TECHNICAL TRICK
Surgical Approaches for Rib Fracture Fixation
Benjamin C. Taylor, MD,* Bruce G. French, MD,* and T. Ty Fowler, MD†
Summary: Operative management of thoracic injuries is an increasingly accepted technique, with multiple reports of improved patient
outcomes as compared with nonoperative treatment. Despite the
evolving support of rib fracture fixation, descriptions of surgical
approaches and tactics remain limited. We present this information to
allow surgeons to begin or improve treatment of these injuries. In
addition, we present the initial treatment results of a series of 21 patients
treated with the approaches described within.
Key Words: rib fracture, flail chest, surgical approach, rib fixation
(J Orthop Trauma 2013;27:e168–e173)
INTRODUCTION
Among trauma patients, thoracic injury ranks behind only
head trauma as a cause of injury-related death in the United
States.1 Rib fractures carry significant clinical importance, as
mortality is directly correlated to the number of rib fractures
present,2 and the simple presence of flail chest alone has
a reported mortality rate of up to 33%.3 Conservative treatment
generally consists of ventilator-assisted respiratory support, tracheostomy, pulmonary toilet, narcotic pain control, and epidural
anesthesia4 but is associated with significant risks of pneumonia,
septicemia, prolonged hospitalization, pulmonary barotrauma,
and chronic pain and long-term pulmonary dysfunction.5–9
Evidence continues to mount regarding improved shortand medium-term outcomes after operative treatment of rib
fixation. Decreased ventilator times, intensive care unit stay
length, and length of hospitalization have all been reported in
several prospective and retrospective case series, with improvements in pulmonary function, chest wall geometry, pneumonia
incidence, and need for tracheostomy noted with operative
stabilization of flail chest.10–16 Despite the positive results noted
in the multiple series from different centers, operative fixation
of rib fractures and flail chest injuries remains an underutilized
procedure.17,18 This underutilization seems to be a result of most
surgeons being unfamiliar with either the literature surrounding
Accepted for publication December 19, 2012.
From the *Department of Orthopedic Surgery, Grant Medical Center, Columbus,
OH; †Department of Orthopaedic Surgery, Mount Carmel Medical Center,
Columbus, OH.
B.G. French is a consultant for Biomet and is on the speaker’s bureau for
Synthes. B.C. Taylor is on the editorial board of orthobullets.com. The
other author reports no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions this article on the journal’s Web site (www.jorthotrauma.com).
Reprints: Benjamin C. Taylor, MD, 285 East State St, Suite 500, Columbus,
OH 43215 (e-mail: drbentaylor@gmail.com).
Copyright © 2013 by Lippincott Williams & Wilkins
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flail chest fixation, chest wall anatomy, and surgical approaches
or fixation techniques/instrumentation.17,18
This article attempts to better delineate the surgical
approaches available to the operating surgeon, to provide a means
to minimize a surgeon’s possible unfamiliarity with thoracic
approaches. This will hopefully lead to improved patient outcomes through surgical treatment of flail chest when indicated.
APPROACHES OVERVIEW
As with any surgical approach, an understanding of the
regional anatomy is required for minimizing iatrogenic injury.
Surface topography is used to facilitate surgical incision
planning, with several reliable landmarks noted. The superior
angle of the scapula typically resides at T3, whereas the
inferior angle of the scapula is usually seen over the seventh
rib. Anteriorly, the inferior aspect of the pectoralis major
corresponds to the fifth rib, whereas the superior-most aspect
of the serratus anterior indicates the sixth rib.
Surgical planning involves evaluation of plain radiographs and traditional computed tomography (CT), but it seems
that 3-dimensional CT has some benefit in detecting rib
fractures.19 With 3-dimensional CT, the surgeon is able to
completely evaluate the bony thorax and can plan a more
focused, or direct, approach to the segments requiring fixation,
potentially obviating the need for a full thoracotomy approach.
STANDARD POSTEROLATERAL THORACOTOMY
The standard posterolateral thoracotomy is an approach
familiar to most cardiothoracic and general surgeons but is
not typically used by the orthopedic surgeon. This approach
allows access to posterior, posterolateral, and lateral rib
fractures, with access anteriorly with extension of the transverse or oblique limb of the incision.
In this approach, the patient is placed in the lateral
decubitus position, with the arm placed on an overhead
armboard for stability. If desired, the ipsilateral arm may be
prepped to allow intraoperative manipulation; forward flexion
of the shoulder on the overhead armboard can lead to scapular
protraction or lateralization, which can limit intraoperative
fracture visualization and manipulation. In addition, if the
surgical table can be broken, or extended, at the thoracic level,
this may serve to further improve visualization by allowing the
hemithorax to “open up” with the contralateral deviation.
The skin incision is begun at an equidistant point
between the spinous processes and the medial border of the
scapula and is continued caudally (Fig. 1A). The inferior extent
of this incision depends on the need for exposure of the lower
ribs; typically, this aspect of the incision is stopped at 1.5–2 cm
caudal to the inferior angle of the scapula. The incision is then
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Surgical Approaches for Rib Fracture Fixation
FIGURE 1. A, Patient in the lateral
decubitus position with anatomic
landmarks and incision line drawn
out. The patient’s head is to the
right. B, Scapular retractor being
used after incision of the latissimus
dorsi muscle (white arrow). The
rhomboid major muscle is intact at
the right edge of the retractor. C,
Blunt splitting of the serratus anterior muscle for fracture access is
easily done (black arrow). The overlying latissimus dorsi muscle has
been transected here for access
(white arrow). D, The addition of
percutaneous “stab” incisions are
frequently needed for placement of
more caudal or anterior fixation.
carried laterally in a curvilinear fashion, with the direction of
angulation and length of incision decided by the need for surgical access. This curvilinear extension generally mirrors the
course of the lower ribs and can be extended anteriorly to the
sternum if needed. Superficial dissection reveals the trapezius
muscle in the vertical limb of the incision, and this muscle can
generally be retracted medially and cranially without difficulty.
Deep to this and medial to the scapula is the rhomboid major,
which is also typically easily elevated off the posterior thorax.
Care must be taken to limit the surgical morbidity to this muscle, as lateral scapular winging will ensue with significant
devitalization or transection. The fibers of the latissimus dorsi
are then identified superficially and caudally as they extend
obliquely from their origin on the thoracic spinous processes
and thoracolumbar fascia toward the humerus. The latissimus is
lifted from the underlying muscles and transected as needed for
surgical access; the enveloping fascia is protected for later
repair (Fig. 1B). The serratus anterior is then seen and the
muscle is split in line with its fibers along the thorax to gain
access to displaced posterolateral rib fractures (Fig. 1C). Care
must be taken with muscle splitting in the midaxillary line, as
the long thoracic nerve is seen superficial to the muscle and can
be injured with errant dissection. A Davidson scapular retractor
is then used deep to the scapula and subscapularis muscle, and
visualization can also be aided by manipulation of the ipsilateral arm, as changes in shoulder position will lead to changes in
scapulothoracic positioning.
Further anterior and caudal dissection will lead to the
external oblique muscle, which is made of fibers that parallel
the lateral and anterolateral ribs, but run at nearly right angles to
the anterior ribs. This muscle is typically split in line with it’s
fibers, but full anterior exposure of a single rib may require
several small muscle splits because of the mismatch of the
! 2013 Lippincott Williams & Wilkins
course of the rib and that of the muscle fibers. The anterior
rib fractures may also be accessed via additional smaller or
percutaneous incisions to minimize morbidity (Fig. 1D).
Access to the posterior most ribs and the costovertebral
junction requires either transection of some of the posterior
trapezius muscle fibers or elevation of its origin off of the
thoracic spinous processes. Similarly, the rhomboid major
muscle requires splitting or transection for access to the
posterior aspects of ribs 2–5. The midline paraspinal musculature, which roughly parallels the spine, should be simply
elevated off the injured area and not transected in efforts
to minimize subsequent back pain and weakness.
MUSCLE SPARING THORACOTOMY
Although muscle-sparing thoracotomy for lung resection
has been shown in several studies to have no advantage as
compared with the traditional muscle-cutting approach,20–23 the
differences remain undetermined when used for rib fracture
fixation. It is possible and even likely that the rib spreading
needed for access in these cases introduces a confounding variable that prevents direct comparison to rib fixation cases. Pure
muscle transection for surgical access to rib fractures is not
without complication; alterations in shoulder function and
cosmesis can be seen (Fig. 2).
The muscle sparing thoracotomy approach uses the same
positioning and incision as described in the previous section, but
differs in the deep dissection (Fig. 3A). The incision is taken
down to the trapezius and latissimus muscle fascia, and the
fascia is elevated off the deeper muscle layers to allow visualization of the muscular intervals (see Video, Supplemental
Digital Content 1, http://links.lww.com/BOT/A83 which
demonstrates this surgical approach). The subcutaneous
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FIGURE 2. This clinical photograph shows significant left-sided
asymmetry and muscle wasting after long-term follow-up of
a muscle-transecting thoracic procedure.
elevation should be minimized, however, to minimize risk of
postoperative seroma formation.20,21 The triangle of
auscultation, which is bordered superiomedially by the
trapezius, inferiorly by the latissimus dorsi, and laterally by
the scapula, is immediately identified and allows for direct
access to the posterior rib cage (Fig. 3B). The surrounding
muscles are retracted with relative ease, allowing direct access
to the posterior aspects of ribs 4–8 (Fig. 3C). The subscapular
bursa can be bluntly entered if needed, and retractors placed
under the subscapularis and serratus anterior muscles to allow
visualization of the subscapular thorax. Access to more anterior
fractures is done with a blunt split of the latissimus dorsi fibers
(Fig. 3D); lateral and anterolateral fractures may also require
posterior retraction of the latissimus dorsi, as well as blunt
splitting of the underlying serratus anterior muscle (Fig. 3E).
More cephalad posterior and posterolateral fractures will require
blunt splitting of the trapezius and underlying rhomboid major
muscle in line with their respective fibers to allow access.
However, even in muscular individuals, generally, no splitting
of the trapezius or rhomboid muscles is needed unless surgical
fixation of the fourth rib or above is performed. The posterior
aspect of the ribs near their costovertebral articulation may be
approached with elevation and midline retraction of the
paraspinal musculature.
No deep muscular interval closure is needed for this
approach, but suturing the deep aspect of the full thickness
skin flaps down to the appropriate muscle will limit postoperative “dead space” and limit postoperative hematoma or
seroma formation. Alternatively, the full thickness flap may
be closed over a drain.
AXILLARY APPROACH
This approach is used for anterolateral rib fractures
requiring fixation. It affords a fairly large exposure of the
anterolateral thorax and direct visualization of the long thoracic
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nerve. Unfortunately, it does not allow access to the chondral
aspect of the ribs anteriorly without significant anterior
extension of the incision, although also limiting the surgical
visualization of posterolateral rib fractures, and therefore is
typically used only in situations that require a broad exposure
for reduction and fixation of multiple anterolateral rib fractures.
The patient is placed either in a true lateral decubitus
position or alternatively in a “sloppy” lateral position, with the
injured side elevated approximately 45 degrees. A vertical incision is made approximately 1.5 cm lateral to the lateral border
of the scapula, and this is carried inferiorly down to a level
approximately 1–2 ribs above the level of required fixation.
The incision is then carried anteriorly in a transverse fashion
as needed for appropriate exposure (Fig. 4A). The long thoracic
nerve is identified on the lateral aspect of the serratus anterior
and protected throughout the procedure to minimize postoperative scapular winging (Fig. 4B). The latissimus dorsi can be
seen posteriorly, and a retractor can be placed under the muscle
here to improve visualization, if necessary. The displaced rib
fractures in this region typically injure the serratus anterior, but
this muscle can be easily split in line with its fibers to gain
access to the rib fractures for reduction and fixation. Extension
anteriorly requires blunt splitting of the external oblique muscle
or extension into a pectoralis-lifting approach, which will be
described below.
INFRAMAMMARY/PECTORALIS-LIFTING
APPROACH
With this approach, the patient is placed in the supine
position or if access is needed anterolaterally, a small bump
can be placed under the ipsilateral hemithorax to increase
lateral access. The skin incision is made in the inframamillary
crease for improved cosmesis (Fig. 5A) and access to the
anterior ribs and costal cartilage can be obtained with lifting
the breast tissue and pectoralis major muscle anteriorly and
superiorly (Fig. 5B). The pectoralis minor muscle can be seen
at its origin near the costochondral junctions of the third to
fifth ribs and may require elevation for rib fixation. For more
caudal access, the external oblique muscle is seen caudal to
the pectoralis major, and this muscle can be safely split in line
with its fibers for access to several additional caudal ribs
without enlarging or adding a separate incision. If dissection
is needed laterally, the serratus anterior will be encountered
and can be split in line with its fibers to gain access to the ribs
if needed. This approach can be extended posterolaterally into
either the axillary or standard thoracotomy approach.
RESULTS
Twenty-one patients with flail chest between June 2010
and June 2011 were managed with the operative approaches and
internal fixation outlined in this manuscript. The patient
population averaged 51.5 (range, 18–90) years and was predominately male (66.7%). Motor vehicle collisions (13) and falls (7)
were the prime mechanisms of injury. These patients fractured
a mean of 6.0 (range, 3–10) ribs, with a mean of 3.4 (range, 0–7)
consecutive segmental fractures. In addition, 33.3% of the
patients sustained a mean of 3.9 (range, 0–8) contralateral rib
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Surgical Approaches for Rib Fracture Fixation
FIGURE 3. A, The patient in the lateral decubitus position with the scapular borders drawn out, the spinous processes marked
with dots, and the proposed incision line drawn as well. The patient’s head is to the left. B, The superficial dissection reveals the
triangle of auscultation (white arrowhead), bordered by the latissimus dorsi (black arrow), trapezius (white arrow), and scapula
(black arrowhead). C, The latissimus dorsi (black arrow) is easily lifted off the thorax for access to the underlying thorax. D, The
latissimus dorsi can also be split in line with its fibers for creation of different surgical windows, as shown here. E, The serratus
anterior muscle (white arrows) can also be bluntly split in line with its fibers for anterior access. The latissimus dorsi (black arrows)
is shown posterior to the serratus anterior; the patient’s head is to the right.
fractures. These fractures were treated at a mean of 4.6 (range,
2–11) days after admission.
The initial procedures were performed in conjunction
with the general trauma surgeons, but as surgeon comfort with
the technique improved, the general surgeon involvement
dwindled to chest tube placement and management only. Six
pectoralis-lifting approaches, 2 axillary approaches, 8 standard
thoracotomy approaches, and 5 muscle-sparing thoracotomy
approaches were used as described above. Estimated blood loss
was an average of 98.1 (range, 25–400) mL, and operative time
averaged 160.2 (range, 92–236) minutes. A mean of 4.7
(range, 2–7) ribs were plated per patient, requiring a mean of
5.7 (range, 2–12) plates. All fractures were stabilized with the
MatrixRIB plating system (Synthes, West Chester, PA). All
FIGURE 4. A, Superficial dissection
of the axillary approach shows the
latissimus dorsi (black arrow) in the
posterior aspect of the approach,
with the long thoracic nerve and
lateral thoracic artery (white arrow)
overlying the serratus anterior muscle. B, The serratus anterior muscle
may be split in line with its fibers to
allow access to the underlying rib
fractures. The overlying long thoracic nerve should be identified and
protected to minimize risk of iatrogenic denervation.
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FIGURE 5. A, The incision for the
pectoralis-lifting approach should
be located in the inframammary
crease to improve scar cosmesis
and minimize risk of injury to breast
tissue. B, The pectoralis musculature
(white arrow) is elevated off the thorax and retracted in a cephalad
direction to allow for access to the
more cephalad rib fractures.
patients had placement of a chest tube to the ipsilateral thorax
intraoperatively; an indwelling On-Q pain catheter (I-Flow,
Lake Forest, CA) was also placed in a submuscular fashion
to provide perioperative pain control. The On-Q pump was
removed at 72 hours postoperatively, although the chest tube
was followed by the general surgeons and removed when outputs were minimal on gravity suction. Immediate shoulder and
thoracic range of motion was encouraged and facilitated postoperatively by physical therapists.
Two patients (9.5%) required a tracheostomy for prolonged ventilator dependence, but no other perioperative
complications were noted in this series. This patient cohort
required a mean of 14.6 (range, 4–47) days in the hospital,
postoperatively, with a mean intensive care unit stay of 5.2
(range, 0–13) days. Ventilator dependence was a mean of 4.8
(range, 0–26) days, with chest tube removal at a mean of 7.4
(range 0–28) days. Two patients were lost to follow-up before
12 months. All of the fractures went onto clinical and radiographic union at a mean of 3.4 (range 2–5) months. No soft
tissue healing complications or infections were noted, and no
complaints of intercostal neuralgia were seen.
DISCUSSION
Rib fracture fixation is increasingly used for treatment of
flail chest, with increasing amounts of evidence published
pointing to its efficacy in improving patient outcomes.3,4,10–17
Despite the emerging data, the descriptions of surgical
approaches are largely poorly characterized in the published studies, and little attention is paid to the methods of exposure during
these surgical cases. It is possible, and even likely, that the exposure plays a significant role in the rib fracture patient’s recovery
and eventual outcome, but this currently remains unknown.
No published evidence exists as to the functional
outcomes of patients after differing approaches for rib fracture
fixation, but there has been comparison of traditional and
muscle-sparing techniques for thoracic and spinal surgeries. For
posterolateral thoracotomies performed for lung resections and
lobectomies, several randomized prospective studies have
found that postoperative pain rates were similar, as were
pulmonary function levels.20–23 The muscle-sparing technique
was reported to have improved initial muscle strength in several
of these studies, but no differences were seen between the
patient groups in any of the studies by 1 month, postoperatively. The lack of difference between these 2 groups may be
indirect evidence that other factors play a larger role in this
patient population, as the ribs are forcibly spread apart and
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intercostal nerves may be damaged in the process. In addition,
emerging evidence exists showing that new techniques in closing the intercostal space (avoiding intercostal nerve compression) are able to significantly decrease postthoracotomy pain as
compared with traditional techniques.24 In the spinal surgery
literature, note is also made of the considerable complication
rate after posterolateral thoracotomy. Lubelski et al25 reviewed
the spinal literature regarding approaches to the thoracic spine,
and noted a cumulative complication rate of 39% for the traditional thoracotomy approach, which was significantly higher
than any of the other approaches to the thoracic spine. However,
when further examined, muscle-sparing thoracotomy for access
to the thoracic spine seems to have improved functional outcomes at final follow-up but requires more operative time.25–27 It
remains unseen if patients undergoing rib fracture fixation
would benefit from muscle-sparing techniques, and it is hoped
that worthwhile data on this will be collected, analyzed, and
published in the near future.
In our series, we were able to safely provide improved
pulmonary function, pain relief, and minimal complications
via chest wall fixation using the approaches outlined here. We
believe that rib fracture fixation is an emerging concept and
one that will benefit patients greatly when carried out
appropriately. Our descriptions of surgical approaches will
hopefully allow further development of the techniques and
even approaches themselves, leading to optimal patient
outcomes.
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