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.

Surgical stabilization of traumatic rib fractures is associated with reduced readmissions and increased survival.

BACKGROUND: Surgical stabilization for rib fractures (SSRF) in trauma patients remains controversial, with guidelines currently suggesting the procedure for only select patient groups. How surgical stabilization for rib fractures affect hospital readmission in patients with traumatic rib fractures is unknown. We hypothesized that surgical stabilization for rib fractures would not decrease the risk of readmission. METHODS: The National Readmission Database was examined for adults with any rib fractures from 2010 to 2017. Readmission up to 90 days was examined. Patients receiving surgical stabilization for rib fractures were compared with those receiving nonoperative treatment. RESULTS: In total, 864,485 patients met criteria, with 13,701 (1.6%) receiving SSRF. For patients receiving SSRF, 338 (1.5%) were readmitted. Readmitted patients had higher Charlson Comorbidity Index and were more likely to have flail chest. On multivariate propensity score-matched analysis, SSRF (Hazard Ratio [HR]: 0.55, 95% confidence interval [CI] 0.33-0.92, P = .022) was associated with reduced readmission. Addition of surgical stabilization for rib fractures to video-assisted thoracoscopic surgery (VATS) (Odds Ratio [OR]: 0.95, 95% CI 0.52-1.73, P = .86) or thoracotomy (OR: 1.97, 95% CI 0.83-4.70, P = .13) was not associated with increased readmission. On further propensity matched analysis, VATS + SSRF when compared with SSRF alone (HR: 0.75, 95% CI 0.18-3.20, P = .696), and VATS + SSRF when compared with VATS alone (HR: 0.49, 95% CI 0.11-2.22, P = .355) was also not associated with increased readmission. SSRF on primary admission was associated with increased in-hospital survival (HR: 0.27, 95% CI 0.22-0.32, P < .001). For patients with retained hemothorax who underwent VATS, addition of SSRF did not improve survival (HR = 0.92, 95% CI 0.58-1.46, P = .72). However, for patients requiring thoracotomy for retained hemothorax, concomitant SSRF was associated with improved survival (HR = 0.14, 95% CI 0.06-0.32, P < .001). CONCLUSION: Surgical stabilization for rib fractures is associated with reduced readmission risk while also being associated with improved survival. Patients who had a thoracotomy for retained hemothorax appear to especially benefit from concomitant surgical stabilization for rib fractures.

Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes?

BACKGROUND: Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS: Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS: Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION: Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. LEVEL OF EVIDENCE: Therapeutic, Level IV.

A clinical practice guideline using percentage of predicted forced vital capacity improves resource allocation for rib fracture patients.

BACKGROUND: Predicting rib fracture patients that will require higher-level care is a challenge during patient triage. Percentage of predicted forced vital capacity (FVC%) incorporates patient-specific factors to customize the measurements to each patient. A single institution transitioned from a clinical practice guideline (CPG) using absolute forced vital capacity (FVC) to one using FVC% to improve triage of rib fracture patients. This study compares the outcomes of patients before and after the CPG change. METHODS: A review of rib fracture patients was performed over a 3-year retrospective period (RETRO) and 1-year prospective period (PRO). RETRO patients were triaged by absolute FVC. Percentage of predicted FVC was used to triage PRO patients. Demographics, mechanism, Injury Severity Score, chest Abbreviated Injury Scale score, number of rib fractures, tube thoracostomy, intubation, admission to intensive care unit (ICU), transfer to ICU, hospital length of stay (LOS), ICU LOS, and mortality data were compared. A multivariable model was constructed to perform adjusted analysis for LOS. RESULTS: There were 588 patients eligible for the study, with 269 RETRO and 319 PRO patients. No significant differences in age, gender, or injury details were identified. Fewer tube thoracostomy were performed in PRO patients. Rates of intubation, admission to ICU, and mortality were similar. The PRO cohort had fewer ICU transfers and shorter LOS and ICU LOS. Multivariable logistic regression identified a 78% reduction in odds of ICU transfer among PRO patients. Adjusted analysis with multiple linear regression showed LOS was decreased 1.28 days by being a PRO patient in the study (B = -1.44; p < 0.001) with R2 = 0.198. CONCLUSION: Percentage of predicted FVC better stratified rib fracture patients leading to a decrease in transfers to the ICU, ICU LOS, and hospital LOS. By incorporating patient-specific factors into the triage decision, the new CPG optimized triage and decreased resource utilization over the study period. LEVEL OF EVIDENCE: Therapeutic/Care Management. Trauma, Rib, Triage, level IV.

Surgical stabilization of rib fractures is associated with improved survival but increased acute respiratory distress syndrome.

BACKGROUND: How the surgical stabilization of rib fractures after trauma affects the development of acute respiratory distress syndrome and impacts survival has yet to be determined in a large database. We hypothesized that surgical stabilization of rib fractures would not decrease the incidence of acute respiratory distress syndrome. METHODS: The National Trauma Data Bank was queried for all traumatic rib fractures in 2016. Patients were divided into groups with single rib fractures, multiple rib fractures, and flail chest. Nonoperative therapy was compared with stabilization of rib fractures of 1 to 2 ribs or 3+ ribs. RESULTS: There were 114,972 total patients with rib fractures meeting inclusion criteria, with 5,106 (4.4%) having flail chest, 24,726 (21.5%) having single rib fractures, and 85,140 (74.1%) having multiple rib fractures. Those with flail chest (15.9%) were most likely to get rib plating in comparison to multiple rib fractures (0.9%) and single rib fractures (0.2%); P < .001. On logistic regression, surgical stabilization of rib fractures 1 to 2 ribs (odds ratio: 0.17, 95% confidence interval: 0.10-0.28) or 3+ ribs (odds ratio: 0.17, 95% confidence interval: 0.11-0.28), with nonoperative therapy as the reference was associated with survival. Variables associated with mortality included increasing age, male sex, increasing injury severity score, decreased Glasgow coma scale, requirement of transfusions, and hypotension on admission. Surgical stabilization of rib fractures 3+ ribs (odds ratio: 2.30, 95% confidence interval: 1.58-3.37) was associated with acute respiratory distress syndrome but not 1 to 2 ribs (odd ratio: 1.55, 95% confidence interval: 0.97-2.48). On logistic regression of only patients with flail chest, stabilization of rib fractures was associated with decreased mortality but not increased risk of acute respiratory distress syndrome. CONCLUSION: The increased risk of acute respiratory distress syndrome should be considered in the preoperative assessment for stabilization of rib fractures.

Race and Insurance Status are Associated With Different Management Strategies After Thoracic Trauma.

INTRODUCTION: Health-care disparities based on race and socioeconomic status among trauma patients are well-documented. However, the influence of these factors on the management of rib fractures following thoracic trauma is unknown. The aim of this study is to describe the association of race and insurance status on management and outcomes in patients who sustain rib fractures. METHODS: The Trauma Quality Improvement Program database was used to identify adult patients who presented with rib fractures between 2015 and 2016. Patient demographics, injury severity, procedures performed, and outcomes were evaluated. Multivariate logistic regression analysis was used to determine the effect of race and insurance status on mortality and the likelihood of rib fixation surgery and epidural analgesia for pain management. RESULTS: A total of 95,227 patients were identified. Of these, 2923 (3.1%) underwent rib fixation. Compared to White patients, Asians (AOR: 0.57, P = 0.001), Blacks or African-Americans (AA) (AOR: 0.70, P < 0.001), and Hispanics/Latinos (HL) (AOR: 0.78, P < 0.001) were less likely to undergo rib fixation surgery. AA patients (AOR: 0.67, P = 0.004), other non-Whites (ONW) (AOR: 0.61, P = 0.001), and HL (AOR 0.65, P = 0.006) were less likely to receive epidural analgesia. Compared to privately insured patients, mortality was higher in uninsured patients (AOR: 1.72, P < 0.001), Medicare patients (AOR: 1.80, P < 0.001), and patients with other non-private insurance (AOR: 1.23, P < 0.001). CONCLUSIONS: Non-White race is associated with a decreased likelihood of rib fixation and/or epidural placement, while underinsurance is associated with higher mortality in patients with thoracic trauma. Prospective efforts to examine the socioeconomic disparities within this population are warranted.

No difference in mortality between level I and level II trauma centers performing surgical stabilization of rib fracture.

BACKGROUND: A comparison of outcomes between Level I (LI) and Level II (LII) Trauma Centers (TCs) performing surgical stabilization of rib fracture (SSRF) has not been well described. We sought to compare risk of mortality for patients undergoing SSRF between LI and LII TCs. METHODS: The Trauma Quality Improvement Program was queried for patients presenting with rib fracture to LI or LII TCs from 2010 to 2015. A multivariable logistic regression analysis was performed. RESULTS: 14,046 (7.1%) of 199,020 patients with rib fractures underwent SSRF. SSRF increased from 1304 in 2010 to 3489 in 2015: a geometric mean annual increase of 22%. LI TCs demonstrated a mortality incidence of 1.6% while LII TCs demonstrated a mortality incidence of 1.5% (p > 0.05). There was no statistically significant difference in risk of mortality after SSRF between LI and LII TCs (odds ratio 1.12, confidence interval 0.79-1.59, p-value 0.529). CONCLUSIONS: Patients undergoing SSRF at LI and LII TCs have no significant difference in risk of mortality. Additionally, there is an annually growing trend across all centers in SSRF performed both for flail and non-flail segments.

Late Operative Rib Fixation is Inferior to Nonoperative Management.

BACKGROUND: Operative rib fixation (ORF) of traumatic rib fractures has been shown to decrease hospital length of stay (LOS), ventilator days, and mortality. ORF performed within 1 day of admission has been shown to have favorable outcomes compared to later ORF. This report examines the ORF experience over 10 years at a level I trauma center. METHODS: ORF patients from January 2007-January 2018 were matched to nonoperative controls in a 1:2 ratio based on age, injury severity score (ISS), chest Abbreviated Injury Score (AIS), and head AIS. Patient demographic, injury, and outcome data were collected from the trauma registry and medical records. Hospital day of ORF was identified for each ORF patient. Hospital LOS, ICU LOS, ventilator days, and mortality were compared against matched nonoperative controls. RESULTS: Ninety-five ORF patients were matched to 190 nonoperative patients. ORF patients had a higher number of rib fractures (9.6 vs 6.4, P < .001). ORF patients with short time to operation (0-2 days) had a shorter average hospital stay than those with delayed operations (11.8 vs 12.6 vs 13.4 vs 19.6 days, P = .003). ORF patients with operations performed 3-4 days and >6 days after admission also had statistically significant longer ICU LOS and ventilator days. Patient mortality was higher when ORF was performed after 6 days. DISCUSSION: Early ORF may improve pulmonary function, patient outcomes, and decrease LOS. Shifting practice toward early fixation may help further solidify the benefits of this procedure in the treatment of blunt chest trauma.

Comparison of Surgical Stabilization Time in Patients with Flail Chest.

BACKGROUND: This study aimed to compare the clinical outcomes of early and late surgical stabilization of rib fractures (SSRFs) in patients with flail chest. METHODS: A retrospective analysis was performed on patients with flail chest according to surgical stabilization time of rib fractures (early [≤ 72 hours] and late [>72 hours]). Outcome measures included duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, and morbidity and mortality rates. A correlation analysis was performed between the time from trauma to stabilization and the clinical outcomes after stabilization. RESULTS: A total of 70 patients were evaluated (36 and 34 in the early and late groups, respectively). The demographics and indicators of injury severity were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (23.7 vs. 165.6 hours; p = 0.003), ICU stay (6.5 vs. 19.7 days; p = 0.003), hospital stay (9 vs. 22.5 days; p = 0.001), and lower rate of atelectasis (11 vs. 58%; p = 0.01), pneumonia (8.8 vs. 50%; p = 0.001), and empyema (2.8 vs. 20.6%; p = 0.019). According to the correlation analysis, it was found that early surgical stabilization had a positive significant effect on clinical outcomes after stabilization. CONCLUSION: Early SSRFs in patients with flail chest results in more favorable clinical outcomes. It should be performed as soon as possible in the presence of indication and if feasible.

Alcohol Use Disorder Is Bad for Broken Ribs: A Nationwide Analysis of 19,638 Patients With Rib Fractures.

BACKGROUND: Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes. METHODS: We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days. RESULTS: We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups. CONCLUSIONS: Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes. LEVEL OF EVIDENCE: Level III prognostic.

Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures.

BACKGROUND: Geriatric patients with rib fractures are at risk for developing complications and are often admitted to a higher level of care (intensive care units [ICUs]) based on existing guidelines. Forced vital capacity (FVC) has been shown to correlate with outcomes in patients with rib fractures. Complete spirometry may quantify pulmonary capacity, predict outcome, and potentially assist with admission triage decisions. METHODS: We prospectively enrolled 86 patients, 60 years or older with three or more isolated rib fractures presenting after injury. After informed consent, patients were assessed with respect to pain (visual analog scale), grip strength, FVC, forced expiratory volume 1 second (FEV1), and negative inspiratory force on hospital days 1, 2, and 3. Outcomes included discharge disposition, length of stay (LOS), pneumonia, intubation, and unplanned ICU admission. RESULTS: Mean age was 77.4 (SD, 10.2) and 43 (50.0%) were female. Forty-five patients (55.6%) were discharged home, median LOS was 4 days (interquartile range, 3-7). Pneumonias (2), unplanned ICU admissions (3), and intubation (1) were infrequent. Spirometry measures including FVC, FEV1, and grip strength predicted discharge to home and FEV1, and pain level on day 1 moderately correlated with the LOS. Within each subject, FVC, FEV1, and negative inspiratory force did not change for 3 days despite pain at rest and pain after spirometry improving from day 1 to 3 (p = 0.002, p < 0.001 respectively). Change in pain also did not predict outcomes and pain level was not associated with respiratory volumes on any of the 3 days. After adjustment for confounders, FEV1 remained a significant predictor of discharge home (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and LOS (p = 0.001). CONCLUSION: Spirometry measurements early in the hospital stay predict ultimate discharge home, and this may allow immediate or early discharge. The impact of pain control on pulmonary function requires further study. LEVEL OF EVIDENCE: Diagnostic test, level IV.

Clinical Decision Support Intervention for Rib Fracture Treatment.

BACKGROUND: Rib fractures are associated with significant morbidity and mortality. Despite the publication of management guidelines and national outcomes benchmarking, there is significant variation in evidence-based (EB) adherence and outcomes. Systems for clinical decision support intervention (CDSI) allow rapid ordering of bundled disease-specific EB treatments. We developed an EB rib fracture protocol and CDSI at our institution. The purpose of the current study was to evaluate implementation and clinical outcomes using this CDSI. STUDY DESIGN: A rib fracture care CDSI was developed, disseminated, and implemented in July 2018. Implementation outcomes were evaluated using the Proctor framework. Adherence was tracked monthly via run charts and acceptance was evaluated on a 7-point Likert scale using the Unified Theory of Acceptance and Use of Technology questionnaire. Propensity score matching was used to compare in-hospital morbidity and mortality in pre-implementation (January 1, 2016 through December 31, 2016) vs post-implementation (September 1, 2018 through April 30, 2019) cohorts. RESULTS: A total of 197 patients were eligible for the intervention. Provider CDSI adherence was 83% at 1 month and reached 100% after 7 months. Acceptance of CDSI using the Unified Theory of Acceptance and Use of Technology had a mean Likert score higher than 6 (range 6.1 to 6.8, SD 0.5 to 1.5), indicating high acceptance. A significant reduction in hospital length of stay was found post implementation (incident rate ratio 0.80; 95% CI, 0.66 to 0.98; p = 0.03) comparing propensity-matched subjects. CONCLUSIONS: The development and use of a CDSI resulted in improved provider delivery of EB practice and was associated with reduced hospital length of stay.

Association Between Adherence to Evidence-Based Practices for Treatment of Patients With Traumatic Rib Fractures and Mortality Rates Among US Trauma Centers.

Importance: Rib fractures are sustained by nearly 15% of patients who experience trauma and are associated with significant morbidity and mortality. Evidence-based practice (EBP) rib fracture management guidelines and treatment algorithms have been published. However, few studies have evaluated trauma center adherence to EBP or the clinical outcomes of each practice within a national cohort. Objective: To examine adherence to 6 EBPs for rib fractures across US trauma centers and the association with in-hospital mortality. Design, Setting, and Participants: A retrospective cohort study was conducted from January 1, 2007, to December 31, 2014, of 777 US trauma centers participating in the National Trauma Data Bank. A total of 625 617 patients (age, ≥16 years) were evaluated. Patients without rib fractures and those with no signs of life or institutions with poor data quality were excluded. Data analysis was performed from January 1, 2007, to December 31, 2014. Main Outcomes and Measures: Six EBPs were defined: (1) neuraxial blockade, (2) intensive care unit admission, (3) pneumatic stabilization, (4) chest computed tomographic scans for older adults (≥65 years) with 3 or more rib fractures, (5) surgical rib fixation for flail chest, and (6) tube thoracostomy placement for hemothorax and/or pneumothorax. Multiple imputation was used to account for missing data. Patients were propensity score matched in a 1:1 fashion based on demographic characteristics; injury severity parameters, including the Injury Severity Score (range, 0-75; higher scores indicate more severe injuries); and comorbidities. Logistic regression was used to determine the association of each practice with all-cause in-hospital mortality. Results: Of the 625 617 patients with rib fractures included in this analysis, 456 196 patients (73%) were white and 432 229 patients (69%) were male; the median age of the patients was 51 (interquartile range, 37-65) years, and the mean (SD) Injury Severity Score was 18.3 (11.1). The mean (SD) number of rib fractures was 4.2 (2.6). On univariate analysis, patients treated at verified level I trauma centers were more likely to receive 5 or 6 EBPs (all but pneumatic stabilization). Of those who met eligibility, only 4578 of 111 589 patients (4%) received neuraxial blockade, 46 456 of 111 589 patients (42%) were admitted to the intensive care unit, 3302 of 24 319 patients (14%) received surgical rib fixation, 1240 of 111 589 patients (1%) received pneumatic stabilization, 109 160 of 258 334 patients (42%) received tube thoracostomy, and 32 405 of 81 417 patients (40%) received chest computed tomographic scans. Three EBPs were associated with decreased mortality: neuraxial blockade (odds ratio [OR], 0.64; 95% CI, 0.51-0.79; P < .001) for patients aged 65 years or older with 3 or more rib fractures, surgical rib fixation (OR, 0.13; 95% CI, 0.01-0.18; P < .001), and intensive care unit admission (OR, 0.93; 95% CI, 0.86-1.00; P = .04) for patients aged 65 years or older with 3 or more rib fractures. Pneumatic stabilization (OR, 1.71; 95% CI, 1.25-2.35; P < .001) and chest tube placement (OR, 1.27; 95% CI, 1.21-1.33; P < .001) were associated with increased mortality in older patients with 3 or more rib fractures. On multivariable analysis, insurance status, race/ethnicity, injury severity, hospital bed size, and trauma center verification level were associated with receiving EBPs for rib fractures. Conclusions and Relevance: Significant variation appears to exist in the delivery of EBPs for rib fractures across US trauma centers. Three EBPs were associated with reduced mortality, but EBP adherence was poor. Multiple factors, including trauma center verification level, appear to be associated with patients receiving EBPs for rib fractures.

Rib fixation in geriatric trauma: Mortality benefits for the most vulnerable patients.

BACKGROUND: Rib fractures in the geriatric trauma population are associated with significant morbidity and mortality. The outcomes of surgical stabilization of rib fractures (SSRF) have not been well defined in this population. METHODS: Data from the 2016 to 2017 Trauma Quality Improvement Program database were analyzed. Patients older than 65 years admitted with isolated chest wall injury and multiple rib fractures were abstracted from the database. Multivariate propensity score matching was utilized to stratify patients that underwent rib fixation versus nonoperative management. In the matched cohort, we assessed outcomes including mortality, intensive care unit (ICU) and hospital lengths of stay (LOS), tracheostomy rates, and ventilator-associated pneumonia (VAP) rates. We performed a secondary analysis of patients receiving early (<72 hours) versus late SSRF. RESULTS: Of the 44,450 patients included in the study analysis, 758 (1.7%) underwent SSRF. Patients undergoing SSRF were younger, had a higher prevalence of flail chest, higher rates of emergency room intubation, higher Injury Severity Score, and increased ICU admission rates. The 1:1 propensity score match resulted in 758 patients in each group. The in-hospital mortality rate was significantly lower in patients that underwent SSRF (4.2% vs. 7.3%, p = 0.01). However, the fixation group also had higher rates of tracheostomy during admission (11.2% vs. 4.6%, p < 0.001) and VAP (3.0% vs. 1.6%, p = 0.007). In a secondary matched analysis of 326 pairs of patients undergoing SSRF, we found that early fixation was associated with decreased rates of VAP (1.5% vs. 4.6%, p = 0.01), fewer ventilator days (4 days vs. 7 days, p = 0.003), shorter ICU LOS (6 days vs. 9 days, p = 0.001), and shorter hospital LOS (10 days vs. 15 days, p < 0.001). CONCLUSION: This study demonstrates a mortality benefit in geriatric trauma patients undergoing SSRF. Early SSRF was observed to be associated with decreased rates of VAP, decreased ICU LOS, and decreased hospital LOS. Early SSRF may be associated with improved outcomes in the geriatric trauma population with multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

Smoking is associated with an improved short-term outcome in patients with rib fractures.

BACKGROUND: Smokers with cardiovascular disease have been reported to have decreased mortality compared to non-smokers. Rib fractures are associated with significant underlying injuries such as lung contusions, lacerations, and/or pneumothoraces. We hypothesized that blunt trauma patients with rib fractures who are smokers have decreased ventilator days and risk of in-hospital mortality compared to non-smokers. STUDY DESIGN: The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a blunt rib fracture. Patients that died within 24 h of admission were excluded. A multivariable logistic regression model was performed. RESULTS: From 282,986 patients with rib fractures, 57,619 (20.4%) were smokers. Compared to non-smokers with rib fractures, smokers had a higher median injury severity score (17 vs. 16, p < 0.001). Smokers had a higher rate of pneumonia (7.5% vs. 6.6%, p < 0.001), however, less ventilator days (5 vs. 6, p = 0.04), and lower in-hospital mortality rate (2.3% vs. 4.6%, p < 0.001), compared to non-smokers. After controlling for covariates, smokers with rib fractures were associated with a decreased risk for in-hospital mortality compared to non-smokers with rib fractures (OR 0.64, 0.56-0.73, p < 0.001). CONCLUSION: Despite having more severe injuries and increased rates of pneumonia, smokers with rib fractures were associated with nearly a 40% decreased risk of in-hospital mortality and one less ventilator day compared to non-smokers. The long-term detrimental effects of smoking have been widely established. However, the biologic and pathophysiologic adaptations that smokers have may confer a survival benefit when recovering in the hospital from chest wall trauma. This study was limited by the database missing the number of pack-years smoked. Future prospective studies are needed to confirm this association and elucidate the physiologic mechanisms that may explain these findings.

Early Versus Late Tracheostomy in Trauma Patients With Rib Fractures.

BACKGROUND: Patients with blunt chest trauma with multiple rib fractures (RF) may require tracheostomy. The goal was to compare early (≤7 d) versus late (>7 d) tracheostomy patients and to analyze clinical outcomes, to determine which timing is more beneficial. METHODS: This retrospective review included 124 patients with RF admitted to trauma ICU at two level 1 trauma centers who underwent tracheostomy. Analyzed variables included age, gender, injury severity score, Glasgow Coma Scale, number of ribs fractured, total fractures of the ribs, prevalence of bilateral RF, flail chest, maxillofacial injuries, cervical vertebrae trauma, traumatic brain injuries (TBI), coinjuries, epidural analgesia, surgical stabilization of RF, failure to extubate, hospital LOS, intensive care unit LOS (ICULOS), duration of mechanical ventilation, mortality, and timing and type of tracheostomy. RESULTS: Mean number of RF in all tracheostomized patients with blunt chest trauma was 5.2 and 85% of patients had pulmonary co-injuries. Mean tracheostomy timing was 9.9 d. Early tracheostomy (ET) was correlated with statistically significant reduction in ICULOS and duration of mechanical ventilation. The dominant cause of mortality in all groups was TBI and it was more pronounced in the ET patients. Most deaths were encountered between 3 and 5 wk after admission. ET was more often performed in the operating room with an open technique, whereas late tracheostomy was more often implemented with percutaneous technique at bedside. CONCLUSIONS: ET could be beneficial in chest trauma patients with multiple RF as it reduces ICULOS and ventilation requirements. Mortality benefits are not correlated with tracheostomy timing.

New horizons in rib fracture management in the older adult.

Adults aged ≥60 years now represent the majority of patients presenting with major trauma. Falls are the most common cause of injury, accounting for nearly three-quarters of all traumas in this population. Trauma to the thorax represents the second most common site of injury in this population, and is often associated with other serious injuries. Mortality rates are 2-5 times higher in older adults compared to their younger counterparts, often despite equivalent injury severity scores. Risk scoring systems have been developed to identify rib fracture patients at high risk of deterioration. Overall mortality from rib fractures is high, at approximately 10% for all ages. Mortality and morbidity from rib fractures primarily derive from pain-induced hypoventilation, pneumonia and respiratory failure. The main goal of care is therefore to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications. The provision of analgesia has evolved to incorporate novel regional anaesthesia techniques into conventional multimodal analgesia. Analgesia algorithms may aid early aggressive management and escalation of pain control. The current role for surgical fixation of rib fractures remains unclear for older adults who have been underrepresented in the research literature. Older adults with rib fractures often have multi-morbidity and frailty which complicate their injuries. Trauma services are evolving, and increasingly geriatricians will be embedded into trauma services to deliver comprehensive geriatric assessment. This review aims to provide an evidence-based overview of the management of rib fractures for the physician treating older patients who have sustained trauma.

Rib Fractures and Mortality: Breaking the Causal Relationship.

Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor of mortality, but rarely contribute to cause death. We performed a retrospective study (2008-2015) of blunt trauma patients admitted to our urban, Level I trauma center with one or more rib fractures. Medical records were reviewed in detail. Rib fracture deaths were those from any respiratory sequelae or hemorrhage from rib fractures. There were 4413 blunt trauma patients who sustained one or more rib fractures and 295 (6.8%) died. Rib fracture patients who died had a mean Injury Severity Score = 38 and chest Abbreviated Injury Score = 3.4. Rib fractures were the cause of death in only 21 patients (0.5%). After excluding patients who were dead on arrival, patients dying as a result of their rib fractures were found to be older (P < 0.0001) and had a higher admission respiratory rate (P = 0.02). Multivariable logistic regression found that age ≥65 was the only variable independently associated with mortality directly related to rib fractures (odds ratio 4.1, 95% confidence interval = 1.3-13.3, P value < .0001). Mortality in patients with rib fractures is uncommon (7%), and mortality directly related to rib fractures is rare (0.5%). Older patients are four times more likely to die as a direct result of rib fractures and may require additional resources to avoid mortality.