Rib fixation in non-ventilator-dependent chest wall injuries: A prospective randomized trial
Silvana Francesca Marasco1, Zsolt J Balogh, Martin E Wullschleger
1From the Cardiothoracic Surgery Unit (S.F.M., R.S.), The Alfred Hospital; Department of Surgery (S.F.M., M.F., K.M.) and Department of Epidemiology and Preventative Medicine (M.B.), Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria; Department of Traumatology (Z.J.B.), John Hunter Hospital; Discipline of Surgery (Z.J.B.), University of Newcastle, Newcastle, New South Wales; National Trauma Research Institute (M.F.); Trauma Service (M.F., K.M.), The Alfred Hospital, Melbourne, Victoria; Trauma Service (M.E.W., B.P.), Gold Coast University Hospital; School of Medicine (M.E.W.), Griffith University, Southport, Queensland; Trauma Service (J.H.), Westmead Hospital, Westmead; and Westmead Clinical School (J.H.), Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.
Background:
The aim of this study was to assess pain and quality of life (QoL) outcomes in patients with multiple painful displaced fractured ribs with and without operative fixation. Rib fractures are common and can lead to significant pain and disability. There is minimal level 1 evidence for rib fixation in non-ventilator-dependent patients with chest wall injuries. We hypothesized that surgical stabilization of rib fractures would reduce pain and improve QoL during 6 months.
Methods:
A prospective multicenter randomized controlled trial comparing rib fixation to nonoperative management of nonventilated patients with at least three consecutive rib fractures was conducted. Inclusion criteria were rib fracture displacement and/or ongoing pain. Pain (McGill Pain Questionnaire) and QoL (Short Form 12) at 3 and 6 months postinjury were assessed. Surgeons enrolled patients in whom they felt there was clinical equipoise. Patients who were deemed to need surgical fixation or who were deemed to be too well to be randomized to rib fixation were not enrolled.
Results:
A total of 124 patients were enrolled at four sites between 2017 and 2020. Sixty-one patients were randomized to operative management and 63 to nonoperative management. No differences were seen in the primary endpoint of Pain Rating Index at 3 months or in the QoL measures. Return-to-work rates improved between 3 and 6 months, favoring the operative group.
Conclusion:
In this study, no improvements in pain or QoL at 3 and 6 months in patients undergoing rib fixation for nonflail, non-ventilator-dependent rib fractures have been demonstrated.
Level Of Evidence:
Therapeutic/Care Management; Level II.
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01:26Flail Chest-II
Assessment:
1. Clinical Evaluation:
History:
01:24Flail Chest-I
Flail chest is a severe and potentially life-threatening condition characterized by the fracture of three or more adjacent ribs in multiple places. It is most commonly caused by direct impacts and trauma, such as motor vehicle accidents or injuries from a steering wheel impact. It can also occur due to falls in elderly individuals with osteoporosis, or assaults involving sharp objects.
Pathophysiology
The pathophysiology of flail chest is complex, involving fractures of...