Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries

Abstract

Introduction

The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries.

Patients and Methods

In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups.

Results

Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups.

Conclusions

SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

Keywords

surgical stabilization of rib fractures pelvic fracture rib fracture rib fixation trauma

Introduction

Rib fractures are present in approximately 10-15% of patients admitted to the hospital after trauma and in approximately two-thirds of patients with blunt thoracic trauma, representing a substantial financial burden on the healthcare system.^1,2 Rib fractures are associated with increased morbidity and mortality, pneumonia, prolonged mechanical ventilation, and poor quality of life.^1,3 Surgical stabilization of rib fractures (SSRF) has been shown to improve early clinical outcomes compared to best medical management in patients with a variety of severe fracture patterns.^4-6

The indications for SSRF have broadened to include patients with flail chest, multiple severely displaced rib fractures, and failure of non-operative management leading to an exponential rise in the utilization of SSRF.^7-12 The timing of SSRF has also been investigated with studies showing that early SSRF results in shorter hospital length of stay (LOS), intensive care unit (ICU) LOS, and fewer ventilator days.^10,13-20 Some studies have also demonstrated a decreased rate of pneumonia, tracheostomy, and lower hospital costs in patients undergoing early SSRF.^3,10 Little data exists, however, investigating the timing of SSRF in relation to concomitant injuries that require operative intervention, such as pelvic fractures.

Operative pelvic injuries are often perceived to be a relative contraindication to early SSRF due to concern for displacement during positioning, need for additional imaging, and potential clinical decompensation. The objective of this study was to evaluate the feasibility of early SSRF in patients with concomitant non-urgent operative pelvic fractures, hypothesizing that SSRF can be performed early in these patients without a difference in short term outcomes.

Patients and Methods

Study Design and Patient Population

A retrospective review of a prospectively maintained SSRF database was performed at an urban, level I trauma center. All adult patients who underwent SSRF between 2010 and 2020 were screened to identify 2 groups: those who underwent SSRF as the only operative intervention (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group). Patients were excluded if additional operations were performed beyond SSRF and pelvic fixation, had delayed presentation following trauma, or underwent SSRF remote from index trauma admission. Patients in the SSRF + P group were also excluded if they required emergent pre-peritoneal pelvic packing and external fixation of unstable pelvic ring injury (Figure 1).

Non-urgent operative pelvic fractures were chosen a priori due to its higher frequency in patients undergoing SSRF at our institution between 2010 and 2020 compared to other operative injuries. Of all SSRF patients, 9.9% had a non-urgent operative pelvic injury, which was higher than the rate of exploratory laparotomy (8.3%), spine surgery (7.9%), thoracotomy (1.8%), and craniotomy/craniectomy (.4%). Urgent operative pelvic fracture were defined as those requiring immediate operative fixation for fracture-related bleeding.

At our institution, general indications for SSRF include radiographic or clinical flail chest, three or more displaced fractures, 30% or more loss of hemithorax volume as measured by computed tomography (CT) scan of the chest, or any fracture pattern with persistent physiologic/pain derangement despite optimal medical management as defined by Sequential Clinical Assessment of Respiratory Function (SCARF) score of greater than 2. The SCARF score is a physiologic score that ranges from 0 to 4, taking into consideration a patient’s numeric pain score, percent predicted vital capacity using incentive spirometry, respiratory rate, and ability to cough. It has shown to correlate higher scores with an increased risk of pulmonary complications and greater consumption of analgesic medications.²¹

In the absence of other life-threatening injuries and/or hemodynamic instability, SSRF is performed as soon as possible and ideally within 24 hours of injury, utilizing a previously described operative technique.²² The decision for surgery, method of fixation, and the timing of operation for pelvic fractures was conducted at the discretion of the orthopedic trauma surgeons at our institution. Efforts were made for early definitive fixation (within 36 hours of injury) because this has been shown to reduce complications and improve outcomes.^23-28

Data Collected

Demographics and comorbidities collected included age (years), gender, body mass index (BMI), former or current tobacco use, and diagnosis of asthma or chronic obstructive pulmonary disease (COPD). Injury covariates included mechanism of injury, injury severity score (ISS), traumatic brain injury, blunt cerebrovascular injury, injury to face, sternum, clavicle, scapula, spine, pelvis, long bones, solid organs, pneumothorax, or hemothorax. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score on chest CT.²⁹ Severity of rib fractures was assessed using the number of ribs involved, number of fractures, presence of flail segment, bilateral fractures, first rib fracture, and median Rib Score.

Operative variables included time to pelvic fixation, time to SSRF, operative time, number of ribs plated, and number of plates used. Outcomes included SSRF-related complications (return to operative room within 30 days, need for additional procedures, hardware removal, infection), pelvic fixation related complications (return to operating room within 30 days, hardware removal, infection), median hospital and ICU LOS, need for mechanical ventilation, mechanical ventilator days, pneumonia, need for tracheostomy, and in-hospital mortality.

Statistical Analysis

Descriptive analysis was performed for all patients to characterize demographics, injury patterns, operative factors, and clinical outcomes. Univariate analysis was performed between SSRF and SSRF + P groups to identify differences between the 2 groups. Data are presented as median [interquartile range] or frequency (%). Categorical variables were analyzed using the Chi-square or Fisher’s exact test, as appropriate. Continuous variables were analyzed using the Mann-Whitney U test. Statistical analysis was performed using IBM SPSS© version 26 (IBM, Armonk, NY). A two-tailed P-value of less than .05 was considered statistically significant.

Results

A total of 228 patients underwent SSRF at our institution over 11 years, with 154 (67.5%) meeting study inclusion criteria (Figure 1). Of the included 154 patients, 143 (92.9%) underwent only SSRF (SSRF group) and 11 patients (7.1%) underwent non-urgent fixation of pelvic fractures in addition to SSRF (SSRF + P group). The median age for all the patients was 54 years (IQR 42-63), and the majority were male (70.1%). Fall was the most common mechanism of injury (33.1%), and the median ISS was 17 [10-22]. Median number of ribs fractured was 7 [6-10], with 87 patients (56.5%) having a flail segment and 41 patients (26.6%) having bilateral rib fractures. The median Rib Score was 3 (2-4), median time to SSRF was 1 [0-2] days, median number of ribs plated was 4 (3-6), and median operative time was 138 [107-181] minutes. Median hospital LOS was 8 [5-12] days, median ICU LOS was 3 [1-5] days, and median ventilators days was 6 [3-10]. The incidence of pneumonia was 7.1% and in-hospital mortality was 1.3%.

Table 1 shows the univariate comparison between SSRF and SSRF + P groups. There were no differences in baseline demographics between the 2 groups. More patients in the SSRF + P group sustained injuries secondary to motor vehicle, motorcycle, bicycle, and ski accidents (P = .01) and had a higher median ISS (26 vs 17, P < .01) compared to patients in SSRF group. Patients in SSRF + P group had a higher rate of hemothorax (90.9% vs 56.6%, P = .03) and flail segment (90.9% vs 53.8%, P = .02), along with a greater number of ribs fractured (9 vs 7, P = .04). Except for pelvic fractures, there was no difference in rate of injury to other body regions.

Table 1.

Comparison Between Patients Undergoing SSRF (SSRF Group) and Patients Undergoing SSRF and Pelvic Fixation (SSRF + P Group). Values Presented as Median (Interquartile Ranges) or Number (%) as Appropriate.

	SSRF n = 143	SSRF + P n = 11	P-value
Demographics
Age, years	53 (41-62)	57 (51-70)	.21
Gender			1.00
Male	100 (69.9%)	8 (72.7%)
Female	43 (30.1%)	3 (27.7%)
BMI, kg/m²	26 (23-30)	25(22-30)	.66
History of asthma	13 (9.1%)	0 (0%)	.60
History of COPD	7 (4.9%)	0 (0%)	1.00
Current or former smoker	48 (33.6%)	3 (27.3%)	1.00
Injury Characteristics
Mechanism of injury			.01*
MVC/MCC	41 (28.7%)	4 (36.4%)
Auto vs Ped	16 (11.2%)	1 (9.1%)
Auto vs Bike/Ski accident	26 (18.2%)	4 (36.4%)
Fall	51 (35.7%)	0 (0%)
Crush	4 (2.8%)	0 (0%)
GSW	3 (2.1%)	0 (0%)
Other	2 (1.4%)	2 (18.2%)
Traumatic brain injury	13 (9.1%)	2 (18.2%)	.29
Blunt cerebrovascular injury	6 (4.2%)	1 (9.1%)	.41
Facial fracture	13 (9.1%)	1 (9.1%)	1.00
Chest wall injury
Sternal fracture	10 (7.0%)	2 (18.2%)	.21
Clavicle fracture	22 (15.4%)	4 (36.4%)	.09
Scapula fracture	32 (22.4%)	2 (18.2%)	1.00
Pneumothorax	105 (73.4%)	8 (72.7%)	1.00
Hemothorax	81 (56.6%)	10 (90.9%)	.03*
BPC18 score	4 (2-6)	3 (2-7)	.51
Number of ribs fractured	7 (6-10)	9 (8-12)	.04*
Number of fractures	1 (16-14)	15 (12-20)	<.01*
Flail segment	77 (53.8%)	10 (90.9%)	.02*
Bilateral fracture	38 (26.6%)	3 (27.3%)	1.00
First rib fracture	35 (24.5%)	4 (36.4%)	.47
Rib score	3 (2-4)	4 (3-5)	.05
Spine fracture	10 (7.0%)	4 (45.5%)	.11
Pelvic fracture	3 (2.1%)	11 (100%)	<.01*
Long bone fracture	22 (15.4%)	1 (9.1%)	.26
Solid organ injury	17 (10-21)	1 (9.1%)	1.00
Median ISS	10 (7.0%)	26 (21-29)	<.01*
Operative Management
SSRF	143 (100%)	11 (100%)	N/A
Time to fixation, days	0 (0-2)	1 (0-2)	.20
Operative time, mins	137 (105-173)	178 (123-219)	.14
Number of ribs plated	4 (3-5)	5 (4-6)	.05
Number of plates	4 (3-6)	5(5-9)	.03*
Pelvis fixation		11 (100%)
Median time to fixation, days		3 (1-3)
Outcomes
SSRF complications
Return to OR within 30 days	7 (4.9%)	1 (9.1%)	.46
Additional procedure	13 (9.1%)	0 (0%)	.60
Infection	5 (3.5%)	0 (0%)	1.00
Hardware removal	6 (4.2%)	0 (0%)	1.00
Pelvic fixation complications^a
Return to OR within 30 days	—	1 (14.3%)	—
Infection	—	0 (0%)	—
Hardware removal	—	0 (0%)	—
Hospital LOS, days	7 (5-11)	14 (11-17)	<.01*
ICU LOS, days	3 (1-5)	7 (5-8)	<.01*
Mechanical ventilation	30 (21.0%)	6 (54.5%)	.02*
Ventilator days	5 (2-13)	7 (3-8)	.92
Pneumonia	11 (7.7%)	0 (0%)	1.00
Tracheostomy	12 (8.4%)	2 (18.2%)	.26
In-hospital mortality	2 (1.4%)	0 (0%)	1.00

*P < .05.

^aData only available for 7 out of 11 (63.6%) patients.

BMI, body mass index; BPC18, blunt pulmonary contusion 18; COPD, chronic obstructive pulmonary disease; GSW, gunshot wound; ICU, intensive care unit; ISS, injury severity score; LOS, length of stay; MVC, motor vehicle collision; MCC, motorcycle collision; OR, operative room SSRF, surgical stabilization of rib fracture;

There was no difference in time to rib fixation between the SSRF and SSRF + P groups (0 vs 1 day, P = .20). Median operative time and median number of ribs plated were also similar (Table 1). Median time to pelvis fixation was 3 [1-3] days in the SSRF + P group. There was no difference in SSRF-related complications between the 2 groups, however, patients in SSRF + P group had higher hospital LOS (14 vs 7, P < .01), ICU LOS (7 vs 3, P < .01), and need for mechanical ventilation (54.5% vs 21.0%, P = .02). Ventilator days, incidence of pneumonia, and mortality did not differ between the 2 groups. There was only one complication related to pelvis fixation—return to the operative room within 30 days for hardware adjustment in 1 patient.

Table 2 shows rib fracture and pelvic fracture patterns along with operative details for patients in the SSRF + P group. Eight out of 11 patients (72.7%) underwent SSRF before pelvic fixation during their hospital course (Figure 1). Two patients (18.2%) underwent SSRF concurrently with pelvic fixation; in both cases the pelvis was fixed first by the orthopedic team, followed by SSRF by the trauma team. The only patient who underwent SSRF after pelvic fixation developed an indication for SSRF later in the hospital course after pelvic fixation. As shown in Table 2, patients were able to be positioned as appropriate for SSRF despite a variety of pelvic and acetabular fractures.

Table 2.

Fracture and Operative Details for Patient Undergoing Rib and Pelvic Fixation.

Patient	Number of ribs fractured	Total number of fractures	Days to SSRF	Number of ribs plated	Number of plates used	Ribs fixated	Operative positioning for SSRF	Pelvic fractures	Days to pelvic fixation	Type of pelvic fixation
1	9	14	0	5	7	L Posterior 6-9; L lateral 5, 6, 8	Lateral	L Iliac wing, acetabulum, and inferior pubic ramus	3	ORIF
2	8	13	2	5	5	LAnterolateral 5-7; R anterolateral 5-6	Supine	R Acetabulum with diastasis	3	ORIF
3	7	12	2	4	4	L Lateral 5-8	Lateral	L Acetabulum through anterior and posterior columns	3	ORIF
4	14	22	0	4	5	L Lateral 4-7; L posterolateral 6	Lateral	L acetabulum, iliac wing	2	ORIF
5	12	17	2	4	4	L Lateral 6-9	Lateral	Bilateral acetabula, superior and inferior rami, L sacroiliac diastasis, R sacrum	3	ORIF
6	14	20	2	6	11	R Posterior 3-8; R lateral 3-7	Prone	R Iliac wing, R superior and inferior rami, R pubic root	3	CRPP
7^a	5	11	4	5	5	R Posterior 3-7	Prone	R Iliac wing, R superior and inferior rami, R acetabulum	1	ORIF, CRPP
8	12	20	1	6	6	R Lateral 4-9	Lateral	L Acetabulum	2	ORIF
9	8	12	1	6	9	R Posterior 4-6; R lateral 3-8	Prone and lateral	R Iliac wing, acetabulum, superior and inferior pubic rami, L inferior pubic ramus	3	ORIF
10^b	9	15	1	6	9	R Posterior 4-6, 8-9; R anterolateral 4-7	Prone and lateral	R acetabulum, iliac wing, sacroiliac joint, sacral ala	1	ORIF
11^b,c	8	15	1	5	5	L Lateral 4-8	Lateral	Bilateral sacral ala, L superior and inferior pubic rami	1	CRPP

^aSSRF performed on post-trauma day 4 due to interval displacement of rib fractures and increasing hemothorax; patient also underwent revision of pelvis hardware on POD7 from pelvis fixation.

^bSSRF performed at the same time as pelvic fixation; pelvis fixated first followed by SSRF.

^cPatient returned to operating room on postoperative day 2 for postoperative bleeding from diaphragm laceration.

SSRF – surgical stabilization of rib fracture; L – left; R – right; ORIF – open reduction and internal fixation; CRPP – closed reduction and percutaneous pinning.

Discussion

In this observational study, we found that SSRF can be performed early in the presence of non-urgent operative pelvic injury. The median time to SSRF in patients with an operative pelvic injury in our series was 1 day, and the majority (72.7%) of patients underwent SSRF prior to pelvic fixation. Most patients (54.5%) underwent SSRF within 24 hours of injury, the timeframe that has been associated with the lowest rate of pneumonia and tracheostomy.¹⁰ No differences in pelvic fracture-related or pulmonary complications were observed between SSRF and SSRF + P groups. To our knowledge, this is the first study demonstrating the feasibility of SSRF in the presence of a competing operative pelvic injury.

Early SSRF is associated with decreased hospital and ICU LOS.^3,10 SSRF is sometimes delayed due to fears that the required decubitus or prone positioning would worsen other injuries such as pelvic fractures. Both groups (SSRF and SSRF + P) in our study underwent early SSRF without a difference in median time to SSRF. The SSRF + P group did have a longer hospital and ICU LOS given the greater injury inherent to the defined groups. The SSRF + P group was also had more severe chest injuries with a higher rate of hemothorax, flail segment, and higher medium number of ribs fractured.

Nearly all the patients with SSRF and operative pelvic injuries in our study were able to undergo SSRF prior to, or at the same time as, pelvic fixation without any complications related to pelvic injuries. The only patient who underwent SSRF after pelvic fixation did not have an indication for SSRF upon admission, but later developed interval displacement of rib fractures and increasing hemothorax prompting SSRF. Patients undergoing SSRF were able to be positioned supine, lateral, and prone as appropriate for fixation of targeted fractures despite a variety of pelvic and acetabular fracture patterns, as shown in Table 2.

Patients included in this study were only those with non-urgent pelvic fixation although hemodynamically unstable patient with pelvic injury often undergo pre-peritoneal pelvic packing and external fixation of pelvis.³⁰ Only one such patient was identified, and further studies would be needed to assess the timing of SSRF in relation to pelvic packing and external fixation. Operative pelvic fractures were chosen for this study as they were the most common procedure performed in conjunction with SSRF in our patient population. Other studies are needed to evaluate SSRF timing in relation to additional operative procedures and patients undergoing more than 2 operations.

This study is limited by its small retrospective nature and limited number of patients in the SSRF + P group. The small sample size of this study is likely underpowered to detect differences between these groups of patients. Another limitation of this study is its single center nature which may not be generalizable. The resources and care pathways available at our level 1 center may not be available at other institutions. Although this study was limited to only one other operative injury besides SSRF, polytrauma patients often present with multiple operative injuries, some of which are life-threatening and may require emergent or urgent interventions which may delay SSRF. Another limitation is the inability to control for other confounders, such as the availability of operating room and orthopedic surgeons, as well as patient factors, such as patient preference and medical and pulmonary instability precluding safe operative intervention. Finally, our trauma surgeons are proponents of early SSRF which could represent a potential bias.

Conclusions

Early SSRF, ideally within 24 hours of injury, helps restore pulmonary mechanics and improve pulmonary outcomes.¹⁰ This study has shown that these benefits of early SSRF can be achievable even in patients with a competing non-urgent operative pelvic injury without a difference in operative complications, time on mechanical ventilation, rates of pneumonia, tracheostomy, and in-hospital mortality. No pelvic-fracture related complication were observed related to patient positioning required for SSRF. Furthermore, the benefits of early SSRF may make patients better candidates for earlier definitive pelvic fixation given improved respiratory function. Competing injuries require a multidisciplinary approach in which frequent communication is paramount. Future studies are needed to focus on the timing of SSRF in patients with multiple operative injuries and its impact on outcomes.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Suzanne F.M. van Wijck, MD

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