Analysis of bone healing in flail chest injury: Do we need to fix both fractures per rib? Silvana Marasco, FRACS, Susan Liew, FRACS, Elton Edwards, FRACS, Dinesh Varma, FRANZCR, and Robyn Summerhayes, Bsci, Melbourne, Victoria, Australia BACKGROUND: Surgical rib fixation (SRF) for severe rib fracture injuries is generating increasing interest in the medical literature. It is well documented that poorly healed fractured ribs can lead to chronic pain, disability, and deformity. An unanswered question in SRF for flail chest injury is whether it is sufficient to fix one fracture per rib, on successive ribs, thus converting a flail chest injury into simple fractured ribs, or whether both ends of the floating segment of the chest wall should be fixed. This study aimed to analyze SRF in flail chest injury, assessing 3-month outcomes for nonfixed fractured rib ends in the flail segment. METHODS: This is a retrospective review (2005Y2013) of 60 consecutive patients who underwent SRF for flail chest injury admitted to the Alfred Hospital, Melbourne, Australia. Imaging by three-dimensional computed tomography (3D CT) of the chest at admission was compared with follow-up 3D CT at 3 months after injury. The 3-month CT scans were assessed for degree of healing and presence of residual deformity at the fracture fixation site. Follow-up CT was performed in 52 of the 60 patients. RESULTS: At 3 months after surgery, 86.5% of the patients had at least partial healing with good alignment and adequate fracture stabilization. Hardware failure was noted in five patients (9.6%) and occurred with the absorbable prostheses only. Six patients who had preoperative overlapping or displacement showed no improvement in deformity despite fixing the lateral fractures. Callus formation and bony bridging between adjacent ribs was often noted in the rib fractures not fixed (28 of 52 patients, 54%) CONCLUSION: This retrospective review of 3D CT chest at 3 months after rib fixation indicates that a philosophy of fixing only one fracture per rib in a flail segment does not avoid deformity and displacement, particularly in posterior rib fractures. (J Trauma Acute Care Surg. 2014;77: 452Y458. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeuticstudy, level V; epidemiologic study, levelV. KEY WORDS: Rib fixation; flail chest; rib fracture. S urgical rib fixation (SRF) for severe rib fracture injuries is generating increasing interest in the medical literature. It is well documented that poorly healed fractured ribs can lead to chronic pain, disability, and deformity. 1,2 Three randomized controlled trials have now shown benefits of SRF in flail chest injury. 2Y4 One of the unanswered questions in SRF for flail chest injury is whether it is sufficient to fix one fracture per rib, on successive ribs, thus converting a flail chest injury into simple fractured ribs, or whether both ends of the floating segment of the chest wall should be fixed, completely stabi- lizing the flail segment. At the Alfred Hospital, Melbourne, Australia, our philosophy has been the former approach, fixing one fracture per rib in the flail segment. We have selectively targeted the anterolateral fractures. Posterior fractures are typically more difficult to access, given their position and muscle layers overlying the posterior ribs. Furthermore, we have identified an increased propensity to hardware failure in posterior rib fixation because of increased forces acting on the fractured ribs in this area. 5,6 However, we have noted progressive deformity occurring at these nonfixed posterior fractures and hypothesized that fixing one fracture per rib in a flail segment was insufficient to prevent rib displacement at the nonfixed fracture. Thus, we decided to critically analyze our own experience with SRF in flail chest injury to assess the outcomes at 3 months of the nonfixed fractured rib ends in the flail segment. PATIENTS AND METHODS A retrospective review of 60 consecutive patients who underwent SRF for flail chest injury admitted through our Level 1 trauma center at the Alfred Hospital, Melbourne, Australia, between 2005 and 2013 was performed. With insti- tutional ethics approval, the requirement for individual patient consent was waived. Diagnosis was made clinically with con- firmation on three-dimensional computed tomography (3D CT) imaging. Flail segment was defined as three or more consecutive ribs fractured in more than one place, producing a free floating segment of the chest wall. Admission CT chest was compared with follow-up CT at 3 months after injury to assess healing. The average result for all fixed fractures in each patient is noted, ORIGINAL ARTICLE J Trauma Acute Care Surg Volume 77, Number 3 452 Submitted: February 24, 2014, Revised: May 13, 2014, Accepted: May 13, 2014. From the CJOB Cardiothoracic Surgery Department (S.F.M., R.S.), Department of Orthopaedics (S.L., E.E.), and Department of Radiology (D.V.), The Alfred Hospital; and Departments of Surgery (S.F.M., D.V.), and Epidemiology and Preventive Medicine (E.E.) Monash University, Melbourne, Victoria, Australia. Address for reprints: Silvana Marasco, CJOB Cardiothoracic Department, The Alfred Hospital, Commercial Rd, Prahran 3181, Melbourne, Victoria, Australia; email: s.marasco@alfred.org.au. DOI: 10.1097/TA.0000000000000375 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.