Open Reduction Internal Fixation (ORIF) – Rib

Anesthesia Implications

Position: Supine, Left Lateral, Right Lateral
Time: 1-2 hours (average)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: Yes

The surgical position will depend on whether the fracture is anterior or posterior. Anterior fractures will typically have the supine position whereas posterior ribs will be lateral.

Pulmonary contusions are common with broken ribs so precautions and assessments should be taken.

Plenty of time to plan for emergence as there is a lot of suturing to do.

High pain levels postoperatively. Plan to pretreat and revisit.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.