The Role of Surgical Stabilization of Rib Fractures in Polytrauma

Abstract

T he modern resurgence of surgical stabilization of rib fractures (SSRFs) began in the early 1980s in Portland, Oregon, with William Long. Long had completed a trauma and surgical critical care fellowship at the University of Maryland Shock Trauma Center in Baltimore, followed by cardiothoracic surgery training at the University of California, San Diego, without ever seeing or hearing of SSRF. But after encountering a handful of patients with severe chest wall injury at Legacy Emanuel Medical Center in Portland, Long concluded that surgical stabilization was in select cases warranted. In 1985, Long presented his experience with SSRF in a poster display at the American College of Surgeons Clinical Congress, receiving interest but mostly disapproval.George Haasler at the Medical College of Wisconsin reported dramatic improvement of respiratory function in a patient with multiple, severely displaced rib fractures after SSRF in 1990. 1 Haasler became a strong advocate for early operative stabilization along with his colleagues, Mario Gasparri and William Tisol. 2 In 1992, Donald Trunkey performed the first flail chest SSRF at Oregon Health & Science University (OHSU) in Portland after having observed SSRF earlier in San Francisco. 3 Trunkey, along with Richard Mullins, the Trauma Section Chief, encouraged John Mayberry, Trauma Fellow, to investigate SSRF as a research endeavor. Their goals were to investigate the technical challenges, the indications, and the long-term outcomes of SSRF. 4 The high rate of long-term disability of patients with flail chest treated nonoperatively reported by Landercasper and colleagues 5 greatly influenced their research. Concurrently, Long from across the Willamette River in Portland and Mouton et al 6 from Switzerland theorized that flail chest SSRF could provide not only acute benefits but also prevent longterm pain and disability.Several seminal investigative reports quickly followed. In 1995, Ahmed and Mohyuddin 7 from the United Arab Emirates repaired 26 patients with flail chest equivalents with intramedullary wires. Compared with contemporary controls, these patients required less ventilator time, less tracheostomies, less pneumonia, and had lower mortality. In 1996, Tanaka et al 8 from Japan presented a prospective randomized trial of "severe flail chest patients" treated with either early SSRF or "internal pneumatic stabilization" at the American Association for the Surgery of Trauma's annual meeting with the same positive results and a dramatic return to work advantage for the stabilized patients. In 1998, Voggenreiter et al 9 from Germany presented their similar series and outcomes. From their groupings of patients come the admonition that patients with pulmonary contusion may not benefit from SSRF, which Fokin et al 10 currently dispute.In the first decade of this century, SSRF was progressively accepted by the mainstream trauma surgeon community. The number of case series, cohort comparisons, and randomized trials of SSRF steadily increased, culminating in 2010 with the re...