Background: We sought to ascertain the extent to which advanced age influences the morbidity and mortality after rib fractures (fxs), to define the relationship between number of rib fractures and morbidity and mortality, and to evaluate the influence of analgesic technique on outcome.
Methods: A retrospective cohort study involving all 277 patients ≥ 65 years old with rib fxs admitted to a Level I trauma center over 10 years was undertaken. The control group consisted of 187 randomly selected patients, 18 to 64 years old, with rib fxs admitted over the same time period. Outcomes included pulmonary complications, number of ventilator days, length of intensive care unit and hospital stay (LOS), disposition, and mortality. The specific analgesic technique used was also examined.
Results: The two groups had similar mean number of rib fxs (3.6 elderly vs. 4.0 young), mean chest Abbreviated Injury Scores (3.0 vs. 3.0), and mean Injury Severity Score (20.7 vs. 21.4). However, mean number of ventilator days (4.3 vs. 3.1), intensive care unit days (6.1 vs. 4.0), and LOS (15.4 vs. 10.7 days) were longer for the elderly patients. Pneumonia occurred in 31% of elderly versus 17% of young (p < 0.01) and mortality was 22% for the elderly versus 10% for the young (p < 0.01). Mortality and pneumonia rates increased as the number of rib fxs increased with and odds ratio for death of 1.19 and for pneumonia of 1.16 per each additional rib fracture (p < 0.001). The use of epidural analgesia in the elderly (LOS >2 days) was associated with a 10% mortality versus 16% without the use of an epidural (p = 0.28). In the younger group (LOS >2 days), mortality with and without the use of an epidural was 0% and 5%, respectively.
Conclusion: Elderly patients who sustain blunt chest trauma with rib fxs have twice the mortality and thoracic morbidity of younger patients with similar injuries. For each additional rib fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27%. As the number of rib fractures increases, there is a significant increase in morbidity and mortality in both groups, but with different patterns for each group. Further prospective study is needed to determine the utility of epidural analgesia in this population.
The elderly population in the United States is steadily increasing and, as a result, so too are the number of elderly trauma victims. Approximately 12% of the current US population is 65 years of age or older, and this number is projected to increase to 21% by 2030. 1 Elderly trauma patients account for 25% of injury fatalities per year and consume 33% of the health care resources spent on trauma care. 2 Therefore, it is apparent that trauma surgeons need to focus attention on the care of this group of patients, particularly with regard to common injuries that can lead to significant morbidity and mortality.
Rib fractures are very common in the blunt trauma population, with a recent review demonstrating that 10% of patients admitted to a Level II trauma center had evidence of rib fractures. Furthermore, the overall mortality for this group was 12%, with a 33% incidence of significant pulmonary complications. 3 In addition, clinical experience suggests that increasing number of rib fractures is associated with increasing patient morbidity and mortality after blunt trauma; however, the strength and pattern of this association has not been well defined.
A key factor in the care of patients with rib fractures is believed to be adequate pain control to allow early aggressive respiratory care and, hence, prevent the development of pulmonary complications. Several different strategies of pain relief have been used, including intravenous narcotics, local rib blocks, pleural infusion catheters, and epidural analgesia. Each of these approaches carries its own set of advantages, disadvantages, and complications. A recent study has supported the use of epidural analgesia in the elderly population, demonstrating decreased morbidity and mortality when compared with intravenous narcotics. 4
The purpose of this study was to examine the extent to which advanced age impacts the morbidity and mortality of rib fractures compared with a younger population with similar injuries. We also sought to define the relationship between increasing number of rib fractures and morbidity and mortality and to evaluate the influence of analgesic technique on outcome.
From the Departments of Surgery and Epidemiology (C.N.M.), Harborview Medical Center (E.M.B., G.J.J.), University of Washington, Seattle, Washington, University of Kansas (M.A.A.), Wichita, Kansas
Address for reprints: Eileen M. Bulger, MD, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104-2499; email: firstname.lastname@example.org.
Submitted for publication September 13, 1999.
Accepted for publication February 1, 2000.
Poster presentation at the 59th Annual Meeting of the American Association for the Surgery of Trauma, September 16–18, 1999, Boston, Massachusetts.