TBL Mini: Rib Fixation

Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomised Clinical Trial 

Dehghan et al. JAMA Surg 2022 doi:10.1001/jamasurg.2022.4299


  • Blunt chest wall trauma has high associated rates of morbidity and mortality
  • RCTs have shown a reduced ICU length of stay in those requiring mechanical ventilation, however this has not been replicated in non-ventilated patients

What did they do?

  • Between 2011 and 2018 in 15 US and Canadian trauma centres patients with either displaced rib fractures and a flail chest or non-flail chest injuries but severe chest wall deformity were randomised to operative fixation (within 96 hours of injury) or standard care (pain management, chest physiotherapy, ventilation as needed)
  • Patients did not have to be invasively ventilated
  • Patients who would likely require prolonged mechanical ventilation (severe TBI, severe airway injuries, severe pulmonary contusions) were excluded
  • The primary outcome was ventilator free days (to day 28)

What did it show?

  • 211 patients were randomised
  • Baseline characteristics including injury mechanism, injury severity score, number of rib fractures and associated thoracic injuries (pneumothorax, contusion) were similar between groups
  • ~40% (n=89) required mechanical ventilation at randomisation and a further~15% (n = 31) patients required mechanical ventilation after randomisation
  • The mean VFDs were 22.7 in the operative group and 20.6 in the non-operative group, with mean difference of 2.1 [95% CI -.03 to 4.5, p = 0.09]
  • Complications including VAP, tracheostomy, empyema and death were similar between groups
  • The subgroup, comparing those mechanically ventilated at randomisation compared to those who were not, favoured rib fixation
    • Both an increase in VFD (with a mean difference of 2.8 days [95% CI 0.1 – 5.5]) and shorter hospital length of stay (mean difference of 1.4 days [95% CI 0.9 – 2.1]) was demonstrated

How does this fit into the other evidence?

  • Although no difference in primary outcome was shown, this large MRCT seems to mirror the benefits shown in earlier trials (Marasco et al, Tanaka et al)
  • Rib fixation in mechanically ventilated patients shows short-term benefits (trend to shorter ventilation, and shorter hospital stays) however no longer-term patient focused outcomes have been demonstrated

External Links

Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial

Rib Fixation: Who, What, When?


Summary Author: George Walker

Summary Date: 28th October 2022

Peer Review Editor: Dave Slessor


Image: Pixabay/Rogue Pixie


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