Outcomes of rib fixation versus nonoperative management in flail chest: Does body mass index change the equation?

Document Type

Journal Article

Publication Date

1-1-2026

Journal

The journal of trauma and acute care surgery

Volume

100

Issue

1

DOI

10.1097/TA.0000000000004800

Keywords

Flail chest; nonoperative management; rib fractures; surgical stabilization

Abstract

INTRODUCTION: The aim of this study is to identify the relationship between body mass index (BMI) and outcomes of surgical stabilization of rib fractures (SSRF) versus nonoperative management. METHODS: This is 2017 to 2021 retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database. We included all adult (18 years or older) patients with isolated blunt chest injuries and flail chest. Patients were stratified into five BMI groups: normal, overweight, and obese classes I, II, and III, and each category was then stratified into either SSRF or nonoperative management. The outcomes measured included rates of in-hospital mortality and complications (prolonged ventilator use [≥7 days], pneumonia, and tracheostomy). Multivariable regression analyses were performed. RESULTS: A total of 15,807 patients met the inclusion criteria. There were 26.8% patients in the normal class, 35.7% in the overweight class, 21.3% in class I, 9.4% in class II, and 6.8% in class III. Of all patients, 22.4% underwent SSRF. Patients who underwent SSRF had significantly lower rates of mortality in normal (1.8% vs. 4.5%, p < 0.001), obese class I (1.8% vs. 4.1%, p = 0.003), obese class II (2.4% vs. 5.8%, p = 0.008), and obese class III (3.3% vs. 7.3%, p = 0.028). On unadjusted (univariate) analysis, those who underwent SSRF had higher complication rates in the normal, overweight, class I, and class II groups, while, in class III, patients managed nonoperatively had lower rates of prolonged ventilation. However, after adjusting for confounding factors in multivariable regression, no significant differences in complication rates were observed, and the survival benefit of SSRF persisted across all BMI categories. CONCLUSION: Surgical stabilization of rib fractures is associated with reduced mortality in obese patients with flail chest and appears to offer a survival benefit across all BMI categories, without increasing complication risk. Clear guidelines should be established to ensure that SSRF is considered for all patients who may benefit, particularly those who are overweight or obese, to optimize outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Department

Surgery

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