Does treatment affect in-hospital outcomes in patients with combined injuries to the ribs and clavicle? A propensity score weighted analysis of a retrospective cohort

Abstract text (incl. references and figure legends)

Introduction: The clavicle was named the gatekeeper of the thorax because of its association with adverse outcomes and additional injuries, such as rib fractures and TBI. These injuries are important predictors of pneumonia. Optimal treatment of rib fractures is still debated, and there is scarce literature on concomitant clavicle fractures. We aimed to assess the effect of surgical or conservative treatment on the in-hospital outcomes of patients with combined fractures of the clavicle and ribs.

Material&Methods: All adult patients with clavicle and ³3 rib fractures admitted from 2016-2021 were retrospectively included. Main exclusion criteria were HLOS <24h, admission >48h after trauma, active pneumonia or antibiotic treatment upon admission, rib fractures due to CPR, or history of congenital or malignant bone disease. Regression analyses were performed to evaluate associations of treatment modality and outcomes; inverse propensity score weighting was used to control for confounding.

Results: 252 patients were included (212 conservative, 40 surgical; median age 62, 67% male). Median ISS and GCS were 17 and 15, respectively. Thirty-seven patients developed pneumonia. Effects sizes between clavicle fixation and pneumonia (OR -0.5, 95%CI -2.3–1.1), ILOS (ILOS; b-coefficient -2.6, 95%CI -5.6–0.4), and days on mechanical ventilation (b-coefficient -3.1, 95%CI -9.7–3.4) were considerable. For rib plating, the effect on pneumonia (OR 0.7, 95%CI -1.0–2.3), HLOS (b-coefficient 3.9, 95%CI -1.7–9.4) and ILOS (b-coefficient 2.7, 95%CI -1.2–6.5) was substantial.

Conclusions: Clavicle fixation in patients with combined injuries of the clavicle and ribs does not improve nor worsen in-hospital outcomes; the orthopedic surgeon should make a patient-tailored treatment decision. Rib plating does not improve in-hospital outcomes and should not be performed in non-flail patients with a concomitant clavicle fracture. Guidelines on non-flail rib plating can profit from these findings

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