Post-Discharge Complications and Follow-Up Timing after Hospitalization for Traumatic Rib Fractures

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Anderson, Michelle Earley, Sarah J. Rockwood, Elizabeth J. Zudock, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5183333/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Jan, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 11 You are reading this latest preprint version Abstract Purpose To evaluate frequency and timing of post-discharge complications in patients with traumatic rib fractures undergoing operative or nonoperative management. Methods We retrospectively reviewed adult patients with rib fractures admitted to a Level 1 trauma center from 1/2020-12/2021. Outcomes included rib-related complications, pneumonia within 1 month, new diagnosis of opioid- or alcohol-use disorder, and all-cause mortality. Patients were stratified on whether they underwent surgical stabilization of rib fractures (SSRF). Associations between risk factors and outcomes were evaluated through Fine and Gray hazard models with death (or in-hospital death for the post-discharge death outcome) as a competing risk. Results Of 976 patients admitted with rib fractures, 904(93%) underwent non-operative therapy and 72(7%) underwent SSRF. Nonoperative patients had less-severe injuries and shorter ICU length-of-stay. Rib-related complications occurred in 13(1%) nonsurgical patients and 4(6%) surgical patients. In the nonsurgical group, presence of hemo/pneumothorax on admission was associated with increased risk of rib-related complications [subdistribution hazard ratio (SHR) (95% CI): 5.95(1.8, 19.67)]. Pneumonia within 1 month occurred in 9(1%) nonsurgical patients and 1(1%) surgical patient. New diagnosis of alcohol or opioid-use disorder was made in 14(2%) nonsurgical patients and 1(1%) surgical patients. All-cause mortality was 68(8%) in the nonsurgical group and 2(3%) in the surgical group. Older age was associated with mortality in the nonsurgical cohort [SHR (95% CI): 1.83(1.46, 2.28)]. Conclusion Post-discharge rib-related complications were rare in both groups, but occurred primarily within 2 weeks, suggesting concentrated earlier follow-up may be beneficial. These findings help inform recommendations for follow-up in this population. rib fracture rib fixation trauma pneumonia hemothorax injury Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Rib fractures are the most common type of injury following blunt force chest trauma, accounting for up to half of all blunt thoracic injuries [ 1 , 2 ]. Up to 10% of patients admitted for blunt force chest trauma are diagnosed with one or more rib fractures, leading to over 248,000 ED visits and 48,000 admissions in the United States annually [ 3 , 4 ]. Patients hospitalized with traumatic ribs fractures are at high risk of mortality and post-discharge complications. Mortality in patients requiring ICU admissions has been estimated around 7%, and can approach 22% in older adults [ 5 , 6 ]. Survivors are at risk of both acute and long-term complications. Pulmonary complications are the most frequent and severe complication, occurring in up to 35% [ 7 ]. Following isolated minor rib fractures, 2% of patients develop pneumonia within 30 days [ 8 ]. Patients with multiple rib fractures (17%), patients over 65 with multiple rib fractures (31%), and patients with more than 6 rib fractures (51%) are at increased risk of pneumonia [ 8 ]. Other sequelae include pneumothorax, hemothorax, chest wall instability, and chronic pain. Current management includes multimodal analgesia, early mobility, respiratory therapy, and in select cases, surgical stabilization of rib fractures (SSRF) [ 9 , 10 ]. Surgical stabilization is recommended for patients with chest wall instability, displaced fractures with pulmonary derangements, or rib fracture-associated respiratory failure [ 11 ]. Despite having more severe injuries, patients who undergo surgery do not experience higher mortality rates, and experience lower rates of pneumonia and shorter lengths of mechanical ventilation and ICU admission compared to nonsurgical patients [ 12 – 14 ]. Rates of SSRF in patients with traumatic rib fractures have increased from 1–10% over the past decade in response to mounting evidence of the benefits in appropriate candidates [ 12 , 13 ]. Although SSRF appears to improve immediate outcomes, the incidence and timing of delayed complications has not been well-characterized. Given the morbidity and mortality of acute rib fractures, it is critically important to identify high-risk patients and optimize delivery of follow-up care after hospital discharge. To better understand complications after operatively and non-operatively managed traumatic rib fractures, we analyzed risk factors, timing, and frequency of rib-related complications in the post-hospitalization period. Methods We performed a retrospective chart review of adult patients admitted to a single Level 1 trauma center with acute traumatic injuries from January 2020 to December 2021. Patients were included based on radiographic presence of ≥ 1 rib fractures. Exclusion criteria were penetrating mechanism, isolated chronic and subacute rib fractures, and non-admitted status (emergency department disposition of deceased, transferred, home, or left against medical advice). Baseline demographics and admission data were obtained using a combination of database extraction and manual review. If a patient was transferred from an outside hospital, date of admission was considered the date of admission at the outside hospital. Injury severity score was dichotimized as mild/moderate (≤ 15) and severe/profound (> 15). Rib fractures were characterized by number of fractures ribs, severity of injury (< 3 rib fractures, ≥ 3 fractures, radiographic flail chest, clinically flail chest), laterality, and presence of associated fractures (sternum, clavicle, scapula). For the SSRF cohort, data regarding surgical timing and pre/post-discharge complications were also collected. Opioid use was captured as the morphine milligram equivalents (MME) administered on the day prior to discharge. Outcomes included rib-related complications (rib-related readmissions, symptomatic nonunion, pain management referral at discharge, post-discharge chest wall nerve block, chronic rib-related pain, surgical site infection, and implant failure), new diagnosis of alcohol or opioid use disorder, pneumonia within 1 month of discharge, and post-discharge death (all-cause mortality). Apart from pneumonia, all outcomes were assessed up to 2 years post-discharge. We selected a 1-month cutoff for pneumonia as development of pneumonia beyond this period was less-likely to be physiologically related to acute traumatic rib fractures. Rib-related readmissions were further sub-classified into pain-control, pneumonia, hemo/pneumothorax, or “other” categories. Implant failure was defined as symptomatic plate fracture or deformity. Readmissions were only counted if > 24 hours and unplanned. To account for the low incidence of individual outcomes, we created composite endpoints from similar outcomes. Our first composite endpoint of rib-related complications included rib-related readmissions, nonunion, post-discharge pain management referral, chest wall nerve block, and for the rib fixation group only, post-discharge surgical site infection (SSI) and symptomatic implant failure. A composite outcome was created for new diagnosis of opioid or alcohol use disorder due to anticipated low number of diagnoses. Additional endpoints were pneumonia within 1 month and post-discharge death. Distributions of continuous variables between surgical versus nonsurgical patients were evaluated using a Wilcoxon rank-sum test. Chi-square or Fisher’s exact tests were used for categorical variables. Associations between risk factors and outcomes were evaluated through multivariable Fine and Gray hazard models with death (or in-hospital death for the post-discharge death outcome) as a competing risk. Models were stratified by SSRF status prior to discharge. Variable inclusion was based on clinical importance and significance in univariable models. A two-tailed p < 0.05 was considered statistically significant. All analyses were conducted using SAS, version 9.4 (SAS Institute Inc). Results A total of 976 patients were included, with 904 (93%) managed nonoperatively and 72 (7%) undergoing SSRF (Table 1 ). Overall, patients were predominantly older (median (IQR) 66 (51, 79) years) and male (62%), with a higher proportion of male patients in the SSRF group (83% vs 61% in the nonsurgical group). Patients who underwent SSRF had higher admission injury severity score (ISS), more severe chest wall injuries, longer ICU and hospital length of stay (LOS), and higher MME / day at discharge (Table 1 ). Approximately 57% of surgical patients were admitted to the ICU, with a median (IQR) length stay of 4 (3, 7) days, compared to 34% of nonsurgical patients, with a median (IQR) stay of 3 (2, 5) days. During the hospitalization period, 10% of surgical patients developed pneumonia and 4% developed ARDS, compared to 4% and 1%, respectively, in the nonsurgical group. Among surgical patients, SSRF was performed at a median (IQR) of 2 (1, 3) days post-admission. Three (4%) patients in the SSRF group required an additional chest tube in the postoperative period prior to hospital discharge. No surgical patients experienced symptomatic non-union, plate failure, or implant or surgical site infections. Average (SD) time to follow up (censored at 2 years) was similar in both groups at 80 (39) weeks in both populations, with 36% of patients in both populations lost to follow up before the full 2-year period. Post-discharge rib-related complications were identified in 13 (1%) nonsurgical patients and 4 (6%) surgical patients (Fig. 1 ). In the nonsurgical group, 10 (1%) patients required readmission for rib-related reasons and 3 (0.3%) required a post-discharge pain management referral. Pain management was the most common reason for readmission in the nonsurgical group (n = 7, 70%), followed by hemo/pneumothorax (n = 2, 20%). One nonsurgical patient developed an infected chest wall hematoma. In the surgical group, 4 patients (5%) required readmission for rib-related reasons (empyema, hemo/pneumothorax, pneumonia, hardware discomfort). One surgical patient required delayed surgical hardware removal due to discomfort. Median (IQR) post-discharge time to rib-related complications was 1.6 (0.7, 4.9) weeks in the nonsurgical group and 1.4 (0.9, 33.0) weeks in the surgical group, with more than half of the patients in each group experiencing complications within two weeks (n = 7, 54% in the nonsurgical group and n = 3, 75% in the surgical group). Among nonsurgical patients, hemo/pneumothorax on arrival was associated with increased risk of rib-related complications [subdistribution hazard ratio (SHR) (95% CI): 5.95 (1.8, 19.67)], after adjusting for ISS and age (Table 2 ). In both groups, 1% of patients developed pneumonia within 1 month of discharge (Fig. 2 ). Given the low event rate, risk factors for pneumonia were not evaluated. A new diagnosis of alcohol or opioid use disorder was made in 14 (2%) of the nonsurgical patients and 1 (1%) of surgical patients (Fig. 3 ). Multivariable models did not reveal risk factors significantly associated with this outcome in the nonsurgical group (Table 3 ). All-cause post-discharge mortality was 8% in the nonsurgical group and 3% in the surgical group (Fig. 4 ). The median time to death was 31 (12, 60) weeks in the nonsurgical group and 89 (80, 97) weeks in the surgical group. The majority of post-discharge deaths occurred between 2 months and 1 year in the nonsurgical group (33/68, 49%) and between 1–2 years in the surgical group (2/2, 100%). In the nonsurgical group, mortality was associated with increasing age [SHR (95% CI) 1.83 (1.46, 2.28)], after adjusting for ISS (Table 4 ). Discussion In this study of post-discharge outcomes after traumatic rib fractures, we observed overall low rates of rib-related complications among patients undergoing SSRF as well as nonsurgically-managed patients, with the majority of these occurring within 2 weeks of discharge. In the nonsurgical group, presence of hemo/pneumothorax on arrival imaging was significantly associated with rib-related complications. The majority of readmissions were for treatment of rib fracture pain, highlighting the critical importance of analgesia in the post-hospitalization period. A number of previous studies have examined the timing and frequency of complications after rib fracture. All-cause mortality following rib fractures has been reported as high as 6.9% within 30 days [ 15 ]. A review of post-injury complications after rib or sternal fractures by Forrester et al found that 0.7% (847/121,615) of nonsurgical patients experienced a potentially-modifiable complication, with 98% of occurring within 30 days of injury [ 16 ]. Baker et al reported a 90-day readmission rate of 8% among conservatively-managed patients with chest wall injury, with the majority of these (7%) occurring within 30 days of discharge [ 17 ]. In a multicenter, retrospective study of patients with chest wall injury, 0.5% of patients developed pneumonia within 30 days of hospitalization [ 18 ]. The incidence of delayed hemothorax among patients discharged from the emergency department after chest wall injury has been estimated at 12% [ 19 ], with a separate study reporting an average of 9 days between discharge and readmission for delayed hemothorax [ 20 ]. Post-discharge complications after SSRF have been similarly characterized. In our study, we observed no cases of symptomatic nonunion in either cohort, and none of the 72 surgical patients experienced hardware failure or surgical site infection. Only one patient undergoing SSRF in our study required reoperation for hardware-related discomfort. Forrester et al found that among patients undergoing rib or sternal fixation, 3% (94/2881) experienced potentially-modifiable sequelae, with 27% occurring within 30 days [ 16 ]. Incidence of SSI after rib fixation has been estimated between 1–13%, most often reported in the early postoperative period [ 21 – 28 ]. An estimated 1–3% of patients require operative intervention for chronic pain or implant failure, usually ≥ 1 year postoperatively [ 22 , 25 , 29 – 31 ]. In our institutional practice, patients who undergo SSRF are ideally seen for follow up at 3 sequential visits (1 month, 3 months, 1 year), while nonsurgical patients are seen at 2–3 weeks post-discharge depending on injury severity and symptoms. Other institutions report median follow-up as long as 39 months [ 32 ]. Clinical practice guidelines for follow up after rib fractures recommend follow up for at least 1 month post-discharge for nonsurgical patients and 3 months for patients undergoing SSRF [ 16 ]. In our study, the majority of potentially-modifiable complications occurred within 1 month in both groups, with the greatest proportion within 2 weeks post-discharge. Given the low rate of surgical complications in our SSRF group, further study is necessary to determine whether the extended 3 month follow up period is of clinical benefit in our patient population. While the guidelines do not comment on the time to first follow up appointment, our observations suggest that early time to first follow up (< 2 weeks) may be prudent in both populations, particularly among patients with hemo/pneumothorax at hospital arrival. This study has several limitations. The power of our study was low for surgical patients, and 36% of patients were lost to follow up over the 2-year period. The timing of this study during the height of the COVID-19 pandemic may have had additional impact on follow up due to disruptions in clinical operations and in-person visits. Furthermore, we did not differentiate between causes of pneumonia or assess the impact of heightened respiratory precautions during this period. As a single-institution study, caution should be applied in extrapolating these observations due to variation in institutional protocols and surgeon practice. Further investigation with a larger, multi-institutional cohort is necessary to better characterize the incidence, timing, and risk factors for post-discharge complications in this population. Conclusion We observed low rates of rib-related complications among patients with traumatic rib fractures undergoing operative and nonoperative management. The majority of potentially-modifiable complications occurred within 2 weeks of discharge and were associated with hemo/pneumothorax on hospital arrival in the nonsurgical group. While further study is required to define and validate complication risk factors, this work highlights a potential opportunity for early identification and intervention in the immediate post-discharge period. Statements and Declarations Ethics Approval This study was performed in accordance with the ethical standards denoted in the 1964 Declaration of Helsinki and its later amendments. Research was conducted retrospectively from data obtained for clinical purposes. The study received prior approval from the Stanford University Institutional Review Board, which determined that it did not need ethical approval. Funding The authors did not receive support from any organization for the submitted work. Disclosures Financial interests: Author JDF is a Principal Investigator for an investigator-initiated clinical trial funded in part by Pacira & Varian and an industry-initiated clinical trial funded in part by Eclipse Regenysis. The remaining authors have no relevant financial or non-financial interests to disclose. Non-financial interests: none. Authorship Contributions TNA – study design, literature search, data collection, data interpretation, writing, critical revision; ME – study design, data analysis, data interpretation, writing, critical revision; SJR – literature search, data collection, writing; EJZ - literature search, data collection, writing; SLS - literature search, data collection, writing; JKF – data collection; SC – data collection; AAM – data collection; RABF – data collection; JDF – study design, data interpretation, critical revision. References Lodhia JV, Konstantinidis K, Papagiannopoulos K. Surgical management of multiple rib fractures/flail chest. 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Niziolek G, Goodman MD, Makley A, Millar DA, Heh V, TA P. Early results after initiation of a rib fixation programme: A propensity score matched analysis. Injury 2022;53:137–44. Prins JTH, Van Lieshout EMM, Overtoom HCG, Tekin YS, Verhofstad MHJ, Wijffels MME. Long-term pulmonary function, thoracic pain, and quality of life in patients with one or more rib fractures. J Trauma Acute Care Surg 2021;91:923–31. https://doi.org/10.1097/TA.0000000000003378. Tables Table 1. Baseline demographics and admission data. Values expressed as N (%) unless specified. ISS = injury severity score, IQR = interquartile range, LOS = length of stay, MME = morphine milliequivalents. Characteristic Nonsurgical (N=904) Surgical (N=72) Total (N=976) p-value Age, median (IQR) 67 (51, 82) 59 (60, 66) 66 (51, 79) < 0.001 Male 548 (61) 60 (83) 608 (62) < 0.001 BMI, median (IQR) 25 (22, 29) 27 (24, 30) 25 (23, 29) 0.02 Admission ISS, median (IQR) 10 (9, 17) 17 (13, 22) 12 (9, 17) < 0.001 Admission ISS: severe/profound 270 (30) 42 (58) 312 (32) < 0.001 # of rib fractures, median (IQR) 3 (2, 5) 7 (5, 9) 4 (2, 6) < 0.001 Pneumo- and/or hemothorax on arrival 268 (30) 63 (88) 331 (34) < 0.001 Pulmonary contusions on arrival 146 (16) 31 (43) 177 (18) < 0.001 Flail chest 9 (1) 16 (22) 25 (2) < 0.001 Sternal fracture 71 (8) 13 (18) 84 (9) 0.007 Clavicle fracture 128 (14) 22 (31) 150 (15) < 0.001 Scapula fracture 86 (10) 13 (18) 99 (10) 0.04 Pneumonia during admission 36 (4) 7 (10) 43 (4) 0.03 ARDS during admission 6 (1) 3 (4) 9 (1) 0.02 Pulmonary embolism during admission 15 (2) 1 (1) 16 (2) > 0.99 ICU admission 310 (34) 41 (57) 351 (36) < 0.001 ICU LOS, median (IQR) 3 (2, 5) 4 (3, 7) 3 (2, 5) 0.007 Invasive ventilation 82 (9) 12 (17) 94 (10) 0.06 Ventilator days, median (IQR) 6 (2, 10) 17 (5, 31) 6 (2, 14) 0.05 MME / day at discharge, median (IQR) 15 (4, 46) 50 (8, 107) 19 (4, 52) < 0.001 Hospital LOS, median (IQR) 3 (2, 6) 7 (4, 11) 4 (2, 6) < 0.001 Table 2. Adjusted risk of rib-related complications among nonsurgical patients. SHR = subdistribution hazard ratio. Characteristic SHR (95% CI) p-value Age 0.82 (0.61, 1.11) 0.20 ISS Mild/moderate vs. severe/profound 4.23 (0.9, 19.93) 0.07 Pneumo- and/or hemothorax on arrival yes or no 5.95 (1.8, 19.67) 0.003 Table 3. Adjusted risk of new alcohol or opioid use disorder among nonsurgical patients. SHR = subdistribution hazard ratio. Characteristic SHR (95% CI) p-value Age 0.81 (0.64, 1.01) 0.06 ISS Mild/moderate vs. severe/profound 1.42 (0.49, 4.17) 0.52 MME at discharge 1.03 (1, 1.06) 0.08 Table 4. Adjusted risk of mortality among nonsurgical patients. SHR = subdistribution hazard ratio. Characteristic SHR (95% CI) p-value Age 1.83 (1.46, 2.28) < 0.001 ISS Mild/moderate vs. severe/profound 1.07 (0.54, 2.12) 0.84 Additional Declarations Competing interest reported. Financial interests: Author JDF is a Principal Investigator for an investigator-initiated clinical trial funded in part by Pacira & Varian and an industry-initiated clinical trial funded in part by Eclipse Regenysis. The remaining authors have no relevant financial or non-financial interests to disclose. Non-financial interests: none. Cite Share Download PDF Status: Published Journal Publication published 24 Jan, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 21 Oct, 2024 Reviews received at journal 20 Oct, 2024 Reviews received at journal 11 Oct, 2024 Reviewers agreed at journal 09 Oct, 2024 Reviews received at journal 02 Oct, 2024 Reviewers agreed at journal 02 Oct, 2024 Reviewers agreed at journal 02 Oct, 2024 Reviewers invited by journal 02 Oct, 2024 Editor assigned by journal 02 Oct, 2024 Submission checks completed at journal 02 Oct, 2024 First submitted to journal 30 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5183333","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":368429498,"identity":"a3cdfc4e-62bb-4ceb-b3cf-b09b88f5ab21","order_by":0,"name":"Taylor N. Anderson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYJACiQ8gkvkAAwMPAwNjAyHlQEUMkjMYDBgY2BJI0CLNQ5IWe/azB2/b/Pkjb87GfOzDGwYb2Q0HCNnCk5dsndtmYLizjS155hyGNGPCWhhyzKRzGwwYN9zvMWbmYTicSFgL/xszaYs/BvYbjvGAtPwnQosE0BYGNoNEqJYDRGi58cbYsrfNOHnDMbZkxjkGycYzCWlh788xvPHjj5zthmPMhxneVNjJ9hHSggYMSFM+CkbBKBgFowAHAAALQT0hpYckcAAAAABJRU5ErkJggg==","orcid":"","institution":"Stanford University","correspondingAuthor":true,"prefix":"","firstName":"Taylor","middleName":"N.","lastName":"Anderson","suffix":""},{"id":368429499,"identity":"38b156c3-78b7-46d6-8512-073d94b42d64","order_by":1,"name":"Michelle Earley","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Earley","suffix":""},{"id":368429500,"identity":"46351682-bb6e-4066-9006-4c468b8803bb","order_by":2,"name":"Sarah J. Rockwood","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"J.","lastName":"Rockwood","suffix":""},{"id":368429501,"identity":"365be71a-1197-498f-bf36-048474df74da","order_by":3,"name":"Elizabeth J. Zudock","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"J.","lastName":"Zudock","suffix":""},{"id":368429502,"identity":"9a604dd3-2ee3-4c37-80c5-2d61ac17b130","order_by":4,"name":"Samantha L. Steeman","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Samantha","middleName":"L.","lastName":"Steeman","suffix":""},{"id":368429503,"identity":"a85d303a-89a7-4a11-83a2-c7d7d499ecd5","order_by":5,"name":"Jianna K. Footman","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Jianna","middleName":"K.","lastName":"Footman","suffix":""},{"id":368429504,"identity":"2d5be732-2d08-40d0-a97e-81e8b83119ba","order_by":6,"name":"Samuel Castro","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Castro","suffix":""},{"id":368429506,"identity":"41e20823-0e7b-4c1a-bd01-850b19bf7a90","order_by":7,"name":"Alexandra A. Myers","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Alexandra","middleName":"A.","lastName":"Myers","suffix":""},{"id":368429507,"identity":"031b64d4-9d78-44f6-8ffe-dcf467360009","order_by":8,"name":"Renceh A.B. Flojo","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Renceh","middleName":"A.B.","lastName":"Flojo","suffix":""},{"id":368429508,"identity":"9b77a8d1-1aaf-470a-9c53-9625f18b4f2b","order_by":9,"name":"Joseph D. Forrester","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"D.","lastName":"Forrester","suffix":""}],"badges":[],"createdAt":"2024-09-30 20:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5183333/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5183333/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00068-024-02682-w","type":"published","date":"2025-01-24T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68538538,"identity":"366466ea-4e30-42a8-aeed-797a7b4e378b","added_by":"auto","created_at":"2024-11-08 10:27:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47881,"visible":true,"origin":"","legend":"\u003cp\u003eBeeswarm plot depicting time to development of rib-related complications. Created using Statistical Analysis System (SAS).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5183333/v1/055bca1d19c8f0b471ba3e90.png"},{"id":68537024,"identity":"99126ae2-a2d7-455a-b4ae-4a8ab06447e7","added_by":"auto","created_at":"2024-11-08 10:19:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":31449,"visible":true,"origin":"","legend":"\u003cp\u003eBeeswarm plot depicting time to development of pneumonia. Created using Statistical Analysis System (SAS).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5183333/v1/2e29770ea5a1ab43e3e683ec.png"},{"id":68538539,"identity":"ac47069e-efcc-4166-8e53-c8479902933a","added_by":"auto","created_at":"2024-11-08 10:27:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":49311,"visible":true,"origin":"","legend":"\u003cp\u003eBeeswarm plot depicting time to new diagnosis of alcohol or opioid use disorder. Created using Statistical Analysis System (SAS).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5183333/v1/30afd15107f3a6ce37a957c5.png"},{"id":68537021,"identity":"4b2ea441-5d2a-42e6-9c62-85d9df14d81e","added_by":"auto","created_at":"2024-11-08 10:19:27","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":114853,"visible":true,"origin":"","legend":"\u003cp\u003eBeeswarm plot depicting time to all-cause mortality. Created using Statistical Analysis System (SAS).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5183333/v1/aa049f780e7b56eb0814b9dc.png"},{"id":74858306,"identity":"940c63dd-985e-4a20-b5ce-15318463b49e","added_by":"auto","created_at":"2025-01-27 16:07:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":790544,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5183333/v1/888c3cae-b2f3-4f45-840c-59c1cf34dc18.pdf"}],"financialInterests":"Competing interest reported. Financial interests: Author JDF is a Principal Investigator for an investigator-initiated clinical trial funded in part by Pacira \u0026 Varian and an industry-initiated clinical trial funded in part by Eclipse Regenysis. The remaining authors have no relevant financial or non-financial interests to disclose.\n\nNon-financial interests: none.","formattedTitle":"Post-Discharge Complications and Follow-Up Timing after Hospitalization for Traumatic Rib Fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRib fractures are the most common type of injury following blunt force chest trauma, accounting for up to half of all blunt thoracic injuries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Up to 10% of patients admitted for blunt force chest trauma are diagnosed with one or more rib fractures, leading to over 248,000 ED visits and 48,000 admissions in the United States annually [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients hospitalized with traumatic ribs fractures are at high risk of mortality and post-discharge complications. Mortality in patients requiring ICU admissions has been estimated around 7%, and can approach 22% in older adults [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Survivors are at risk of both acute and long-term complications. Pulmonary complications are the most frequent and severe complication, occurring in up to 35% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Following isolated minor rib fractures, 2% of patients develop pneumonia within 30 days [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Patients with multiple rib fractures (17%), patients over 65 with multiple rib fractures (31%), and patients with more than 6 rib fractures (51%) are at increased risk of pneumonia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Other sequelae include pneumothorax, hemothorax, chest wall instability, and chronic pain.\u003c/p\u003e \u003cp\u003eCurrent management includes multimodal analgesia, early mobility, respiratory therapy, and in select cases, surgical stabilization of rib fractures (SSRF) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Surgical stabilization is recommended for patients with chest wall instability, displaced fractures with pulmonary derangements, or rib fracture-associated respiratory failure [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite having more severe injuries, patients who undergo surgery do not experience higher mortality rates, and experience lower rates of pneumonia and shorter lengths of mechanical ventilation and ICU admission compared to nonsurgical patients [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Rates of SSRF in patients with traumatic rib fractures have increased from 1\u0026ndash;10% over the past decade in response to mounting evidence of the benefits in appropriate candidates [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Although SSRF appears to improve immediate outcomes, the incidence and timing of delayed complications has not been well-characterized.\u003c/p\u003e \u003cp\u003eGiven the morbidity and mortality of acute rib fractures, it is critically important to identify high-risk patients and optimize delivery of follow-up care after hospital discharge. To better understand complications after operatively and non-operatively managed traumatic rib fractures, we analyzed risk factors, timing, and frequency of rib-related complications in the post-hospitalization period.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e We performed a retrospective chart review of adult patients admitted to a single Level 1 trauma center with acute traumatic injuries from January 2020 to December 2021. Patients were included based on radiographic presence of \u0026ge;\u0026thinsp;1 rib fractures. Exclusion criteria were penetrating mechanism, isolated chronic and subacute rib fractures, and non-admitted status (emergency department disposition of deceased, transferred, home, or left against medical advice). Baseline demographics and admission data were obtained using a combination of database extraction and manual review. If a patient was transferred from an outside hospital, date of admission was considered the date of admission at the outside hospital. Injury severity score was dichotimized as mild/moderate (\u0026le;\u0026thinsp;15) and severe/profound (\u0026gt;\u0026thinsp;15). Rib fractures were characterized by number of fractures ribs, severity of injury (\u0026lt;\u0026thinsp;3 rib fractures, \u0026ge;\u0026thinsp;3 fractures, radiographic flail chest, clinically flail chest), laterality, and presence of associated fractures (sternum, clavicle, scapula). For the SSRF cohort, data regarding surgical timing and pre/post-discharge complications were also collected. Opioid use was captured as the morphine milligram equivalents (MME) administered on the day prior to discharge.\u003c/p\u003e \u003cp\u003eOutcomes included rib-related complications (rib-related readmissions, symptomatic nonunion, pain management referral at discharge, post-discharge chest wall nerve block, chronic rib-related pain, surgical site infection, and implant failure), new diagnosis of alcohol or opioid use disorder, pneumonia within 1 month of discharge, and post-discharge death (all-cause mortality). Apart from pneumonia, all outcomes were assessed up to 2 years post-discharge. We selected a 1-month cutoff for pneumonia as development of pneumonia beyond this period was less-likely to be physiologically related to acute traumatic rib fractures. Rib-related readmissions were further sub-classified into pain-control, pneumonia, hemo/pneumothorax, or \u0026ldquo;other\u0026rdquo; categories. Implant failure was defined as symptomatic plate fracture or deformity. Readmissions were only counted if\u0026thinsp;\u0026gt;\u0026thinsp;24 hours and unplanned.\u003c/p\u003e \u003cp\u003eTo account for the low incidence of individual outcomes, we created composite endpoints from similar outcomes. Our first composite endpoint of rib-related complications included rib-related readmissions, nonunion, post-discharge pain management referral, chest wall nerve block, and for the rib fixation group only, post-discharge surgical site infection (SSI) and symptomatic implant failure. A composite outcome was created for new diagnosis of opioid or alcohol use disorder due to anticipated low number of diagnoses. Additional endpoints were pneumonia within 1 month and post-discharge death.\u003c/p\u003e \u003cp\u003eDistributions of continuous variables between surgical versus nonsurgical patients were evaluated using a Wilcoxon rank-sum test. Chi-square or Fisher\u0026rsquo;s exact tests were used for categorical variables. Associations between risk factors and outcomes were evaluated through multivariable Fine and Gray hazard models with death (or in-hospital death for the post-discharge death outcome) as a competing risk. Models were stratified by SSRF status prior to discharge. Variable inclusion was based on clinical importance and significance in univariable models. A two-tailed p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All analyses were conducted using SAS, version 9.4 (SAS Institute Inc).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 976 patients were included, with 904 (93%) managed nonoperatively and 72 (7%) undergoing SSRF (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Overall, patients were predominantly older (median (IQR) 66 (51, 79) years) and male (62%), with a higher proportion of male patients in the SSRF group (83% vs 61% in the nonsurgical group). Patients who underwent SSRF had higher admission injury severity score (ISS), more severe chest wall injuries, longer ICU and hospital length of stay (LOS), and higher MME / day at discharge (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Approximately 57% of surgical patients were admitted to the ICU, with a median (IQR) length stay of 4 (3, 7) days, compared to 34% of nonsurgical patients, with a median (IQR) stay of 3 (2, 5) days. During the hospitalization period, 10% of surgical patients developed pneumonia and 4% developed ARDS, compared to 4% and 1%, respectively, in the nonsurgical group.\u003c/p\u003e \u003cp\u003eAmong surgical patients, SSRF was performed at a median (IQR) of 2 (1, 3) days post-admission. Three (4%) patients in the SSRF group required an additional chest tube in the postoperative period prior to hospital discharge. No surgical patients experienced symptomatic non-union, plate failure, or implant or surgical site infections.\u003c/p\u003e \u003cp\u003eAverage (SD) time to follow up (censored at 2 years) was similar in both groups at 80 (39) weeks in both populations, with 36% of patients in both populations lost to follow up before the full 2-year period.\u003c/p\u003e \u003cp\u003ePost-discharge rib-related complications were identified in 13 (1%) nonsurgical patients and 4 (6%) surgical patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the nonsurgical group, 10 (1%) patients required readmission for rib-related reasons and 3 (0.3%) required a post-discharge pain management referral. Pain management was the most common reason for readmission in the nonsurgical group (n\u0026thinsp;=\u0026thinsp;7, 70%), followed by hemo/pneumothorax (n\u0026thinsp;=\u0026thinsp;2, 20%). One nonsurgical patient developed an infected chest wall hematoma. In the surgical group, 4 patients (5%) required readmission for rib-related reasons (empyema, hemo/pneumothorax, pneumonia, hardware discomfort). One surgical patient required delayed surgical hardware removal due to discomfort. Median (IQR) post-discharge time to rib-related complications was 1.6 (0.7, 4.9) weeks in the nonsurgical group and 1.4 (0.9, 33.0) weeks in the surgical group, with more than half of the patients in each group experiencing complications within two weeks (n\u0026thinsp;=\u0026thinsp;7, 54% in the nonsurgical group and n\u0026thinsp;=\u0026thinsp;3, 75% in the surgical group). Among nonsurgical patients, hemo/pneumothorax on arrival was associated with increased risk of rib-related complications [subdistribution hazard ratio (SHR) (95% CI): 5.95 (1.8, 19.67)], after adjusting for ISS and age (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn both groups, 1% of patients developed pneumonia within 1 month of discharge (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Given the low event rate, risk factors for pneumonia were not evaluated. A new diagnosis of alcohol or opioid use disorder was made in 14 (2%) of the nonsurgical patients and 1 (1%) of surgical patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Multivariable models did not reveal risk factors significantly associated with this outcome in the nonsurgical group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). All-cause post-discharge mortality was 8% in the nonsurgical group and 3% in the surgical group (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The median time to death was 31 (12, 60) weeks in the nonsurgical group and 89 (80, 97) weeks in the surgical group. The majority of post-discharge deaths occurred between 2 months and 1 year in the nonsurgical group (33/68, 49%) and between 1\u0026ndash;2 years in the surgical group (2/2, 100%). In the nonsurgical group, mortality was associated with increasing age [SHR (95% CI) 1.83 (1.46, 2.28)], after adjusting for ISS (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eIn this study of post-discharge outcomes after traumatic rib fractures, we observed overall low rates of rib-related complications among patients undergoing SSRF as well as nonsurgically-managed patients, with the majority of these occurring within 2 weeks of discharge. In the nonsurgical group, presence of hemo/pneumothorax on arrival imaging was significantly associated with rib-related complications. The majority of readmissions were for treatment of rib fracture pain, highlighting the critical importance of analgesia in the post-hospitalization period.\u003c/p\u003e \u003cp\u003eA number of previous studies have examined the timing and frequency of complications after rib fracture. All-cause mortality following rib fractures has been reported as high as 6.9% within 30 days [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A review of post-injury complications after rib or sternal fractures by Forrester et al found that 0.7% (847/121,615) of nonsurgical patients experienced a potentially-modifiable complication, with 98% of occurring within 30 days of injury [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Baker et al reported a 90-day readmission rate of 8% among conservatively-managed patients with chest wall injury, with the majority of these (7%) occurring within 30 days of discharge [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a multicenter, retrospective study of patients with chest wall injury, 0.5% of patients developed pneumonia within 30 days of hospitalization [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The incidence of delayed hemothorax among patients discharged from the emergency department after chest wall injury has been estimated at 12% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], with a separate study reporting an average of 9 days between discharge and readmission for delayed hemothorax [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePost-discharge complications after SSRF have been similarly characterized. In our study, we observed no cases of symptomatic nonunion in either cohort, and none of the 72 surgical patients experienced hardware failure or surgical site infection. Only one patient undergoing SSRF in our study required reoperation for hardware-related discomfort. Forrester et al found that among patients undergoing rib or sternal fixation, 3% (94/2881) experienced potentially-modifiable sequelae, with 27% occurring within 30 days [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Incidence of SSI after rib fixation has been estimated between 1\u0026ndash;13%, most often reported in the early postoperative period [\u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. An estimated 1\u0026ndash;3% of patients require operative intervention for chronic pain or implant failure, usually\u0026thinsp;\u0026ge;\u0026thinsp;1 year postoperatively [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our institutional practice, patients who undergo SSRF are ideally seen for follow up at 3 sequential visits (1 month, 3 months, 1 year), while nonsurgical patients are seen at 2\u0026ndash;3 weeks post-discharge depending on injury severity and symptoms. Other institutions report median follow-up as long as 39 months [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Clinical practice guidelines for follow up after rib fractures recommend follow up for at least 1 month post-discharge for nonsurgical patients and 3 months for patients undergoing SSRF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In our study, the majority of potentially-modifiable complications occurred within 1 month in both groups, with the greatest proportion within 2 weeks post-discharge. Given the low rate of surgical complications in our SSRF group, further study is necessary to determine whether the extended 3 month follow up period is of clinical benefit in our patient population. While the guidelines do not comment on the time to first follow up appointment, our observations suggest that early time to first follow up (\u0026lt;\u0026thinsp;2 weeks) may be prudent in both populations, particularly among patients with hemo/pneumothorax at hospital arrival.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The power of our study was low for surgical patients, and 36% of patients were lost to follow up over the 2-year period. The timing of this study during the height of the COVID-19 pandemic may have had additional impact on follow up due to disruptions in clinical operations and in-person visits. Furthermore, we did not differentiate between causes of pneumonia or assess the impact of heightened respiratory precautions during this period. As a single-institution study, caution should be applied in extrapolating these observations due to variation in institutional protocols and surgeon practice. Further investigation with a larger, multi-institutional cohort is necessary to better characterize the incidence, timing, and risk factors for post-discharge complications in this population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe observed low rates of rib-related complications among patients with traumatic rib fractures undergoing operative and nonoperative management. The majority of potentially-modifiable complications occurred within 2 weeks of discharge and were associated with hemo/pneumothorax on hospital arrival in the nonsurgical group. While further study is required to define and validate complication risk factors, this work highlights a potential opportunity for early identification and intervention in the immediate post-discharge period.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cu\u003eEthics Approval\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in accordance with the ethical standards denoted in the 1964 Declaration of Helsinki and its later amendments. Research was conducted retrospectively from data obtained for clinical purposes. The study received prior approval from the Stanford University Institutional Review Board, which determined that it did not need ethical approval.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDisclosures\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFinancial interests: Author JDF is a Principal Investigator for an investigator-initiated clinical trial funded in part by Pacira \u0026amp; Varian and an industry-initiated clinical trial funded in part by Eclipse Regenysis. The remaining authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eNon-financial interests: none.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthorship Contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eTNA – study design, literature search, data collection, data interpretation, writing, critical revision; ME – study design, data analysis, data interpretation, writing, critical revision; SJR – literature search, data collection, writing; EJZ - literature search, data collection, writing; SLS - literature search, data collection, writing; JKF – data collection; SC – data collection; AAM – data collection; RABF – data collection; JDF – study design, data interpretation, critical revision.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLodhia JV, Konstantinidis K, Papagiannopoulos K. Surgical management of multiple rib fractures/flail chest. J Thorac Dis 2019;11:1668\u0026ndash;75. https://doi.org/10.21037/jtd.2019.03.54.\u003c/li\u003e\n \u003cli\u003eHaines K, Rust C, Nguyen BP, Agarwal S. Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status. Am Surg 2018;84:1869\u0026ndash;75.\u003c/li\u003e\n \u003cli\u003eKasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017;82:618\u0026ndash;26. https://doi.org/10.1097/TA.0000000000001350.\u003c/li\u003e\n \u003cli\u003eMartin TJ, Eltorai AS, Dunn R, Varone A, Joyce MF, Kheirbek T, et al. Clinical management of rib fractures and methods for prevention of pulmonary complications: A review. Injury 2019;50:1159\u0026ndash;65. https://doi.org/10.1016/j.injury.2019.04.020.\u003c/li\u003e\n \u003cli\u003eColling KP, Goettl T, Harry ML. Outcomes after rib fractures: more complex than a single number. J Trauma Inj 2022;35:268\u0026ndash;76. https://doi.org/10.20408/jti.2021.0096.\u003c/li\u003e\n \u003cli\u003eBulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib Fractures in the Elderly. J Trauma Acute Care Surg 2000;48:1040.\u003c/li\u003e\n \u003cli\u003eWitt CE, Bulger EM. Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol. Trauma Surg Acute Care Open 2017;2:e000064. https://doi.org/10.1136/tsaco-2016-000064.\u003c/li\u003e\n \u003cli\u003eHo S-W, Teng Y-H, Yang S-F, Yeh H-W, Wang Y-H, Chou M-C, et al. Risk of pneumonia in patients with isolated minor rib fractures: a nationwide cohort study. BMJ Open 2017;7:e013029. https://doi.org/10.1136/bmjopen-2016-013029.\u003c/li\u003e\n \u003cli\u003eSimon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward TI, 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:S351. https://doi.org/10.1097/TA.0b013e31827019fd.\u003c/li\u003e\n \u003cli\u003eBrasel KJ, Moore EE, Albrecht RA, deMoya M, Schreiber M, Karmy-Jones R, et al. Western Trauma Association Critical Decisions in Trauma: Management of rib fractures. J Trauma Acute Care Surg 2017;82:200\u0026ndash;3. https://doi.org/10.1097/TA.0000000000001301.\u003c/li\u003e\n \u003cli\u003eDelaplain PT, Facs SDS, Pieracci FM, Bs AS, Bs DEB, Loftus J, et al. Chest Wall Injury Society Guideline for SSRF Indications, Contraindications, and Timing n.d.\u003c/li\u003e\n \u003cli\u003eCha PI, Hakes NA, Choi J, Rosenberg G, Tennakoon L, Spain DA, et al. National Readmission Rates after Surgical Stabilization of Traumatic Rib Fractures. J Cardiothorac Trauma 2020;5:16. https://doi.org/10.4103/jctt.jctt_6_20.\u003c/li\u003e\n \u003cli\u003eCraxford S, Owyang D, Marson B, Rowlins K, Coughlin T, Forward D, et al. Surgical management of rib fractures after blunt trauma: a systematic review and meta-analysis of randomised controlled trials. Ann R Coll Surg Engl 2022;104:249\u0026ndash;56. https://doi.org/10.1308/rcsann.2021.0148.\u003c/li\u003e\n \u003cli\u003eHisamune R, Kobayashi M, Nakasato K, Yamazaki T, Ushio N, Mochizuki K, et al. A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures. World J Emerg Surg 2024;19:11. https://doi.org/10.1186/s13017-024-00540-z.\u003c/li\u003e\n \u003cli\u003ePeek J, Beks RB, Hietbrink F, De Jong MB, Heng M, Beeres FJP, et al. Epidemiology and outcome of rib fractures: a nationwide study in the Netherlands. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc 2022;48:265\u0026ndash;71. https://doi.org/10.1007/s00068-020-01412-2.\u003c/li\u003e\n \u003cli\u003eForrester JD, Choudhry MS, Fernandez-Moure J, Patel B, Tung J, Kartiko S. Chest Wall Injury Society recommendations for LOng-term Follow-Up (CWIS-LOFU) after non-operatively and operatively managed traumatic rib and sternal fractures [Manuscript submitted for publication]. Department of Surgery, Stanford University.\u003c/li\u003e\n \u003cli\u003eBaker JE, Skinner M, Heh V, Pritts TA, Goodman MD, Millar DA, et al. Readmission rates and associated factors following rib cage injury. J Trauma Acute Care Surg 2019;87:1269\u0026ndash;76. https://doi.org/10.1097/TA.0000000000002390.\u003c/li\u003e\n \u003cli\u003eDehghan N, Mah JM, Schemitsch EH, Nauth A, Vicente M, McKee MD. Operative Stabilization of Flail Chest Injuries Reduces Mortality to That of Stable Chest Wall Injuries. J Orthop Trauma 2018;32:15\u0026ndash;21.\u003c/li\u003e\n \u003cli\u003e\u0026Eacute;mond M, Sirois MJ, Guimont C, Chauny JM, Daoust R, E B. Functional Impact of a Minor Thoracic Injury: An Investigation of Age, Delayed Hemothorax, and Rib Fracture Effects. Ann Surg 2015;262:1115\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eChoi J, Anand A, Sborov KD, Walton W, Chow L, O G. Complication to consider: Delayed traumatic hemothorax in older adults. Trauma Surg Acute Care Open 2021;6.\u003c/li\u003e\n \u003cli\u003eThiels CA, Aho JM, Naik ND, Zielinski MD, Schiller HJ, DS M. Infected hardware after surgical stabilization of rib fractures: Outcomes and management experience. J Trauma Acute Care Surg 2016;80:819\u0026ndash;23.\u003c/li\u003e\n \u003cli\u003eDehghan N, Nauth A, Schemitsch E, Vicente M, Jenkinson R, Kreder H, et al. Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial. JAMA Surg 2022;157:983\u0026ndash;90. https://doi.org/10.1001/jamasurg.2022.4299.\u003c/li\u003e\n \u003cli\u003eWijffels MME, Hagenaars T, Latifi D, Lieshout EMM, Verhofstad MHJ. Early results after operatively versus non-operatively treated flail chest: a retrospective study focusing on outcome and complications. Eur J Trauma Emerg Surg 2020;46:539\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eLodin D, Florio T, Genuit T, Hus N. Negative Pressure Wound Therapy Can Prevent Surgical Site Infections Following Sternal and Rib Fixation in Trauma Patients: Experience From a Single-Institution Cohort Study. Cureus 2020;12.\u003c/li\u003e\n \u003cli\u003eGargur Assuncao A, Leasia K, White T, Majercik S, Gardner S, Mauffrey C, et al. Characterization and influence of ipsilateral scapula fractures among patients who undergo surgical stabilization of sub-scapular rib fractures. Eur J Orthop Surg Traumatol Orthop Traumatol 2021;31:429\u0026ndash;34. https://doi.org/10.1007/s00590-020-02789-x.\u003c/li\u003e\n \u003cli\u003ePrins JTH, Leasia K, Dull MB, Lawless RA, Platnick KB, NL W. Surgical Site Infection after Surgical Stabilization of Rib Fractures: Rare but Morbid. Surg Infect Larchmt 2022;23:5\u0026ndash;11.\u003c/li\u003e\n \u003cli\u003evan Gool MH, van Roozendaal LM, Vissers YLJ, van den Broek R, van Vugt R, Meesters B, et al. VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases. Gen Thorac Cardiovasc Surg 2022;70:985\u0026ndash;92. https://doi.org/10.1007/s11748-022-01830-6.\u003c/li\u003e\n \u003cli\u003eBelaroussi Y, Drevet G, Soldea V, Patoir A, Grima R, A L. When to proceed to surgical rib fixation?\u0026mdash;A single-institution clinical experience. J Thorac Dis 2023;15:323\u0026ndash;34.\u003c/li\u003e\n \u003cli\u003eKocher GJ, Sharafi S, Azenha LF, Schmid RA. Chest wall stabilization in ventilator-dependent traumatic flail chest patients: who benefits? Eur J Cardiothorac Surg 2017;51:696\u0026ndash;701.\u003c/li\u003e\n \u003cli\u003eLiu Y, Xu S, Yu Q, Tao Y, Peng L, S Q. Surgical versus conservative therapy for multiple rib fractures: a retrospective analysis. Ann Transl Med 2018;6.\u003c/li\u003e\n \u003cli\u003eNiziolek G, Goodman MD, Makley A, Millar DA, Heh V, TA P. Early results after initiation of a rib fixation programme: A propensity score matched analysis. Injury 2022;53:137\u0026ndash;44.\u003c/li\u003e\n \u003cli\u003ePrins JTH, Van Lieshout EMM, Overtoom HCG, Tekin YS, Verhofstad MHJ, Wijffels MME. Long-term pulmonary function, thoracic pain, and quality of life in patients with one or more rib fractures. J Trauma Acute Care Surg 2021;91:923\u0026ndash;31. https://doi.org/10.1097/TA.0000000000003378.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u0026nbsp;Table 1. Baseline demographics and admission data. Values expressed as N (%) unless specified. ISS = injury severity score, IQR = interquartile range, LOS = length of stay, MME = morphine milliequivalents.\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"558\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNonsurgical\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=904)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=72)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=976)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eAge, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e67 (51, 82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e59 (60, 66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e66 (51, 79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e548 (61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e60 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e608 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eBMI, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e25 (22, 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e27 (24, 30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e25 (23, 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eAdmission ISS, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e10 (9, 17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e17 (13, 22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e12 (9, 17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eAdmission ISS: severe/profound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e270 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e42 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e312 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003e# of rib fractures, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e3 (2, 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e7 (5, 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e4 (2, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003ePneumo- and/or hemothorax on arrival\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e268 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e63 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e331 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003ePulmonary contusions on arrival\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e146 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e31 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e177 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eFlail chest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e9 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e16 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e25 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eSternal fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e71 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e13 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e84 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eClavicle fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e128 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e22 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e150 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eScapula fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e86 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e13 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e99 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003ePneumonia during admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e36 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e7 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e43 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eARDS during admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e6 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e3 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e9 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003ePulmonary embolism during admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e15 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e16 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u0026gt; 0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e310 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e41 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e351 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eICU LOS, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e3 (2, 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e4 (3, 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e3 (2, 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eInvasive ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e82 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e12 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e94 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eVentilator days, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e6 (2, 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e17 (5, 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e6 (2, 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eMME / day at discharge, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e15 (4, 46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e50 (8, 107)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e19 (4, 52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 40.8602%;\"\u003e\n \u003cp\u003eHospital LOS, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e3 (2, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.9785%;\"\u003e\n \u003cp\u003e7 (4, 11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e4 (2, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable 2. Adjusted risk of rib-related complications among nonsurgical patients. SHR = subdistribution hazard ratio.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36.6509%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.545%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0095%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSHR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.79463%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36.6509%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.545%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0095%;\"\u003e\n \u003cp\u003e0.82 (0.61, 1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.79463%;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36.6509%;\"\u003e\n \u003cp\u003eISS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.545%;\"\u003e\n \u003cp\u003eMild/moderate vs. severe/profound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0095%;\"\u003e\n \u003cp\u003e4.23 (0.9, 19.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.79463%;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36.6509%;\"\u003e\n \u003cp\u003ePneumo- and/or hemothorax on arrival\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.545%;\"\u003e\n \u003cp\u003eyes or no\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0095%;\"\u003e\n \u003cp\u003e5.95 (1.8, 19.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.79463%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3. Adjusted risk of new alcohol or opioid use disorder among nonsurgical patients. SHR = subdistribution hazard ratio.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39.2628%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;SHR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5192%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39.2628%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e0.81 (0.64, 1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5192%;\"\u003e\n \u003cp\u003eISS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39.2628%;\"\u003e\n \u003cp\u003eMild/moderate vs. severe/profound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e1.42 (0.49, 4.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5192%;\"\u003e\n \u003cp\u003eMME at discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 39.2628%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e1.03 (1, 1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4. Adjusted risk of mortality among nonsurgical patients. SHR = subdistribution hazard ratio.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4423%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3397%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;SHR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4423%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3397%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e1.83 (1.46, 2.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4423%;\"\u003e\n \u003cp\u003eISS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3397%;\"\u003e\n \u003cp\u003eMild/moderate vs. severe/profound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.9615%;\"\u003e\n \u003cp\u003e1.07 (0.54, 2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"rib fracture, rib fixation, trauma, pneumonia, hemothorax, injury","lastPublishedDoi":"10.21203/rs.3.rs-5183333/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5183333/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003ePurpose\u003cbr\u003e\n \u003c/u\u003eTo evaluate frequency and timing of post-discharge complications in patients with traumatic rib fractures undergoing operative or nonoperative management.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods\u003cbr\u003e\n \u003c/u\u003eWe retrospectively reviewed adult patients with rib fractures admitted to a Level 1 trauma center from 1/2020-12/2021. Outcomes included rib-related complications, pneumonia within 1 month, new diagnosis of opioid- or alcohol-use disorder, and all-cause mortality. Patients were stratified on whether they underwent surgical stabilization of rib fractures (SSRF). Associations between risk factors and outcomes were evaluated through Fine and Gray hazard models with death (or in-hospital death for the post-discharge death outcome) as a competing risk.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults\u003cbr\u003e\n \u003c/u\u003eOf 976 patients admitted with rib fractures, 904(93%) underwent non-operative therapy and 72(7%) underwent SSRF. Nonoperative patients had less-severe injuries and shorter ICU length-of-stay. Rib-related complications occurred in 13(1%) nonsurgical patients and 4(6%) surgical patients. In the nonsurgical group, presence of hemo/pneumothorax on admission was associated with increased risk of rib-related complications [subdistribution hazard ratio (SHR) (95% CI): 5.95(1.8, 19.67)]. Pneumonia within 1 month occurred in 9(1%) nonsurgical patients and 1(1%) surgical patient. New diagnosis of alcohol or opioid-use disorder was made in 14(2%) nonsurgical patients and 1(1%) surgical patients. All-cause mortality was 68(8%) in the nonsurgical group and 2(3%) in the surgical group. Older age was associated with mortality in the nonsurgical cohort [SHR (95% CI): 1.83(1.46, 2.28)].\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusion\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003ePost-discharge rib-related complications were rare in both groups, but occurred primarily within 2 weeks, suggesting concentrated earlier follow-up may be beneficial. These findings help inform recommendations for follow-up in this population.\u003c/p\u003e","manuscriptTitle":"Post-Discharge Complications and Follow-Up Timing after Hospitalization for Traumatic Rib Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-08 10:19:23","doi":"10.21203/rs.3.rs-5183333/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-21T08:42:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-20T21:12:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-11T17:22:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48229379249248019411927954541612797408","date":"2024-10-09T07:15:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-02T21:18:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165988334540622852185105569232401071605","date":"2024-10-02T19:46:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280856798899933209939237736599286046535","date":"2024-10-02T18:57:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-02T16:08:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-02T16:03:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-02T12:29:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2024-09-30T20:22:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a3ec7006-1549-4eba-9a76-8b026369b61d","owner":[],"postedDate":"November 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-11T00:55:03+00:00","versionOfRecord":{"articleIdentity":"rs-5183333","link":"https://doi.org/10.1007/s00068-024-02682-w","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2025-01-24 15:57:06","publishedOnDateReadable":"January 24th, 2025"},"versionCreatedAt":"2024-11-08 10:19:23","video":"","vorDoi":"10.1007/s00068-024-02682-w","vorDoiUrl":"https://doi.org/10.1007/s00068-024-02682-w","workflowStages":[]},"version":"v1","identity":"rs-5183333","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5183333","identity":"rs-5183333","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}