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Indications for surgical stabilization of rib fractures in patients without flail chest: surveyed opinions of members of the Chest Wall Injury Society

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Abstract

Purpose

There are currently no evidence-based indications for surgical stabilization of rib fractures (SSRF) in patients without flail chest. The purpose of this survey was to identify patients for whom there is relative equipoise (operative vs. non-operative) in order to assist in designing a randomized clinical trial.

Methods

Members of the Chest Wall Injury Society were sent an online survey, in which 18 patient scenarios were presented. The baseline patient had ≥ three displaced, contiguous fractures and had no other contraindications for surgery. This default scenario was then varied based upon patient age, degree of traumatic brain injury (TBI), fracture series location, and number of abnormal pulmonary physiologic variables (oxygen requirement, respiratory rate, incentive spirometry ability, cough, and numeric pain score).

Results

Thirty respondents provided a total of 540 answers. Overall, the majority of responses were in favor of SSRF (n = 413, 84.1%). Furthermore, the vast majority of responses indicated that some degree of pulmonary compromise was necessary to recommend SSRF (n = 44, 90.4%), with ≥ two abnormal parameters being the most common threshold (n = 156, 31.8%). Decision to recommend SSRF varied significantly by number of abnormal clinical variables, age, and degree of TBI, but not by fracture series location. Patients aged 85 years old and those with moderate TBI were the least likely to be recommended for SSRF, regardless of abnormal pulmonary physiologic variables. The most appropriate cutoff for equipoise appeared to be a patient aged 21–79 years old, with no or mild TBI, ≥ two abnormal pulmonary parameters, and regardless of fracture location (44.8% consensus for SSRF).

Conclusions

SSRF was recommended for most patients with non-flail, displaced rib fractures. However, this recommendation was contingent upon patient age, degree of TBI, and pulmonary clinical status. Results of this survey may be used to inform inclusion criteria for a future randomized, clinical trial.

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Funding

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Authors and Affiliations

  1. Denver Health Medical Center, Denver, CO, USA

    Fredric M. Pieracci

  2. Duke University School of Medicine, Durham, NC, USA

    Suresh Agarwal

  3. Baystate Medical Center, Springfield, MA, USA

    Andrew Doben

  4. University of Pennsylvania School of Medicine, Philadelphia, PA, USA

    Adam Shiroff

  5. St. Mary’s Medical Center, West Palm Beach, FL, USA

    Larwence Lottenberg

  6. Intermountain Medical Center, Salt Lake City, UT, USA

    Sarah Ann Whitbeck & Thomas W. White

Authors
  1. Fredric M. Pieracci
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  2. Suresh Agarwal
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  3. Andrew Doben
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  4. Adam Shiroff
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  5. Larwence Lottenberg
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  6. Sarah Ann Whitbeck
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  7. Thomas W. White
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Contributions

FMP: Study conception, design, data collection, data analysis, manuscript drafting

SA: Study conception, study design, critical revisions

AD: Study conception, study design, critical revisions

AS: Study design, critical revisions

LL: Study design, critical revisions

SAW: Critical revisions

TWW: Study design, critical revisions

Corresponding author

Correspondence to Fredric M. Pieracci.

Ethics declarations

Conflict of interest

FMP: Paid speaker and consultant, DePuy Synthes and Zimmer Biomet

SA: The author declares that they have no conflicts of interest

AD: The author declares that they have no conflicts of interest

AS: The author declares that they have no conflicts of interest

LL: The author declares that they have no conflicts of interest

SAW: The author declares that they have no conflicts of interest

TWW: Paid speaker and consultant, DePuy Synthes and KLS Martin

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Pieracci, F.M., Agarwal, S., Doben, A. et al. Indications for surgical stabilization of rib fractures in patients without flail chest: surveyed opinions of members of the Chest Wall Injury Society. International Orthopaedics (SICOT) 42, 401–408 (2018). https://doi.org/10.1007/s00264-017-3612-1

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  • DOI: https://doi.org/10.1007/s00264-017-3612-1

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