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Ferrari, P.A.; , .; Santoru, M.; Riva, L. Management of Advanced Aged Patients with Rib Fractures. Encyclopedia. Available online: https://encyclopedia.pub/entry/22756 (accessed on 27 July 2024).
Ferrari PA,  , Santoru M, Riva L. Management of Advanced Aged Patients with Rib Fractures. Encyclopedia. Available at: https://encyclopedia.pub/entry/22756. Accessed July 27, 2024.
Ferrari, Paolo Albino, , Massimiliano Santoru, Laura Riva. "Management of Advanced Aged Patients with Rib Fractures" Encyclopedia, https://encyclopedia.pub/entry/22756 (accessed July 27, 2024).
Ferrari, P.A., , ., Santoru, M., & Riva, L. (2022, May 10). Management of Advanced Aged Patients with Rib Fractures. In Encyclopedia. https://encyclopedia.pub/entry/22756
Ferrari, Paolo Albino, et al. "Management of Advanced Aged Patients with Rib Fractures." Encyclopedia. Web. 10 May, 2022.
Management of Advanced Aged Patients with Rib Fractures
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This entry is adapted from the peer-reviewed paper 10.3390/traumacare2020008

Rib fractures are painful and disabling injuries found in chest trauma patients. Elderly patients (age > 60 years old) represent the majority of the victims of major trauma, and rib fractures account for 10% of all trauma admissions. Rib fracture management includes operative and non-operative approaches. Conservative treatment generally consists of satisfactory pain control, respiratory assistance, cough strategies, and deep breathing exercises. Surgical fixation in elderly patients seems to result in better outcomes than conservative treatment in terms of shorter hospitalization time, more favorable pain feedback and reduced associated morbidity. 

conservative treatment ribs fractures flail chest elderly population rib fixation

1. Introduction

Rib fractures are painful and disabling injuries found in chest trauma patients. Simple rib fractures typically heal with minimal intervention or consequence, but as the number of fractured ribs increases, the morbidity and mortality rates increase exponentially, particularly among elderly patients [1][2].
Rib fracture management includes operative and non-operative approaches. Conservative treatment generally consists of satisfactory pain control, respiratory assistance, cough strategies, and deep breathing exercises [3]. Patients receiving conservative treatment have fewer complications, a more significant length of hospital stay, and worse functional status after hospitalization [4].
Despite the favorable results emerging from multiple studies reported in the literature, surgical fixation of rib fractures and fluctuating chest injuries has not been used to its full potential [5][6]. Furthermore, it is controversial whether older age patients benefit from surgical fixation.

2. Management of Advanced Aged Patients with Rib Fractures

The data concerning the mortality rate, as reported in Table 1, showed a lower overall weighted mean in the operatively-treated group (3%) compared to conservative-treated patients (8.3%).

Table 1. Studies comparing conservative and operative treatment of rib fractures.
  Authors (Year, Country)
Outcomes   Fitzgerald et al. (2017, USA) [7] Ali-Osman et al. (2018, USA) [7] Kane et al. (2018, USA) [8] Chen Zhu et al. (2020, USA) [9] Pieracci et al. (2021, USA) [10] Cooper et al. (2021, Australia) [11] Christie et al. (2021, USA) [12]
Subjects (number) CT 50 135 392 758 227 280 172
OT 23 64 43 758 133 15 85
Male (%) CT nr 73 (54) nr 518 (68) 116 (51) † 185 (63) nr
OT nr 41 (61) nr 530 (70) 81 (61) nr
Age (IQR/SD) CT 75 (65–97) 72 (66–81) 75.4 ± 6.8 72 (68–79) 86 (80–90) 77 (73–84) 75 (65–100)
OT 68 (63–89) 69 (63–74) 71.3 ± 6.0 72 (68–78) 84 (80–100) 78 (75–83) 74 (65–69)
Rib fractures (IQR/SD) CT nr 5 (3–7) nr nr 5 (1–7) 4 (3–6) nr
OT nr 7 (5–9) nr nr 9 (1–30) 8 (6–12) nr
Flail chest (IQR/SD) CT nr nr nr 348 (46) 36 (16) 42 (15) nr
OT nr nr nr 345 (46) 76 (57) 7 (50) nr
ISS (IQR/SD) CT 19 (14–23) 14 (8–24) 14.1 ± 10.3 nr 13 (4–34) 14 (10–19) 13 (1–38)
OT 21 (16–26) 17.5 (9–25) 20.1 ± 8.5 nr 14 (4–57) 17 (13–29) 20 (9–59)
Mortality (%) CT 2 (4) 13 (10) 33 (8) 55 (7) 21 (9) 27 (10) 18 (10)
OT 0 (0) 1 (2) 1 (2) 32 (4) 10 (8) 0 (0) 4 (5)
Pneumonia (%) CT 7 (14) 16 (12) 54 (14) 8 (1) 9 (4) 25 (10) 20 (12)
OT 0 (0) 5 (8) 2 (5) 23 (3) 16 (12) 2 (13) 0 (0)
MVL (IQR/SD) CT nr 4 (1–10) nr 7 (3–14) nr 5 (2–12) nr
OT nr 3 (1–15) nr 6 (2–13) nr 12 (3–30) nr
ICU-LOS (IQR/SD) CT 12 (7–17) 4 (3–7) 0 (0–3) 4 (2–8) 0 3 (1–6) 10 (1–32)
OT 8 (5–11) 6 (3–10) 5 (0–8) 7 (4–13) 4.5 6 (2–13) 8 (1–11)
IH-LOS (IQR/SD) CT 17 (10–23) 4.8 (3–8) 5 (3–9) 7 (4–12) 6 6.5 (3–13) 8 (1–39)
OT 18 (14–23) 12 (9–16) 12 (10–16) 13 (9–18) 11 12 (9–15) 15 (3–49)
† Overall male distribution; IQR: interquartile range; SD: standard deviation; nr: not reported; CT: conservative treatment; OT: operative treatment; ISS: Injury Severity Score; MVL: mechanical ventilation length; ICU-LOS: intensive care unit-length of stay; IH-LOS: in hospital-length of stay.
Secondary outcomes, such as pneumonia, were reported at a reasonably higher rate in the non-operative patients’ group (9.6% vs. 5.8%).
Historically, the standard of care for rib fractures has been nonoperative management. The choice of nonoperative management may have resulted from a lack of knowledge about fracture fixation techniques among those managing the chest wall injuries in this set of patients. As rib fracture fixation has gained popularity and fixation techniques and implant devices have been refined, the clinical results are encouraging [13]. Operative techniques for rib fixation include rigid devices such as plates, struts, intramedullary nails, malleable Kirschner wires, and sutures. These surgical approaches differ in their safety and efficacy, and the optimal approach has not been determined so far [14]. The evidence supporting rib fracture fixation to improve patient survival statistics and accelerate patient’s recovery to a normal functional state is increasing. Several studies have shown that rib fracture fixation results in reductions in narcotic use, avoidance of tracheostomy, and better quality of life [7][15][16].
Rib fractures are a known threat to the survival of geriatric trauma patients and can adversely affect the recovery and rehabilitation of other injuries. Functional and lifestyle limitations relative to the patient’s baseline are crucial endpoints after chest wall trauma in the elderly population. Along with the age-associated deterioration in global pulmonary function, pain from rib fractures, and subsequent respiratory impairment, rib fractures can alter the survival potential and quality of recovery. Rib plating procedures appear to enhance these outcome measures and should be strongly considered as an adjunct, if not a first-line therapeutic alternative for rib fractures in the geriatric patient population [17].
Elderly trauma patients with rib fractures are currently understudied with few published studies and data defining best practices. With the evolution of plating systems for fixation and chest wall stabilization, the practical paradigm for rib fracture management is shifting as a viable operative intervention now exists [12][17][18][19][20]. The clinical outcomes in this group of patients may be ameliorated by the systematic use of thoracic trauma protocols, anesthetic techniques, and rib-stabilization interventions. A tailored rehabilitation nursing care program has also significantly improved the functional status and quality of life in patients with severe rib fractures at discharge and six-month follow-up, improving the quality of nursing care itself [21]. However, few of these studies have included elderly subjects to date. Therefore, it is unclear whether the results of these studies can be extrapolated to the geriatric trauma population [22].
Considering the available results, surgical fixation in elderly patients seems to result in better outcomes than conservative treatment in terms of shorter hospitalization time, more favorable pain feedback and reduced associated morbidity.

References

  1. Ziegler, D.W.; Agarwal, N.N. The morbidity and mortality of rib fractures. J. Trauma 1994, 37, 975–979.
  2. Moore, E.E.; Feliciano, D.V.; Mattox, K.L. Trauma, 5th ed.; McGraw-Hill: New York, NY, USA, 2004; Chap 25.
  3. Caragounis, E.-C.; Olsén, M.F.; Pazooki, D.; Granhed, H. Surgical treatment of multiple rib fractures and flail chest in trauma: A one-year follow-up study. World J. Emerg. Surg. 2016, 11, 27.
  4. Gordy, S.; Fabricant, L.; Ham, B.; Mullins, R.; Mayberry, J. The contribution of rib fractures to chronic pain and disability. Am. J. Surg. 2014, 207, 659–663.
  5. Richardson, J.D.; Franklin, G.A.; Heffley, S.; Seligson, D. Operative fixation of chest wall fractures: An underused procedure? Am. Surg. 2007, 73, 591–597.
  6. Mayberry, J.C.; Ham, L.B.; Schipper, P.H.; Ellis, T.J.; Mullins, R.J. Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. J. Trauma 2009, 66, 875–879.
  7. Fitzgerald, M.T.; Ashley, D.W.; Abukhdeir, H.; Christie, D.B., 3rd. Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a Level I trauma center. J. Trauma Acute Care Surg. 2017, 82, 524–527.
  8. Ali-Osman, F.; Mangram, A.; Sucher, J.; Shirah, G.; Johnson, V.; Moeser, P.; Sinchuk, N.K.; Dzandu, J.K. Geriatric (G60) trauma patients with severe rib fractures: Is muscle sparing minimally invasive thoracotomy rib fixation safe and does it improve post-operative pulmonary function? Am. J. Surg. 2018, 216, 46–51.
  9. Zhu, R.C.; De Roulet, A.; Ogami, T.; Khariton, K. Rib fixation in geriatric trauma: Mortality benefits for the most vulnerable patients. J. Trauma Acute Care Surg. 2020, 89, 103–110.
  10. Pieracci, F.M.; Leasia, K.; Hernandez, M.C.; Kim, B.; Cantrell, E.; Bauman, Z.; Gardner, S.; Majercik, S.; White, T.; Dieffenbaugher, S.; et al. Surgical stabilization of rib fractures in octogenarians and beyond—what are the outcomes? J. Trauma Acute Care Surg. 2021, 90, 1014–1021.
  11. Cooper, E.; Wake, E.; Cho, C.; Wullschleger, M.; Patel, B. Outcomes of rib fractures in the geriatric population: A 5-year retrospective, single-institution, Australian study. ANZ J. Surg. 2021, 91, 1886–1892.
  12. Christie, D.B.; Nowack, T.E.; Nonnemacher, C.J.; Montgomery, A.; Ashley, D.W. Surgical Stabilization of Rib Fractures Improves Outcomes in the Geriatric Patient Population. Am. Surg. 2022, 88, 658–662.
  13. Swart, E.; Laratta, J.; Slobogean, G.; Mehta, S. Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis. J. Orthop. Trauma 2017, 31, 64–70.
  14. Liu, T.; Liu, P.; Chen, J.; Xie, J.; Yang, F.; Liao, Y. A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients with Flail Chest. J. Surg. Res. 2019, 242, 223–230.
  15. Fitzpatrick, D.C.; Denard, P.J.; Phelan, D.; Long, W.B.; Madey, S.M.; Bottlang, M. Operative stabilization of flail chest injuries: Review of literature and fixation options. Eur. J. Trauma Emerg. Surg. 2010, 36, 427–433.
  16. Schulman, A.M.; Claridge, J.A.; Young, J.S. Young versus old: Factors affecting mortality after blunt traumatic injury. Am. Surg. 2002, 68, 942.
  17. Christie, D.B., 3rd; Nowack, T.; Drahos, A.; Ashley, D.W. Geriatric chest wall injury: Is it time for a new sense of urgency? J. Thorac. Dis. 2019, 11 (Suppl. S8), S1029–S1033.
  18. Bulger, E.M.; Arneson, M.A.; Mock, C.; Jurkovich, G.J. Rib fractures in the elderly. J. Trauma 2000, 48, 1040–1047.
  19. Tanaka, H.; Yukioka, T.; Yamaguti, Y.; Shimizu, S.; Goto, H.; Matsuda, H.; Shimazaki, S. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J. Trauma 2002, 52, 727–732.
  20. Marasco, S.F.; Davies, A.R.; Cooper, D.J.; Varma, D.; Bennett, V.; Nevill, R.; Lee, G.; Bailey, M.; Fitzgerald, M. Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest. J. Am. Coll. Surg. 2013, 216, 924–932.
  21. Santiago, M.G.; Valenza, M.C.; Román, E.P.; López, L.L.; Vigueras, N.M.; Martos, I.C.; Cebrià i Iranzo, M.À. Impacts of tailored, rehabilitation nursing care on functional ability and quality of life in hospitalized elderly patients after rib fractures. Clin. Rehabil. 2021, 35, 1544–1554.
  22. Coary, R.; Skerritt, C.; Carey, A.; Rudd, S.; Shipway, D. New horizons in rib fracture management in the older adult. Age Ageing 2019, 49, 161–167.
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Subjects: Rehabilitation; Surgery
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Paolo Albino Ferrari
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Massimiliano Santoru
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Laura Riva
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Update Date: 11 May 2022
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