Rib Fractures With Concomitant Spinal Fractures May Benefit From Surgical Stabilization

As recently reported, ¹ blunt traumatic injury remains one of the leading causes of death in the United States. Identifying advances in traumatological practice that can ameliorate the sequelae of blunt traumatic injury, such as rib fractures, is an important response to this injury burden. Complex thoracic trauma in patients suffering rib fractures has been a point of differential practice discussions amongst practitioners. The earliest recorded case of rib fixation (FIX) ² was performed in 1900 by Dr Charles Locke Scudder, and over one-hundred years later, we are still working to decipher which patients will benefit from surgical rib FIX remains a necessary but challenging endeavor. In this interest, we set out to identify: Are patients suffering rib fractures with concomitant spinal fractures (RFWSFs) more likely to receive surgical FIX compared to patients with rib fractures alone (RFWO)? Are there any clinical outcome differences between these 2 groups?

In our retrospective review of all adult patients with rib injuries retrospective review of all adult patients with rib injuries from years 2015 to 2019 were pooled from the National Trauma Data Bank. Patients were grouped by single, multiple, and flail rib fractures. Second, patients were grouped by rib fractures vs rib and spine fractures. All analysis was performed on R version 4.1.2. Mann-Whitney U tests were used for all two-group quantitative variables, and the Kruskal-Wallis test for three-group quantitative variables as all quantitative variables failed normality tests. All categorical variables were tested with chi-squared tests.

In review, 178 818 patients with rib RFWSF met inclusion criteria. 11 989 (6.7%) had flail chest and spinal fractures, 31 726 (17.7%) had single RFWSF, and 135 103 (75.5%) had multiple RFWSF. Multiple rib fractures carried an increased risk of spinal fracture (55%) vs flail chest (42.8%) vs single rib fracture (2.2%). Mortality with surgical FIX RFWSF decreased by 6.1% vs without the surgical fixation (NFIX) group, whereas mortality of FIX of RFWO decreased by 2.2% vs the NFIX group. Ventilator-free days for RFWSF FIX vs NFIX group were 9 vs 5 (P < .001) vs RFWO FIX vs NFIX group were 6 vs 3 (P < .001). Overall hospital length of stay (LOS) and ICU LOS were decreased in FIX groups. Tracking differences in patient selection and clinical outcomes differing by surgical FIX, we were able to determine that patients with RFWSF are more likely to receive surgical FIX compared to patients with RFWO. When interrogating all patients receiving surgical therapy, we found statistically significant benefits in patients suffering RFWSF. First, we were able to determine that FIX RFWSF had a 3.9% mortality reduction compared to FIX RFWO (P < .001). Second, patients in the FIX RFWSF group had more ventilator-free days compared to those in the FIX RFWO group; however, both groups had more ventilator-free days compared to the NFIX patients. Lastly, length of hospital stay and length of ICU stay were reduced in both FIX RFWSF and FIX RFWO groups compared to NFIX patients.

In one sense, we can infer that patients suffering a greater traumatic injury burden are more likely to acquire rib fractures accompanied by spinal injuries. In setting out to better understand which patients should undergo FIX, our retrospective view elucidates here that patients suffering a higher degree of thoracic trauma are more likely to receive surgical rib FIX. Regardless of RFWSF or RFWO, both groups display measurable benefit from surgical intervention compared to the NFIX group. More so, we can see that the FIX RFWSF group has a distinctly more favorable outcome when compared to the FIX RFWO group.

In our attempt to clarify what patients could benefit from rib FIX, we have identified a subgroup of patients that should be at least considered for surgical intervention. RFWSF, however, is just 1 indicator to be considered for surgical candidacy. Limitations to our study are due to its retrospective nature and vulnerable to a significant selection bias. As previously demonstrated,^3,4 challenges surgeons will continue to face are not limited to timing of repair, individual selection, overall degree of injury, ventilator status, concurrent infection, surgical risk, etc. Rib FIX, even when performed in a minimally invasive manner, is an extensive operation, and not without risks that should be seriously considered. It is for this reason that selection of surgical candidacy for patients suffering complex thoracic injuries will need continued investigation.