Rib plating of acute and sub-acute non-union rib fractures in an adult with cystic fibrosis: a case report

Abstract

BackgroundRib fractures associated with osteoporosis have been reported to occur ten times more frequently in adults with cystic fibrosis. Fractures cause chest pain, and interfere with cough and sputum clearance leading to worsened lung function and acute exacerbations which are the two main contributors to early mortality in cystic fibrosis. Usual treatment involves analgesics and time for healing; however considerable pain and disability result due to constant re-injury from chronic repetitive cough. Recently, surgical plating of rib fractures has become commonplace in treating acute, traumatic chest injuries. We describe here successful surgical plating in a White cystic fibrosis patient with multiple, non-traumatic rib fractures.Case presentationA-37-year old White male with cystic fibrosis was readmitted to Intermountain Medical Center for a pulmonary exacerbation. He had developed localized rib pain while coughing 2 months earlier, with worsening just prior to hospital admission in conjunction with a “pop” in the same location while bending over. A chest computerized tomography scan at admission demonstrated an acute 5th rib fracture and chronic non-united 6th and 7th right rib fractures. An epidural catheter was placed both for analgesia and to make secretion clearance possible in preparation for the surgery performed 2 days later. Under general anesthesia, he had open reduction and internal fixation of the right 5th, 6th and 7th rib fractures with a Synthes Matrix rib set. After several days of increased oxygen requirements, fever, fluid retention, and borderline vital signs, he stabilized. Numerical pain rating scores from his ribs were lower post-operatively and he was able to tolerate chest physical therapy and vigorous coughing.ConclusionsIn our case report, rib plating with bone grafting improved rib pain and allowed healing of the fractures and recovery, although the immediate post-op period required close attention and care. We believe repair may be of benefit in selected cystic fibrosis patients, such as our patient who had suffered multiple rib fractures that were healing poorly.

Outcomes After Operative Reconstruction of Symptomatic Rib Nonunions

“…Four case reports and 2 retrospective case series that have also used similar techniques have been described in the literature. 9,10,16–18,38 At final follow-up, all 4 case report patients achieved union, remained pain free, and returned to original activities. In addition to the previous report from our institution, 9 the only other published case series using plate fixation and bone grafting is a study by Hernandez et al 18 These authors performed a retrospective review on 6 patients who had 15 rib nonunions and underwent rib plate fixation with autologous cancellous tibial bone graft.…”

“…8,9,15 To treat the chronic symptoms that develop due to rib nonunion, multiple studies have described fixation with various types of plates, bone grafts, reconstruction with resection, and masquelet for ribs. 9, [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]38,39 Our study details outcomes after rib nonunion reconstruction surgery using a consistent technique of iliac crest bone grafting with plating under compression.…”

“…Reports describing the operative treatment of rib nonunions include a total of 102 patients. [8][9][10][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] These include mostly case reports, with only 6 clinical case series of limited numbers of patients, and authors often describe various mixed operative techniques in the same series. The purpose of this study was to detail the outcomes after rib nonunion reconstruction by a single surgeon using a consistent technique of autogenous graft and plating.…”

Vertical plate for flail chest repair

“…In another patient with osteoporosis secondary to cystic fibrosis, with multiple rib fractures, horizontal rib plating system and bone grafting were utilized. [3] Berthet et al…”