Thoracic Trauma in the Elderly

  • T. Robert Qaqish
  • JoAnn Coleman
  • Mark Katlic


Age-related changes to the respiratory system predispose the elderly patient to more severe traumatic injury and may consequently result in a more prolonged and complicated clinical course. Although rib fractures are the most common injury from blunt thoracic trauma, associated injuries such as sternal fractures and/or pulmonary contusions are not uncommonly seen. Deleterious pulmonary sequelae such as respiratory failure and pneumonia often occur in the elderly thoracic trauma patient. Furthermore, the overall incidence of mortality is higher than their younger counterparts when they are equally injured. Although there are a relatively small number of reports supporting the operative management of bony injury (rib/flail chest) to the thorax, the existing literature is promising and should prompt more clinical studies. As the evaluation of the elderly trauma patient becomes a more frequent clinical encounter, those caring for these patients should maintain a high index of suspicion for thoracic injury and a greater appreciation for this population’s intolerance to thoracic trauma.


  1. 1.
    Hanna R, Hershman L. Evaluation of thoracic injuries among older motor vehicle occupants. 2009. Technical Report. NHTSA US DOT HS 811 101.Google Scholar
  2. 2.
    Shelby SG. Delta-v as a measure of traffic conflict severity. 2011.,S.pdf. Accessed 1 June 2016.
  3. 3.
    Rahman I, Morrison D, Donaldson K, MacNee W. Systemic oxidative stress in asthma, COPD, and smokers. Am J Respir Crit Care Med. 1996;154:1055–60.CrossRefPubMedGoogle Scholar
  4. 4.
    Verbeken EK, Cauberghs M, Mertens I, Clement J, Lauweryns JM, Van de Woestijne KP. The senile lung: comparison with normal and emphysematous lungs. Chest. 1992;101:793–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Davies GA, Bolton CE. Age related changes in the respiratory system. In: Brocklehurst’s textbook of geriatric medicine and gerontology. Philadelphia: Elsevier; 2010. p. 97–100.CrossRefGoogle Scholar
  6. 6.
    Anthonisen NR, Danson J, Robertson PC, Ross WR. Airway closure as a function of age. Respir Physiol. 1970;8:58–65.CrossRefGoogle Scholar
  7. 7.
    Gomez CR, Boehmer ED, Kovacs EJ. The aging innate immune system. Curr Opin Immunol. 2005;17:457–62.CrossRefPubMedGoogle Scholar
  8. 8.
    Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37:975–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Lin FC, Li RY, Tung YW, Jeng KC, Tsai SC. Morbidity, mortality, associated injuries, and management of traumatic rib fractures. J Chin Med Assoc. 2016;79(6):329–34.CrossRefPubMedGoogle Scholar
  10. 10.
    Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R, Stombaugh HA. Perils of rib fractures. Am Surg. 2008;74:310–4.PubMedGoogle Scholar
  11. 11.
    Bulger EM, Arneson MA, Mock CN, Jurokovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Bansal V, Conroy C, Chang D, Tominaga GT, Coimbra R. Rib and sternum fractures in the elderly and extreme elderly following motor vehicle crashes. Accid Anal Prev. 2011;43:661–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Lotfipour S, Kaku SK, Vaca FE, Patel C, Anderson CL, Ahmed SS, Menchine MD. Factors associated with complications in older adults with isolated blunt chest trauma. West J Emerg Med. 2009;10:79–84.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Simon BJ, Cushman J, Barraco R, Lane V, Luchette FA, Miglietta M. Pain management guidelines for blunt thoracic trauma. J Trauma. 2005;59:1256–67.CrossRefPubMedGoogle Scholar
  15. 15.
    Karmakar MJ, Ho AM. Acute pain management of patients with multiple rib fractures. J Trauma. 2003;54:615–25.CrossRefPubMedGoogle Scholar
  16. 16.
    Dittmann M, Ferstl A, Wolff G. Epidural analgesia for the treatment of multiple rib fractures. Eur J Intensive Care Med. 1975;1:71–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Pedersen VM, Schulze S, Hoier-Madsen K, Halkier E. Air flow meter assessment of the effect of intercostal nerve blockade on respiratory function in rib fractures. Acta Chir Scand. 1983;149:119–20.PubMedGoogle Scholar
  18. 18.
    Karmakar MJ, Critchley AH, Ho AM, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral infusion of bupivacaine in patients with multiple rib fractures. Chest. 2003;123:424–31.CrossRefPubMedGoogle Scholar
  19. 19.
    Kvalheim L, Reiestad F. Interpleural catheter in the management of postoperative pain. Anesthesiology. 1984;61:A231.CrossRefGoogle Scholar
  20. 20.
    Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001;95:771–80.CrossRefPubMedGoogle Scholar
  21. 21.
    Haenel JB, Moore FA, Moore EE, Sauaia A, Read RA, Burch JM. Extrapleural bupivacaine for amelioration of multiple rib fractures. J Trauma. 1995;38(1):22–7.CrossRefPubMedGoogle Scholar
  22. 22.
    O’Kelly E. Continuous pain relief for multiple fractures ribs. Br J Anaesth. 1981;53:989–91.CrossRefPubMedGoogle Scholar
  23. 23.
    Richardson J, Sabanathan S, Mearns AJ, Shah RD, Goulden C. A prospective randomized comparison of interpleural and paravertebral analgesia in thoracic surgery. Br J Anaesth. 1995;75:405–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Mccool D. Diseases of the diaphragm, chest wall, pleura and mediastinum. In: Goldman L, Schafer AI, editors. Goldman-Cecil Medicine. Philadelphia: Elsevier Health Sciences; 2016. p. 627–37.Google Scholar
  25. 25.
    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(2):462–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Albaugh G, Kann B, Puc MM, Vemurlapalli P, Marra S, Ross S. Age-adjusted outcomes in traumatic flail chest injuries in the elderly. Am Surg. 2000;66:978–81.PubMedGoogle Scholar
  27. 27.
    Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation versus non-operative management of flail chest: a meta-analysis. J Am Coll Surg. 2013;216:302–11.CrossRefPubMedGoogle Scholar
  28. 28.
    Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg. 2013;258(6):914–21.CrossRefPubMedGoogle Scholar
  29. 29.
    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.CrossRefPubMedGoogle Scholar
  30. 30.
    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. 2002;52(4):727–32.PubMedGoogle Scholar
  31. 31.
    Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4(6):583–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Budd JS. Effect of seat belt legislation on the incidence of sternal fractures seen in the accident department. Br Med J (Clin Red Ed). 1985;291(6498):785.CrossRefGoogle Scholar
  33. 33.
    Yeh DD, Hwabejire JO, DeMoya MA, Alam HB, King DR. Sternal fracture – an analysis of the National Trauma Data Bank. J Surg Res. 2014;186(1):39–43.CrossRefPubMedGoogle Scholar
  34. 34.
    Velissaris T, Tang AT, Patel A, Khallifa K, Weeden DF. Traumatic sternal fracture: outcome following admission to a Thoracic Surgical Unit. Injury. 2003;34:924–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Harston A, Roberts C. Fixation of sternal fractures: a systemic review. J Trauma. 2011;71(6):1875–9.PubMedGoogle Scholar
  36. 36.
    Barnea Y, Kashtan H, Skornick Y, Werbin N. Isolated rib fractures in elderly patients: mortality and morbidity. Can J Surg. 2002;45(1):43–6.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Elmistekawy EM, Hammad AA. Isolated rib fractures in geriatric patients. Ann Thor Med. 2007;2(4):166–8.CrossRefGoogle Scholar
  38. 38.
    Mowery NT, Gunter OL, Collier BR, Diaz JJ, Haut E, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma. 2011;70(2):510–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Schweigert M, Beron M, Dubecz A, Stadlhuber AR, Stei H. Video-assisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly. Thorac Cardiovasc Surg. 2012;60(7):474–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Simon B, Ebert J, Bokhari F, Capella J, Emhoff T. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5):S351–61.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgerySinai Hospital of BaltimoreBaltimoreUSA

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