Surgical management of rib fractures after blunt trauma: a systematic review and meta-analysis of randomised controlled trials

• Published in: Annals of the Royal College of Surgeons of England Vol. 104; no. 4; pp. 249 - 256
• Main Authors: Craxford, S, Owyang, D, Marson, B, Rowlins, K, Coughlin, T, Forward, D, Ollivere, B
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 01-04-2022; Royal College of Surgeons
• Subjects: Bias; Flail Chest - surgery; Humans; Intensive care; Length of Stay; Meta-analysis; Mortality; Ostomy; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Review; Rib Fractures - surgery; Surgery; Systematic review; Trauma; Ventilators; Wounds, Nonpenetrating - complications; Wounds, Nonpenetrating - surgery; flail; Rib; Fractures; Surgical; Non-flailing
• ISSN: 0035-8843; 1478-7083
• DOI: 10.1308/rcsann.2021.0148

Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation for both flail and non-flail rib fractures; the evidence for this has come from largely retrospective studies. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management.
A systematic search of the literature was performed to identify randomised controlled trials (RCTs) comparing surgical stabilisation to non-operative management. Both flail and non-flail injuries were included.
Five RCTs reported the results of 286 patients. Only one study assessed non-flail fractures. The studies were heterogenic in nature and of mixed quality. Surgical stabilisation was associated with a reduction in pneumonia (RR 0.46, 95% confidence intervals (CI) 0.29 to 0.73, I
=42%,
=0.001). The duration of mechanical ventilation (mean difference (MD) -6.3, 95% CI -12.16 to -0.43, I
=95%,
=0.05) and critical care length of stay was also shorter after surgery (mean difference -6.46 days, 95% CI 9.73 to -3.19,
<0.001); however, the overall length of stay in hospital was not (MD -7.18, 95% CI -15.63 to -1.28, I
=94%,
=0.1). No study demonstrated a significant reduction in mortality (RR 0.54, 95% CI 0.18 to 1.8, I
=0%,
=0.28).
Surgical stabilisation of rib fractures is associated with some improved clinical outcomes. Further large RCTs are still needed to confirm if there is also a survival benefit.