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Surgical stabilization bests medical management for rib fractures

Key clinical point: Surgical stabilization of severe rib fractures leads to better outcomes than does best medical management in critically ill trauma patients.

Major finding: Surgery patients were significantly less likely than medically managed patients to experience respiratory failure and tracheotomy (OR, 0.22 and 0.20, respectively).

Data source: A prospective, controlled clinical trial involving 70 patients.

Disclosures: Dr. Pieracci reported serving as a speaker for, and receiving research funding and honorarium from DePuy Synthes.


 

AT THE AAST ANNUAL MEETING

References

LAS VEGAS – Surgical stabilization of severe rib fractures leads to better outcomes than does the best medical management in critically ill trauma patients, findings from a 2-year, single-center, clinical trial suggest.

For example, the likelihood of respiratory failure was significantly lower in 35 patients who underwent surgical stabilization of severe rib fractures (SSRF) than among 35 who received optimal medical management (odds ratio, 0.22), and the likelihood of tracheostomy was also significantly lower with SSRF (OR, 0.20). These findings remained significant after controlling for a significantly higher RibScore – a radiographically derived score that predicts pulmonary outcomes in rib fracture patients – in the surgery group (score of 4 vs. 3 on a 0-6 scale), and for a significantly lower incidence of intracranial hemorrhage in the surgery group (5.7% vs. 28.6%), Dr. Fredric Pieracci reported at the annual meeting of the American Association for the Surgery of Trauma.

Further, the average daily spirometry value was 280 mL higher in the operative group, and there were nonsignificant trends toward a decreased likelihood of pneumonia (20.1% vs. 31.5%, respectively), decreased number of ventilator days (6.4 vs. 10.6), decreased ICU length of stay (8.3 vs. 10.4 days), and decreased hospital length of stay (15.2 vs. 25.3 days).

Narcotic requirements were similar in the groups, and no deaths occurred, said Dr. Pieracci, of Denver Health Medical Center.

The study, which was conducted at a level 1 trauma center from 2013 to 2014, enrolled adult patients with various rib fracture patterns, including 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. Only those who presented within 72 hours of their injury were included.

All eligible patients were managed nonoperatively in the first year of the study, and all were managed operatively in the second year using a standardized technique described recently in the Journal of Trauma and Acute Care Surgery. The nonoperative and operative patient groups were well matched with respect to age, gender, mechanism of injury, preexisting lung pathology, and tobacco use, Dr. Pieracci noted.

“In conclusion, we found that surgical stabilization of severe rib fractures was independently associated with improved pulmonary outcomes, specifically respiratory failure, tracheostomy, duration of mechanical ventilation, and spirometry, and based on this we recommend consideration of surgical stabilization in trauma patients who meet one or more of our inclusion criteria,” he said.

Dr. Pieracci reported serving as a speaker for, and receiving research funding and honorarium from DePuy Synthes.

sworcester@frontlinemedcom.com

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