Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial

Chest Wall Injury Society recommendations for long-term follow-up after nonoperatively and operatively managed traumatic rib and sternal fractures

LEVEL OF EVIDENCE

Systematic Review/Meta-analysis; Level IV.

Implant irritation and removal rates in operatively treated multiple rib fractures: a 49-month follow-up study

PURPOSE

Little is known about the prevalence, impact and change of the symptoms after implant removal due to irritation in multiple rib fractures. This study aims to explore these aspects to improve treatment decision-making.

METHODS

Data was collected from two hospitals in the Netherlands and Switzerland. The study included only adults with operatively treated multiple rib fractures, regardless of whether the fractures were flail or non-flail. The primary outcome was the incidence of implant removal due to irritation. Secondary outcomes included implant irritation not leading to removal, other postoperative complications, and remission rates after implant removal. These outcomes were assessed during a follow-up phone call using a standardized questionnaire.

RESULTS

Hundred-twenty patients were identified, with 83 (69.2%) completing the final follow-up after a median of 49 months (IQR 40-59). Twenty-five (30.1%) patients experienced implant irritation, of whom four (4.8%) got their implant removed. Two (2.4%) reported significant improvement, one (1.2%) moderate, and one (1.2%) no improvement of symptoms.

CONCLUSION

Implant irritation in patients with multiple rib fractures is a common problem, even years after surgery, without guaranteed symptom improvement post-removal. These results provide an additional argument to be more selective in offering rib fixation to patients with multiple rib fractures in the first place.

Post-discharge complications and follow-up timing after hospitalization for traumatic rib fractures

PURPOSE

To evaluate frequency and timing of post-discharge complications in patients with traumatic rib fractures undergoing operative or nonoperative management.

METHODS

We retrospectively reviewed adult patients with rib fractures admitted to a Level 1 trauma center from 1/2020 to 12/2021. Outcomes included rib-related complications, pneumonia within 1 month, new diagnosis of opioid- or alcohol-use disorder, and all-cause mortality. Patients were stratified on whether they underwent surgical stabilization of rib fractures (SSRF). Associations between risk factors and outcomes were evaluated through Fine and Gray hazard models with death (or in-hospital death for the post-discharge death outcome) as a competing risk.

RESULTS

Of 976 patients admitted with rib fractures, 904(93%) underwent non-operative therapy and 72(7%) underwent SSRF. Nonoperative patients had less-severe injuries and shorter ICU length-of-stay. Rib-related complications occurred in 13(1%) nonsurgical patients and 4(6%) surgical patients. In the nonsurgical group, presence of hemo/pneumothorax on admission was associated with increased risk of rib-related complications [subdistribution hazard ratio (SHR) (95% CI): 5.95(1.8, 19.67)]. Pneumonia within 1 month occurred in 9(1%) nonsurgical patients and 1(1%) surgical patient. New diagnosis of alcohol or opioid-use disorder was made in 14(2%) nonsurgical patients and 1(1%) surgical patients. All-cause mortality was 68(8%) in the nonsurgical group and 2(3%) in the surgical group. Older age was associated with mortality in the nonsurgical cohort [SHR (95% CI): 1.83(1.46, 2.28)].

CONCLUSION

Post-discharge rib-related complications were rare in both groups, but occurred primarily within 2 weeks, suggesting concentrated earlier follow-up may be beneficial. These findings help inform recommendations for follow-up in this population.

Outcomes of internal rib fixation through complete video-assisted thoracoscopic surgery for multiple rib fractures and flail chest in severe chest trauma

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is a standard treatment for multiple rib fractures and flail chest. The aim of this study is to evaluate the outcomes of internal rib fixation through complete video-assisted thoracoscopic surgery (VATS) for multiple rib fractures and flail chest in patients with severe chest trauma.

METHODS

Thirty-nine patients with multiple rib fractures caused by severe chest trauma were divided into two groups according to the surgical approach used. Twenty-one patients were diagnosed with flail chest. In the thoracoscopic surgery group, 17 patients underwent internal rib fixation through complete VATS. In the open surgery group, 22 patients underwent surgery with open reduction and internal fixation. Surgical variables, such as operation time, intraoperative blood loss, chest tube drainage volume, complications, visual analog scale (VAS) of pain score, postoperative ventilator days, Intensive Care Unit (ICU) stay and hospital stay, were compared between the two groups.

RESULTS

There were no differences in operation time, intraoperative blood loss, chest tube drainage volume, postoperative ventilator days, ICU stay or hospital stay between the two groups (P > 0.05). Although there was no significant difference in overall postoperative complications (P = 0.358), the incidence of postoperative pleural effusion was lower in the thoracoscopic surgery group than in the open surgery group (P = 0.025). The VAS score in the thoracoscopic surgery group was also significantly lower than that in the open surgery group on the seventh day after surgery (P = 0.014).

CONCLUSIONS

Internal rib fixation through complete VATS is a feasible and safe approach for treating multiple rib fractures and flail chest in patients with severe chest trauma.

Comparison of patients who meet criteria for surgical stabilization of rib fractures versus those who actually get rib fixation: A single center review

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has shown benefits for rib fracture patients. However, the incidence of SSRF performed remains low. We compare our institution's rib fracture patients meeting criteria for SSRF versus those actually receiving the operation, hypothesizing a significant portion are not undergoing SSRF.

METHODS

A retrospective review of rib fracture patients presenting to our Level 1 trauma center from 1/2016 to 4/2023. Patients were categorized as those who met SSRF inclusion criteria versus those who didn't based on the 2023 Chest Wall Injury Society (CWIS) SSRF Guidelines. Basic demographics were obtained. Patients meeting SSRF criteria were divided into those who received SSRF versus those who didn't. Outcomes of interest included type and frequency of SSRF indications and frequency of absolute/relative contraindications. Descriptive statistics were used. Median test and t-test were used for statistical analysis. Statistical significance was set at p < 0.05.

RESULTS

A total of 3,432 patients presented with ≥1 rib fracture(s). Of those, 1,573(45.8 %) met SSRF inclusion criteria. These patients were predominantly male, with mean age of 57.4(±18.5) and a similar Injury Severity Score but significantly higher chest-Abbreviated Injury Score of 3 (Interquartile range 3,4)(p = 0.048). Only 458(29.1 %) patients underwent SSRF, leaving 1,115(70.9 %) managed non-operatively, of which 215(19.3 %) were ventilated and "failure to wean from the ventilator" was the most common (81.4 %) indication for SSRF. Of the 900(80.7 %) non-ventilated patients managed non-operatively, 659 (69.9 %) had ≥two indications for SSRF, 382(34.3 %) had zero relative contraindications and 394(35.3 %) had one relative contraindication for SSRF. Lastly, 52.6 % of patients in this cohort had reported "clicking/popping" of their fractures.

CONCLUSION

Only 29.1 % of patients meeting criteria for SSRF had the operation based on data from our institution. There may be additional opportunity to benefit this cohort of patients meeting SSRF criteria but not undergoing surgery.

An early analysis of polyetheretherketone (PEEK) plates for the surgical stabilization of rib fractures: A pilot study

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is a viable treatment option for rib fracture patients. Polyetheretherketone (PEEK) plates have become available for SSRF. The objective of this pilot study was to examine the use of PEEK plates for SSRF.

METHODS

A prospective, observational, multi-center study of patients undergoing SSRF with PEEK plates from 4/23 through 2/24. Standard indications for SSRF were followed and the decision to use PEEK plates was left to the discretion of the treating surgeon. Basic demographics were obtained. Outcomes included the number of rib fractures stabilized with PEEK plates, complications related to SSRF, and 6-month follow-up with chest computed tomography (CT) to assess healing of PEEK repaired fracture sites, identified as complete or incomplete union. Patients also answered a five-question quality-of-life survey regarding mobility, self-care, usual activities, chest pain/discomfort, and anxiety/depression. Answers were scaled 1 to 5 (1=worse condition possible; 5=best possible condition). Patients rated their health on a scale of 0 to 100 (100=closet to their health preinjury). All data was reported as descriptive.

RESULTS

Forty-six patients were included. Average age was 57(±16) years; 82.6 % were male. Median ISS was 18 (IQR 14,29) and median chest-AIS was 4 (IQR 3,4). 219 rib fractures were stabilized with PEEK plates. Sixteen (34.8 %) had a combination (PEEK + titanium) procedure. Three patients had a complication: one required a second surgery for additional SSRF, and two patients were readmitted. Twenty-seven patients were surveyed at 6 months, and 19 agreed to CT scan. Eighty PEEK repaired rib fractures were assessed for healing. 80 % of fractures had complete union and no hardware failure. Quality-of-life survey averaged >4.5/category and mean overall health was 89.

CONCLUSION

PEEK plates for SSRF are safe and effective, allowing for adequate rib fracture healing and are associated with positive patient reported outcomes.

Discussion of Surgical Indications: The Black, White, and Gray

SUMMARY

Chest wall trauma is rapidly evolving and now represents a multidisciplinary field with incredible growth in research and surgical intervention; however, even with more than 800 publications on chest wall trauma to date, surgical indications are not black and white. Injury patterns need to be better defined and outcome measurements need to evolve for accurate longer term functional assessment of patients if this field of surgery is to move beyond historical indications for operative intervention. This essay will communicate what is known about operative indications in a way that stratifies the need for surgery.

Best Available Outcomes Evidence Informing Standard of Care

SUMMARY

Although nonoperative management is the mainstay for rib fracture treatment, surgical stabilization of rib fractures is becoming more common. Recently, the number of high-quality studies on management of rib fractures has also increased. The primary purpose of this review is to analyze the currently available prospective randomized studies on the management of rib fractures. In addition, we will summarize both short-term and long-term outcomes of patients with rib fractures.

Surgical management of multiple rib fractures in polytrauma patients: semi-damage control surgery

Background: To investigate the timing and extent of surgery for rib fractures in polytrauma patients. Methods: Data from polytrauma patients who underwent early and partial rib fracture fixation after successful resuscitation were retrospectively analyzed. The study encompassed demographic data, clinical data, and outcomes. Results: In total, 71 patients with polytrauma were included. ISS ranged from 16 to 50 with a mean score of 25.3±7.5. The median lactate level was 3.6 mmol/L (IQR: 3.1 to 4.5), the median base deficit (BD) was 8.2 mmol/L (IQR: 6.4 to 9.8) and the shock index (SI) median was 1.2 (IQR: 0.9 to 1.3). Total fractured ribs in 71 patients were 726; individually, the minimum and maximum number of fractured ribs was 3 and 22, respectively (median, 10; mean, 10.2 ± 4.0). The average time to surgery was 42.9±42.6 h. Specifically, 41(57.7%) received the surgery within 24h and 52 (73.2%) patients received the surgery within 3 days following successful resuscitation. A total of 246 (33.9%) ribs underwent open reduction and internal fixation with plate, 3.46 ribs for each patient, with high frequencies of the 6th (49, 19.9%), 5th (46, 18.7%), 4th and 7th ribs (both 36, 14.6%). The average length of ICU stay was 11.5 ± 7.5 days and the duration of hospitalization was 16.3 ± 9.9 days. No surgical site infection or mortality was observed. Conclusions: Early and partial rib fracture fixation to restore the relative stability of the thorax is safe and effective for polytrauma patients after successful resuscitation. This surgery strategy is called semi-damage control surgery.

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

BACKGROUND

Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements.

RESULTS

A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection.

CONCLUSION

This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Do we have to redefine type B-fractures of the rib cartilage?

OBJECTIVES

Aim of this work was the evaluation and validation of the AO/OTA classification of the anterior chest wall, here especially for the rib cartilage.

METHODS

Study design was a retrospective analysis of patients who were hospitalized with fractures of the thoracic wall in the years 2010-2016. This resulted in a collective of n = 124 patients. All fractures of the anterior chest wall were classified according to their location, dislocation and fracture type according to the AO classification. An analysis of possible subtypes was carried out.

RESULTS

29.0% (36) of the patients had fractures of the rib cartilage. 23 of the 36 (64%) patients had multiple fractures, the total number of single fractures amounted to 94. 53.2% (50) of these fractures were in the right hemithorax, 46.8% (44) in the left hemithorax. 95.7% (90) of the fractures were A-fractures, 4.3% (4) were C-fractures. There were no B fractures. The C fractures also consisted exclusively of A fractures (AA fractures). 59.6% (56) of the fractures showed a dislocation. 30.9% (29) were avulsion fractures of either the osteochondral (22.3% (21)) or the sternocostal junction (8.5% (8)).

DISCUSSION AND CONCLUSION

The costal cartilage obviously does not show typical B fractures as we know them from shaft fractures of long bones. We have compiled a structured analysis in the attached manuscript and validated the classification proposal. In conclusion, we propose an adaptation of the classification proposal based on our data with redefining type B fractures as fractures of the osteochondral joints.

When more is more: Utilizing finite element analysis to assess chest wall injury stability after surgical stabilization of all rib fractures versus only a portion of the rib fractures

BACKGROUND

Surgical stabilization of rib fractures (SSRF) continues to gain acceptance. Controversary exists around the number of rib fractures needing stabilization. We sought to analyze chest wall stability (CWS) after SSRF using finite element analysis (FEA) modeling in various rib fracture patterns, hypothesizing not stabilizing all fractures leaves the chest wall unstable.

METHODS

FEA thoracic model development was described previously. Two fracture patterns with three case scenarios each were defined for right ribs 4 to 9. Fracture Pattern 1; Case 1-all 6 ribs with lateral fractures and no stabilization; Case 2-all six fractures stabilized; Case 3-only fractures 5 to 7 were stabilized. Fracture Pattern 2; Case 4-all six ribs fractured in a flail pattern (anterior-lateral and posterior-lateral) and no stabilization; Case 5-all 12 fractures stabilized; Case 6-only six anterior-lateral fractures were stabilized. Three assessment criteria were used to quantify thoracic motion: normalized mean absolute error (NMAE), normalized root mean square error (NRMSE), and normalized interfragmentary motion (NIFM).

RESULTS

Fracture Pattern 1: Case 1-NMAE and NRMSE analysis demonstrated significant loss of CWS up to 50% with left axial rotation; Case 2-CWS almost completely returned to nonfractured state; Case 3-CWS loss up to 37%. Fracture Pattern 2: Case 4-up to 49% of CWS lost with right axial rotation; Case 5-less than 3% CWS lost; Case 6-over 40% CWS lost. For both fracture patterns, when stabilizing all fractures, NIFM decreased by 95%. In Case 3, NIFM decreased by 56% and in Case 6, NIFM increased by 1% at the non-stabilized fracture line.

CONCLUSION

Stabilizing all rib fractures significantly improves CWS. Not stabilizing both fractures of a flail segment worsens motion at the non-stabilized fractures.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Surgical stabilisation of rib fractures: A meta-analysis of randomised controlled trials

INTRODUCTION

Rib fixation for ventilator dependent flail chest patients has become a mainstay of management in major trauma centres. However, the expansion of rib fixation for fractured ribs beyond this remains largely in the hands of enthusiasts with the benefits in non ventilator dependent groups largely unproven. Previous meta-analyses have largely included non-randomised and retrospective data, much of which is now more than two decades out of date. We wanted to perform an updated meta-analysis including only rigorous prospective trials which were randomised. Further we wanted to include quality of life outcomes which have not been previously examined in published meta-analyses.

METHODS

This meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and included randomised controlled trials only, of rib fixation compared to non-operative management in adult patients.

RESULTS

Eight studies comprising 752 patients of whom 372 had been randomised to receive rib fixation were included. Benefits of rib fixation were identified with significant reductions in mechanical ventilation and lengths of stay (both ICU and hospital) as well as rates of pneumonia and tracheostomy. No significant benefit in quality of life at 6 months was identified.

CONCLUSION

Operative intervention for rib fractures leads to significantly lower rates of pneumonia, lengths of intensive care stay and time on mechanical ventilation compared to non-operative intervention. Further study is needed to investigate quality of life improvements after rib fractures as operative rib fixation expands to non-ventilator dependent groups.

Surgical stabilization of rib fractures for flail chest: Analysis of center-based variability in practice and outcomes

BACKGROUND

Given the lack of high-quality data on patient selection for surgical stabilization of rib fractures (SSRF), significant variability in practice likely exists across trauma centers. We aimed to determine whether centers with a more liberal approach to SSRF had improved outcomes.

METHODS

We performed a retrospective cohort study of adult patients with flail chest admitted to Level I or II trauma centers participating in the American College of Surgeons' Trauma Quality Improvement Program. The primary outcome was hospital mortality; secondary outcomes included discharge status, tracheostomy, duration of mechanical ventilation, and hospital length of stay. Logistic regression was performed to calculate center-level observed/expected rates of SSRF and centers were grouped into quintiles from "most liberal" to "most restrictive." Multivariable regression was used to determine the association between these quintiles and outcomes. We also used an instrumental variable analysis to evaluate the association between SSRF and mortality at the patient level.

RESULTS

Among 23,619 patients with flail chest across 354 centers, 22% underwent SSRF. Center rates of fixation ranged from 0% to 88%. Higher rates of SSRF were not associated with lower mortality overall (highest vs. lowest quintile: odds ratio, 0.86; 95% confidence interval, 0.63-1.17). However, centers with a more liberal approach to SSRF had lower rates of independent status at discharge, higher tracheostomy rates, longer duration of mechanical ventilation, and longer hospital and ICU length of stay. The patient level analysis demonstrated that SSRF as was associated with a 25% lower risk of death.

CONCLUSION

Overall, centers with a liberal approach to SSRF do not show improved outcomes among patients with a flail chest, but have higher resource utilization. Results at the patient level suggest that there is a population likely to benefit but these patients remain to be identified through further research.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients

BACKGROUND

Optimal treatment (i.e., nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment.

METHODS

The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with 1-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life.

RESULTS

Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic nonunion. The median HLOS was 7 days (4-13 days), and median intensive care unit length of stay was 2 days (1-5 days). Mean 5-Level Quality of Life Questionnaire index value was 0.83 ± 0.18 1 year after trauma. Polytrauma patients had a median HLOS of 10 days (6-18 days), a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 days (5-15 days), a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12).

CONCLUSION

Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after 1 year. Future studies evaluating the benefit of operative stabilization should use contemporary outcomes to establish the therapeutic margin of rib fixation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Association of Early Rib Plating on Clinical and Financial Outcomes: A National Analysis

BACKGROUND

With reported improvements in patient outcomes, surgical stabilization of rib fractures (SSRF) has been increasingly adopted. While institutional series have sought to define the role of early SSRF, large scale analysis remains lacking. The present study evaluated clinical and financial outcomes of SSRF in a nationally representative cohort.

METHODS

Patients (≥16 years) admitted with multiple rib fractures were identified using the 2016-2020 National Inpatient Sample. Those who underwent rib plating >14 days following admission were omitted. Using restricted cubic spline analysis, patients who underwent SSRF within 2 days of hospitalization were classified as Expedited while fixation >2 days were deemed Routine. Multivariable regressions were used to evaluate the association of operative timing on outcomes of interest.

RESULTS

Of 8150 patients meeting final inclusion criteria, 4090 (50.2%) were Expedited. Compared to Routine, Expedited tended to be older but were of comparable race, primary payer, and income quartile. Traumatic mechanism was also similar but rates of concomitant sternal fracture as well as intra-abdominal and cardiac injuries were higher in Routine. After adjustment, Expedited was associated with lower odds of respiratory complications, which included need for mechanical ventilation, prolonged mechanical ventilation, and pneumonia, compared to Routine. Expedited was associated with similar hospitalization duration but had lower incremental costs (β: -$19.1 K, 95% CI: -24.1 to -14.2).

DISCUSSION

Early SSRF was associated with lower likelihood of a number of respiratory complications and in-hospital costs. While patient selection criteria may limit our findings, expeditious fixation may limit morbidity while enhancing value of care.

A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures

BACKGROUND

Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures.

METHODS

A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research.

RESULTS

From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence.

CONCLUSION

Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients.

SYSTEMATIC REVIEW REGISTRATION

UMIN Clinical Trials Registry UMIN000049365.

Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials

PURPOSE

Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment.

METHODS

Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics.

RESULTS

Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD - 4.34, 95% CI - 6.98, - 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI - 13.51, 4.84); length of intensive care unit stay (WMD - 4.62, 95% CI - 7.19, - 2.05; p < 0.01; I2 = 78%; GRADE: low; PI - 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD - 5.39, 95% CI - 11.38, - 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI - 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found.

CONCLUSIONS

Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.

Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury

OBJECTIVE

To compare the effectiveness of surgical stabilization of rib fractures (SSRFs) to nonoperative management in severe chest wall injury.

BACKGROUND

SSRF has been shown to improve outcomes in patients with clinical flail chest and respiratory failure. However, the effect of SSRF outcomes in severe chest wall injuries without clinical flail chest is unknown.

METHODS

Randomized controlled trial comparing SSRF to nonoperative management in severe chest wall injury, defined as: (1) a radiographic flail segment without clinical flail or (2) ≥5 consecutive rib fractures or (3) any rib fracture with bicortical displacement. Randomization was stratified by the unit of admission as a proxy for injury severity. Primary outcome was hospital length of stay (LOS). Secondary outcomes included intensive care unit (ICU) LOS, ventilator days, opioid exposure, mortality, and incidences of pneumonia and tracheostomy. Quality of life at 1, 3, and 6 months was measured using the EQ-5D-5L survey.

RESULTS

Eighty-four patients were randomized in an intention-to-treat analysis (usual care = 42, SSRF = 42). Baseline characteristics were similar between groups. The numbers of total fractures, displaced fractures, and segmental fractures per patient were also similar, as were the incidences of displaced fractures and radiographic flail segments. Hospital LOS was greater in the SSRF group. ICU LOS and ventilator days were similar. After adjusting for the stratification variable, hospital LOS remained greater in the SSRF group (RR: 1.48, 95% CI: 1.17-1.88). ICU LOS (RR: 1.65, 95% CI: 0.94-2.92) and ventilator days (RR: 1.49, 95% CI: 0.61--3.69) remained similar. Subgroup analysis showed that patients with displaced fractures were more likely to have LOS outcomes similar to their usual care counterparts. At 1 month, SSRF patients had greater impairment in mobility [3 (2-3) vs 2 (1-2), P = 0.012] and self-care [2 (1-2) vs 2 (2-3), P = 0.034] dimensions of the EQ-5D-5L.

CONCLUSIONS

In severe chest wall injury, even in the absence of clinical flail chest, the majority of patients still reported moderate to extreme pain and impairment of usual physical activity at one month. SSRF increased hospital LOS and did not provide any quality of life benefit for up to 6 months.

Early Internal Fixation of Concomitant Clavicle Fractures in Severe Thoracic Trauma Prevents Posttraumatic Pneumonia

BACKGROUND

Severe thoracic trauma can lead to pulmonary restriction, loss of lung volume, and difficulty with ventilation. In recent years, there has been increasing evidence of better clinical outcomes following surgical stabilization of clavicle fractures in the setting of this combination of injuries. The aim of this study was to evaluate surgical versus non-surgical treatment of clavicle fractures in severe thoracic trauma in terms of clinical and radiological outcomes in order to make a generalized treatment recommendation based on the results of a large patient cohort.

PATIENTS AND METHODS

This retrospective study included 181 patients (42 women, 139 men) from a European level I trauma centre with a median of 49.3 years in between 2005 and 2021. In 116 cases, the clavicle fracture was stabilized with locking plate or hook plate fixation (group 1), and in 65 cases, it was treated non-surgically (group 2). Long-term functional outcomes at least one year postoperatively using the disabilities of the arm, shoulder and hand (DASH) questionnaire and the Nottingham Clavicle Score (NCS) as well as radiological outcomes were collected in addition to parameters such as hospital days, intensive care days, and complication rates.

RESULTS

The Injury Severity Score (ISS) was 17.8 ± 9.8 in group 1 and 19.9 ± 14.4 in group 2 (mean ± SEM; p = 0.93), the time in hospital was 21.5 ± 27.2 days in group 1 versus 16 ± 29.3 days in group 2 (p = 0.04). Forty-seven patients in group 1 and eleven patients in the group 2 were treated in the ICU. Regarding the duration of ventilation (group 1: 9.1 ± 8.9 days, group 2: 8.1 ± 7.7 days; p = 0.64), the functional outcome (DASH group 1: 11 ± 18 points, group 2: 13.7 ± 18. 4 points, p = 0.51; NCS group 1: 17.9 ± 8.1 points, group 2: 19.4 ± 10.3 points, p = 0.79) and the radiological results, no significant differences were found between the treatment groups. With an overall similar complication rate, pneumonia was found in 2% of patients in group 1 and in 14% of patients in group 2 (p = 0.001).

DISCUSSION

This study could demonstrate that surgical locking plate fixation of clavicle fractures in combination with CWI significantly reducing the development of posttraumatic pneumonia in a large patient collection and, therefore, can be recommended as standard therapeutic approach for severe thoracic trauma.

Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis

BACKGROUND

Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients.

METHODS

Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8).

RESULTS

Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004).

CONCLUSION

In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Comprehensive Review of Current Pain Management in Rib Fractures With Practical Guidelines for Clinicians

Rib fractures are present in 15% of all traumas and 60% of patients with chest traumas. Rib fractures are not life-threatening in isolation, but they can be quite painful which leads to splinting and compromise of respiratory function. Splinting limits the ability of a patient to take a deep breath, which leads to atelectasis, atelectasis to poor secretion removal, and poor secretion removal leads to pneumonia. Pneumonia is the common pathway to respiratory failure in patients with rib fractures. It is noted that in the elderly, each rib fracture increases developing pneumonia by 27% and the risk of dying by 19%. From a public health perspective, rib fractures have long-term implications with only 59% of patients returning to work at 6 months. In this review we will examine the state of art as it currently exists with regard to the management of pain associated with rib fractures. Included in this overview will be a brief review of the anatomy of the thorax and some important physiologic concepts, the latest trends in pharmacologic and noninvasive means of managing rib pain, a special section on epidural anesthesia, some other alternative invasive methods of pain control, and a review of the recent literature on rib plating. Finally, a practical, easy to follow guideline, to manage the patient with pain from rib fractures will be presented.

Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: A multicentre prospective cohort study

Introduction

Most studies about rib fractures focus on mortality and morbidity. Literature is scarce on long term and quality of life (QoL) outcomes. Therefore, we report QoL and long-term outcomes after rib fixation in flail chest patients.

Methods

A prospective cohort study of clinical flail chest patients admitted to six level 1 trauma centres in the Netherlands and Switzerland between January 2018 and March 2021. Outcomes included in-hospital outcomes and long-term outcomes, such as QoL measurements 12 months after hospitalization using the EuroQoL five dimensions (EQ-5D) questionnaire.

Results

Sixty-one operatively treated flail chest patients were included. Median hospital length of stay was 15 days and intensive care length of stay was 8 days. Sixteen (26%) patients developed pneumonia and two (3%) died. One year after hospitalization the mean EQ5D score was 0.78. Complication rates were low and included hemothorax (6%) pleural effusion (5%) and two revisions of the implant (3%). Implant related irritation was commonly reported by patients (n = 15, 25%).

Conclusions

Rib fixation for flail chest injuries can be considered a safe procedure and with low mortality rates. Future studies should focus on quality of life rather than solely short-term outcomes.

Trial registration: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017 and the Swiss Ethics Committees Registration Number 2019-00668