A nationwide survey of practice on available services and current clinical input to the care of patients with rib fractures

Abstract

Context: Increasing use of rib fracture fixation, despite lack of robust evidence of its effectiveness, has led to calls for large well-designed randomized controlled trials (RCTs). Aims: The aim of this survey is to ascertain the current clinical care of patients with rib fractures, identify pathways to aid patient selection, and establish whether clinicians would be willing to randomize patients into a surgical trial. Subjects and Methods: An electronic survey was distributed to trauma unit (TU) and major trauma center (MTC) leads were identified by the trauma network managers in England and Wales. Institutional ethical approval granted. Results: Most national health service (NHS) trusts have an emergency department chest trauma protocol (n = 34, 81%); seven (88%) MTCs provide a rib fracture surgery service. General surgery is the lead specialty in TUs (TUs: n = 26, 77% vs. MTCs: n = 2, 25%) and thoracic surgery in MTCs (n = 26, 77% vs. n = 3, 38%). When intubation is required, intensive care medicine leads this care (n = 19, 56% vs. n = 3, 38%). Specialist physiotherapy (n = 17, 41%) and rehabilitation consultants (n = 7, 17%) were available in some hospitals. Clinicians reported that they would be willing to take part or identify patients for an RCT of flail chest fixation (n = 34, 81%) and multiple rib fracture fixation (n = 35, 83%). Conclusions: Care of rib fracture patients involves both MTCs and TUs with variation in care protocols, referral pathways, lead specialties, and rehabilitation services. Several challenges are highlighted that would need consideration in the design and delivery of a clinical trial of surgical fixation of rib fractures. A feasibility trial is required in the first instance.