Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review

Jaap Schuurmans, J C Goslings, T Schepers, Jaap Schuurmans, J C Goslings, T Schepers

Abstract

Purpose: Flail chest is a life-threatening complication of severe chest trauma with a mortality rate of up to 15 %. The standard non-operative management has high comorbidities with pneumonia and often leads to extended Intensive Care Unit (ICU) stay, due to insufficient respiratory function and complications. The aim of this literature study was to investigate how operative management improves patient care for adults with flail chest.

Methods: Randomized-controlled trials comparing operative management versus non-operative management of flail chest were included in this systematic review and meta-analysis. PubMed, Trip Database, and Google Scholar were used for study identification. We compared operative-to-non-operative management in adult flail chest patients. Mean difference and risk ratio for mortality, pneumonia rate, duration of mechanical ventilation, duration of ICU stay, duration of hospital stay, tracheostomy rate, and treatment costs were calculated by pooling these publication results.

Results: Three randomized-controlled trials were included in this systematic review. In total, there were 61 patients receiving operative management compared to 62 patients in the non-operative management group. A positive effect of surgical rib fracture fixation was observed for pneumonia rate [ES 0.5, 95 % CI (0.3, 0.7)], duration of mechanical ventilation (DMV) [ES -6.5 days 95 % CI (-11.9, -1.2)], duration of ICU stay [ES -5.2 days 95 % CI (-6.2, -4.2)], duration of hospital stay (DHS) [ES -11.4 days 95 % CI (-12.4, -10.4)], tracheostomy rate (TRCH) [ES 0.4, 95 % CI (0.2, 0.7)], and treatment costs (saving $9.968,00-14.443,00 per patient). No significant difference was noted in mortality rate [ES 0.6, 95 % CI (0.1, 2.4)] between the two treatment strategies.

Conclusions: Despite the relatively small number of patients included, different methodologies and differences in presentation of outcomes, operative management of flail chest seems to be a promising treatment strategy that improves patients' outcomes in various ways. However, the effect on mortality rate remains inconclusive. Therefore, research should continue to explore operative management as a viable method for flail chest injuries.

Keywords: Flail chest; Mortality; Pneumonia; Randomized clinical trials; Surgery; Systematic review.

Conflict of interest statement

Conflict of interest

Tim Schepers, J. Carel Goslings, and Jaap Schuurmans declare that they have no conflict of interest. No funds were used for this systematic review.

Informed consent

Our research consisted of literary research only. Research did not involve human participants or animals.

Figures

Fig. 1
Fig. 1
Risk ratio for mortality in patients with flail chest treated with operative managements versus non-operative management. SD standard deviation, M–H Mantel–Haenszel Method
Fig. 2
Fig. 2
Risk ratio for pneumonia in patients with flail chest treated with operative managements versus non-operative management. SD standard deviation, M–H Mantel–Haenszel Method
Fig. 3
Fig. 3
Difference in duration (days) of mechanical ventilation between operative and non-operative managements in patients with flail chest. SD standard deviation, IV inverse variance
Fig. 4
Fig. 4
Difference in duration (days) of Intensive Care Unit stay between operative and non-operative managements in patients with flail chest. SD standard deviation, IV inverse variance
Fig. 5
Fig. 5
Difference in duration (days) of hospital stay between operative and non-operative managements in patients with flail chest. SD standard deviation, IV inverse variance

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Source: PubMed

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