Management of Post-Rib Plating Complications with Hardware Malposition

Primary Issue: Hardware Malposition

The American College of Radiology recommends CT with contrast to evaluate the exact position of displaced hardware relative to neurovascular structures, status of underlying rib healing, characteristics of pleural effusion, and presence of any chest wall abscess or fluid collection 5, 7
The presence of hardware malposition can cause ongoing chest wall irritation and pain from hardware impingement on surrounding structures, with a strength of evidence based on case reports and clinical guidelines 2
The European Respiratory Society suggests that pleural irritation leading to persistent or recurrent effusion may be caused by hardware malposition, although the exact mechanism is not fully understood 4
The American Thoracic Society recommends that failure of fracture stabilization be addressed through surgical reassessment and likely revision, as it defeats the original purpose of the surgery 1

The American Journal of Respiratory and Critical Care Medicine recommends obtaining thoracentesis if the effusion is large enough to determine if it is exudative, transudative, hemorrhagic, or infected, with a strength of evidence based on clinical trials and guidelines 3, 4
The British Thoracic Society suggests that if the effusion is too small for safe thoracentesis, serial imaging is appropriate to monitor for progression, with a strength of evidence based on clinical experience and case reports 5

The American College of Chest Physicians recommends monitoring for signs of pleural infection or empyema, including fever >100.4°F (38°C), worsening dyspnea or respiratory distress, productive cough with purulent or bloody sputum, and persistent sepsis despite antibiotics, with a strength of evidence based on clinical trials and guidelines 2, 4, 6

The Society of Thoracic Surgeons recommends that the malpositioned hardware necessitates surgical evaluation for assessment of hardware integrity and position, evaluation of fracture healing status, and determination if revision fixation is needed, with a strength of evidence based on clinical guidelines and expert opinion 1

The American Pain Society recommends scheduled acetaminophen 1000mg every 6 hours as baseline analgesia, with NSAIDs for inflammatory component, opioids only for breakthrough pain, and ice application to affected area for symptomatic relief, with a strength of evidence based on clinical trials and guidelines 8

The American Association for Respiratory Care recommends incentive spirometry every 1-2 hours while awake, chest physiotherapy to prevent atelectasis progression, and early mobilization to promote lung expansion, with a strength of evidence based on clinical trials and guidelines 8

The American College of Surgeons recommends thoracic surgery consultation within 24-48 hours given symptomatic hardware failure, with immediate surgical consultation if signs of infection develop, and thoracentesis for diagnostic and therapeutic purposes if effusion enlarges significantly, with a strength of evidence based on clinical guidelines and expert opinion 1, 4, 6