Elsevier

Surgery

Volume 138, Issue 4, October 2005, Pages 717-725
Surgery

Central Surgical Association
Half-a-dozen ribs: The breakpoint for mortality

https://doi.org/10.1016/j.surg.2005.07.022Get rights and content

Background

We hypothesized that the number of rib fractures independently impacted patient pulmonary morbidity and mortality.

Methods

The National Trauma Data Bank (NTDB, v. 3.0 American College of Surgeons, Chicago, IL) was queried for patients sustaining 1 or more rib fractures. Data abstracted included the number of rib fractures by International Classification of Diseases-9 code, Injury Severity Score, the occurrence of pneumonia, acute respiratory distress syndrome, pulmonary embolus, pneumothorax, aspiration pneumonia, empyema, and associated injuries by abbreviated injury score, the need for mechanical ventilation, number of ventilator days, intensive care unit (ICU) length of stay (LOS), hospital LOS, mortality, and use of epidural analgesia. Statistical analysis was performed using the Student t test and linear regression analysis. Statistical significance was defined as a P value of less than .05.

Results

The NTDB included 731,823 patients. Of these, 64,750 (9%) had a diagnosis of 1 or more fractured ribs. Thirteen percent (n = 8,473) of those with rib fractures developed 13,086 complications, of which 6,292 (48%) were related to a chest-wall injury. Mechanical ventilation was required in 60% of patients for an average of 13 days. Hospital LOS averaged 7 days and ICU LOS averaged 4 days. The overall mortality rate for patients with rib fractures was 10%. The mortality rate increased (P < .02) for each additional rib fracture. The same pattern was seen for the following morbidities: pneumonia (P < .01), acute respiratory distress syndrome (P < .01), pneumothorax (P < .01), aspiration pneumonia (P < .01), empyema (P < .04), ICU LOS (P < .01), and hospital LOS for up to 7 rib fractures (P < .01). An association between increasing hospital LOS and number of rib fractures was not shown (P = .19). Pulmonary embolism also was not related to the number of rib fractures (P = .06). Epidural analgesia was used in 2.2% (n = 1,295) of patients with rib fractures. A reduction in mortality with epidural analgesia was shown at 2, 4, and 6 through 8 rib fractures. The use of epidural analgesia had no impact on the frequency of pulmonary complications. When stratifying data by Injury Severity Score and the presence or absence of rib fractures the mortality rates were similar.

Conclusions

Increasing the number of rib fractures correlated directly with increasing pulmonary morbidity and mortality. Patients sustaining fractures of 6 or more ribs are at significant risk for death from causes unrelated to the rib fractures. Epidural analgesia was associated with a reduction in mortality for all patients sustaining rib fractures, particularly those with more than 4 fractures, but this modality of treatment appears to be underused.

Section snippets

The National Trauma Data Bank

This study was performed by querying the National Trauma Data Bank (NTDB, v. 3.0).16 The NTDB is the most complete national database for injured patients currently available. It is maintained by the American College of Surgeons and includes data voluntarily submitted by trauma centers of all levels of designation. The data are subjected to quality checks using mechanisms that are part of the National Trauma Registry of the American College of Surgeons software and an additional logistic checks

Results

The NTDB (v 3.0) included 731,823 patients. Of these, 8.85% (n = 64,661) had a diagnosis of rib fracture(s) as identified by ICD-9 codes. Fewer patients, (6.5%; n = 47,658) were identified as having rib fractures using AIS codes. There were a total of 67,221 unique incidents (9.91%) identified by either the ICD-9 or AIS coding systems as having at least 1 rib fracture (Table). By using ICD-9 codes there were 19,295 patients (29.84%) with an unspecified number of fractured ribs, whereas 8,085

Discussion

Fractured ribs are seen as an isolated injury or in conjunction with other injuries in trauma patients. In this series, rib fractures occurred in 9% of all patients reported to the NTDB. This incidence corresponds with the rate observed at single trauma centers and suggests that the trauma centers contributing data to the NTDB are diagnosing this injury accurately.2, 3 When analyzing morbidity and mortality related to rib fractures, many variables must be taken into account. These include age,

Conclusion

Multiple rib fractures are a sign of major injury that correlates with mortality rate and pulmonary morbidity. When 6 or more ribs are fractured, mortality rate and associated injuries to the head and thorax are increased significantly. Epidural analgesia was associated with a reduction in mortality for all patients sustaining rib fractures, particularly those with more than 5 fractures, but appears to be underused.

References (18)

  • E.M. Bulger et al.

    Epidural analgesia improves outcome after multiple rib fractures

    Surgery

    (2004)
  • D.D. Trunkey

    Trauma

    Sci Am

    (1983)
  • D.W. Ziegler et al.

    The morbidity and mortality of rib fractures

    J Trauma

    (1994)
  • E. Bergeron et al.

    Elderly trauma patients with rib fractures are at greater risk of death and pneumonia

    J Trauma

    (2003)
  • P. Cameron et al.

    Rib fractures in major trauma

    Aust N Z J Surg

    (1996)
  • R.M. Shorr et al.

    Blunt chest trauma in the elderly

    J Trauma

    (1989)
  • R.B. Lee et al.

    Three or more rib fractures as an indicator for transfer to a level I trauma center: a population-based study

    J Trauma

    (1990)
  • E.M. Bulger et al.

    Rib fractures in the elderly

    J Trauma

    (2000)
  • M. Palvanen et al.

    Epidemiology of minimal trauma rib fractures in the elderly

    Calcif Tissue Int

    (1998)
There are more references available in the full text version of this article.

Cited by (355)

  • Physiotherapy management of rib fractures

    2023, Journal of Physiotherapy
View all citing articles on Scopus

Presented at the 62nd Annual Meeting of the Central Surgical Association, Tucson, Arizona, March 10-15, 2005.

View full text