Creating a Chest Wall Injury and Reconstructive program: A single center experience with rib fractures

Published:September 24, 2022DOI:


      • Complex rib fracture patients have improved outcomes if admitted to a center with a dedicated rib fracture program.
      • Rib fracture programs can be quickly implemented into trauma centers.
      • All level one trauma programs should have a dedicated rib fracture management program.



      New Chest Wall Injury and Reconstructive Centers (CWIRC) are emerging; this study aims to investigate the potential benefits of implementing a CWIRC at a single institution. We hypothesized that patients treated at CWIRC will have improved outcomes.


      We instituted a CWIRC in 2019 at our American College of Surgeons (ACS) Level One Trauma Center. We retrospectively compared trauma patients with rib fractures who presented to our center 18 months before (PRE-C) and 18 months after CWIRC implementation (POST-C). Outcomes measured included mortality, length of stay (LOS), intensive care unit (ICU-LOS), readmission rates, and unplanned ICU admission.


      There were 192 PRE-C patients, compared to 388 POST-C. The mortality in PRE-C was not significantly different compared to the POST-C group (11.46% vs 8.8%, p=0.308). There were also no differences in LOS, ICU-LOS, readmission, and unplanned ICU admission. ICU utilization was dramatically different: PRE-C 17.8% were admitted to ICU compared to 35.6% POST-C (p<0.0001).


      The number of patients admitted with rib fractures to our center nearly doubled after CWIRC establishment. Early diagnosis and triage led to significantly more admissions to higher levels of care. There are trends toward improved outcomes using practice management protocols, albeit with higher ICU utilization. Establishment of a CWIRC should be considered for level 1 ACS trauma centers and as utilization of established CWIRC protocols are increased, patients will have improved outcomes.

      Level of Evidence


      Study Type

      Retrospective chart review.


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        • Peek J.
        • Beks R.B.
        • Hietbrink F.
        • Jong M.B.D.
        • Heng M.
        • Beeres F.J.
        • et al.
        Epidemiology and outcome of rib fractures: a nationwide study in the Netherlands.
        Eur J Trauma Emerg Surg. 2022; 48: 265-271
        • Arneson M.A.
        • Mock C.N.
        • Jurkovich G.J.
        Rib fractures in the elderly.
        J Trauma. 2000; 48: 1040-1046
        • Brasel K.J.
        • Moore E.E.
        • Albrecht R.A.
        • Schreiber M.
        • Karmy-jones R.
        • Rowell S.
        • et al.
        Western trauma association critical decisions in trauma : management of rib fractures.
        J Trauma Acute Care Surg. 2017; 82: 200-203
        • Kane E.D.
        • Jeremitsky E.
        • Bittner K.R.
        • Kartiko S.
        • Doben A.R.
        Surgical stabilization of rib fractures: a single institution experience.
        J Am Coll Surg. 2018; 226: 961-966
        • Kane E.D.
        • Jeremitsky E.
        • Pieracci F.M.
        • Majercik S.
        • Doben A.R.
        Quantifying and exploring the recent national increase in surgical stabilization of rib fractures.
        J Trauma Acute Care Surg. 2017; 83: 1047-1052
        • Pieracci F.M.
        • Majercik S.
        • Ali-Osman F.
        • Ang D.
        • Doben A.
        • Edwards J.G.
        • et al.
        Consensus statement: surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines.
        Injury. 2017; 48: 307-321
        • Slobogean G.P.
        • Macpherson C.A.
        • Sun T.
        Surgical fixation vs nonoperative management of flail chest : a meta-analysis.
        J Am Coll Surg. 2013; 216: 302-311
        • Simon B.
        • Ebert J.
        • Bokhari F.
        • Capella J.
        • Emhoff T.
        • Hayward T.
        • et al.
        Management of pulmonary contusion and flail chest : an eastern association for the surgery of trauma practice management guideline.
        J Trauma Acute Care Surg. 2012; 73
        • Battle C.E.
        • Hutchings H.
        • Evans P.A.
        Risk factors that predict mortality in patients with blunt chest wall trauma : a systematic review and meta-analysis.
        Injury. 2012; 43: 8-17
        • Fabricant L.
        • Ham B.
        • Mullins R.
        • Mayberry J.
        Prolonged pain and disability are common after rib fractures.
        Am J Surg. 2013; 205: 511-516
        • Niziolek G.
        • Goodman M.D.
        • Makley A.
        • Millar D.A.
        • Heh V.
        • Pritts T.A.
        • et al.
        “Early results after initiation of a rib fixation programme : a propensity score matched analysis”.
        Injury. 2022; 53: 137-144
        • Tanaka H.
        • Yukioka T.
        • Yamaguti Y.
        • Shimizu S.
        • Goto H.
        • Matsuda H.
        • et al.
        Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe.
        J Trauma. 1998; 52: 727-732
        • Granetzny A.
        • El-aal M.A.
        • Emam E.
        • Shalaby A.
        • Boseila A.
        Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status.
        Interact Cardiovasc Thorac Surg. 2005; 4: 583-587
        • Liu T.
        • Liu P.
        • Chen J.
        • Xie J.
        • Yang F.
        • Liao Y.
        A randomized controlled trial of surgical rib fixation in polytrauma patients with flail chest.
        J Surg Res. 2019; 242: 223-230
        • Cataneo A.J.M.
        • Cataneo D.C.
        • de Oliveira F.H.S.
        • Arruda K.A.
        • El Dib R.
        • de Oliveira Carvalho P.E.
        Surgical versus nonsurgical interventions for flail chest (Review).
        Cochrane Database Syst Rev. 2015; 7: 1-30
        • Schuurmans J.
        • Goslings J.C.
        • Schepers T.
        Operative management versus non ‑ operative management of rib fractures in flail chest injuries : a systematic review.
        Eur J Trauma Emerg Surg. 2017; : 163-168
        • Liang Y.
        • Yu K.
        • Wong C.
        • Kao Y.
        • Tiong T.
        • Tam K.
        Does surgery reduce the risk of complications among patients with multiple rib fractures? A meta-analysis.
        Clin Orthop Relat Res. 2019; : 193-205
        • Swart E.
        • Laratta J.
        • Slobogean G.
        • Mehta S.
        Operative treatment of rib fractures in flail chest injuries : a meta-analysis and cost-effectiveness analysis.
        J Orthop Trauma. 2016; 01605: 64-70
        • Pieracci F.M.
        • Leasia K.
        • Bauman Z.
        • Eriksson E.A.
        • Lottenberg L.
        • Majercik S.
        • et al.
        A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).
        J Trauma Acute Care Surg. 2020; 88: 249-257
        • Choi J.
        • Kaghazchi A.
        • Dickerson K.L.
        • Tennakoon L.
        • Spain D.A.
        • Forrester J.D.
        Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers.
        Am J Surg. 2021; 222: 849-854
        • Forrester J.D.
        • Bauman Z.M.
        • Doben A.R.
        • Eriksson E.A.
        Chest wall injury centers — how we did it.
        J Thorac Dis. 2021; 13: 6104-6107
        • Prins J.T.H.
        • Wijffels M.M.E.
        • Pieracci F.M.
        What is the optimal timing to perform surgical stabilization of rib fractures?.
        J Thorac Dis. 2021; 13: 0-3
        • Riojas C.
        • Cunningham K.W.
        • Green J.M.
        • Sachdev G.
        • Ross S.W.
        • Lauer C.W.
        • et al.
        Attention to detail : a dedicated rib fracture consultation service leads to earlier operation and improved clinical outcomes.
        Am J Surg. 2021; 223: 410-416
        • Prins J.T.H.
        • Leasia K.
        • Sauaia A.
        • Burlew C.C.
        • Cohen M.J.
        • Coleman J.J.
        • et al.
        A decade of surgical stabilization of rib fractures: the effect of study year on patient selection, operative characteristics, and in-hospital outcome.
        Injury. Epub. 2021;
        • Marasco S.F.
        • Davies A.R.
        • Cooper J.
        • Varma D.
        • Bennett V.
        • Nevill R.
        • et al.
        Prospective randomized controlled trial of operative rib fixation in traumatic flail chest.
        J Am Coll Surg. 2013; 216: 924-932
        • Marasco S.F.
        • Balogh Z.J.
        • Hsu J.
        • Martin K.
        • Summerhayes R.
        • Bailey M.
        • et al.
        Rib fixation in non-ventilator dependent chest wall injuries: a prospective randomized trial.
        J Trauma Acute Care Surg. Epub. 2022;