By Dr Sanjay Sharma, Cardiothoracic Surgeon, Perth
Rib and chest wall fractures are common. Rib fracture is associated with 15% of all trauma admission, while 30% of all rib fractures develop chronic pain six months post-injury.
Factors associated with increased risk of chronic pain include pre-trauma smoking history, two or more rib fractures, oxygen saturation less than 95% on admission, osteoporosis and prolonged opiate requirement. Sternal fracture is present in 4-8% of all blunt trauma injuries and can be painful chronically.
Traditional management has been conservative based on analgesia and physiotherapy. However, increased patient demand for earlier return to work and sport, intolerance of long-term analgesics and chronic pain has led to a push for early fixation.
RELATED: Putting musculoskeletal under the x-ray
Technology has also improved, with a large array of rib and sternal specific plates now available. Rib plates are designed for each rib with their own individual angulation and spiral, which allows for stronger, more minimally invasive fixation often with earlier discharge, return to work and sport and decreased opioid use.
Case 1: chronic sternal fracture
A 51-year-old female teacher fell down some stairs five months ago. Ongoing opioid requirements left her unable to return to work or exercise. The patient had fibrous non-union of sternum on CT. Patient had plating.
Three weeks post fixation, the patient was on intermittent Panadol and able to return to work and exercise.
Case 2: acute sternal fracture
A 67-year-old female driver with an acute sternal fracture. She was discharged with an opioid prescription but was later readmitted with pain, productive sputum and sepsis.
The patient underwent a sternal fixation two days post IV antibiotics for pneumonia.
She returned to work three weeks post fixation with occasional Panadol.
Case 3: chronic rib fracture
An elite sportsman fractured their rib. They were unable to train and sleep due to pain with clicking. CXR showed fibrous non-union of the left 10th rib fracture.
The patient received a rib-specific plate and was able to return to professional sport in four weeks.
Case 4: acute rib fractures
A 54-year-old policeman was left injured after being attacked at work. They were only able to sleep in an upright position because of severe pain.
They had displaced fractures of right 5th,6th and 7th ribs. The ribs were plated and the patient returned to light duties three weeks post-op and full duties eight weeks post-plating.
Due to higher patient expectations and advanced plating systems, rib and sternal fixation greatly decreases pain and morbidity and accelerates return to work and sport in selected patients.
Patients are advised not to lift more than 5kg for at least three weeks post plating. Procedures are relatively low risk with a low rate of bleeding, infection and plate migration.
Key messages
- Rib fractures are common
- Historically management has been conservative
- Surgical fixation can speed recovery and improve outcomes
Author competing interests – nil
Want more news, clinicals, features and guest columns delivered straight to you? Subscribe for free to WA’s only independent magazine for medical practitioners.
Want to submit an article? Email editor@mforum.com.au