Rib fractures in the elderly: physiology trumps anatomy

Abstract

IntroductionRib fractures in elderly patients are associated with increased morbidity and mortality. Predicting which patients are at risk for complications is an area of debate. Current models use anatomic, physiologic or laboratory parameters in isolation to answer this question. The ‘RibScore’ is an anatomic model that assesses fracture severity. Given that frailty is a major driver of adverse outcomes in the elderly, we hypothesize that the combined analysis of fracture severity, physiologic reserve and current pulmonary function are better predictors of respiratory compromise in this population.MethodsThis is a retrospective chart review of 263 trauma patients age ≥55 from January 2014 to June 2017. Criteria included blunt mechanism and ≥ 1 rib fracture identified by CT. Variables indicating adverse pulmonary outcomes were defined by: pneumonia, respiratory failure and tracheostomy. Three models were assessed: (1) RibScore, (2) Modified Frailty Index (mFI) and (3) initial partial pressure of carbondioxide (PaCO2).ResultsA total of 263 patients met inclusion criteria. 13% developed pulmonary complications. Increased RibScore, mFI and PaCO2 were each statistically associated with risk of complications. Receiver operating characteristics area under the curve analysis of individual models predicted complications with the following concordance statistic (CS): anatomic (RibScore) yielded a CS of 0.79 (95% CI 0.69 to 0.89); physiologic (mFI) yielded a CS of 0.83 (95% CI 0.75 to 0.91) and laboratory (PaCO2) yielded a CS of 0.88 (95% CI 0.80 to 0.95). The PaCO2 had the highest discriminative ability of the three individual models. Combining all three models yielded the best performance with a CS of 0.90 (95% CI 0.81 to 0.97).DiscussionThe RibScore maintains discriminative ability in the elderly. However, models based on mFI and PaCO2 individually outperform the RibScore. A combination of all three models yields the highest discriminative ability. This combined approach is best for assessing the severity of rib fractures and prediction of complications in the elderly.Level of evidencePrognostic Study, Level III.

Triage of Patients With Rib Fractures

“…In fact, recent studies in patients with chest wall trauma suggest that physiologic parameters and patient reserve are more useful assessment tools than age groups and anatomical descriptions. 17,18 This is also consistent with the more recent realization in geriatric trauma patients that functional status and physiologic reserve, that is, frailty or the lack thereof, are more useful and accurate descriptors of patient risk than many traditional parameters. 19,20 The only adverse consequence of the revised triage guidelinewefoundwasasignificantlyincreasedICUand hospital LOS, though by 1 day only.…”

“…Despite a substantial proportion of patients with multiple fractured ribs, sternal fractures, scapula fractures, and hemothorax or pneumothorax, the morbidity and mortality of our patient population were lower than traditionally reported 1,[3][4][5]14 but consistent with the results of other, primarily more recent studies that similarly demonstrated improved outcomes. 2,9,18 These changes likely not only reflect the positive impact of advanced critical care and aggressive ICU admission guidelines but also the widespread use of chest CT scans that have much higher sensitivity for rib fractures than chest X-ray, thus increasing the number of patients with a low number of rib fractures. 2 In our analysis, we excluded patients with severe associated polytrauma that would have mandated ICU admission for these injuries given the study focus on improving rib fracture triage and ICU admission guidelines.…”

A clinical practice guideline using percentage of predicted forced vital capacity improves resource allocation for rib fracture patients

“…The effectiveness of a scoring system that is easily standardized across institutions should not be understated, but recent literature would suggest that patient physiological status may play a more integral role in predicting adverse outcomes. 13,23 The sequential clinical assessment of respiratory function score described by Hardin et al 13 in 2019 is similar to the current study's CPG in that it relies on serial patient assessments rather than only the admission assessment, and it uses FVC as one of the measured parameters. Performing admission and serial assessments allows care teams to appropriately triage patients at admission and identify changes in physiologic status in a timely manner.…”

A survey of current practice in UK emergency department management of patients with blunt chest wall trauma not requiring admission to hospital

“…Consideration of frailty, social circumstances and co-morbidities should now have as equal emphasis as age and injury severity when discharging patients directly home from the ED [27][28][29]. A recent study found that in addition to the anatomic features that compose the RibScore, frailty is a significant risk factor for predicting pulmonary complications in this patient population [27]. These variables should therefore be considered for inclusion in risk prediction tools and pathways and patient advice sheets.…”