STOP FLAILING: THE IMPACT OF BICORTICALLY DISPLACED RIB FRACTURES ON PULMONARY OUTCOMES IN PATIENTS WITH CHEST TRAUMA - AN AAST MULTI-INSTITUTIONAL STUDY

Background Current evaluation of rib fractures focuses almost exclusively on flail chest with little attention on bicortically displaced fractures. Chest trauma severe enough to cause fractures, leads to worse outcomes. An association between bicortically displaced rib fractures and pulmonary outcomes would potentially change patient care in the setting of trauma. We tested the hypothesis that bicortically displaced fractures were an important clinical marker for pulmonary outcomes in patients with non-flail rib fractures. Methods This nine center AAST multi-institutional study analyzed adults with two or more rib fractures. Admission CT scans were independently reviewed. The location, degree of rib fractures and pulmonary contusions were categorized. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia, ARDS and tracheostomy. Analyses were performed in non-flail patients and also while controlling for flail chest to determine if bicortically displaced fractures were independently associated with outcomes. Results Of the 1110 patients 103 (9.3%) developed pneumonia, 78 (7.0%) required tracheostomy, and 30 (2.7%) developed ARDS. Bicortically displaced fractures were present in 277 (25%) of patients and in 206 (20.3%) of patients without flail chest. After adjusting for patient demographics, injury and admission physiology, negative pulmonary outcomes occurred over twice as frequently in those with bicortically displaced fractures without flail chest (n = 206) when compared to those without bicortically displaced fractures - pneumonia (OR 2.0, 95% CI 1.1-3.6), ARDS (OR 2.6, 95% CI 1.0-6.8) and tracheostomy (OR 2.7, 95% CI 1.4-5.2). When adjusting for the presence of flail chest, bicortically displaced fractures remained an independent predictor of pneumonia, tracheostomy and ARDS. Conclusions Patients with bicortically displaced rib fractures are more likely to develop pneumonia, ARDS and need for tracheostomy even when controlling for flail chest. Future studies should investigate the utility of flail chest management algorithms in patients with bicortically displaced fractures. Level of evidence Prognostic and Epidemiological Study - Level IIIRetrospective Cohort Study.