Rib fractures are common injuries that can have significant morbidity and mortality. While several randomized controlled trials have shown benefits of surgical stabilization for flail chest injuries, national guidelines conditionally recommend rib fixation only for flail injuries. Recent large observational studies suggest mortality may be lower with surgery for flail chest. Further research is still needed to determine if surgical stabilization provides benefits for non-flail rib fractures.

1. Rib Fractures: to fix or not to fix?
Miss Kate Martin. FRACS.
General and Trauma Surgeon
Alfred Hospital
8th June 2019

2. Declarations
Nothing to disclose.
2

3. 14 August 2019 3

4. Overview
• Epidemiology
• Mortality
• Surgical stabilisation
• Randomised controlled trials
• Subsequent publications
• National guidelines
• Recent trends
• Long-term outcomes and QoL
• Where to from here?
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5. Epidemiology
Incidence varies depending on patient population:
• North America (NTDB) 2016: 10% ≥1 rib #
• Major trauma only: 21-39%
Alfred:
• All patients admitted into Trauma Service: 21% ≥1 rib #
Mechanism:
• Motor vehicle-related trauma: 57-79%
• Fall from standing: 16-23%
5
Flagel et al. Surgery. 2005;138(4):717-25 Ziegler, Agarwal. J Trauma. 1994;37(6):975-979.
Cameron et al. Aust NZ J Surg. 1996;66(8):530-534 Sirmali et al. Eur J Cardiothorac Surg. 2003;24(1):133-38
Dehghan et al. J Trauma. 2014;76(2):462-68

6. Mortality Associated with Rib Fractures
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2003: 5.7%
1996: 9.8%
1999: 4%

7. 7
J Trauma 2003. Kerr-Valentic et al.
Patients:
•Prospective evaluation of 40 patients out to 120 days
•18 patients ≤2 rib #; 22 patients ≥3 rib fractures
•Compared to a chronically ill reference population
Results:
•At 30 days, 70% still using narcotics
•As a group, more disabled at 30 days
•Mean lost work days: 70

8. • Retrospective cohort study
• Trauma patients admitted with AISThorax≥3 and included in VSTR
• Excluded patients undergoing surgical fixation
Results:
• Patients had a clinically significant decrease in QoL out to 24
months: 56% isolated chest injury, 70% multi-trauma had less than
good recovery
• Only 59% had returned to work at 6 months
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Marasco et al. Injury. 2015;46(1):61-65

9. Mortality Associated with Rib Fractures
Rib fractures occur in isolation in only 6-13% patients
• PTHx, HTHx, H-PTHx: 32-72%
• Pulmonary contusions: 17-26%
Mortality in trauma determined by a number of factors:
• Patient demographics and co-morbidities
• Injuries sustained and severity (ISS)
• Treatment
Correlation between mortality and:
• Number of ribs fractured
• Chest wall stability
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Flagel et al. Surgery. 2005;138(4):717-25 Cameron et al. Aust NZ J Surg. 1996;66(8):530-534
Barnea et al. Can J Surg. 2002;45(1):43-46 Bulger et al. J Trauma. 2000;48(6):1040-6
Dehghan et al. J Ortho Trauma. 2018;32(1):15-21 Sirmali et al. Eur J Cardiothorac Surg. 2003;24(1):133-38
Ziegler, Agarwal. J Trauma. 1994;37(6):975-979

10. Flail Chest Wall Injury
Flail chest wall injury:
• ≥3 sequential ribs, fractured in ≥2 places each
• Incidence (Alfred):
- 2% of all trauma admissions (Approximately 80 per year)
- 10% of all patients ≥1 rib #
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11. Flail Chest Wall Injury and Associated Morbidity
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3,467 patients with flail chest injury: (2007-2009)
• 54% associated lung contusions
• Intubation and ventilation required in 59% (mean 12.1 days)
• 82% required ICU (mean 11.7 days)
• Mean hospital stay overall: 16.6 days
Dehghan et al. J Trauma. 2014;76(2):462-468

12. Flail Chest wall Injury and Associated Mortality
Mortality:
• Flail chest wall injury: 9.5%
• Multiple rib fractures without flail: 3.4%
• Single rib or sternal fracture: 1.3%
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Dehghan et al. J Ortho Trauma. 2018;32(1):15-21

13. Surgical Stabilisation of Rib Fractures
First described over 50 years ago:
• 1950’s: wire suture fixation and intramedullary wire fixation
Potential use recognised in the setting of:
• Severe chest wall defects and deformity
• Prolonged mechanical ventilation
• Cases where thoracotomy was indicated for other reasons
Increased use over the last 10-15 years associated with:
• Recognition of significant short and longer term complications
of flail chest injury
• Development of rib-specific fixation devices and systems
13

14. Surgical Stabilisation of Rib Fractures
Aim to:
• Restore mechanical integrity
• Reduce the pain associated with spontaneous ventilation
Resulting in:
• Reduced need for prolonged mechanical ventilation and
tracheostomy
• Reduced incidence of complications associated with flail chest
injury
• Reduced length of stay: ICU, hospital, rehabilitation
• Improved quality of life
• Health system cost savings
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15. Randomised Controlled Trials
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Tanaka et al. 2002. J Trauma;52(4):727-32 Granetzny et al. Int Card Thor Surg. 2005;4(6):583-87
Marasco et al. J Am Coll Surg. 2013;216(5):924-32

16. RCT: Summary of Findings. Tanaka
• Judet strut.
• N=37 (18 operative, 19 non-operative)
• MV decreased: 18 to 11 days
• ICU LOS decreased: 27 to 17 days
• Need for trache at D21 decreased: 79% down to 17%
• Incidence of pneumonia (out to D21) decreased: 90% v’s 22%
• Improvement in spirometry
• Cost savings: US$23,423 down to US13,455 per patient
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Limitations:
• Small study
• Single institution
• Outcomes for non-operative group were
sub-optimal by standards at the time.

17. RCT: Summary of Findings. Granetzney
• Kirschner and stainless steel wires.
• N= 40 (20 non-operative, 20 operative)
• Non-operative Mx involved strapping and packing chest wall
Outcomes:
• Decreased MV: 12 to 2 days (mean)
• Decreased ICU LOS: 14.6 to 9.6 (mean)
• Decreased hospital LOS: 23 to 12 days (mean)
• Decreased incidence of pneumonia
• Improved spirometry
• No significant difference in mortality: 15 v’s10%
Limitations:
• Outdated techniques (both arms)
• Small study
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18. RCT: Summary of Findings. Marasco
• Inion resorbable (vicryl) plates and bicortical screws
• N=46 (23 operative, 23 non-operative)
• Decrease hours in ICU: 456 down to 317 (mean)
• Decreased need for trache: 70% down to 39%
• Decreased hours of non-invasive ventilation: 67 down to 22
(mean)
• Decrease in 5 days in ICU resulted in a cost saving per
operation of A$14,443.
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Limitations:
• Single institution
• Obsolete technique
• Small study

19. RCT: Summary
• Three studies show early clinical
benefits of operative fixation of rib
fractures in selected patients
• Two studies demonstrated a
significant cost saving for patients
managed with operative fixation
• Two studies showed improved
spirometry results post-discharge,
after operative fixation
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20. Subsequent Publications
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• Meta-analysis of the only 3 randomised trials
• 123 patients in total
• Surgical v’s non-surgical treatment of flail chest
• No evidence that surgery improves mortality
• ‘…there is some evidence that surgical intervention is superior
to non-surgical intervention in the tratment of flail chest.’
Cataneo et al. Cochrane Database of Systematic Reviews 2015. (7).
Cochrane Databaseof SystematicReviews
Surgical versusnonsurgical interventionsfor flail chest
(Review)
Cataneo AJM, Cataneo DC, deOliveiraFHS, Arruda KA, El Dib R, deOliveiraCarvalho PE
Cataneo AJM, Cataneo DC, de Oliveira FHS, Arruda KA, El Dib R, de Oliveira Carvalho PE.
Surgical versusnonsurgical interventionsfor flail chest.
CochraneDatabaseof SystematicReviews 2015, Issue7. Art. No.: CD009919.
DOI: 10.1002/14651858.CD009919.pub2.
www.cochranelibrary.com
Surgical versus nonsurgical interventions for flail chest (Review)
Copyright © 2015The CochraneCollaboration. Published by John Wiley &Sons, Ltd.
Cochrane Review
2015

21. Subsequent Publications
• Improvement in clinical outcomes: ventilator time, ICU LOS,
hospital LOS, pneumonia and need for tracheostomy.
• Average total costs and QALY:
Non-operative: US$8,629 with average of 30.84 QALY
Operative: US$23,682 with average of 32.60 QALY
• Incremental cost effectiveness ratio (ICER): US$8577/QALY
(Threshold often quoted is US$50,000)
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Swart et al. J Ortho Trauma. 2017;31:64-70

22. Subsequent Publications
• Large retrospective cohort study: n=117,204 (2004-2015)
- Flail injury: 1.5%; (mortality: 9.5%)
- Multiple # wo flail: 40.6%; (mortality: 3.4%)
- Single rib or sternum #: 57.9% (mortality: 1.3%)
• Surgical fixation: 4.5%
• Mortality significantly lower in flail patients who had surgery:
- 2.6% v’s 9.8% (30 days)
- 8% v’s 17% (2 years)
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Dehghan et al. J Ortho Trauma. 2018;32(1):15-21

23. Subsequent Publications
• Mortality in patients with flail chest injury was 3 times that of
patients with multiple fractures though no flail- associated
improvement in mortality to that of non-flail patients after
surgery
• Author’s conclusion: “Chest wall instability may be an even
more important prognostic factor than the number of fractured
ribs”.
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Dehghan et al. J Ortho Trauma. 2018;32(1):15-21

24. National Guidelines: NHS 2010
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‘Current evidence on insertion of metal rib
reinforcements to stabilise a flail chest wall is limited in
quantity but consistently shows efficacy. In addition
there are no major safety concerns….’

25. National Guidelines: EAST 2016
Kasotakis et al. J Trauma. 2017;82(3):618-26
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26. National Guidelines: EAST 2016
PICO Question 1:
In adult patients with flail chest after blunt trauma, should rib
ORIF be performed (versus non-operative management) to
decrease mortality, duration of ventilation, ICU and hospital LOS,
incidence of pneumonia and tracheostomy and improve pain
control?
Recommendation:
• In adult patients with flail chest after blunt trauma, conditionally
recommend rib ORIF to decrease mortality, shorten duration of
mechanical ventilation, ICU LOS and hospital LOS, decrease
the incidence of pneumonia and decrease the need for
tracheostomy.
• Cannot offer a recommendation for pain control with current
evidence.
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27. National guidelines: EAST 2016
PICO Question 2:
In adult patients with non-flail rib fractures after blunt trauma,
should rib ORIF be performed (versus non-operative
management) to decrease mortality, duration of mechanical
ventilation, ICU and hospital LOS, incidence of pneumonia and
tracheostomy and improve pain control?
Recommendation:
• For patients with non-flail rib fractures after blunt trauma,
cannot offer a recommendation with the currently available
evidence.
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28. Recent Trends in Use of Surgical Stabilisation
• NTDB 2007-2014; all patients with rib fractures
• 687,137 patients- 29,981 had surgical fixation (4.36%)
• Surgical fixation increased by 36% annually
- Flail: 5.6% to 16.7%
- Non-flail: 3.8% to 4.7%
• Over 96% of patients undergoing rib fixation had a non-flail
pattern of injury
• In-hospital mortality lower for surgical patients: 1.58% v’s 5.3%
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Kane et al. J Trauma. 2017;83(6):1047-52

29. Long-Term Outcomes and Quality of Life
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• Retrospective review of patients with multiple fractured ribs
• Major trauma admitted into the Alfred and entered onto the
VSTR
• Surgical fixation v’s non-operative management
Primary outcomes:
• QoL at 6, 12 and 24 months
• GOS-E, SF-12, numerical pain questionnaire.
• Return to work
Marasco et al. Injury. 2019;50(1):119-124.

30. Long-Term Outcomes and Quality of Life
Results:
• 40 month period 2012-2015
• n=1482; rib fixation=67 (4.5%)
• Mortality 2.1%
• Follow-up: 87%(6); 85%(12); 63%(24)
GOS-E: (whole group)
• Good recovery (7-8): 36%(6); 37%(12); 38%(24)
Any pain:
• 49%(6); 43%(12); 43%(24)
Return to work: 58%
After multi-variable analysis over 24 months, there was no
significant difference in QoL between the operative and
non-operative groups.
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31. Patient Selection: where to from here?
Challenges:
• Poor long-term QoL not improved with surgery
• Increased use in non-flail chest wall injury, despite lack
of evidence or conditional recommendation
• Increase in real numbers of elderly trauma patients
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32. Current Randomised Controlled Trial
Operative fixation of displaced, painful rib fractures –
outcomes and quality of life
• Non-ventilated patients
• Randomised & controlled
• Multi-centre
Hypothesis:
• Patients with multiple, painful, displaced fractured ribs
undergoing surgical fixation will have significantly less
acute and chronic pain and significantly improved long
term functional outcomes and quality of life compared to
patients undergoing non-surgical intervention
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33. RCT: Non-Ventilated Patients
Primary outcomes:
• Pain and disability at 3 months (SF-12 and McGill pain
questionnaire)
Secondary endpoints:
• Acute pain control and analgesic requirements
• Non-invasive ventilator requirements
• Respiratory complications including requirement for intubation
and MV, ICC insertion, tracheostomy, admission to ICU
• Wound complications
• Hospital LOS
• Mortality
• Discharge destination
• Work or usual activity days lost
• Pain and QoL at 6 and 12 months
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34. RCT: Non-Ventilated Patients
Inclusion Criteria:
• Previously functionally independent patients with multiple,
closed fractured ribs between levels 3 to 10, confirmed on
CXR and CT-chest
• Uncontrolled pain from fractured ribs and/or displaced
fractured ribs
Exclusion criteria:
• Age <18 or >85
• Severe TBI
• Invasive MV
• ARDS
• Uncorrected sepsis or coagulopathy
• Open fractures
• Spinal injuries precluding positioning of patient
• Dependency requiring ADL support
• Known opiate dependency
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35. Rib Fractures: to fix or not to fix?
Evidence supports the use of surgical fixation in patients
with:
• Flail chest wall injury and
• Severely-displaced fractures or
• Thoracic wall pain not controlled with contemporary
multimodal analgesic techniques or
• Unable to be weaned from mechanical ventilation
To minimise need for ventilation, ICU LOS, hospital LOS
To improve complication rates and
To decrease hospital costs
At this stage, surgical fixation does not convincingly
improve long-term quality of life
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36. Rib Fractures: to fix or not to fix?
There are probably benefits from surgical fixation in
selected patients:
• With flail chest who are not ventilator dependent
• With non-flail multiple rib fractures, especially if
displaced and/or painful
Such benefits have only been shown in retrospective
studies.
Patients should ideally be treated within the context of a
clinical trial or by a multi-disciplinary specialised team
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37. Thank-you!
ka.martin@alfred.org.au
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