Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

References

  1. Peek J, Ochen Y, Saillant N, Groenwold RHH, Leenen LPH, Uribe-Leitz T, et al. Traumatic rib fractures: a marker of severe injury A nationwide study using the National Trauma Data Bank. Trauma Surg Acute Care Open. 2020;5:e000441.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Marasco SF, Nguyen Khuong J, Fitzgerald M, Summerhayes R, Sekandarzad MW, Varley V, et al. Flail chest injury-changing management and outcomes. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc. 2023;49:1047–55.

    Article  Google Scholar 

  3. Marro A, Chan V, Haas B, Ditkofsky N. Blunt chest trauma: classification and management. Emerg Radiol. 2019;26:557–66.

    Article  PubMed  Google Scholar 

  4. Hietbrink F, Houwert RM, van Wessem KJP, Simmermacher RKJ, Govaert GAM, de Jong MB, et al. The evolution of trauma care in the Netherlands over 20 years. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc. 2020;46:329–35.

    Article  Google Scholar 

  5. Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: A review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76:462.

    Article  PubMed  Google Scholar 

  6. Geiseler J, Westhoff M. Weaning von invasiver Beatmung. Med Klin Intensivmed Notfallmedizin. 2021;116:715–26.

    Article  Google Scholar 

  7. Wijffels MME, Hagenaars T, Latifi D, Van Lieshout EMM, Verhofstad MHJ. Early results after operatively versus non-operatively treated flail chest: a retrospective study focusing on outcome and complications. Eur J Trauma Emerg Surg. 2020;46:539–47.

    Article  PubMed  Google Scholar 

  8. Tobin MJ. Physiologic Basis of Mechanical Ventilation. Ann Am Thorac Soc. 2018;15:S49-52.

    Article  PubMed  Google Scholar 

  9. Dehghan N, Nauth A, Schemitsch E, Vicente M, Jenkinson R, Kreder H, et al. Operative vs Non-operative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial. JAMA Surg. 2022;157:983.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Liu T, Liu P, Chen J, Xie J, Yang F, Liao Y. A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients With Flail Chest. J Surg Res. 2019;242:223–30.

    Article  PubMed  Google Scholar 

  11. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest. J Am Coll Surg. 2013;216:924–32.

    Article  PubMed  Google Scholar 

  12. Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: a practice management guideline from the eastern association for the surgery of trauma. J Trauma Acute Care Surg [Internet]. 2017;82. Available from: https://journals.lww.com/jtrauma/Fulltext/2017/03000/Operative_fixation_of_rib_fractures_after_blunt.25.aspx. Accessed 6 Jun 2023

  13. Pieracci FM, Schubl S, Gasparri M, Delaplain P, Kirsch J, Towe C, et al. The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures. Injury. 2021;52:1241–50.

    Article  PubMed  Google Scholar 

  14. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical Stabilization of Internal Pneumatic Stabilization? A Prospective Randomized Study of Management of Severe Flail Chest Patients. J Trauma Inj Infect Crit Care. 2002;52:727–32.

    Google Scholar 

  15. Granetzny A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4:583–7.

    Article  PubMed  Google Scholar 

  16. Coughlin TA, Ng JWG, Rollins KE, Forward DP, Ollivere BJ. Management of rib fractures in traumatic flail chest: a meta-analysis of randomized controlled trials. Bone Jt J. 2016;98:1119–25.

    Article  Google Scholar 

  17. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, The PRISMA, et al. statement: an updated guideline for reporting systematic reviews. BMJ. 2020;2021: n71.

    Google Scholar 

  18. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. Rob 2: a revised tool for assessing the risk of bias in randomized trials. BMJ. 2019;366:l4898

  19. Page MJ. Page MJ, Higgins JPT, Sterne JAC. Chapter 13: Assessing the risk of bias due to missing results in synthesis. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from www.training.cochrane.org/handbook. 2022.

  20. Deeks et al. Deeks JJ, Higgins JPT, Altman DG, Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA. Chapter 10: Analysing data and undertaking meta-analyses. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.2,

  21. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64:401–6.

    Article  PubMed  Google Scholar 

  22. Schandelmaier S, Briel M, Varadhan R, Schmid CH, Devasenapathy N, Hayward RA, et al. Development of the Instrument to assess the Credibility of Effect Modification Analyses (ICEMAN) in randomized controlled trials and meta-analyses. CMAJ Can Med Assoc J J Assoc Medicale Can. 2020;192:E901–6.

    Article  Google Scholar 

  23. Thorlund K, Engstrøm J, Wetterslev J, Brok J, Imberger G, Gluud C. User manual for Trial Sequential Analysis (TSA) [Internet]. 2017 [cited 2023 June 6]. Available from: https://ctu.dk/wp-content/uploads/2021/03/2017-10-10-TSA-Manual-ENG_ER.pdf

  24. Wu W-M, Yang Y, Gao Z-L, Zhao T-C, He W-W. Which is better multiple rib fractures, surgical treatment, or conservative treatment? Int J Clin Exp Med. 2015;8:7930–6.

    PubMed  PubMed Central  Google Scholar 

  25. Beks RB, Peek J, de Jong MB, Wessem KJP, Öner CF, Hietbrink F, et al. Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc. 2019;45:631–44.

    Article  Google Scholar 

  26. Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: an overview. Chin J Traumatol. 2020;23:125–38.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Mangram AJ, Sohn J, Zhou N, Hollingworth AK, Ali-Osman FR, Sucher JF, et al. Trauma-associated pneumonia: time to redefine ventilator-associated pneumonia in trauma patients. Am J Surg. 2015;210:1056–62.

    Article  PubMed  Google Scholar 

  28. Hoepelman RJ, Minervini F, Beeres FJP, van Wageningen B, IJpma FF, van Veelen NM, et al. Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: a multicentre prospective cohort study. Front Surg. 2023;10:1156489.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Ho AM-H, Ho AK, Mizubuti GB, Klar G, Karmakar MK. Regional analgesia for patients with traumatic rib fractures: A narrative review. J Trauma Acute Care Surg. 2020;88:e22.

  30. Thorlund K, Engstrøm J, Wetterslev J, et al. User manual for Trial Sequential Analysis (TSA). 2017. http://www.ctu.dk/tsa/files/tsa_manual.pdf. Accessed 6 Jun 2023

  31. Pieracci FM, Coleman J, Ali-Osman F, Mangram A, Majercik S, White TW, et al. A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures. J Trauma Acute Care Surg. 2018;84:1–10.

    Article  PubMed  Google Scholar 

  32. Prins JTH, Wijffels MME, Pieracci FM. What is the optimal timing to perform surgical stabilization of rib fractures? J Thorac Dis [Internet]. 2021 [cited 2023 June 27];13. Available from: https://jtd.amegroups.com/article/view/54550

  33. Divisi D, Mucilli F, Leonardo GD, Zaccagna G, De Vico A, Camplese P, et al. Plates versus struts versus an extracortical rib fixation in flail chest patients: Two-center experience. Injury. 2021;52:235–42.

    Article  PubMed  Google Scholar 

  34. Adereti C, Fabien J, Adereti J, Pierre-Louis M, Chacon D, Adereti V. Rib Plating as an Effective Approach to Managing Traumatic Rib Injuries: A Review of the Literature. Cureus. 2022;14: e29664.

    PubMed  PubMed Central  Google Scholar 

  35. Edwards JG, Clarke P, Pieracci FM, Bemelman M, Black EA, Doben A, et al. Taxonomy of multiple rib fractures: Results of the chest wall injury society international consensus survey. J Trauma Acute Care Surg. 2020;88:e40–5.

    Article  PubMed  Google Scholar 

  36. Battle CE, Evans PA. Predictors of mortality in patients with flail chest: a systematic review. Emerg Med J. 2015;32:961–5.

    Article  PubMed  Google Scholar 

  37. Thiruvenkatarajan V, Cruz Eng H, Adhikary SD. An update on regional analgesia for rib fractures. Curr Opin Anaesthesiol. 2018;31:601–7.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil

    Rafael Oliva Morgado Ferreira, Eric Pasqualotto, Pedro Henrique Siedschlag Schmidt, Leonardo Andrighetti, Matheus Pedrotti Chavez, Felippe Flausino & Getúlio Rodrigues de Oliveira Filho

  2. Joana de Gusmão Children’s Hospital, Florianópolis, Santa Catarina, Brazil

    Felippe Flausino

  3. University of the Extreme South of Santa Catarina, Criciúma, Santa Catarina, Brazil

    Patrícia Viana

Authors
  1. Rafael Oliva Morgado Ferreira
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Eric Pasqualotto
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Patrícia Viana
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pedro Henrique Siedschlag Schmidt
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Leonardo Andrighetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Matheus Pedrotti Chavez
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Felippe Flausino
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Getúlio Rodrigues de Oliveira Filho
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rafael Oliva Morgado Ferreira.

Ethics declarations

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.

Supplementary Information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ferreira, R.O.M., Pasqualotto, E., Viana, P. et al. Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials. Eur J Trauma Emerg Surg 49, 2531–2541 (2023). https://doi.org/10.1007/s00068-023-02339-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-023-02339-0

Keywords

Search

Navigation