Clinical outcomes of multiple rib fractures: does age matter?

Eur J Trauma Emerg Surg (2013) 39:605 611 DOI 10.1007/s00068-013-0291-5 ORIGINAL ARTICLE Clinical outcomes of multiple rib fractures: does age matter? H. Abdulrahman I. Afifi A. El-Menyar A. Al-Hassani A. Almadani H. Al-Thani R. Latifi Received: 29 August 2012 / Accepted: 8 April 2013 / Published online: 23 April 2013 Ó Springer-Verlag Berlin Heidelberg 2013 Abstract Purpose To evaluate the clinical outcomes of multiple rib fracture due to blunt trauma in young patients, a 3-year retrospective study was conducted. Patients with C3 rib fractures were divided into two groups (group I:\45 years old and group II: C45 years old). Mortality, hospital stay, ventilatory support, chest tubes insertion and associated injuries were studied. Results Of the 902 patients admitted with blunt chest trauma, 240 (27 %) met the inclusion criteria and 72.5 % patients were \45 years old. The most common causes of injury were motor vehicle crash (59 %) and fall (29 %). The Injury Severity Score (ISS) was higher in group I (16 ± 9 vs. 13 ± 6; p = 0.04). Hospital mortality was higher in group II (6 vs. 2 %; p = 0.18). Pneumothorax, haemothorax and ventilatory support were comparable. Patients in group II were more likely to undergo chest tubes insertion (26 vs. 14 %; p = 0.04), while group I had a This paper has been presented, in part, at the Southwestern Surgical Congress 2012 Annual meeting, Terranea Resort, Rancho Palos Verdes, CA, USA, March 25 28, 2012. H. Abdulrahman I. Afifi A. Al-Hassani A. Almadani H. Al-Thani R. Latifi Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar A. El-Menyar (&) Clinical Research, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar e-mail: aymanco65@yahoo.com; TraumaResearch@hmc.org.qa A. El-Menyar Clinical Medicine, Weill Cornell Medical College, Doha, Qatar R. Latifi Department of Surgery, Arizona University, Tucson, AZ, USA significantly higher incidence of associated abdominal injuries (25 vs. 12 %; p = 0.03). Conclusion Old age presenting with rib fractures is associated with higher mortality in comparison to young age; however, this difference becomes statistically insignificant in the presence of multiple rib fracture. Keywords Age Introduction Multiple rib fracture Blunt chest trauma Chest injury is commonly reported in up to 50 % of multitrauma patients and is responsible for 25 % of trauma mortality [1]. Rib fractures are among the most common chest injuries encountered (around two-thirds of patients with chest trauma); however, the true incidence of rib fractures is not well defined, and is estimated to be around 10 % [1 3]. Despite the high incidence of rib fractures among injured patients, the literature on this subject is scarce [3]. In Qatar, blunt trauma secondary to motor vehicle crashes (MVCs) is very high; however, to the best of our knowledge, few reports on the incidence and outcome of rib fractures from our region are available so far [4]. The outcome of rib fracture is complex, as they are a sentinel injury and are also important indicators of associated injuries, such as intra-thoracic, abdominal or skeletal injuries [4 6]. The number of fractured ribs has different implications; for example, the fracture of C3 ribs has been used as an indication to admit the patient to the trauma centre [7] and the fracture of C6 ribs was identified as the break point for mortality of these patients [8]. Age is an important determinant of trauma outcome, although there is no consensus

606 H. Abdulrahman et al. on the specific cut-off for age [9]. Moreover, previous data in patients with rib fracture showed that the age cut-off varies [2, 9 13]. These reports suggest that age begins to exert a negative impact on the clinical outcomes as early as 45 years old in the multiple rib fracture setting [12, 13] and, thus, the multiplicity of rib fractures cannot be separated from age-related outcomes [7, 8, 12, 13]. Hence, there is a justifiable need to explore this relationship in patients with multiple rib fractures in all age groups. Method Data were collected retrospectively from the trauma registry database of Hamad General Hospital, the only Level I trauma centre in the state of Qatar, from November 2007 to October 2009. The present study was approved by the Institutional Review Board of Hamad General Hospital. Data collection included patient demographics (age, gender and nationality), mechanism of injury, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), hospital length of stay, pneumonia, need for ventilation, ventilator days, intensive care unit (ICU) length of stay, number of rib fractures and location, presence of haemothorax, pneumothorax, need for chest tubes, need for thoracotomy, associated injuries and mortality. The inclusion criteria were adult patients, above 14 years of age (our local discriminating age between adult and paediatric services), admitted with a diagnosis of multiple rib fracture (C3 ribs) to our trauma centre. Exclusion criteria were patients with significant head injuries, penetrating trauma and those who died within 24 h of admission. The aim of the study was to describe the incidence and outcome of multiple rib fractures, with particular emphasis on the impact of age. The study aimed to focus on those patients who are younger than the previously identified age of 45 years with multiple rib fractures (C3 ribs) and further characterise their injuries, intervention needed (chest tube and intubation and ventilation) and outcome in comparison to the group of patients who are C45 years of age. All patients were immediately assessed and managed using Advanced Trauma Life Support (ATLS) guidelines, attended by our trauma surgeons from the time of admission and diagnosed by a combination of clinical and radiological assessment using chest X-ray and computed tomography (CT) in all cases. Patients were admitted for pain control and respiratory care, including a combination of oral and parenteral analgesia, patient-controlled analgesia (PCA), chest physiotherapy and incentive spirometry. There is no defined clinical pathway or protocol for patient admission to the ICU. The use of epidural analgesia in our hospital is very rare. The study was approved by Medical Research Committee (MRC), HMC, for the analysis and publication of this study [Institutional Review Board (IRB) #9062/11]. Statistical analysis Patients were divided into two groups according to their age (group I: \45 years and group II: C45 years). Data were presented as proportions or mean ± standard deviation (SD), as appropriate. Baseline demographic characteristics, presentation, management and outcomes were compared between the two groups using the Student s t-test for continuous variables and Pearson s Chi-square (v 2 ) test for categorical variables. A significant difference was considered when the p-value was\0.05. Data analysis was carried out using the Statistical Package for the Social Sciences version 18 (SPSS, Inc., Chicago, IL, USA). Results Of the 902 patients admitted with blunt chest trauma during the study period, 240 (27 %) met the inclusion criteria, with a mean age of 38 ± 13 years, 174 patients were under the age of 45 years (group I) and 66 patients were C45 years old (group II). Table 1 shows the demographic and clinical profile of the patients with multiple rib fracture, stratified by age. The majority of patients were male amongst both groups (94.25 vs. 91.0 %; p = 0.52). The most common causes of injury in both groups were MVC (34 vs. 44 %; p = 0.20), followed by fall from height (32 vs. 27 %; p = 0.56) and pedestrian injuries with direct chest trauma (14.3 vs. 6 %; p = 0.12). The median number of rib fractures was 4 (3 11). Patients in group II had a greater number of rib fractures (27 vs. 18 %), but the difference was statistically non-significant (p = 0.21). Furthermore, no differences were observed between the two groups with respect to the side of rib fracture (right, left or bilateral), presence of pneumothorax (41 vs. 42 %; p = 0.92), haemothorax (45 vs. 51 %; p = 0.59) and lung contusion (32 vs. 32 %; p = 0.96). Abdominal injuries in group I were significantly higher when compared to group II (25 vs. 12 %; p = 0.03). The median chest AIS score was comparable in the two groups (p = 0.98). The mean ISS was 15 ± 9 and was higher in group I in comparison to group II (16 ± 9 vs. 13 ± 6; p = 0.04). Table 2 demonstrates the complications and outcome in the two groups. Patients in group II were more likely to undergo chest tube insertion compared to group I (26 vs. 14 %; p = 0.04). Eleven percent of patients required

Rib fractures and age 607 Table 1 Demographic and clinical profile of the patients with multiple rib fracture, stratified by age Group I: patients aged \45 years; group II: patients aged C45 years MVC motor vehicle crash, ISS Injury Severity Score, RF rib fracture, AIS Abbreviated Injury Scale * p-value statistically significant Group I (n = 174) Group II (n = 66) p-value Males 164 (94.25 %) 60 (91.0 %) 0.52 Age (median) 30 (14 44) 52 (45 82) 0.001 Mechanism of injury MVC 59 (34.0 %) 29 (44.0 %) 0.20 Fall 56 (32.0 %) 18 (27.0 %) 0.56 Pedestrian 25 (14.3 %) 4 (6 %) 0.12 Rib fracture site 0.22 Right 68 (39.0 %) 19 (29.0 %) Left 64 (37.0 %) 32 (48.5 %) Bilateral 24 (14.0 %) 9 (14.0 %) RF C6 28 (18 %) 16 (27 %) 0.21 Ribs number (median) 3 (3 11) 4 (3 11) 0.78 Pneumothorax 71 (41.0 %) 29 (42.0 %) 0.92 Haemothorax 79 (45.0 %) 34 (51.0 %) 0.59 Lung contusion 56 (32.0 %) 21 (32.0 %) 0.96 Associated injuries Abdominal 44 (25.0 %) 8 (12.0 %) 0.03* Extremities 35 (20.0 %) 10 (15.0 %) 0.49 Head 45 (26.0 %) 13 (20.0 %) 0.41 Pelvic 22 (13.0 %) 6 (9.0 %) 0.59 Spinal 32 (18.0 %) 7 (11.0 %) 0.21 ISS (mean ± SD) 16 ± 9 13 ± 6 0.04* Chest AIS 3 (1 4) 3 (1 4) 0.98 Table 2 Complications and outcome of the patients with multiple rib fracture, stratified by age Group I (n = 174) Group II (n = 66) p-value Chest tubes 20 (14.0 %) 13 (26.0 %) 0.04* Ventilator 19 (11.0 %) 7 (10.3 %) 0.94 Pneumonia 27 (15.5 %) 10 (15.0 %) 0.94 TICU stay (median and 3 (1 37) 11 (1 35) 0.001* range) Mortality 4 (2.3 %) 4 (6.1 %) 0.18 Group I: patients aged \45 years; group II: patients aged C45 years TICU stay in trauma intensive care unit (days) * p-value statistically significant ventilatory support in group I and 10.3 % in group II (p = 0.94). Pneumonias with positive sputum culture were observed in 37 (15.4 %) patients in the cohort [27 (15.5 %) in group I vs. 10 (15.0 %) in group II; p = 0.94], with different isolates. Two of the deaths in group I were linked to pneumonia, while only one death in group II had documented Acinetobacter pneumonia. The overall length of hospital stay of the patients was comparable in the two groups. However, the median duration of stay in the trauma ICU was significantly higher in group II patients [11 (1 35) vs. 3 (1 37) days; p = 0.001). The mortality rate in the cohort was 3 % (8 patients). In comparison to group I, the hospital mortality rate was non-significantly higher in group II (6.1 vs. 2.3 %; p = 0.18). Discussion The present study demonstrates a high incidence of multiple rib fractures (27 %) in the state of Qatar related to blunt trauma. MVC is the leading mechanism of injury in those patients in all age groups. This incidence exceeds that of previously published reports of 10 % [1 3]. Our diagnosis has been supported by the liberal use of the most sensitive imaging tool, i.e. CT of the chest, in all the cases. Plain chest radiographs may overlook rib fractures in more than 50 % of cases [14, 15]. Radiology reports in the emergency units are often not sufficiently descriptive with respect to the number and location of fractures and, therefore, reliance on these data may lead to erroneous conclusions and underdiagnosis of multiple rib fractures. The young population in Qatar is steadily increasing, a fact that has a great impact on the population pyramid in the state (Fig. 1). This fact may explain

608 H. Abdulrahman et al. the obvious young male predominance (95 %) in our data [16]. The current study used the lowest reported age that determines the outcome of rib fractures (45 years) and the least number of fractured ribs (3 ribs) that requires referral to specialised centres [7, 12, 13]. Consistent with previous reports on rib fractures, our study showed that old age is associated with higher mortality in comparison to young patients; however, in our cohort, this difference was statistically insignificant. This finding may raise the question as to whether the mortality rate has dropped in old age or increased in young age with multiple fractures. There are several reports in the literature on the outcome of rib fracture in relation to age showing that both age and number of rib fractures are the most frequent determinants of outcome (Table 3) [2, 3, 5, 12 14]. A closer look at these reports has shown that the trend for age as a predictor for mortality is in favour of younger age in the recent era. Moreover, morbidity-related age has been reported to be as low as 40 years [17]. Our overall mortality of rib fracture patients (3.3 %) is consistent with the data reported by Testerman [12] (2.3 %). However, a higher mortality rate (20 %) was reported in elderly patients ([65 years of age) [2]. There was no significant difference between the two groups with regard to mortality in our study populations. This may be explained, in part, by the fact that the more rib fractures, the higher the number of associated injuries and the more pulmonary-related complications, such as pneumonia and respiratory failure, which demand ventilatory support and impact mortality much more than the age per se. Our data showed that younger patients had high ISS as well as associated abdominal injuries in comparison to old age patients, which may be related to the more severe multitraumas to which they were subjected. On the other hand, older patients had a higher number of rib fractures and a greater need for chest tubes insertion in comparison to the younger group. Of note, the chest AIS score was comparable in both groups (p = 0.98). Rib fracture pattern and location has been linked to different patterns of injury association; for example, fracture of the upper ribs has been linked to heart and great vessels injury, while fracture of the lower ribs is frequently associated with solid organ injuries; however, this was not the focus of our cohort [4, 6]. The important role of adequate analgesia cannot be overemphasised, as pain is a well known adverse factor of pulmonary function, complications and outcome [18, 19]; however, our data could not clarify this. We stated earlier that the use of epidural analgesia in our institute is very rare. According to Holcomb and others, only 15 % of patients received epidural pain control and showed no decrease in morbidity or mortality. Possible reasons for the lack of frequent use and beneficial effect of epidural pain control include technical difficulty in placement, haemodynamic instability after initiation and early dislodgment with patients movement [2, 13]. Moreover, the thoracotomy rate in the present study was very low, which coincided with earlier reports of lower thoracotomy requirement in rib fracture patients, i.e.\5 % [17, 20]. Fig. 1 Graphical representation of the age and sex distribution of the population in Qatar. Adopted from http://www.nationmaster. com/country/qa-qatar/age- _distribution

Rib fractures and age 609 Table 3 Review of the published studies on the association of rib fractures with age and mortality RF rib fracture, Path pathological fracture, CPR cardiopulmonary resuscitation, Gp group * GpI (no RF), Gp II (1 or 2 RF) ** Gp I, Gp II and Gp III Rib fracture patients Age categories Mortality Testerman [12] 307 (10 %) \45 years with 1 4 RF 0 % \45 years with [4 RF 1.1 % [45 years with 1 4 RF 1.6 % [45 years with [4 RF 4.3 % Holcomb et al. [13] 171 (3 %) 15 44 years with 1 4 RF 1 % 15 44 years with [4 RF 2% C45 years with 1 4 RF 0 % C45 years with [4 RF 4% Livingston et al. [14] 388 with C1 RF Mean age 44 ± 18 years 6 % (22) Present study 240 (27 %) \45 years?c3 RF 2.3 % vs. 6.1 %; p = 0.18 C45 years?c3rf Bulger et al. [2] 187 \65 years (18 64 years) 10 % 277 C65 years 22 % Bergeron et al. [3] 405 (Path and CPR excluded) \65 years (n = 292) All patients: 9.2 % late death [72 h: 2.7 % Isolated chest trauma: 0 % C65 years (n = 113) All patients: 19.4 % late death: 18.6 % Isolated: 14.6 % Shorr et al. [5] Subgroup C1 RF C65 years (n = 40) Overall: 37 % (Path and CPR included) Liman et al. [21] *Gp III: [2 RF 14 59 years (n = 151) 4 % C60 years (n = 98) 9 % Lee et al. [7] (Gp I: no RF, 14 64 1.3, 0.7 and 3.2 %, respectively** Gp II: 1 2 RF and [64 4, 1.4 and 5.5 %, respectively** Gp III: C3 RF) Our results are unique with regard to the overall lower mortality (6 %) among older patients, in addition to the low need for mechanical ventilator and shorter ICU and hospital length of stay, suggesting a low incidence of pneumonia and respiratory failure. In our study, no significant differences in mortality or morbidity were demonstrated between the two groups, with the exception of the need for chest tubes insertion in patients [45 years of age. The higher ISS noticed in group I (\45 years old) patients did not reflect higher mortality. The present study showed that age alone has no impact on the outcome, which is similar to the observations by Testerman [12], who identified the highrisk group in terms of patients aged C45 years with C4 rib fractures. In contrast, Bulger et al. [2] showed a linear relationship between age, rib fractures and outcome, particularly in patients C65 years old with four rib fractures. Moreover, the investigators recommended patients with four rib fractures to be managed at specialised trauma centres. The lack of standard radiologic reports on rib fracture numbers and specifics of fracture patterns, including flail segments and fracture displacement, is one of the limitations of the current study. Other identified limitations in our study included the retrospective nature, the relatively small sample size and exclusion of early death (within 24 h). Furthermore, pneumonia was not well defined in our records. Conclusions Old age presenting with rib fracture is associated with higher mortality in comparison to young age; however, this difference becomes statistically insignificant in the presence of multiple rib fracture. Multiple rib fractures in young as well as in old age are associated with significant complications and should be considered as a high-risk injury by itself, rather than a mere marker of other associated injuries. Furthermore, their management should be approached carefully, with meticulous attention to detail of assessment, appropriate respiratory support and adequate pain control in order to limit their high potential for serious complications and death.

610 H. Abdulrahman et al. Fig. 2 Algorithm for the management of traumatic rib fractures We believe that these data will highlight the clinical significance of multiple rib fracture, prompt the development of specific clinical pathways (Fig. 2) and would certainly support the demand for efficient preventive efforts to minimising traffic- as well as work-related injuries in our society and also globally. Acknowledgments We would like to thank our registry database office for their cooperation. Conflict of interest All the authors have read and approved the manuscript and all have no conflict of interest or financial issues to disclose. References 1. Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37:975 9. 2. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48:1040 6. 3. Bergeron E, Lavoie A, Clas D, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478 85. 4. Al-Hassani A, Abdulrahman H, Afifi I, et al. Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury. Am Surg. 2010;76(8):888 91. 5. Shorr RM, Rodriguez A, Indeck MC, et al. Blunt chest trauma in the elderly. J Trauma. 1989;29(2):234 7. 6. Shweiki E, Klena J, Wood GC, Indeck M. Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients. J Trauma. 2001;50(4):684 8. 7. Lee RB, Bass SM, Morris JA Jr, MacKenzie EJ. Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study. J Trauma. 1990;30(6):689 94. 8. Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138(4):717 23; discussion 723 5. 9. Maull KI. Age and adverse outcomes in rib fracture patients. South Med J. 2006;99:333.

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