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

Jonne T H Prins; Esther M M Van Lieshout; Francis Ali-Osman; Zachary M Bauman; Eva-Corina Caragounis; Jeff Choi; D Benjamin Christie 3rd; Peter A Cole; William B DeVoe; Andrew R Doben; Evert A Eriksson; Joseph D Forrester; Douglas R Fraser; Brendan Gontarz; Claire Hardman; Daniel G Hyatt; Adam J Kaye; Huan-Jang Ko; Kiara N Leasia; Stuart Leon; Silvana F Marasco; Allison G McNickle; Timothy Nowack; Temi D Ogunleye; Prakash Priya; Aaron P Richman; Victoria Schlanser; Gregory R Semon; Ying-Hao Su; Michael H J Verhofstad; Julie Whitis; Fredric M Pieracci; Mathieu M E Wijffels

doi:10.1007/s00068-022-01906-1

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

Eur J Trauma Emerg Surg. 2022 Aug;48(4):3327-3338. doi: 10.1007/s00068-022-01906-1. Epub 2022 Feb 22.

Authors

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.

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.

Publication types

Multicenter Study

MeSH terms

Brain Injuries, Traumatic* / complications
Brain Injuries, Traumatic* / therapy
Flail Chest* / surgery
Fracture Fixation, Internal
Humans
Length of Stay
Pneumonia*
Retrospective Studies
Rib Fractures* / complications