Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

Jonne T H Prins¹, Esther M M Van Lieshout¹, Francis Ali-Osman², Zachary M Bauman³, Eva-Corina Caragounis⁴, Jeff Choi⁵, D Benjamin Christie 3rd⁶, Peter A Cole^{7

8

9}, William B DeVoe¹⁰, Andrew R Doben¹¹, Evert A Eriksson¹², Joseph D Forrester⁵, Douglas R Fraser¹³, Brendan Gontarz¹¹, Claire Hardman¹⁴, Daniel G Hyatt¹⁰, Adam J Kaye¹⁵, Huan-Jang Ko¹⁶, Kiara N Leasia¹⁷, Stuart Leon¹², Silvana F Marasco^{18

19}, Allison G McNickle¹³, Timothy Nowack⁶, Temi D Ogunleye^{8

9}, Prakash Priya¹⁵, Aaron P Richman²⁰, Victoria Schlanser²¹, Gregory R Semon¹⁴, Ying-Hao Su¹⁶, Michael H J Verhofstad¹, Julie Whitis²², Fredric M Pieracci²³, Mathieu M E Wijffels²⁴

Affiliations

¹ Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
² Department of Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, 85020, USA.
³ Division of Trauma, Emergency General Surgery, Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
⁴ Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
⁵ Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, 94305, USA.
⁶ Department of Trauma Surgery/Critical Care, Mercer University School of Medicine, The Medical Center Navicent Health, Macon, GA, 31201, USA.
⁷ HealthPartners Orthopedics and Sports Medicine, Bloomington, MN, 55420, USA.
⁸ Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, 55455, USA.
⁹ Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, 55101, USA.
¹⁰ Department of Surgery, Riverside Methodist Hospital, Columbus, 43214 OH, USA.
¹¹ Department of Surgery, Saint Francis Hospital, Hartford, CT, 06105, USA.
¹² Division of Trauma and Critical Care, Department of Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA.
¹³ Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, 89102, USA.
¹⁴ Division of Trauma, Department of Surgery, Wright State University/Miami Valley Hospital, Dayton, OH, 45409, USA.
¹⁵ Department of Surgery, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA.
¹⁶ Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, 30059, Taiwan.
¹⁷ Department of Surgery, Denver Health Medical Center, Denver, CO, 80204, USA.
¹⁸ CJOB Department of Cardiothoracic Surgery, The Alfred, Melbourne, Australia.
¹⁹ Department of Surgery, Monash University, Clayton, VIC, Australia.
²⁰ Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
²¹ Department of Trauma/Burn, John H Stroger Hospital of Cook County, Chicago, IL, 60612, USA.
²² Department of Surgery, University of Texas Rio Grande Valley, Doctors Hospital at Renaissance, Edinburg, TX, 78539, USA.
²³ Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, 80204, USA.
²⁴ Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. m.wijffels@erasmusmc.nl.

PMID: 35192003
PMCID: PMC9360098
DOI: 10.1007/s00068-022-01906-1

Multicenter Study

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

Jonne T H Prins et al. Eur J Trauma Emerg Surg. 2022 Aug.

. 2022 Aug;48(4):3327-3338.

doi: 10.1007/s00068-022-01906-1. Epub 2022 Feb 22.

Authors

Affiliations

¹ Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
² Department of Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, 85020, USA.
³ Division of Trauma, Emergency General Surgery, Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
⁴ Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
⁵ Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, 94305, USA.
⁶ Department of Trauma Surgery/Critical Care, Mercer University School of Medicine, The Medical Center Navicent Health, Macon, GA, 31201, USA.
⁷ HealthPartners Orthopedics and Sports Medicine, Bloomington, MN, 55420, USA.
⁸ Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, 55455, USA.
⁹ Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, 55101, USA.
¹⁰ Department of Surgery, Riverside Methodist Hospital, Columbus, 43214 OH, USA.
¹¹ Department of Surgery, Saint Francis Hospital, Hartford, CT, 06105, USA.
¹² Division of Trauma and Critical Care, Department of Surgery, Medical University of South Carolina, Charleston, SC, 29425, USA.
¹³ Department of Surgery, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, 89102, USA.
¹⁴ Division of Trauma, Department of Surgery, Wright State University/Miami Valley Hospital, Dayton, OH, 45409, USA.
¹⁵ Department of Surgery, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA.
¹⁶ Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, 30059, Taiwan.
¹⁷ Department of Surgery, Denver Health Medical Center, Denver, CO, 80204, USA.
¹⁸ CJOB Department of Cardiothoracic Surgery, The Alfred, Melbourne, Australia.
¹⁹ Department of Surgery, Monash University, Clayton, VIC, Australia.
²⁰ Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
²¹ Department of Trauma/Burn, John H Stroger Hospital of Cook County, Chicago, IL, 60612, USA.
²² Department of Surgery, University of Texas Rio Grande Valley, Doctors Hospital at Renaissance, Edinburg, TX, 78539, USA.
²³ Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, 80204, USA.
²⁴ Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands. m.wijffels@erasmusmc.nl.

PMID: 35192003
PMCID: PMC9360098
DOI: 10.1007/s00068-022-01906-1

Abstract

Purpose: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients.

Methods: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern.

Results: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034).

Conclusion: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Keywords: Flail chest; Rib fracture; Surgical stabilization of rib fractures; Thoracic trauma; Traumatic brain injury.

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Conflict of interest statement

PAC reports grants from DepuySynthes, Stryker, AORF, grants from COTA, AONA, OMeGA, OREF, grants from Zimmer-Biomet, Acumed, personal fees from AO Foundation, other from BoneFoams, Inc, grants from KLS Martin, personal fees from Exactech, personal fees from J&J DepuySynthes, outside the submitted work. ARD is a consultant for Zimmer-Biomet. JDF reports an unrestricted research grant from Varian for an investigator-initiated trial. EAE is a paid speaker for Synthes. SFM receives lecture fees from Johnson & Johnson and Zimmer-Biomet. FMP is part of the teaching faculty for KLS-Martin and Zimmer-Biomet. MMEW and EMMVL report grants from the Netherlands Organization for Health Research and Development (ZonMw), DepuySynthes, Stichting Coolsingel, and Ostheosynthesis and Trauma Care Foundation, outside the submitted work. All other authors declare no conflict of interest.

Figures

**Fig. 1**
Study inclusion and exclusion criteria. *CPR* cardiopulmonary resuscitation, CT computed tomography, *GCS* Glasgow Coma Scale, HD hemodynamic, *TBI* traumatic brain injury

**Fig. 2**
Study flow chart. *CPR* cardiopulmonary resuscitation, *GCS* Glasgow Coma Scale, HD hemodynamic, *SSRF* surgical stabilization of rib fractures

See this image and copyright information in PMC

References

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Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

Affiliations

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical