title: A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures.
abstract: BACKGROUND
  Previous studies of surgical stabilization of rib fractures (SSRF) have been limited by small sample sizes, retrospective methodology, and inclusion of only patients with flail chest. We performed a prospective, controlled evaluation of SSRF as compared with optimal medical management for severe rib fracture patterns among critically ill trauma patients. We hypothesized that SSRF improves acute outcomes.
  
  
  METHODS
  We conducted a 2-year clinical evaluation of patients with any of the following rib fracture patterns: flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. In the year 2013, all patients were managed nonoperatively. In the year 2014, all patients were managed operatively. Outcomes included respiratory failure, tracheostomy, pneumonia, ventilator days, tracheostomy, length of stay, daily maximum incentive spirometer volume, narcotic requirements, and mortality. Univariate and multivariable analyses were performed.
  
  
  RESULTS
  Seventy patients were included, 35 in each group. For the operative group, time from injury to surgery was 2.4 day, operative time was 1.5 hours, and the ratio of ribs fixed to ribs fractured was 0.6. The operative group had a significantly higher RibScore (4 vs. 3, respectively, p < 0.01) and a significantly lower incidence of intracranial hemorrhage (5.7% vs. 28.6%, respectively, p = 0.01). After controlling for these differences, the operative group had a significantly lower likelihood of both respiratory failure (odds ratio, 0.24; 95% confidence interval, 0.06-0.93; p = 0.03) and tracheostomy (odds ratio, 0.18; 95% confidence interval, 0.04-0.78; p = 0.03). Duration of ventilation was significantly lower in the operative group (p < 0.01). The median daily spirometry value was 250 mL higher in the operative group (p = 0.04). Narcotic requirements were comparable between groups. There were no mortalities.
  
  
  CONCLUSIONS
  In this evaluation, SSRF as compared with the best medical management improved acute outcomes among a group of critically ill trauma patients with a variety of severe fracture patterns.
  
  
  METHODS
  Therapeutic study, level II.
authors.affiliation: From the Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, University of Colorado School of Medicine, Denver Colorado.
authors.forename: Fredric M
authors.initials: FM
authors.lastname: Pieracci
authors.forename: Yihan
authors.initials: Y
authors.lastname: Lin
authors.forename: Maria
authors.initials: M
authors.lastname: Rodil
authors.forename: Madelyne
authors.initials: M
authors.lastname: Synder
authors.forename: Benoit
authors.initials: B
authors.lastname: Herbert
authors.forename: Dong Kha
authors.initials: DK
authors.lastname: Tran
authors.forename: Robert T
authors.initials: RT
authors.lastname: Stoval
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Johnson
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Carlton C
authors.initials: CC
authors.lastname: Barnett
authors.forename: Clay
authors.initials: C
authors.lastname: Cothren-Burlew
authors.forename: Charles
authors.initials: C
authors.lastname: Fox
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
mesh_terms: D000328:Adult; D000368:Aged; D058109:Airway Management; D005260:Female; D005409:Flail Chest / Q000150:complications / Q000601:surgery*; D005593:Fracture Fixation, Internal; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000209:etiology / Q000628:therapy; D011446:Prospective Studies; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy; D012253:Rib Fractures / Q000150:complications / Q000601:surgery*; D016896:Treatment Outcome