title: Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib?
abstract: 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 (2005-2013) 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%)
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Therapeutic study, level V; epidemiologic study, level V.
authors.affiliation: 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.
authors.forename: Silvana
authors.initials: S
authors.lastname: Marasco
authors.forename: Susan
authors.initials: S
authors.lastname: Liew
authors.forename: Elton
authors.initials: E
authors.lastname: Edwards
authors.forename: Dinesh
authors.initials: D
authors.lastname: Varma
authors.forename: Robyn
authors.initials: R
authors.lastname: Summerhayes
mesh_terms: D005260:Female; D005409:Flail Chest / Q000000981:diagnostic imaging / Q000601:surgery*; D005592:Fracture Fixation / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012253:Rib Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed