest
Socioprofessional
6 intractable pain or disability rehabilitation
3 chest wall deformity
Respiratory function

Case report
(level 4)
Cacchione et al.,
2000, USA [11]
Case report
(level 4)

Low levels of pain at rest (1.0/10)

and when coughing (1.3/10)
Chest wall stiffness: 60% of patients
Dyspnoea: 20% of patients
Socioprofessional rehabilitation
Complete overall satisfaction

Low response rate to the

survey andmean time between
surgery and the questionnaire
is 1.039 days (480 days)

Surgical management of 32
patients using inion orthopaedic
trauma plating system wraps

Pain level (visual pain

scale)
Chest stiffness and
movement
Shortness of breath
Employment status
Quality of life

Surgical management of
multiple rib fractures on a
49-year-old man involved in a
motorcycle accident presenting
with persistent pain and
shortness of breath

Complete pain relief achieved at

Pain control
Respiratory function (FVC, POD 14
Normalization of pulmonary
FEV1, DLCO)
function
Socioprofessional
Resumption of normal activity at
disability
POD 10

Non-union of multiple rib

fractures managed by operative
stabilization on a 46-year-old
patient involved in a vehicle
crash 2 years before and
presenting with chest wall
deformity, chronic pain and
shortness of breath

Pain control
Respiratory function
Disability

Retrospective study
(200408)
(level 3)
Gasparri et al.,
2003, USA [10]

Case-matched study, no
long-term follow-up and no
standardized protocol for pain
management

Length of:

Case control study

(19962000)
(level 3)
Campbell et al.,
2009, Australia
[9]

Length of Intensive care unit and

total hospital stay was similar
ICU and hospital stay Trend towards fewer total ventilator
Mechanical ventilation days
(P = 0.12) and fewer ventilator days
from the time of stabilization (P =
0.02)

30 patients undergoing surgical

stabilization were matched with
30 controls

Disclosed minimal pain

Improved shortness of breath
Socioprofessional rehabilitation

Continued

THORACIC
NON-ONCOLOGIC

Table 1: Overview of the studies

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314

Table 1: Continued
Author, date and
country;
study type
(level of evidence)

Patient group

Outcomes

Key results

Comments/weaknesses

Kerr-Valentic et al.,
2003, USA [12]

40 patients with 1 rib fracture

on a chest radiograph (mean of
2.7 1.6 fractures)
Group 1 (n = 12): 2 rib fractures
and no associated injury
Group 2 (n = 6): 2 rib fractures
and an associated extrathoracic
injury with AIS 2
Group 3 (n = 11): 3 rib fractures
without extrathoracic injury
Group 4 (n = 11): 3 rib fractures
and an associated extra thoracic
injury with AIS 3

Pain level assessed using

a visual pain scale at 1, 5,
30 and 120 days after
injury
Disability at 30 days
assessed using the SF-36
Health Status Survey
Total number of days lost
from work/usual activity
recorded at day 120

Mean rib fracture pain was 3.5 2.1

at 30 days and 1.0 1.4 at 120 days
The patients were more disabled at
30 days (P < 0.001) compared with
the chronically ill reference
population in all category except
emotional stability and general
health
Total mean days lost from work/
usual activity was 70 41

Need more studies for

definitive conclusions

Prospective study
(from 1 June 2001
to 31 October
2001)
(level 3)

AIS, abbreviated injury scale; DLCO, diffusion capacity; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; ICU, intensive care unit; MPQ,
McGill pain questionnaire; POD, post-operative day.

RESULTS
Nirula and Mayberry [4] performed a review of rib fracture
repair, summarizing clinical presentations and potential indications of stabilization. Excluding ail chest, they dened the
operative indications as painful, movable rib fractures, failure of
narcotics or epidural pain catheter, fracture movements exacerbating pain and minimal associated injuries (abbreviated injury
scale 2). They added chest wall deformity/defect, symptomatic
rib fracture non-union and thoracotomy on the way out as
other surgical indications.
Mayberry et al. [5] studied long-term morbidity, pain and
disability after repair of severe chest wall injury in 46 patients.
Indications included the ail chest with failure to wean from the
ventilator (n = 18), intractable pain associated with severely
displaced rib fractures (n = 15), acute chest wall defect/deformity
(n = 5), acute pulmonary hernia (n = 3) and thoracotomy for other
traumatic indications (n = 5). Pain was assessed by the McGill pain
questionnaire (MPQ) and disability using a RAND 36-Item Health
Survey. Mean long-term MPQ pain rating was 6.7 2.1. RAND-36
indices indicated equivalent or better health status with the
exception of role limitations due to physical problems, when
compared with the general population. They concluded that
repair of severe chest wall injuries in selected patients may
diminish their expected long-term pain and disability.
Richardson et al. [6] analysed 3844 patients with rib fractures from 1993 to 2005. They performed open reduction
and internal xation (ORIF) on seven patients with multiple
rib fractures. All of these patients had signicant pain relief
and both ventilator-dependent patients were rapidly weaned.
Long-term results indicated that there was no post-operative
infection, non-union or disability. They concluded that operative xation, while underused, is a useful modality for patients
with multiple rib fractures.

Moreno De La Santa Barajas et al. [7] analysed 22 patients

with rib fractures who underwent ORIF using the STRATOS
system (Strasbourg Thoracic Osteosyntheses System, MedXpert,
Germany). All patients recovered and returned to work after an
average of 2 months. They concluded that stabilization could be
recommended in patients with chest wall lesions to improve
outcomes.
Nirula et al. [8] performed a casecontrol study of patients
undergoing rib fracture stabilization. They concluded that surgical stabilization seemed to reduce ventilator requirements for
severe thoracic injuries.
Campbell et al. [9] analysed 32 patients who underwent ORIF
of fractured ribs. All patients were followed up with a questionnaire assessing pain, chest stiffness and movement, shortness of
breath, exercise tolerance, employment status, quality of life and
overall satisfaction with the operation. They concluded that a
surgical approach for the treatment of displaced rib fractures
may be appropriate.
Gasparri et al. [10] reported a case of surgical management of
multiple rib fractures, using plates, on a 49-year-old man exhibiting persistent pain and shortness of breath. The patient had
complete pain relief achieved at POD 14, and resumption of
normal activity at POD 10.
Cacchione et al. [11] reported a case of non-union multiple rib
fractures managed by operative stabilization on a 46-year-old
patient involved in a vehicle crash 2 years prior, presenting with
chest wall deformity and chronic pain. All pain-reducing therapy
failed. Post-operative results showed that the patient was discharged on the fth day with minimal pain, improved shortness
of breath and socio-professional rehabilitation.
Kerr-Valentic et al. [12] determined the magnitude and
duration of pain and disability in patients with rib fractures
treated by a conservative medical method. Forty injured
patients with 1 rib fracture on chest radiograph were asked

E. Girsowicz et al. / Interactive CardioVascular and Thoracic Surgery

CLINICAL BOTTOM LINE

In general, of the nine studies presented, all indicated that surgical stabilization in the management of isolated multiple non-ail
and painful rib fractures improved outcomes. Indeed, the interest and benet was shown not only in terms of pain and respiratory function but also in improved quality of life and reduced
socio-professional disability. Hence, the current evidence shows
surgical stabilization to be safe and effective in alleviating postoperative pain and improving patient recovery, thus enhancing
the outcome of the procedure. However, retrieved studies provided a low level of evidence (small studies with few numbers of
patients and short-term follow-up or case reports). Large prospective controlled trials are thus necessary to conrm these encouraging results.

ACKNOWLEDGEMENTS
The authors thank Ilana Adleson for her editorial assistance.

Conict of interest: none declared.

REFERENCES
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medicine in cardiothoracic surgery: best BETS. Interact CardioVasc
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[2] Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H et al.
Surgical stabilization or internal pneumatic stabilization? A prospective
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[3] Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical
versus conservative treatment of ail chest. Evaluation of the pulmonary
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[4] Nirula R, Mayberry JC. Rib fracture xation: controversies and technical
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[5] Mayberry JC, Kroeker AD, Ham LB, Mullins RJ, Trunkey DD. Long-term
morbidity, pain, and disability after repair of severe chest wall injuries.
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THORACIC
NON-ONCOLOGIC

to participate. Pain was assessed using a visual pain scale.

Mean rib fracture pain was 3.5 2.1 at day 30 and 1.0 1.4
at day 120. Disability was assessed by comparing the patients
to the chronically ill population reference of the RAND
Medical Outcome Study. The patients were more disabled at
day 30 (P < 0.001) in all categories except emotional stability
and general health. They concluded that rib fractures are a
signicant cause of pain and disability in patients with thoracic injury and that the development of new therapiesincluding surgeryto accelerate pain relief and healing would
substantially improve the outcomes.

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