The main respiratory complications that arise from fractured ribs are multifactorial. It is well known that inadequate pain management in these patients leads to complications arising from poor ventilatory function. With an already compromised underlying pulmonary system, this compounds the effect on an already failing system leading to significant pulmonary complications. Rib fractures in the form of flail segments pose a particular problem in this regard.

When one considers an elderly patient with limited Functional Residual Capacity with an underlying diagnosis of chronic obstructive airway disease, the addition of the presence of a flail segment will invariably lead to respiratory embarrassment either acutely and /or lead to pulmonary complications in the form of basal atelectasis and pneumonia.

The main determinants of the rib score generally underpin the number of ribs that are fractured as well as the age of the patient directly correlate with morbidity and mortality. The traditional rib score is the product of the number of breaks and the sides with the addition of the age factor. Our rib score is more detailed and encompasses several other variables that have been thought to indicate a more accurate picture of mortality and morbidity.

It is recognized that if there are four or more fractures that are associated with a higher mortality rate and if there are 7 or more fractures then the mortality rate can be as high as 29%^. In the presence of the flail segment, the mortality rate is noted to be higher at 33% perhaps due to further respiratory embarrassment stemming from the paradoxical movement of the ribs on respiration [1,2].

The data collected from the TARN (Trauma Audit Research Network) registry with individual case reviews over a consecutive period of 12 months, studying patients with rib fractures.

This was done in our Major Trauma Centre in the North West of England.

Inclusion criteria for the study were all patients with rib fractures irrespective of whether it was the primary or secondary diagnosis. The individual patients were tabulated based on their ISS (Injury Severity Score).

This indicates that the most severely injured patients required operative management of their chest wall injuries.

Fig-3: The number of ribs fixed and their indication.

Fig-4: Indications and Length of stay in days (LOS)

Fig-6: The traditional multiple rib fracture pain management algorithm

Traditional Rib Score [3]

Rib fracture Score= (Breaks x Sides) + Age Factor

Rib Score used in our Trust [4]

Age + 1 for every 10 years from aged 10

Ribs + 3 for each fracture

Chronic lung disease + 5

Existing anti-platelet or anti-coagulant use + 4

SaO2 + 2 for each 5% decrease in saturation below 95%

Outcome of scoring

Score 0-10 = CONSERVATIVE

Simple oral analgesia

? safe to discharge home. Review in the knowledge of age and comorbidities.

If pain persists or increases add in a PCA

Score 11-20 = PROGRESSIVE

PCA +/- adjuncts

If unable to take deep breaths or cough consider an epidural or paravertebral catheter

Score 21-30 = AGGRESSIVE

Epidural or paravertebral catheter

Also, consider intrapleural and intercostal blocks

If CPAP indicated for respiratory support level two bed required

Score > 31 = EMERGENT

Epidural or paravertebral catheter

Do not site epidural in a ventilated patient until they are suitable for extubation

As it can be seen that the rib score that the current study use in our Trust is more detailed and incorporates several important patient characteristics that have a direct correlation to patient outcomes. As explained earlier that if the patient has underlying chronic lung disease, any traumatic injuries to the chest would lead to impaired ventilator function leading to complications.

The main confounding factor that the authors identified in the studies available were the varying indications for the procedure.

Indications for operative management [8]

Recommended: ▸

• ≥5 rib flail chest requiring mechanical ventilation;
• Symptomatic non-union;
• Severe displacement was found during a thoracotomy for another reason.

Consider:

• ≥3 rib flail not requiring mechanical ventilation;
• ≥3 ribs with severely displaced fractures (bi-cortical displacement);
• ≥3 ribs with mild to moderate displacement and 50% reduction of expected forced vital capacity percent despite optimal pain management.

Absolute contraindications: Contaminated field.

Relative contraindications:

• Severe lung contusion requiring prolonged mechanical ventilation;
• High cervical spine injury requiring mechanical ventilation.

Pain scores in isolation are not currently being considered [9] as an indication for operative intervention due to the subjectivity and the patient-to-patient variability.

One of the main domains of trauma care that is poorly studied is the follow-up period. Once the patient has had their immediate management and subsequently admitted/transferred for rehabilitation there is usually a loss to follow-up. Not including these results in an incomplete data set and the true impact of any intervention. The length of time and the frequency of follow-up is a matter of debate with some authors purporting a longer period of follow-up with a reduced frequency to gain a true understanding of the intervention.

Historically, there had been an increased uptake of patients undergoing fixation of rib fractures in patients with flail segments in the 1950s in patients with respiratory failure. However, with the increase in uptake of positive pressure ventilation the need for open reduction had reduced. It is only recently that there has been renewed interest in open reduction and internal fixation in patients with multiple rib fractures.

The mainstay management of rib fracture is the provision of adequate analgesia and the prevention of respiratory complications that can all stem from poor ventilatory function amongst other patient factors and injury patterns. Through the decades, surgical stabilization has gained pace and has found its niche in the management of rib fractures.

The reader would agree that this indeed a large study that raises the scope for a detailed in-depth analysis of various factors. The current study has identified that the individual mechanism of injuries that lead to rib fractures can be studied and appropriate primary prevention management strategies implemented. Through this article, we hope the reader would appreciate the scope for a further study comparing the traditional rib score with the new proposed rib fracture score. The current study has appreciated the fact that the traditional rib fracture score does not incorporate the significant factors that significantly contribute to the outcome of the overall rib fracture management.

Through this article, we sincerely hope that the orthopedic surgeons/cardiothoracic surgeons would consider operative interventions in patients that have significant rib fractures but do not necessarily meet the currently proposed criteria. With time we hope that the surgeons would have a lower threshold for operative intervention to maximize patient outcomes. Larger multicentric randomized controlled trials are needed to demonstrate the difference in outcomes in these two groups for comparative analysis.

Dr. D. Chowdhury was the lead author of this project and was involved in the final writing of this article. Dr. P. Okoh and Dr. H. Dambappa was involved in the collection, analysis of the data as well as in writing this article

The authors would like this opportunity to thank the patients and the staff involved in the care of the severely injured patients included in the present study