Rib Plating Versus Nonsurgical Treatment of Flail Chest: Comparison of Adverse Events in More than 12,500 Patients

Guidelines for flail chest, defined as three or more segmental rib fractures, remain largely consensus based with variable supporting evidence. Prior work suggests that surgical management may reduce mortality and pulmonary complications, although existing data are often underpowered and include nonflail fracture patterns.

This retrospective, matched cohort study leveraged the PearlDiver M170 data set. Flail chest was identified using International Classification of Disease codes, and surgical treatment (rib plating) with Current Procedural Terminology codes. Patients with and without surgical treatment were matched (1:4) based on age, sex, and Elixhauser comorbidity index score. Thirty-day and 90-day adverse events (pneumonia, pulmonary embolism, acute respiratory distress syndrome, tracheostomy, and thoracostomy) were compared were compared using univariable analysis and multivariable logistic regression, controlling for age, sex, and Elixhauser comorbidity index. Significance was defined as P < 0.05.

A total of 12,513 patients were identified, of which 11,492 (92%) were managed nonsurgically and 1021 (8%) were managed with surgically. Matching yielded 3921 nonsurgical and 984 surgical patients. On multivariable analysis, surgical management was associated with an increased risk of pneumonia (odds ratios [OR], 1.67), pulmonary embolism (OR, 2.00), and tracheostomy (OR, 3.07) at 30 days. Similar findings persisted at 90 days. No reduction in adverse events was observed with surgical treatment.

This study leveraged a unique database to identify 12,500 flail chest patients and compare postoperative courses following divergent management of these rare injuries. Surgical treatment was less commonly used for flail chest injuries and associated with markedly increased odds of postoperative adverse events.