A contemporary algorithm to manage acute rib fractures in the intensive care unit

Operative stabilization of both flail and nonflail rib fractures has become very common, with a 76% increase in community hospitals over the past 10 years. This review will explain the rationale and evidence for improved outcomes with operative management of rib fractures, describe the contemporary strategy, and give an algorithm to follow for the management of critical patients in the intensive care unit (ICU) setting with rib fractures. A PubMed and Medline literature search was conducted with the search terms of rib fractures, rib stabilization, rib plating, chest trauma, chest wall, flail chest, nonflail, and ribs. The level of evidence supporting an intervention was evaluated based on the available prospective, randomized trials, nonrandomized trials, retrospective studies, meta-analyses, cohort studies, and reviews. Selected publications of interest on both rib plating and conservative treatment were retrieved and their bibliographies were also reviewed to identify relevant publications. Data from the relevant publications were reviewed, summarized, and the information synthesized. Rib plating has shown improved outcomes in both flail and nonflail rib fractures. Both prospective and retrospective data document a decreased duration of mechanical ventilation, decreased mortality, less pain, decreased incidence of pneumonia, decreased need for tracheostomy, decreased length of ICU and hospital stay, faster return to work, less overall cost, and better pulmonary function at 6 months. The proposed algorithm based on the presented data allows the physician to easily determine which patients are appropriate for rib plating.