At the AAOS 2024 Annual Meeting, Claire Donnelley, MD, orthopaedic surgery resident at Yale School of Medicine, presented a study on plating rib fractures in flail chests. Her group’s research, using the PearlDiver database, analyzed 12,000 patients with flail segment rib fractures, finding only 4 percent underwent operative management. Operatively managed patients had significantly lower rates of acute respiratory distress syndrome (ARDS) and shorter hospital stays. The study also highlighted the limitations of the database, which lacks mortality data. AAOS Now Editorial Board member Stuart A. Green, MD, FAAOS, sat down with Dr. Donnelley to discuss these findings, as well as the historical evolution of orthopaedic surgery and the current practice of general surgeons plating rib fractures, raising questions about specialization and practice changes over time.

Dr. Green: How did this study come about?
Dr. Donnelley: The impetus for this study came when I was an intern on the general surgery service, seeing a lot of rib plating being done by non-orthopaedic surgeons and wondering, “What are the indications for plating these fractures? Are there any absolute indications? And why are the general surgeons and cardiothoracic surgeons managing [them]?” At Yale, we have access to this PearlDiver database. At the time we ran the study, it contained 90 million orthopaedic patients, and now the most recent iteration will be 165 million.

How did you put the data together?
The database relies on International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes. So, to some extent, it’s limited in that people have to accurately code patients when they come in. And if you look at the definition of the ICD codes, it segregates flail segments from other rib plating types, flail segments being three segmental rib fractures leading to an unstable chest wall. I should say a minimum of three, because it can be many more and often is in these complex polytrauma patients.

The cool thing about the database is that it contains so many patients, you can look at ICD as well as CPT codes, and then you have a lot of other demographic data, like age, length of hospital stay, complications like ARD and tracheostomy, things that would relate to the complications that occur from plating or not plating ribs. But unfortunately, it doesn’t include mortality, which is a huge limitation.

The other thing that is standard practice within PearlDiver is to include comorbidities as a function of the ECI score (Elixhauser Comorbidity Index). But unfortunately, it doesn’t really get at the polytrauma patient, because when you look at a complex polytrauma patient, you’re not as concerned if they have heart failure as how many bones are broken, whether they also have long-bone injury, visceral injury, [or] neurologic deficit like subdural hematoma.

What are the conclusions you came to after looking over all this data?
We were specifically interested in flail segment rib fractures, and what we found was that although there were about 12,000 patients who were identified as having a flail segment rib fracture, only 4 percent of those patients underwent operative management. Within those 4 percent, the majority of those who were treated operatively had a decrease in adverse events postoperatively, specifically a decreased rate of ARDS, and a decreased rate of hospital stay compared to those who were not managed operatively. The decreased rate of ARDS was half the percentage of people who did not undergo operative management.

I think it’s interesting that rib fractures have become something [treated by] general surgeons and not orthopaedic surgeons. I’d be interested to know how that happened, because we consider ourselves the bone experts, and we look at outcomes for all different types of bones we manage.

Stuart A. Green, MD, FAAOS, is cofounder and past president of the Limb Lengthening and Reconstruction Society, past president of the Association of Bone and Joint Surgeons, and an attending surgeon at the Rubin Tibor Long Beach VA Medical Center. He is the son, first cousin, and father of AAOS Fellows. Dr. Green is a member of the AAOS Now Editorial Board.