title: Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review.
abstract: OBJECTIVE
  Flail chest is a life-threatening complication of severe chest trauma with a mortality rate of up to 15 %. The standard non-operative management has high comorbidities with pneumonia and often leads to extended Intensive Care Unit (ICU) stay, due to insufficient respiratory function and complications. The aim of this literature study was to investigate how operative management improves patient care for adults with flail chest.
  
  
  METHODS
  Randomized-controlled trials comparing operative management versus non-operative management of flail chest were included in this systematic review and meta-analysis. PubMed, Trip Database, and Google Scholar were used for study identification. We compared operative-to-non-operative management in adult flail chest patients. Mean difference and risk ratio for mortality, pneumonia rate, duration of mechanical ventilation, duration of ICU stay, duration of hospital stay, tracheostomy rate, and treatment costs were calculated by pooling these publication results.
  
  
  RESULTS
  Three randomized-controlled trials were included in this systematic review. In total, there were 61 patients receiving operative management compared to 62 patients in the non-operative management group. A positive effect of surgical rib fracture fixation was observed for pneumonia rate [ES 0.5, 95 % CI (0.3, 0.7)], duration of mechanical ventilation (DMV) [ES -6.5 days 95 % CI (-11.9, -1.2)], duration of ICU stay [ES -5.2 days 95 % CI (-6.2, -4.2)], duration of hospital stay (DHS) [ES -11.4 days 95 % CI (-12.4, -10.4)], tracheostomy rate (TRCH) [ES 0.4, 95 % CI (0.2, 0.7)], and treatment costs (saving $9.968,00-14.443,00 per patient). No significant difference was noted in mortality rate [ES 0.6, 95 % CI (0.1, 2.4)] between the two treatment strategies.
  
  
  CONCLUSIONS
  Despite the relatively small number of patients included, different methodologies and differences in presentation of outcomes, operative management of flail chest seems to be a promising treatment strategy that improves patients' outcomes in various ways. However, the effect on mortality rate remains inconclusive. Therefore, research should continue to explore operative management as a viable method for flail chest injuries.
authors: Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands. j.schuurmans2@amc.uva.nl.
authors: Jaap
authors: http://orcid.org/0000-0001-7471-8304
authors: J
authors: Schuurmans
authors: Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
authors: J C
authors: JC
authors: Goslings
authors: Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
authors: T
authors: T
authors: Schepers
mesh_terms: D005409:Flail Chest / Q000503:physiopathology / Q000628:therapy*; D005593:Fracture Fixation, Internal / Q000379:methods / Q000401:mortality; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D010147:Pain Measurement; D016032:Randomized Controlled Trials as Topic; D012121:Respiration, Artificial / Q000379:methods; D012253:Rib Fractures / Q000503:physiopathology / Q000628:therapy*; D015996:Survival Rate; D019616:Thoracic Surgical Procedures / Q000379:methods; D016896:Treatment Outcome
keywords: Flail chest; Mortality; Pneumonia; Randomized clinical trials; Surgery; Systematic review