Technique for Repair of Fractures and Separations Involving the Cartilaginous Portions of the Anterior Chest Wall

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1 [ Selected Reports ] Technique for Repair of Fractures and Separations Involving the Cartilaginous Portions of the Anterior Chest Wall Stephanie L. Bonne, MD ; Isaiah R. Turnbull, MD, PhD ; and Robert E. Southard, MD Internal fixation of the ribs has been shown in numerous studies to decrease complications following traumatic rib fractures. Anterior injuries to the chest wall causing cartilaginous fractures, although rare, can cause significant disability and can lead to a variety of complications and, therefore, pose a unique clinical problem. Here, we report the surgical technique used for four patients with internal fixation of injuries to the cartilaginous portions of the chest wall treated at our center. All patients had excellent clinical outcomes and reported improvement in symptoms, with no associated complications. Patients who have injuries to the anterior portions of the chest wall should be considered for internal fixation of the chest wall when the injuries are severe and can lead to clinical disability. CHEST 2015; 147 ( 6 ): e199 - e204 Management of severe rib fractures and flail chest with internal fixation has been shown to decrease ICU and hospital stay, decrease resource use, speed patients return to work, and improve pulmonary status following injury. 1,2 Multiple studies have shown this procedure to be efficacious for a variety of rib fracture patterns; however, most of the previous work in this area has focused on stabilization of the lateral and posterior thoracic cage. 3-6 Thus far, little data are available regarding the technique, indications, and success of operative fixation of anterior rib fractures and cartilaginous injuries of the chest wall. Here, we describe a novel operative approach to managing fractures and separations of the cartilaginous portion of the ribs in a series of four patients with blunt chest trauma. Little data and few descriptions exist in the literature to support the fixation of the cartilaginous portions of the chest wall. In these patients, we found that operative fixation of the anterior thoracic cage resulted in improved convalescence and clinical results, analogous to posterior rib plating. Case Reports Four patients were treated between November 2010 and November Case 1 The first was a 74-year-old man who fell from a 5-m -high roof. He had complete costochondral separation of ribs 2 through 6. Although he was not intubated on arrival, Manuscript received March 27, 2014 ; revision accepted November 3, AFFILIATIONS: From the Department of Surgery, Section of Acute and Critical Care Surgery, Washington University in St. Louis, St. Louis, MO. CORRESPONDENCE TO: Stephanie Bonne, MD, Department of Surgery, Section of Acute and Critical Care Surgery, Washington University in St. Louis, 660 S Euclid Ave, Box 8109, St. Louis, MO 63122; bonnes@wudosis.wustl.edu 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: /chest journal.publications.chestnet.org e199

2 he was admitted to the surgical ICU for aggressive pulmonary toilet and monitoring. An epidural catheter was placed, but this was inadequate to manage his pain, and he was offered surgical fixation. Following his surgery, he was hospitalized for management of his thoracic spine fractures and was eventually discharged on postoperative day 7. In follow-up after several weeks, he had no pain and had returned to work. Case 2 The second case was that of a 57-year-old man who was involved in a motor vehicle collision. He presented to the ED 3 days after his injury, after attempting to manage his pain at home. In the ED, he was in severe respiratory distress secondary to inadequate pain control and poor respiratory mechanics and was emergently intubated for respiratory failure. On imaging studies, his injuries included a comminuted distal sternal fracture; left displaced rib fractures measuring 9 mm on rib 2, 8 mm on rib 3 with foreshortening, and 6 mm on rib 4 with 7 mm foreshortening; angulated fracture of rib 5; and a 10-mm displaced fracture of rib 6. He was treated for respiratory failure, initially requiring 70% F io 2, and subsequently positive end-expiratory pressure of 7.5 with 60% F io 2. He was extubated on hospital day 3 but required noninvasive ventilation following his extubation. He also had an epidural catheter in place at that time but had inadequate pain control. Surgical fixation was then offered. In the operating room, he was found to have chondrosternal dislocations at the fractures, which were reduced and plated. He was extubated on postoperative day 1 and discharged on day 4. He was subsequently lost to clinical follow-up but was contacted by phone and reported no pain and return to his baseline function status. Case 3 The third patient was a 59-year-old man who fell 5 to 7 m, landing on his right side. He presented with chest pain with respiratory motion. A CT scan revealed no rib fractures; however, he had anterior fractures of the right fourth through seventh chondral cartilages and a nondisplaced sternal fracture. An epidural catheter was placed but was inadequate to manage his pain, and he had respiratory decompensation requiring intermittent noninvasive ventilation and increasing supplemental oxygen. He was offered surgical fixation, to which he agreed. His procedure was uncomplicated, and he was extubated on postoperative day 1 and discharged on day 4. He returned to his baseline functional status (Fig 1 ). Case 4 The fourth case was a 57-year-old man who presented after being pinned between a crane and a wall. He had fractures of the right anterior costochondral cartilage of ribs 1 to 5. These fractures were posteriorly displaced with respect to the sternum. He also had minimally displaced posterior left ribs 1 to 7 fractures, nondisplaced right ribs 3 to 4 fractures, and a displaced right clavicle fracture. He was initially treated nonoperatively and did not require mechanical ventilation during his index hospitalization. He did, however, develop an empyema, which precluded insertion of metal plates at the time of thoracotomy for this empyema. After 1 year, he had persistent pain, particularly with coughing, sneezing, or sudden movement. This pain required chronic narcotic pain medication and precluded his ability to return to work as a construction worker. He also complained of visible deformities on the chest wall, which were palpable and clearly unstable with chest wall motion on examination. CT scanning demonstrated chronic hypertrophic nonunion of the costosternal joints on the right. His presenting complaint was deformity rather than pain, and epidural catheter was not indicated at this time. He was then offered, and underwent, an uncomplicated surgical fixation procedure ( Fig 2 ). He did not require mechanical ventilation in the perioperative period. In follow-up, the patient reported improvement in his respiratory symptoms and resolution of his chest pain and deformity. He had not yet returned to work at the time of his last visit and was then lost to fol low-up. Discussion When providing internal fixation of the anterior chest wall, there are a variety of fracture patterns that may involve the bones or costal cartilage. Despite the variety of injuries, the surgical technique is the same for each patient in our series. First, the nature of the fracture is established with CT scanning for operative planning. Sagittal reconstructions or three-dimensional views can be very helpful. The patient is placed in the supine position with arms extended on a rotating arm board, and the chest is prepared from the lower neck to the umbilicus between the midaxillary lines with an Ioban antimicrobial drape (3M.) A curvilinear incision is made from the midline at the sternal notch inferiorly to the level of the inferior border of the pectoralis major, and a short (2- to 3-cm) cutaneous flap is raised above the pectoral fascia bilaterally with electrocautery. The pectoralis fascia is divided in the midline. The fascial incision is likewise curved toward the inferior border of e200 Selected Reports [ 147#6 CHEST JUNE 2015 ]

3 Figure 1 Imaging for patient 3. High-definition CT scan threedimensional reconstruction demonstrating anterior rib fractures. A, Before operative fixation. B, After operative fixation. the pectoralis muscle. Along the inferior portion of the pectoralis, 2 cm of residual fascia should remain to allow for closure. The muscular attachment of the pectoralis major to the anterior chest wall is then divided. Perforating vascular bundles are commonly present at the borders of the pectoralis arising from the internal mammary vessels. These vessels are ligated, because they are difficult to control if divided inadvertently. The pectoralis is then easily retracted, allowing access to the sternum, the cartilaginous portion of the rib, and the costochondral junctions ( Fig 3 ). Fractures are reduced with locking forceps and are internally fixed with low-profile titanium plates and locking screws (MatrixRib system, Synthes.) Preformed or universal plates are fitted to conform to the rib, cartilage, and sternum. The depth of each rib is measured using calipers, and screw length is chosen to ensure adequate bicortical purchase on the rib without extension into the pleural space. Typical screw length is 8 to 12 mm. A drill guard is used to drill pilot holes, protecting the pleura and mediastinum. The locking screw is then placed through the plate into the hole. The screw is usually palpable on the deep surface of the rib without projecting more than 1 mm beyond the posterior surface. Mechanical testing of the product shows optimal fixation with three screws on each side of the fracture; therefore, a minimum of a total of six screws is used. Similarly, sternal thickness is measured with calipers to select screw length. These screws are typically longer than the costal counterpart (12-16 mm). Pilot holes are drilled, and the plates are secured to the sternum with locking screws of appropriate length. Additional screws may be placed into the cartilage to reduce the cartilage and facilitate union ( Fig 3 ). Figure 2 Imaging for patient 4. High-definition CT scan threedimensional reconstruction demonstrating anterior rib fractures. A, Before operative fixation. B, After operative fixation. journal.publications.chestnet.org e201

4 Figure 3 Technique for anterior rib plating. A, A curvilinear incision is made from the sternal notch over the lower border of the pectoralis major. B, The pectoralis fascia is incised in the midline, and the pectoralis is reflected laterally. C, Plates are placed across the costochondral cartilage from the rib to the lateral aspect of the sternum. The pleural space is entered in a routine manner, and a tube thoracostomy is placed at the conclusion of the procedure. Closed suction drains are placed under the mobilized muscle flap. The pectoral fascia is reapproximated in the midline using heavy monofilament suture (eg, 0-polydiaxanone). To facilitate closure, the arms are moved to the patient s side. The skin is closed in layers. All patients were extubated in the operating room or on the first postoperative day, and no patient required reintubation at any time. No patient had any complications related to this procedure in the immediate postoperative period. Hospital stay is generally, 3 days postoperatively, unless it is increased for treatment of concomitant injuries. For example, one patient stayed for 9 days to complete treatments unrelated to his rib plating. All patients reported improved pain and reported satisfaction with their operation and results when contacted in May of All patients completed a medical authorization form for the use and publication of their protected health information. Internal fixation of the ribs was first introduced to manage posterolateral rib fractures and flail chest. Initially, it was described through a traditional lateral thoracotomy; however, the technique has evolved over time. Today, a variety of incisions and muscle-sparing techniques are used to gain exposure for operative fixation. 7,8 Additionally, a variety of techniques and commercial products is available to perform the fixation of the ribs. 9 Because familiarity with internal fixation of the chest wall has increased, this procedure is being performed for a wider variety of injuries and through less morbid incisions. As interest in chest wall fixation has increased, injuries of the cartilaginous portion of the chest wall have been described. These injuries are uncommon but can significantly impair pulmonary function. Injuries include fractures of the cartilage and separation of the cartilage from the rib (costochondral separation) or the sternum (chondrosternal separation.) Costochondral separation, especially when bilateral, has been associated with an increased risk of morbidity and an increased need for mechanical ventilation. 10 These injuries may also be associated with lung herniation 11 and underlying solid organ injury. 12 Such fractures can present a diagnostic challenge because they are not readily apparent on plain chest radiography and may require advanced CT scanning to diagnose and characterize the injury. 13 Anterior thoracic cage injuries are treated surgically, but techniques for internal fixation of ribs are difficult to apply to cartilaginous fractures. For example, Judet struts may be used to fixate costal cartilage but cannot be placed onto the sternum for chondrosternal separations. 14,15 Likewise, intramedullary splints cannot be applied to the sternum or across costochondral joints. 16 e202 Selected Reports [ 147#6 CHEST JUNE 2015 ]

5 We have adapted titanium plating techniques to fixate cartilaginous fractures and costochondral and chondrosternal separations. 17 Like the posterior approach, the anterior approach is muscle sparing and adaptable to fractures at various levels. Patient positioning facilitates manipulation of the chest wall. Surgeon knowledge of the procedure, familiarity with the equipment, and understanding of the relevant anatomy are essential. This includes a familiarity with the perforating vessels along the medial aspect of the pectoralis to avoid significant bleeding. Once adequate exposure is obtained, standard preformed plates used for plating elsewhere are easily adapted to the anterior chest wall. Patient selection for this procedure requires careful clinical consideration and is likely a strong determining factor in the success of the operation. We have used selection criteria similar to those used for patients with posterior rib fractures. Literature on posterior rib plating suggests that patients with flail segments see the greatest benefit to rib plating and that patients who are unable to wean from mechanical ventilation despite optimal pain management, including epidural catheter placement, or those who have significant deformity of the chest wall may benefit from such a procedure. 3 As with the indications for posterior plating, we feel that inadequate pain control and inability to wean from ventilation alone can be adapted as indications for anterior chest wall injuries. Three of the patients had inadequate pain control with epidural catheter placement and the fourth patient had a persistent deformity of the chest wall. For patients with anterior chest wall injuries without significant deformity or impairment of chest wall mechanics, the risks and recovery time of operation should be considered carefully before proceeding. As with any surgical procedure, inherent risks exist, which include wound infection and hardware failure. We were unable to assess for failure in this small case series, but feel that the risk-benefit ratio for this procedure is similar to that of traditional plating of posterior ribs. Infection risk is likely similar. Further studies with this specific injury pattern are indicated, to evaluate both the morbidity and the efficacy of anterior rib plating, but will be challenging because of the rarity of injury in this location. This series suggests that fixation of anterior chest wall injuries has similar clinical benefit to posterior rib fixation regarding ventilator days, ICU and hospital length of stay, and subjective pain control. This approach has been successful both acutely and after interval failure of nonoperative management. Patient recovery was similar and postoperative care and management were not significantly different from those of patients who have undergone posterior rib fixation. Patients were satisfied with their results long term and had no life-threatening complications. Conclusions Patients presenting with anterior fractures causing costochondral dislocation or costosternal dislocation have benefitted from chest wall fixation. Fixation of these injuries can be performed safely and efficaciously using currently available commercial products for chest wall fixation. Patients who have anterior chest wall injuries who meet indications should be considered for operative fixation through the approach described. Careful selection of patients for operative intervention remains important, and as with plating of the posterior ribs, the patients most likely to benefit are those with flail segments, those who have inadequate pain control despite optimal pain management, those who are unable to wean from mechanical ventilation, and those who are likely to have significant deformity that will impair chest wall mechanics. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Southard has been a speaker on behalf of DePuy Synthes. Drs Bonne and Turnbull have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. References 1. Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. 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