Meta-analysis Results
# of paatients
# of sttudies
y 22 of 11 comparative
Results from a 2013 meta-analysis p studies,, including
g 753 patients,
p , suggest
gg
significant benefits to operative repair compared with nonoperative management of flail chest
injuries.
every 5 patients treated prevents one mortality (number needed to treat) 582 7
21421 NW Jacobson Road Suite 700 | Hillsboro, OR 97124 | 866.623.4137 | www.acuteinnovations.com | RBP7035C | Effective 9/2013
SUMMARY OF LITERATURE
Days
Days
Operative
p Group:
p
Pain score of 8-10 at 6.0 Patients
P ti t undergoing
d i operativeti repairi
6.3
time of inclusion reported lower pain levels after 15 days,
Pain 4.5 despite the fact that their pain at time of
Non-op Group:
Pain score of 5-7 at time
inclusion was greater than that of the
of inclusion nonoperative group.9
2.3
1.1
ACUTE Innovations
Indications for Operative Repair Timing for Operative Repair
Potential indications and inclusion criteria for repair as laid out Optimal timing for repair is not well studied and relies on
by Doctors Nirula, Diaz, Trunkey, and Mayberry.199 many patient-specific factors. While no consensus exists, it has
been suggested that patients treated earlier may have better
1. Flailchest
short-term outcomes.1, 5 The following table summarizes
Failure to wean from ventilator
Paradoxical movement visualized during weaning timing for repair reported in recent literature.
No significant brain injury
Author: Year (n=) RepairTiming (days)
2. Reductionofpainanddisability
Painful, moveable rib fractures Karev: 1997 (133) 1
Failure of narcotics or epidural pain catheter V
Voggenreiter:
it 1998 (42) 27
2-7
Minimal associated injuries (AIS < 2)
Tanaka: 2002 (37) 7
3. Chestwalldeformity/defect
Loss of thoracic volume Granetzny: 2005 (40) 1.5
Severely displaced, multiple fractures resulting in
Nirula: 2006 (60) 2.7
permanent deformity, pulmonary hernia, or are impaling
the lung Solberg: 2009 (16) 2
Patient expected to survive other injuries Althausen: 2011 (50) 2.3
4 Symptomatic
4. Symptomaticribfracturenonunion
rib fracture nonunion
Khandelwal: 2011 (118) 12
CT scan evidence of fracture nonunion
Patient reports persistent, symptomatic fracture Bhatnagar: 2012 (N/A) 5
movement Marasco: 2013 (46) 2
5. Thoracotomyforotherindications
The ACUTE Innovations RibLoc rib fracture plate is a unique, The U-shaped design of the RibLoc plate aids in placement and
U-shaped titanium implant specifically designed to provide ensures that screws are installed through the thickest portion of the
stable, less-invasive fixation for rib fractures and non-unions. rib while avoiding the neurovascular bundle.20
The RibLoc plating system: RibLoc
Width of
Maintains stability without relying Plate dissection
on screw threads engaging into
RibLoc
bone20 Rib midline screw line
li
PreoperativePlanning
Chest X-rays, 3D CT reconstruction: locate fractures, plan
incision, assess degree of chest wall deformity11
Patients are placed in the lateral decubitus position.5,5 11 A small, muscle-sparing
incision can be used to
IncisionApproaches repair multiple fractures.
Standard posterolateral thoracotomy, muscle sparing
thoracotomy.5, 25
Multiple small incisions (10-15 cm), with latissimus dorsi
muscle division in line with fibers, expose three rib levels per FracturestoAddress
incision.11 A spinal ring retractor may help manipulate and Highly displaced fractures and/or those that can be identified
hold retraction.
retraction pain 19
as causing pain.
The periosteum should be preserved for blood supply with It may be unnecessary to plate all fractures, but enough
the plate placed over the top.11 stability to support and restore the thoracic contour is
Subscapular fractures may be accessed with retraction5 and needed.11 Others advocate plating all fractures to maximize
by releasing the rhomboid fascia. pain control and thoracic volume.5
Where access is limited, counterincisions may be used for Subscapular rib fractures are often difficult to access and,
drilling and placing screws.5, 25 given the added muscular protection, may generally be left
Manual fracture reduction can be aided from inside the chest, unaddressed.11 In addition, fracture deformity of the upper
space 5
through the pleural space. loss.11
ribs can result in less lung volume loss