Operative Stabilization of Flail Chest Injuries Reduces Mortality to That of Stable Chest Wall Injuries

OBJECTIVE: To determine the prevalence, management and outcomes of patients with flail chest injuries, compared to patients without flail chest injuries (single rib fractures and multiple rib fractures without a flail segment). DESIGN: Retrospective cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Ontario residents over the age of 16 years who had been admitted to hospital with a chest wall injury from 2004 to 2015 were identified using administrative health care databases. MAIN OUTCOME MEASUREMENTS: Outcomes included treatment modalities such as rate of surgical repair, days on mechanical ventilation, days in the intensive care unit, days in hospital, rate of chest tube placement; and rates of complication, including pneumonia, tracheostomy, readmission, and death. RESULTS: In total 117,204 patients with fractures of the chest wall were identified. Of the entire cohort, 1.5% of them had a flail chest injury, 41% had multiple rib fractures, and 58% had single rib fractures. Patients with flail chest injuries had significantly worse outcomes compared to patients with multiple rib fractures in all categories (P < 0.0001). Similarly, patients with multiple rib fractures had significantly worst outcomes compared with patients with single rib fractures (P < 0.0001). Only 4.5% of patients with flail chest injuries were treated surgically, however, the number increased from 1% before 2010 to 10% after 2010 (P < 0.0001). After adjustment for potential confounders, patients with flail chest injuries treated surgically had a reduced risk of early mortality compared to those treated nonoperatively (OR 0.16, P = 0.019). CONCLUSIONS: Surgical stabilization of flail chest injuries has increased significantly in recent years. The results of this study provide preliminary evidence that the increasing rate of surgical intervention may be warranted by reducing mortality. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.