Rib Fracture Outcomes for High-Risk Patients Vary by Trauma Capacity

By Lisa Rapaport

March 10, 2021

(Reuters Health) - Two groups of high-risk rib fracture patients, the elderly and those with flail chest, have better outcomes at trauma centers than at non-trauma centers, a U.S. study suggests.

Researchers examined data on 504,085 rib fracture cases from the 2016 National Emergency Department Sample. Overall, 229,762 (46%) of these cases were treated at non-trauma centers.

Compared to elderly patients treated at non-trauma centers, the risk of pneumonia dropped as trauma capacity rose, from level III (odds ratio 0.08) to level I (OR 0.05). The odds of inpatient admission for these patients climbed with increasing trauma capacity, from level III (OR 1.8) to level I (OR 5.2).

Relative to non-trauma centers, trauma centers also were more likely to have patients with flail chest undergo surgical stabilization, with odds steadily increasing from level III (OR 2.2) to level I (OR 4.9).

"Patients with flail chest and other indications for surgical stabilization of rib fractures may benefit from timely transfer to centers capable of performing this surgery, and there should be a low threshold to aggressively monitor and treat elderly patients with rib fractures," said lead study author Dr. Jeff Choi of the department of surgery at Stanford University in California.

Mortality outcomes for elderly patients with multiple rib fractures were generally better at level III and level II trauma centers (OR 0.8-1.2) than at non-trauma centers, but slightly higher at level I centers (OR 1.2-2.0).

For flail chest, mortality odds didn't vary significantly by trauma center designation, but survival was more likely when these patients underwent surgical stabilization for rib fractures, the study also found.

Because almost half of rib fracture patients present to non-trauma centers, it's also critical that evidence-based rib fracture management practices are distributed broadly and adopted widely in the community, Dr. Choi said by email.

One limitation of the study is that the authors lacked data on outcomes after discharge, they note in the American Journal of Surgery. The data set used for the study also designates level IV trauma centers as non-trauma centers.

The skill and experience of surgeons and emergency physicians can also vary, influencing outcomes, said Dr. Ivan Puente, chief of trauma and critical care services at Broward Health and a clinical assistant professor of surgery at the Herbert Wertheim College of Medicine at Florida International University in Miami.

"Non-trauma centers that treat these injuries have the responsibility of providing evidence-based optimal care to their patients," Dr. Puente, who wasn't involved in the study, said by email. "Whether they perform surgery or not, they should have the staff that understands and is comfortable treating patients with rib fractures and pulmonary contusions."

If non-trauma centers do perform surgical stabilization, they should do enough volume to maintain proficiency. Otherwise, patients should be transferred, Dr. Puente said.

"Best practices would be to refer all patients with rib fractures to trained surgeons," said Dr. Nir Hus, a trauma and acute care surgeon at Delray Medical Center at Florida Atlantic University who wasn't involved in the study.

"Most trauma centers currently do not offer chest wall reconstruction services due to lack of trained personnel," Dr. Hus said by email. "It is only in the past few years that open reduction internal fixation of ribs has entered the mainstream discourse amongst trauma surgeons."

SOURCE: https://bit.ly/3v9OLc3 The American Journal of Surgery, online February 15, 2021.