Morbidity from rib fractures increases after age 45

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Holcomb, John B.^1,2; McMullin, Neil R.¹; Kozar, Rosemary A.¹; Lygas, Marjorie H.³; Moore, Frederick A.⁴

Morbidity from rib fractures increases after age 45

J Am Coll Surg. April 2003;196(4):549-555

©2003 American College of Surgeons. Published by Elsevier Science Inc.

Affiliations

¹Department of Surgery, University of Texas Health Sciences Center

²Department of Surgery, Uniformed Sevices University of the Health Sciences, Bethesda, MD

³Memorial Hermann Hospital, Houston, TX

⁴Department of Trauma and Critical Care University of Texas Health Sciences Center
Abstract

Background: Recent studies have demonstrated increased morbidity in elderly patients with rib fractures after blunt trauma. As a first step in creating a multidisciplinary rib fracture clinical pathway, we sought to determine the relationship between increasing age, number of rib fractures, and adverse outcomes in blunt chest trauma patients, without major abdominal or brain injury.

Study design: We performed a retrospective cohort study involving all blunt patients greater than 15 years old with rib fractures, excluding those with Abbreviated Injury Scores (AIS) greater than 2 for abdomen and head, admitted to an urban Level I trauma center during 20 months. Outcomes parameters included the number of rib fractures, Injury Severity Score (ISS), intrathoracic injuries, pulmonary complications, number of ventilator days, length of stay in the intensive care unit (ICU), hospital stay, and type of analgesia.

Results: Of the 6,096 patients admitted, 171 (2.8%) met the inclusion criteria. Based on an analysis of increasing age, number of rib fractures, and adverse outcomes variables, patients were separated into four groups: group 1, 15 to 44 years old with 1 to 4 rib fractures; group 2, 15 to 44 years old with more than 4 rib fractures; group 3, 45 years or older with 1 to 4 rib fractures; and group 4, 45 years or more with more than 4 rib fractures. The four groups had similar numbers of pulmonary contusions (30%) and incidence of hemopneumothorax (51%). Ventilator days (5.8 ± 1.8), ICU days (7.5 ± 1.8), and total hospital stay (14.0 ± 2.2) were increased in group 4 patients compared with the other groups (p < 0.05). Epidural analgesia did not affect outcomes. Overall mortality was 2.9% and was not different between groups.

Conclusions: Patients over the age of 45 with more than four rib fractures are more severely injured and at increased risk of adverse outcomes. Efforts to decrease rib fracture morbidity should focus not only on elderly patients but those as young as 45 years. Based on these data we have initiated a multidisciplinary clinical pathway focusing on patients 45 years and older who have more than four rib fractures.
Links

DOI: 10.1016/S1072-7515(02)01894-X

PubMed: 12691929

WoS: 000182139000007
History

Received: 2002-07-11

Revised: 2002-09-24

Accepted: 2002-10-22

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Cited By (24)

Year	Entry
2013	Weaver AA. Morphological Analysis of Changes in the Thoracic Skeleton With Age and Gender [PhD thesis]. Winston-Salem, NC: Wake Forest University; December 2013.
2008	Kent R, Woods W, Bostrom O. Fatality risk and the presence of rib fractures. In: 52nd Annual Proceedings, Association for the Advancement of Automotive Medicine (AAAM). October 6-8, 2008; San Diego, CA.73-82.
2010	Stitzel JD, Kilgo PD, Weaver AA, Martin RS, Loftis KL, Meredith JW. Age thresholds for increased mortality of predominant crash induced thoracic injuries. In: 54th Annual Proceedings, Association for the Advancement of Automotive Medicine (AAAM). October 17-20, 2010; Las Vegas, NV.41-49.
2005	Hardy RN, Watson JW, Cook R, Zioupos P, Forrester B, Frampton R, Page M, Kennedy A, Peach S, Sproston P. Development and assessment of a bone scanning device to enhance restraint performance. In: Proceedings of the 19th International Technical Conference on the Enhanced Safety of Vehicles (ESV). June 6-9, 2005; Washington, DC.
2011	Weaver AA, Armstrong EG, Moody EA, Stitzel JD. Image segmentation and registration algorithm to collect homologous landmarks for age-related thoracic morphometric analysis. In: Proceedings of the 22nd International Technical Conference on the Enhanced Safety of Vehicles (ESV). June 13-16, 2011; Washington, DC.
2010	Weaver AA, Moody EA, Armstrong EG, Stitzel JD. Image segmentation and registration algorithm to collect homologous landmarks for age-related thoracic morphometric analysis. In: Proceedings of the 38th International Workshop on Human Subjects for Biomechanical Research. 2010.
2019	Harden AL, Kang Y-S, Moorhouse K, Stammen J, Agnew AM. Human rib fracture characteristics and relationships with structural properties. In: Proceedings of the 2019 International IRCOBI Conference on the Biomechanics of Injury. September 11-13, 2019; Florence, Italy.465-474.
2022	Jenerowicz M, Haase T, Linnenberg M, Hoschke K, Boljen M, Hiermaier S. Comparison of rib bone surrogates from additive manufacturing, cast material and PMHS data under dynamic loading. In: Proceedings of the 2022 International IRCOBI Conference on the Biomechanics of Injury. September 14-16, 2022; Porto, Portugal.597-609.
2014	Schafman M, Kang Y-S, Moorhouse K, Agnew AM. The effect of age on the structural properties of ribs in dynamic frontal loading. In: Proceedings of the 10th Ohio State University Injury Biomechanics Symposium. May 18-20, 2014; Columbus, OH.
2015	Murach MM, Schafman M, Kang Y-S, White S, Bolte JH IV, Moorhouse K, Agnew AM. Geometric properties of human ribs as predictors of structural properties. In: Proceedings of the 11th Ohio State University Injury Biomechanics Symposium. May 17-19, 2015; Columbus, OH.
2015	Kalra A, Saif T, Shen M, Jin X, Zhu F, Begeman P, Yang KH, Millis S. Characterization of human rib biomechanical responses due to three-point bending. Stapp Car Crash J. November 2015;59:113-130.
2018	Agnew AM, Murach MM, Dominguez VM, Sreedhar A, Misicka E, Harden A, Bolte JH IV, Kang Y-S, Stammen J, Moorhouse K. Sources of variability in structural bending response of pediatric and adult human ribs in dynamic frontal impacts. Proceedings of the Stapp Car Crash Conference. November 2018;62:119-192.
2017	Murach MM, Kang Y-S, Goldman SD, Schafman MA, Schlecht SH, Moorhouse K, Bolte JH IV, Agnew AM. Rib geometry explains variation in dynamic structural response: potential implications for frontal impact fracture risk. Ann Biomed Eng. September 2017;45(9):2159-2173.
2014	Weaver AA, Schoell SL, Stitzel JD. Morphometric analysis of variation in the ribs with age and sex. J Anat. August 2014;225(2):246-261.
2016	Schafman MA, Kang Y-S, Moorhouse K, White SE, Bolte JH IV, Agnew AM. Age and sex alone are insufficient to predict human rib structural response to dynamic A-P loading. J Biomech. October 3, 2016;49(14):3516-3522.
2015	Agnew AM, Schafman M, Moorhouse K, White SE, Kang Y-S. The effect of age on the structural properties of human ribs. J Mech Behav Biomed Mater. January 2015;41:302-314.
2020	Prins JTH, Van Lieshout EMM, Reijnders MRL, Verhofstad MHJ, Wijffels MME. Rib fractures after blunt thoracic trauma in patients with normal versus diminished bone mineral density: a retrospective cohort study. Osteoporos Int. February 2020;31(2):225-231.
2011	Agnew AM. Histomorphometry of the Elderly Rib: A Methodological Approach With Implications for Biomechanics, Function, and Fracture Risk [PhD thesis]. The Ohio State University; 2011.
2015	Schafman MA. Dynamic Structural Properties of Human Ribs in Frontal Loading [Master's thesis]. The Ohio State University; 2015.
2017	Crowe NM. Histomorphometric Analysis of Elderly Ribs At Various Locations [Master's thesis]. The Ohio State University; 2017.
2018	Dominguez VM. Defining Bone Quality: Cortical Microdamage and Its Contribution to Fracture Risk in the Human Rib [PhD thesis]. The Ohio State University; 2018.
2021	Harden AL. A Multidisciplinary Approach to Skeletal Trauma Research: Interdisciplinary Methods and Applications [PhD thesis]. The Ohio State University; 2021.
2017	Kalra A. Development of an Elderly Female Torso Finite Element Model for Restraint System Research and Development Applications [PhD thesis]. Detroit, MI: Wayne State University; May 2017.
2015	Lynch SK. Characterization of Rib Cortical Bone Thickness Changes With Age and Sex [Master's thesis]. Winston-Salem, NC: Wake Forest University; May 2015.