When to proceed to surgical rib fixation?-A single-institution clinical experience

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.

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.

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.