Rib Fracture Repair: Indications, Technical Issues, and Future Directions Raminder Nirula Æ Jose J. Diaz Jr. Æ Donald D. Trunkey Æ John C. Mayberry Published online: 24 October 2008 Ó Socie ´te ´ Internationale de Chirurgie 2008 Abstract Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been estab- lished and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Poten- tial indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib’s relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effec- tive repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials. Introduction Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. In this review, the historical perspective, pertinent clinical presentations, potential indications, and the unique technical challenges of rib fracture repair are reviewed with the objective of 1) iden- tifying the patient population most likely to benefit from rib fracture repair, 2) delineating the most efficacious tech- niques of repair, and 3) quantifying the potential short and long-term individual benefits of repair. Historical perspective Open surgical treatment of rib fractures dates at least as far back as the first century of the Common Era (CE) when the Roman surgeon Soranus (CE 78–117) described the resection of depressed rib fractures for the relief of pleuritic pain [1]; 1500 years later, Ambroise Pare advised an initial attempt at closed reduction of displaced rib fractures by adhering strong cloth to the chest wall with pitch and flour and then ‘‘plucking with great violence’’ to elevate the fracture [2]. If that failed, he recommended open resection of the offending fragment(s). Closed reduction of displaced rib fractures was eventually abandoned as ineffective [3], but resection of rib fragments driven into the pleural space and lung was advocated during the first half of the Twen- tieth Century [4], was performed by American surgeons during World War II [5], and recently has been achieved thorascopically [6, 7]. Flail chest, described historically in the American lit- erature as ‘‘stoved-in’’ or ‘‘crushed’’ chest, was a very ominous finding during the preventilator era. Nonoperative attempts at stabilizing unilateral flail chest with external strapping, the placement of sandbags, or by positioning the patient laterally with the injured side down were potentially successful, and, for bilateral flail or sternal flail, external R. Nirula Surgery, Burns/Trauma/Critical Care Section, University of Utah, Saltlake City, UT, USA J. J. Diaz Jr. Surgery, Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Vanderbilt University, Nashville, TN, USA D. D. Trunkey Á J. C. Mayberry (&) Department of Surgery, Oregon Health & Science University, Portland, OR, USA e-mail: mayberrj@ohsu.edu 123 World J Surg (2009) 33:14–22 DOI 10.1007/s00268-008-9770-y