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J Trauma Acute Care Surg. 2017 Mar;82(3):618-626. doi: 10.1097/TA.0000000000001350.

Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma.

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From the Section of Trauma, Acute Care Surgery & Surgical Critical Care, Department of Surgery (G.K.), Boston University School of Medicine, Boston, Massachusetts; Department of Orthopedic Surgery Adult and Trauma Service (E.A.H.), Johns Hopkins Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Department of Surgery (E.W.S.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (N.P., J.J.C.); MetroHealth Medical Center, Cleveland, Ohio; Section of Surgical Sciences, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences (N.P., J.J.C.), Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Vanderbilt Brain Institute, Center for Health Services Research, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee (M.B.P.); Trauma Surgery (L.A.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (P.L.B.), University of Alabama, Birmingham, Alabama; Department of Surgery (J.L.), University of Texas at Houston, Houston, Texas; and Division of Acute Care Surgery, Department of Surgery (E.R.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland.



Rib fractures are identified in 10% of all injury victims and are associated with significant morbidity (33%) and mortality (12%). Significant progress has been made in the management of rib fractures over the past few decades, including operative reduction and internal fixation (rib ORIF); however, the subset of patients that would benefit most from this procedure remains ill-defined. The aim of this project was to develop evidence-based recommendations.


Population, intervention, comparison, and outcome (PICO) questions were formulated for patients with and without flail chest. Outcomes of interest included mortality, duration of mechanical ventilation (DMV), hospital and intensive care unit (ICU) length of stay (LOS), incidence of pneumonia, need for tracheostomy, and pain control. A systematic review and meta-analysis of currently available evidence was performed per the Grading of Recommendations Assessment, Development, and Evaluation methodology.


Twenty-two studies were identified and analyzed. These included 986 patients with flail chest, of whom 334 underwent rib ORIF. Rib ORIF afforded lower mortality; shorter DMV, hospital LOS, and ICU LOS; and lower incidence of pneumonia and need for tracheostomy. The data quality was deemed very low, with only three prospective randomized trials available. Analyses for pain in patients with flail chest and all outcomes in patients with nonflail chest were not feasible due to inadequate data.


In adult patients with flail chest, we conditionally recommend rib ORIF to decrease mortality; shorten DMV, hospital LOS, and ICU LOS; and decrease incidence of pneumonia and need for tracheostomy. We cannot offer a recommendation for pain control, or any of the outcomes in patients with nonflail chest with currently available data.


Systematic review/meta-analysis, level III.

[Indexed for MEDLINE]

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