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Rib fractures in the elderly: physiology trumps anatomy
  1. Nathan Schmoekel1,
  2. Jon Berguson2,
  3. Jerry Stassinopoulos1,
  4. Efstathios Karamanos3,
  5. Joe Patton1,
  6. Jeffrey L Johnson1
  1. 1 Department of Surgery, Henry Ford Health System, Detroit, USA
  2. 2 Wayne State University School of Medicine, Detroit, USA
  3. 3 Plastic and Reconstructive Surgery, University of Texas Health San Antonio, San Antonio, USA
  1. Correspondence to Dr Nathan Schmoekel, Department of Surgery, Henry Ford Health System, Detroit, MI, USA; nschmoekel{at}


Introduction Rib fractures in elderly patients are associated with increased morbidity and mortality. Predicting which patients are at risk for complications is an area of debate. Current models use anatomic, physiologic or laboratory parameters in isolation to answer this question. The ‘RibScore’ is an anatomic model that assesses fracture severity. Given that frailty is a major driver of adverse outcomes in the elderly, we hypothesize that the combined analysis of fracture severity, physiologic reserve and current pulmonary function are better predictors of respiratory compromise in this population.

Methods This is a retrospective chart review of 263 trauma patients age ≥55 from January 2014 to June 2017. Criteria included blunt mechanism and ≥ 1 rib fracture identified by CT. Variables indicating adverse pulmonary outcomes were defined by: pneumonia, respiratory failure and tracheostomy. Three models were assessed: (1) RibScore, (2) Modified Frailty Index (mFI) and (3) initial partial pressure of carbondioxide (PaCO2).

Results A total of 263 patients met inclusion criteria. 13% developed pulmonary complications. Increased RibScore, mFI and PaCO2 were each statistically associated with risk of complications. Receiver operating characteristics area under the curve analysis of individual models predicted complications with the following concordance statistic (CS): anatomic (RibScore) yielded a CS of 0.79 (95% CI 0.69 to 0.89); physiologic (mFI) yielded a CS of 0.83 (95% CI 0.75 to 0.91) and laboratory (PaCO2) yielded a CS of 0.88 (95% CI 0.80 to 0.95). The PaCO2 had the highest discriminative ability of the three individual models. Combining all three models yielded the best performance with a CS of 0.90 (95% CI 0.81 to 0.97).

Discussion The RibScore maintains discriminative ability in the elderly. However, models based on mFI and PaCO2 individually outperform the RibScore. A combination of all three models yields the highest discriminative ability. This combined approach is best for assessing the severity of rib fractures and prediction of complications in the elderly.

Level of evidence Prognostic Study, Level III.

  • rib fractures
  • frailty
  • elderly
  • respiratory failure

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  • Contributors NS contributed to the conception and final approval of the article. JB contributed to the data collection. JS and EF contributed to the data analysis. JS, JHP and JLJ critically revised the article. NS, JS and JLJ contributed to the design of the work. NS, JS, EF and JLJ contributed to data interpretation. NS, JB and EF contributed to the drafting and revision of the article.

  • Competing interests None declared.

  • Patient consent for publication Not Required

  • Provenance and peer review Not commissioned; externally peer reviewed.

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