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A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures

Pieracci, Fredric M. MD, MPH; Lin, Yihan MD; Rodil, Maria; Synder, Madelyne MPH; Herbert, Benoit MD; Tran, Dong Kha MD; Stoval, Robert T. MD; Johnson, Jeffrey L. MD; Biffl, Walter L. MD; Barnett, Carlton C. MD; Cothren-Burlew, Clay MD; Fox, Charles MD; Jurkovich, Gregory J. MD; Moore, Ernest E. MD

Journal of Trauma and Acute Care Surgery: February 2016 - Volume 80 - Issue 2 - p 187–194
doi: 10.1097/TA.0000000000000925
AAST Plenary Papers
Editor's Choice

BACKGROUND Previous studies of surgical stabilization of rib fractures (SSRF) have been limited by small sample sizes, retrospective methodology, and inclusion of only patients with flail chest. We performed a prospective, controlled evaluation of SSRF as compared with optimal medical management for severe rib fracture patterns among critically ill trauma patients. We hypothesized that SSRF improves acute outcomes.

METHODS We conducted a 2-year clinical evaluation of patients with any of the following rib fracture patterns: flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. In the year 2013, all patients were managed nonoperatively. In the year 2014, all patients were managed operatively. Outcomes included respiratory failure, tracheostomy, pneumonia, ventilator days, tracheostomy, length of stay, daily maximum incentive spirometer volume, narcotic requirements, and mortality. Univariate and multivariable analyses were performed.

RESULTS Seventy patients were included, 35 in each group. For the operative group, time from injury to surgery was 2.4 day, operative time was 1.5 hours, and the ratio of ribs fixed to ribs fractured was 0.6. The operative group had a significantly higher RibScore (4 vs. 3, respectively, p < 0.01) and a significantly lower incidence of intracranial hemorrhage (5.7% vs. 28.6%, respectively, p = 0.01). After controlling for these differences, the operative group had a significantly lower likelihood of both respiratory failure (odds ratio, 0.24; 95% confidence interval, 0.06–0.93; p = 0.03) and tracheostomy (odds ratio, 0.18; 95% confidence interval, 0.04–0.78; p = 0.03). Duration of ventilation was significantly lower in the operative group (p < 0.01). The median daily spirometry value was 250 mL higher in the operative group (p = 0.04). Narcotic requirements were comparable between groups. There were no mortalities.

CONCLUSION In this evaluation, SSRF as compared with the best medical management improved acute outcomes among a group of critically ill trauma patients with a variety of severe fracture patterns.

LEVEL OF EVIDENCE Therapeutic study, level II.

Supplemental digital content is available in the text.

From the Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, University of Colorado School of Medicine, Denver Colorado.

Submitted: September 18, 2015, Revised: October 23, 2015, Accepted: November 3, 2015, Published online: November 21, 2015.

This study was presented at the 74th annual meeting of the American Association for the Surgery of Trauma, September 9–12, 2015, in Las Vegas, Nevada.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's website (

Address for reprints: Fredric M. Pieracci, MD, MPH, Trauma and Acute Care Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 777 Bannock St, MC0206 Denver, CO 80206; email:

© 2016 Lippincott Williams & Wilkins, Inc.