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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 23-27

Rib Fractures in Geriatric Patients: An Observational Study of Surgical Management


1 Department of Surgery, Mayo Clinic, Rochester, MN, USA
2 Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
3 Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA
4 Department of Surgery, Intermountain Healthcare, Murray, UT, USA

Date of Web Publication30-Dec-2019

Correspondence Address:
Joy Dowden Hughes
Department of Surgery, Mayo Clinic, Rochester, MN
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jctt.jctt_9_19

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  Abstract 


Background: Due to increased frailty and comorbidities, surgeons may be reluctant to perform surgical stabilization of rib fractures (SSRF) in geriatric (≥65yr) and super-geriatric (≥80yr) patients. We hypothesized that elderly patients would have delayed time to operation and more complications. We aimed to determine whether advanced age was a factor in deciding to proceed with SSRF and presented a risk for mortality.
Methods: Single-institution review of rib fracture (RF) patients from 8/2009-2/2017. Univariate analysis was performed for groups age ≤64yr, 65-79yr, and ≥80yr, and SSRF vs non-SSRF. Baseline injury characteristics were compared for all age groups.
Results: We identified 3098 non-SSRF patients (≤64yr, n=1770; 65-79yr, n=706; ≥80yr, n= 622) and 277 SSRF (≤64yr, n=162pt; 65-79yr, n=73pt; ≥80yr, n=42pt). For SSRF, there were no differences in sex or race, time from admission to operation, number of RF, or SSRF indications between any age group. Mortality was greater for non-SSRF patients overall [155/3098 (5%) vs 4/277 (1.4%), P < 0.01], for non-SSRF patients less than 65 years old [63/1770 (3.6%) vs 0/159, P < 0.01], and between 65-79 years old [35/706 (5%) vs 0/76, P = 0.03] but similar between non-SSRF and SSRF patients in the 80 and older cohort [57/622 (9.2%) vs 4/42(9.2%), P = 0.9]. In analysis of injury characteristics, for SSRF≥80yr greater mortality was associated with GCS <14 vs GCS≥14 (1/3 vs 0/39, P < 0.01), and more RF [median 20RF in pts with mortality (IQR:5-13) vs 10RF in patients without mortality (IQR:10-29), P = 0.02).
Conclusions: Age was not associated with longer time to OR nor with difference in injury pattern or severity as indication for SSRF. Although mortality increases for RF after 80yr, among appropriately selected super-geriatric patients SSRF is a safe and effective treatment.
Level of Evidence: IV Study type: Therapeutic.

Keywords: Geriatric, rib fractures, surgical stabilization of rib fractures


How to cite this article:
Hughes JD, Berning MJ, Hunt AS, Kim BD, Rivera M, Morris DS, Schiller HJ, Zielinski MD. Rib Fractures in Geriatric Patients: An Observational Study of Surgical Management. J Cardiothorac Trauma 2019;4:23-7

How to cite this URL:
Hughes JD, Berning MJ, Hunt AS, Kim BD, Rivera M, Morris DS, Schiller HJ, Zielinski MD. Rib Fractures in Geriatric Patients: An Observational Study of Surgical Management. J Cardiothorac Trauma [serial online] 2019 [cited 2020 Jul 5];4:23-7. Available from: http://www.jctt.org/text.asp?2019/4/1/23/274215




  Introduction Top


Surgical stabilization of rib fracture (SSRF) injuries have been shown to improve functional outcomes, control pain, reduce chest wall deformity, shorten length of stay in the intensive care unit and hospital, and reduce mortality for appropriately selected patients. Indications for rib fixation include flail chest, symptomatic nonunion, and thoracotomy for other reasons, with consideration given to less severe injuries with severe pain or poor pulmonary function, with increasing usage of SSRF in nonflail injury patterns.[1],[2],[3],[4] Early surgical intervention has been shown to improve the outcomes of SSRFs.[5],[6] Contraindications for rib fixation cited in the literature include field contamination.[1] Previous studies have shown that elderly patients are at increased risk for mortality, thoracic morbidity, pneumonia, and need for nursing home care.[7],[8] Analogous studies of hip fracture injuries in the elderly population show that injury is more likely to result from a fall and occur in multiply-comorbid patients,[9] and that delay in hip fracture repair in elderly patients results in worse outcomes.[10] Elderly patients with RFs represent a major and growing demographic,[11] and the decision to pursue conservative versus surgical management is possibly influenced by advanced age and associated comorbidities. Age has been identified as a major determinant of morbidity and mortality in RF patients.[12] Studies comparing the outcomes of traumatic brain injury (TBI) and multi-trauma have identified an additional cohort of patients ≥80 years, termed “super-geriatric” patients, who are at high risk for complications even with aggressive nonoperative management and may need more in-depth deliberation before pursuing surgical management compared to younger cohorts.[13],[14]

We hypothesized that because elderly patients with RFs have more baseline comorbidities, they would be more likely to have delayed time to operation, have distinct indications for rib fixation, and have postoperative complications compared to other groups. The objective of this study is to determine baseline health characteristics, injury patterns, and outcomes of geriatric and super-geriatric patients with RFs and to compare these findings to a younger cohort of patients undergoing SSRFs.


  Methods Top


With institutional review board's approval, we analyzed prospectively collected data on adult patients undergoing surgical rib fixation from August 2009 to February 2017. We obtained data regarding age and mortality for all RF patients from this same time period. All admissions took place at our facility, a Level I Trauma Center. We divided the patients into groups based on ages as follows: 18–64 years, 65–79 years, and ≥80 years. For SSRF data, characteristics of baseline health, injuries, clinical course, outcomes, and disposition were compared among these three groups. Follow-up occurred at our outpatient clinic in the weeks following admission and also over the phone. Favorable disposition was defined as dismissal to home or a rehabilitation facility. In addition, details on mortality, defined as death during hospitalization, for all RF patients, were obtained from our Trauma Center database, and mortality rates between SSRF and non-SSRF patients were analyzed overall and for each age range. Univariate analysis was employed with t-tests or Wilcoxon rank-sum tests for continuous factors and Chi-square test or Fisher's exact test for categorical factors. Analysis was performed using JMP software, JMP version 15 software from SAS, Cary, NC, USA.


  Results Top


We identified 3375 participants with RF between August 2009 and February 2017, with 277 patients who underwent SSRF. For SSRF patients, follow-up averaged 152 days, with range from 5 to 730 days (34 patients had no follow-up; due to death, n = 4, or being lost to follow-up, n = 30). Among SSRF patients, 162 patients (58.5%) belonged to the ≤64 years' age group; 73 patients (26.4%) belonged to the 65–79 years' age group; and 42 patients (15.2%) belonged to the ≥80 years' age group. The comparison of preoperative characteristics is summarized in [Table 1]. There were no differences in sex, incidence of asthma, number of RFs, or incidence of flail chest. The median Injury Severity Score was significantly lower for the super-geriatric group, with a median of 11.0 (interquartile range [IQR]: 9–17), when compared to ≤64 years' age group, with a median of 17 (IQR: 13–24), and 65–79 years' age group with a median of 14 (IQR: 9–23) (P< 0.01). Older patients were less likely to be smokers, with 13.7% of patients aged 65–79 years (n = 10), and only 4.8% of patients aged 80 years (n = 2) were identified as smokers as compared to 30.9% of patients ≤64 years who were identified as smokers (n = 50) (P< 0.01). Older patients were more likely to have diabetes, affecting 8.6% of patients ≤64 years (n = 14), 21.9% of patients aged 65–79 years (n = 16), and 13.7% of patients aged ≥80 years (n = 8) (P = 0.01). Hypertension was more common among older patients, occurring in 21% of patients ≤64 years (n = 34), 58.9% of patients aged 65–79 years (n = 43), and 69.1% of patients aged ≥80 years (n = 29) (P< 0.01).
Table 1: Baseline characteristics and injury patterns among surgical stabilization of rib fracture patients

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Older patients undergoing SSRF were less likely to have Glasgow Coma Scale (GCS) <14 (32 patients in the age group ≤64 years [19.8%]; 9 patients in group aged 65–79 years[12.3%]; and 1 patient in the age group ≥80 years [2.4%]; P < 0.01), scapula fractures (36 patients in the age group ≤64 years [22.2%]; 12 patients in the group aged 65–79 years [16.9%]; and 2 patients in the age group ≥80 years [4.8%]; P = 0.01), and clavicle fractures (42 patients in the age group ≤64 years [25.9%]; 13 patients in the age group 65–79 years [17.8%]; and 3 patients in the age group ≥80 years [7.1%]; P = 0.01). Rib score was compared among the groups and was found to be slightly lower among the super-geriatric patients; patients ≤64 years had a median rib score[15] of 3 (IQR: 1–4), patients aged 65–79 years had a median score of 2 (IQR: 1–4), and patients aged ≥80 years had a median score of 2 (IQR: 0–3) (P = 0.03).

Age did not affect the likelihood of patients undergoing SSRF, with 8.2% of patients aged ≤64 years (159/1929), 9.4% of patients aged 65–79 years (73/779), and 6.3% of patients aged ≥80 years (42/664) undergoing SSRF (P = 0.09).

Among SSRF patients, the mechanism of injury for RF among geriatric and super-geriatric participants was significantly more likely to be fall related: 49/162 in the age group ≤64 years (30.3%), 35/73 in the age group of 65–79 years (48.0%), and 33/42 in the age group ≥80 years (78.6%). Among the SSRF participants, there was no difference in “time from admission to operating room” between the three age groups, when three outliers were excluded from the younger group (age group ≤64 years had a mean time of 69.3 h with 95% confidence interval [CI]: 61.6–76.9; age group 65–79 years had a mean 77.5 h with 95% CI: 66.2–88.8 h; and age group ≥80 years had a mean 63.7 h with 95% CI: 48.8–78.6; P = 0.3; all the excluded outliers belonged to the age group ≤64 years with times of 474, 622, and 810 h). There were also no differences between the groups and indications for surgery (included options were flail, impaired pulmonary function, pain, retained hemothorax, and pulmonary toilet).

For all participants with RF, mortality was 4.7% (159/3375). For age group ≤64 years, mortality rate was 63/1932 (3.3%); for age group 65–79 years, mortality was 35/779 (4.5%); and for age group ≥80 years, mortality was 61/664 (9.2%). For SSRF patients, mortality was lower at 4/277 for the entire cohort (1.4%, P < 0.01); all mortalities occurred in the super-geriatric group with 4/42 deaths (9.5%, P < 0.01). The mortality rates of SSRF versus non-SSRF were similar for super-geriatric patients [Table 2]. In the super-geriatric group who underwent SSRF, only 1 patient had GCS <14, and that patient died while hospitalized; 3/41 patients with GCS ≥14 died (7.3%), and this difference was statistically significant with P = 0.02.
Table 2: Mortality by age group and surgical stabilization of rib fractures versus nonsurgical stabilization of rib

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Patient deaths are detailed as follows: mortality #1 was an 89-year-old male with multiple comorbidities including pacemaker presenting with unilateral RF of the 7th–10th ribs. Postoperatively, he required biphasic positive airway pressure (BIPAP) support and aggressive diuresis for 9 days; at that time, he declined further respiratory support and was placed under palliative care. Mortality #2 was an 82-year-old male with multiple comorbidities including atrial fibrillation presenting with concurrent C-spine fracture of C2 vertebrae and bilateral RF numbering 18 in total, in addition to several other injuries. On postoperative day 2, he developed a massive posterior cerebral artery infarct and died. Mortality #3 occurred in an 88-year-old male with multiple comorbidities including heart failure and atrial fibrillation, who presented after a fall resulting in 5 RFs. On hospital day 7, he underwent SSRF. Postoperatively, he required prolonged BIPAP for respiratory support, but he did not tolerate this intervention; his family elected for comfort cares on postoperative day 8 and he expired on hospital-day 19. Mortality #4 occurred in an 89-year-old male with multiple comorbidities including chronic obstructive pulmonary disease, chronic kidney disease, and prior non-ST-elevation myocardial infarction, who presented with 15 total RFs and multiple other injuries sustained in an all-terrain vehicle (ATV) accident; on postoperative day 3, he required reintubation for respiratory distress and sepsis, and he was transferred to comfort cares on postoperative day 4. In summary, three of the four deaths involved the need for further respiratory support, and two of these were directly related to an intolerance for prolonged BIPAP care. It is not apparent from any of these histories that nonoperative management would have avoided the mortality.

Older age was associated with more complications overall. Specifically, geriatric and super-geriatric patients had higher incidences of urinary tract infection, acute kidney injury, and respiratory insufficiency; however, they had similar rates of pneumonia, pulmonary embolism/deep-vein thrombosis, stroke/cerebrovascular accident, sepsis, surgical-site infection, empyema, hardware infection, reoperation within 30 days, and readmission within 30 days [Table 3]a. There were similar rates of tracheostomy, mechanical ventilation, and chest tube placement between age groups [Table 3]b.


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Older age was associated with unfavorable disposition in SSRF patients, with 35/42 (83.3%) patients in ≥80-year-old age group dismissing to skilled facility other than rehabilitation versus 35/73 (48.0%) in the 65–79-year-old age group and 21/162 (13.0%) in the ≤64-year–old age group (P< 0.01).


  Discussion Top


Older age was not apparently associated with delayed time to SSRF or with distinct indications for SSRF compared to younger patients. While older age is predictably associated with higher mortality, comparison of SSRF with non-SSRF patients does not demonstrate that mortality is attributed to surgical intervention for RF. There is a significant difference in mortality and other outcomes between the geriatric and super-geriatric populations. Super-geriatric patients have more complications and are more likely to need skilled nursing care following dismissal from the hospital, a similar finding to that of Halevi et al.[16] Only 16.7% of super-geriatric patients returned home or proceeded to rehabilitation programs from the hospital. As discussed by Hung et al. for hip-fracture patients, posthospital skilled nursing care is essential to the care plan for elderly individuals with RF.[9] Our data support continuation to offer SSRF to super-geriatric patients with RF, even with severe injuries (excluding TBI) and comorbidities, as these are likely the patients with the greatest need for chest wall stabilization.

Palliative care measures played an important role in the treatment course of the patients who suffered mortality. Analogous researches in patients with hip fractures have concluded that early involvement of the palliative care team is of great benefit to select patients with severe injuries.[17],[18]

Our study is limited because it was not randomized. In addition, given the low number of mortalities among the SSRF patients, it is difficult to draw conclusions as to characteristics attributing to these mortalities. Similarly, for many categories of complications and associated interventions, such as tracheostomy, the number of patients is too low to meaningfully analyze. Additionally, institutional characteristics and personnel likely have a large effect on the outcomes of our study, and a multi-institutional study would improve generalizability and validity. Our data do not include prehospital settings of patients, and so we cannot determine the rate at which elderly patients shifted from being independent to requiring skilled nursing care. Frailty scores were not available, but may certainly add important information regarding a patient's fitness to undergo any invasive surgical procedure.


  Conclusion Top


SSRF is routinely and successfully utilized in geriatric and super-geriatric patients with RF, and age alone should not determine eligibility for surgical management. The super-geriatric population is a distinct group; health-care teams should anticipate more complications among super-geriatric patients, as well as the need for skilled nursing care following dismissal from the hospital.

Evidence Level IV: Case series with limited control of confounding variables, more than minimal bias, heterogeneous population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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de Moya M, Nirula R, Biffl W. Rib fixation: Who, what, when? Trauma Surg Acute Care Open 2017;2:e000059.  Back to cited text no. 1
    
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Lodhia, JV, Konstantinidis K, Papagiannoupoulos K. “Surgical management of multiple rib fractures/flail chest. J Thorac Dis. 2019;11:1668-75. doi: 10.21037/jtd.2019.03.54.   Back to cited text no. 3
    
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Pieracci FM, Agarwal S, Doben A, Shiroff A, Lottenberg L, Whitbeck SA, et al. Indications for surgical stabilization of rib fractures in patients without flail chest: Surveyed opinions of members of the chest wall injury society. Int Orthop 2018;42:401-8.  Back to cited text no. 4
    
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Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB 3rd. Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a level I trauma center. J Trauma Acute Care Surg 2017;82:524-7.  Back to cited text no. 7
    
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Declarador N, Ramason R, Tay L, Chan WL, Kwek EB. Beyond comanaged inpatient care to community integration: Factors leading to surgical delay in hip fractures and their associated outcomes. J Orthop Surg (Hong Kong) 2018;26:2309499018783909.  Back to cited text no. 10
    
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Bennett KM, Scarborough JE, Vaslef S. Outcomes and health care resource utilization in super-elderly trauma patients. J Surg Res 2010;163:127-31.  Back to cited text no. 14
    
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Chapman BC, Herbert B, Rodil M, Salotto J, Stovall RT, Biffl W, et al. RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. J Trauma Acute Care Surg 2016;80:95-101.  Back to cited text no. 15
    
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Davies A, Tilston T, Walsh K, Kelly M. Is there a role for early palliative intervention in frail older patients with a neck of femur fracture? Geriatr Orthop Surg Rehabil 2018;9:2151459318782232.  Back to cited text no. 17
    
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Harrington KD. Orthopedic surgical management of skeletal complications of malignancy. Cancer 1997;80:1614-27.  Back to cited text no. 18
    



 
 
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