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Trauma is an important cause of mortality in New Zealand. It is the leading cause of death between the ages of 1 and 34 and the fifth largest cause of health loss across all age groups.[[1,2]] Thoracic trauma is second only to head and spinal cord injuries as the cause of death in trauma patients.[[3,4]] In New Zealand over 40% of patients presenting with major trauma have thoracic injuries with most of these patients having rib fractures.[[5]]

Rib fractures occur commonly in hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax.[[6,7]] The pain from rib fractures and associated underlying pulmonary pathology may lead to impaired gas exchange and increase the risk of pneumonia and respiratory failure.[[8]] Rib fractures are associated with a significant mortality rate ranging from 3% to 13% and up to 20% in elderly patients.[[8,9]] Although rib fractures are a marker of injury severity and rarely the proximate cause of death, there are a group of patients with isolated thoracic injury that are also at risk of morbidity and mortality directly related to rib fractures. This is especially true in the elderly, who poorly tolerate the subsequent respiratory failure and pneumonia.[[10]] Mortality in young patients with rib fractures is generally attributed to associated injuries.

There is strong evidence that elderly patients, usually defined as 65 and older, have worse outcomes and a higher mortality rate compared with younger patients with isolated thoracic trauma. There is, however, evolving evidence to suggest the inflection point for adverse outcomes starts at a younger age.[[11–22]] Despite this, current clinical guidelines for management of patients with rib fractures mainly include age 65 and older as a trigger for increased level of care in patients with rib fractures.[[23,24]]

The care of trauma patients in New Zealand poses certain unique challenges. New Zealand is geographically diverse and patients often travel large distances to access care. There are high rates of co-morbidity, including obesity and diabetes, and significant inequities in care and outcomes for Māori, Pacific Islanders and low-income populations.[[25–27]] A large proportion of trauma care for patients in New Zealand occurs outside of major trauma centres: this is a key difference to much of the published literature on rib fractures, which is predominantly based on studies from large trauma centres.[[28]] There are no previous studies in New Zealand that have addressed age and its association with outcomes in patients with rib fractures.

The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

Methods

A retrospective study was performed of patients admitted to all hospitals in Northland District Health Board (NDHB) between 1 January 2018 and 31 December 2019. NDHB includes Whangārei Hospital, Dargaville Hospital, Kaitaia Hospital, Bay of Island Hospital and Rawene Hospital. Data were collected from the NDHB’s data warehouse, which was searched to identify patients admitted with rib fractures. Inclusion criteria were patients aged 16 and older with one or more radiologically proven rib fractures sustained secondary to blunt trauma. Exclusion criteria were delayed presentation >48 hours after injury, penetrating trauma, intubation for reason other than thoracic trauma, injury as a result of cardiopulmonary resuscitation or an Abbreviated Injury Scale score >2 in the head or abdomen to remove the impact of polytrauma on management and outcomes of rib fractures.[[29]] Radiological confirmation of a rib fracture was based on a consultant radiologist’s report of either a computer tomography scan or a chest x-ray. NDHB’s electronic medical records were accessed to review injury characteristics, hospital management and outcomes. Number of rib fractures and associated injuries were collected from consultant radiology reports and electronic records. Injury Severity Score (ISS) and Trauma and Injury Severity Score (TRISS) were retrospectively calculated where possible from radiology reports and clinical notes.[[30,31]] Hospital discharge summaries and representation notes were reviewed to determine rates of complications. Patients were followed for six months after their index admission.

The primary outcomes of interest were rates of complications associated with rib fractures and length of stay (LOS). The secondary outcomes of interest were mortality, intensive care unit (ICU) admission rates and rates of intubation.

Data were entered into IBM SPSS for analysis. Median and interquartile range (IQR) were calculated for number of rib fractures, LOS, TRISS and ISS. Non-parametric data were tested with a Mann-Whitney U test. Nominal data was tested using a Chi-square or Fischer’s exact test.

This study was deemed out of scope by the New Zealand Health and Disability Ethics Committee. Locality approval was gained from NDHB and the project guidance was given by a representative from the Northland Māori Health Directorate.

Results

Demographics

One hundred and seventy patients who met study criteria were identified. Fifty-two (31%) were female and 118 (69%) were male. One hundred and four (61%) were New Zealand European, 49 (29%) were Māori and 17 (10%) were other ethnicities. Median age was 60 (IQR 21). The study population was stratified by age into three groups: 59 patients (35%) were >65 years old, 77 (45%) were aged 45 to 65 and 34 (20%) were aged <45. Demographic difference between groups is outlined in Table 1. The difference found between ethnicities was expected and aligned with ethnicity-specific age structures.[[32]] The incidence was calculated at 75/100,000 people per year based on the 2018 Northland census data.[[32]]

Table 1: Demographics by age group.

Injury characteristics

The injury characteristics are outlined in Table 2. The mechanism of injury was significantly different between groups. Road traffic crash (RTC) was the most common mechanism in patients <45 and 45–65, and a fall from height <2m was the most common mechanism in patients >65. Patients aged <45 sustained more severe injuries, evidenced by significantly more severe ISS and TRISS and higher rates of pulmonary contusions, pneumothoraces and clavicular fractures. There was a significant difference in number of flail segments between groups, with the highest rate in patients aged 45–65, and a significant difference in the number of patients with bilateral rib fractures, with the highest rates in patients aged >65.

Table 2: Injury characteristics by age group.

Hospital management

Hospital management is outlined in Table 3. A significant difference in the admitting services was found between groups, with 20% of patients aged >65 admitted to general medicine. Regional block use, paracetamol use and placement of a chest drain and rib plating was similar across groups. There was a significantly higher rate of patient-controlled analgesia (PCA) and ketamine use in patients aged 45–65 and significantly less use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients >65.

Table 3: Hospital management by age group.

Primary and secondary outcomes

The primary and secondary outcomes are outlined in Table 4. Patients aged <45 had a significantly shorter LOS and significantly lower rates of pneumonia compared to patients aged 45 and older. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome (ARDS).

Table 4: Outcomes by age group.

Discussion

This study shows increased rates of pneumonia and a longer LOS in patients aged 45 and older, despite their lower overall injury severity when compared to patients under 45. Patients aged 45–64 showed a LOS and rate of pneumonia similar to patients aged 65 and older, adding evidence to the growing literature that suggests increased complications after age 45.

Management guidelines for patients with rib fractures often include age 65 and older as a trigger for increased level of care.[[23,24]] Although the literature points to age as a continuous variable with respect to risk, it is still often necessary to choose an age cut-off for the purpose of patient decision-making and clinical guidelines. This study adds to the literature suggesting a younger age should be considered in these clinical guidelines, given patients over age 45 have outcomes more closely aligned with patients over age 65, rather than those aged <45. This is highlighted in this study by pneumonia rates of 23% and 19% in patients aged 45–65 and >65 respectively, compared with 3% in patients aged <45.

Multiple studies from trauma centres have examined the relationship between age and outcomes in patients with rib fractures. Different age cut-offs have been used, including ages 45, 50, 60, 65 and 70.[[11–22]] There is strong evidence that patients aged 65 and older have higher mortality rates and worse outcomes, with growing evidence to suggest adverse outcomes starts at a younger age.[[11–22]] Two large retrospective studies have concordant results: both showed stepwise increases in morbidity and mortality in patients aged 45 and older compared to patients aged <45.[[20,33]] Two small single institution studies, similar to this study, have investigated adverse outcomes starting at a younger age with an age cut-off of 45. The findings are in line with this study, which has shown increased morbidity, in the form of respiratory complications, in patients aged 45 and older.[[19,21]]

The mortality rate of 2% found in this study is similar to that of other studies also focused on isolated thoracic trauma.[[19,21]] Rib fracture mortality is consistently quoted in the literature as ranging from 3–20%. However, this high mortality rate is largely due to associated injuries, with rib fractures being a marker of injury severity rather than the proximate cause of death.[[10]] The low mortality rate in this study is therefore likely due to the exclusion of patients with major head or abdominal injuries. The high rates of pneumonia in this study are also in line with literature reporting rates ranging from 6–31% in patients with rib fractures.[[11,20]]

This study is limited by its sample size and retrospective methodology. The relatively small sample size potentially obscures clinically relevant, significant differences in parameters that are known to have low rates between groups, including a difference in mortality found in studies with greater power.[[20,33]] However, the sample is contemporary and all patients were individually reviewed with a reasonable follow-up time allowed. The results of this study are in line with recent publications and add further evidence to the growing body of work that suggests a younger inflection point for adverse outcomes. It is likely that these findings are generalisable to a large number of provincial centres throughout New Zealand. Larger prospective studies are needed to confirm these findings, but consideration should be given to using local data to drive changes in guidelines if needed.

Conclusion

This study found higher rates of pneumonia and an increased LOS in patients aged 45 and older despite their lower overall injury severity when compared to patients under the age of 45. Patient aged 45–64 had outcomes similar to patients aged >65, in keeping with literature that suggests adverse outcomes increase in patients aged 45 and older. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Summary

Abstract

Aim

Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

Method

A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old.

Results

170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome.

Conclusion

This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45–64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Author Information

Matthew J McGuinness: MBChB; General Surgical Registrar, Department of General Surgery, Northland District Health Board. Liam Ryan Ferguson: Medical student, University of Auckland. Imogen Watt: Medical student, University of Auckland. Christopher Harmston: FRCS(Eng), FRACS; Consultant Colorectal and General Surgeon, Department of General Surgery, Northland District Health Board; Honorary Associate Professor, University of Auckland.

Acknowledgements

Correspondence

Matthew J McGuinness, Department of General Surgery, Whangārei Hospital, Manu Road, Whangarei 0148, New Zealand

Correspondence Email

Matt@McGuinness.net.nz

Competing Interests

Nil.

1) Christey GR. Trauma care in New Zealand: it's time to move ahead. World J Surg. 2008;32(8):1618-21.

2) Corporation MoHaAC. Injury-related Health Loss: A report from teh New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006-2016. In: Health Mo, editor. Wellington.

3) Wanek S, Mayberry JC. Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin. 2004;20(1):71-81.

4) Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent). 2013;26(2):120-3.

5) Te Hononga Whētuki ā-Motu National Trauma Network [Internet]. Annual report 2016-2017: New Zealand Major Trauma Registry & National Clinical Network; 2017.  Available from: www.majortrauma.nz/assets/Publication-Resources/Annual-reports.

6) Martin 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(6):1159-65.

7) Peek 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. 2020.

8) Brasel 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(1):200-3.

9) Galvagno SM, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, et al. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936-51.

10) Bankhead-Kendall B, Radpour S, Luftman K, Guerra E, Ali S, Getto C, et al. Rib Fractures and Mortality: Breaking the Causal Relationship. Am Surg. 2019;85(11):1224-7.

11) Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib Fractures in the Elderly. Journal of Trauma and Acute Care Surgery. 2000;48(6):1040-7.

12) Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478-85.

13) Van Vledder MG, Kwakernaak V, Hagenaars T, Van Lieshout EMM, Verhofstad MHJ, Group SWNTRS. Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study. Eur J Trauma Emerg Surg. 2019;45(4):575-83.

14) Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23(3):374-8.

15) Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R, Stombaugh HA. Perils of rib fractures. Am Surg. 2008;74(4):310-4.

16) Svennevig JL, Bugge-Asperheim B, Geiran OR, Vaage J, Pillgram-Larsen J, Fjeld NB, et al. Prognostic factors in blunt chest trauma. Analysis of 652 cases. Ann Chir Gynaecol. 1986;75(1):8-14.

17) Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133-8.

18) Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. 2004;52(5):805-8.

19) Holcomb JB, McMullin NR, Kozar RA, Lygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003;196(4):549-55.

20) Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures: relationship with pneumonia and mortality. Crit Care Med. 2006;34(6):1642-6.

21) Testerman GM. Adverse outcomes in younger rib fracture patients. South Med J. 2006;99(4):335-9.

22) Harrington DT, Phillips B, Machan J, Zacharias N, Velmahos GC, Rosenblatt MS, et al. Factors associated with survival following blunt chest trauma in older patients: results from a large regional trauma cooperative. Arch Surg. 2010;145(5):432-7.

23) Witt 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(1):e000064.

24) Sahr SM, Webb ML, Renner CH, Sokol RK, Swegle JR. Implementation of a rib fracture triage protocol in elderly trauma patients. J Trauma Nurs. 2013;20(4):172-5; quiz 6-7.

25) Goodyear-Smith F, Ashton T. New Zealand health system: universalism struggles with persisting inequities. Lancet. 2019;394(10196):432-42.

26) Poppitt SD, Silvestre MP, Liu A. Etiology of Obesity Over the Life Span: Ecologic and Genetic Highlights from New Zealand Cohorts. Curr Obes Rep. 2014;3(1):38-45.

27) Civil I, Twaddle B. Trauma care systems in New Zealand. Injury. 2003;34(9):740-4.

28) Te Hononga Whētuki ā-Motu National Trauma Network [Internet]. Australia New Zealand Trauma Registry: Management of the Severely Injured. Annual Report. 2017-2018. Available from: www.majortrauma.nz/assets/Publication-Resources/Publications.

29) Association for the Advancement of Automotive Medicine. Abbreviated Injury Scale: 2015 Revision (6 ed.), (2018).

30) Schluter PJ. The Trauma and Injury Severity Score (TRISS) revised. Injury. 2011;42(1):90-6.

31) Baker SP, O'Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-96.

32) Starts NZ [Internet]. New Zealand population statistics 2020. Available from: www.stats.govt.nz/topics/population.

33) Lien YC, Chen CH, Lin HC. Risk factors for 24-hour mortality after traumatic rib fractures owing to motor vehicle accidents: a nationwide population-based study. Ann Thorac Surg. 2009;88(4):1124-30.

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Trauma is an important cause of mortality in New Zealand. It is the leading cause of death between the ages of 1 and 34 and the fifth largest cause of health loss across all age groups.[[1,2]] Thoracic trauma is second only to head and spinal cord injuries as the cause of death in trauma patients.[[3,4]] In New Zealand over 40% of patients presenting with major trauma have thoracic injuries with most of these patients having rib fractures.[[5]]

Rib fractures occur commonly in hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax.[[6,7]] The pain from rib fractures and associated underlying pulmonary pathology may lead to impaired gas exchange and increase the risk of pneumonia and respiratory failure.[[8]] Rib fractures are associated with a significant mortality rate ranging from 3% to 13% and up to 20% in elderly patients.[[8,9]] Although rib fractures are a marker of injury severity and rarely the proximate cause of death, there are a group of patients with isolated thoracic injury that are also at risk of morbidity and mortality directly related to rib fractures. This is especially true in the elderly, who poorly tolerate the subsequent respiratory failure and pneumonia.[[10]] Mortality in young patients with rib fractures is generally attributed to associated injuries.

There is strong evidence that elderly patients, usually defined as 65 and older, have worse outcomes and a higher mortality rate compared with younger patients with isolated thoracic trauma. There is, however, evolving evidence to suggest the inflection point for adverse outcomes starts at a younger age.[[11–22]] Despite this, current clinical guidelines for management of patients with rib fractures mainly include age 65 and older as a trigger for increased level of care in patients with rib fractures.[[23,24]]

The care of trauma patients in New Zealand poses certain unique challenges. New Zealand is geographically diverse and patients often travel large distances to access care. There are high rates of co-morbidity, including obesity and diabetes, and significant inequities in care and outcomes for Māori, Pacific Islanders and low-income populations.[[25–27]] A large proportion of trauma care for patients in New Zealand occurs outside of major trauma centres: this is a key difference to much of the published literature on rib fractures, which is predominantly based on studies from large trauma centres.[[28]] There are no previous studies in New Zealand that have addressed age and its association with outcomes in patients with rib fractures.

The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

Methods

A retrospective study was performed of patients admitted to all hospitals in Northland District Health Board (NDHB) between 1 January 2018 and 31 December 2019. NDHB includes Whangārei Hospital, Dargaville Hospital, Kaitaia Hospital, Bay of Island Hospital and Rawene Hospital. Data were collected from the NDHB’s data warehouse, which was searched to identify patients admitted with rib fractures. Inclusion criteria were patients aged 16 and older with one or more radiologically proven rib fractures sustained secondary to blunt trauma. Exclusion criteria were delayed presentation >48 hours after injury, penetrating trauma, intubation for reason other than thoracic trauma, injury as a result of cardiopulmonary resuscitation or an Abbreviated Injury Scale score >2 in the head or abdomen to remove the impact of polytrauma on management and outcomes of rib fractures.[[29]] Radiological confirmation of a rib fracture was based on a consultant radiologist’s report of either a computer tomography scan or a chest x-ray. NDHB’s electronic medical records were accessed to review injury characteristics, hospital management and outcomes. Number of rib fractures and associated injuries were collected from consultant radiology reports and electronic records. Injury Severity Score (ISS) and Trauma and Injury Severity Score (TRISS) were retrospectively calculated where possible from radiology reports and clinical notes.[[30,31]] Hospital discharge summaries and representation notes were reviewed to determine rates of complications. Patients were followed for six months after their index admission.

The primary outcomes of interest were rates of complications associated with rib fractures and length of stay (LOS). The secondary outcomes of interest were mortality, intensive care unit (ICU) admission rates and rates of intubation.

Data were entered into IBM SPSS for analysis. Median and interquartile range (IQR) were calculated for number of rib fractures, LOS, TRISS and ISS. Non-parametric data were tested with a Mann-Whitney U test. Nominal data was tested using a Chi-square or Fischer’s exact test.

This study was deemed out of scope by the New Zealand Health and Disability Ethics Committee. Locality approval was gained from NDHB and the project guidance was given by a representative from the Northland Māori Health Directorate.

Results

Demographics

One hundred and seventy patients who met study criteria were identified. Fifty-two (31%) were female and 118 (69%) were male. One hundred and four (61%) were New Zealand European, 49 (29%) were Māori and 17 (10%) were other ethnicities. Median age was 60 (IQR 21). The study population was stratified by age into three groups: 59 patients (35%) were >65 years old, 77 (45%) were aged 45 to 65 and 34 (20%) were aged <45. Demographic difference between groups is outlined in Table 1. The difference found between ethnicities was expected and aligned with ethnicity-specific age structures.[[32]] The incidence was calculated at 75/100,000 people per year based on the 2018 Northland census data.[[32]]

Table 1: Demographics by age group.

Injury characteristics

The injury characteristics are outlined in Table 2. The mechanism of injury was significantly different between groups. Road traffic crash (RTC) was the most common mechanism in patients <45 and 45–65, and a fall from height <2m was the most common mechanism in patients >65. Patients aged <45 sustained more severe injuries, evidenced by significantly more severe ISS and TRISS and higher rates of pulmonary contusions, pneumothoraces and clavicular fractures. There was a significant difference in number of flail segments between groups, with the highest rate in patients aged 45–65, and a significant difference in the number of patients with bilateral rib fractures, with the highest rates in patients aged >65.

Table 2: Injury characteristics by age group.

Hospital management

Hospital management is outlined in Table 3. A significant difference in the admitting services was found between groups, with 20% of patients aged >65 admitted to general medicine. Regional block use, paracetamol use and placement of a chest drain and rib plating was similar across groups. There was a significantly higher rate of patient-controlled analgesia (PCA) and ketamine use in patients aged 45–65 and significantly less use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients >65.

Table 3: Hospital management by age group.

Primary and secondary outcomes

The primary and secondary outcomes are outlined in Table 4. Patients aged <45 had a significantly shorter LOS and significantly lower rates of pneumonia compared to patients aged 45 and older. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome (ARDS).

Table 4: Outcomes by age group.

Discussion

This study shows increased rates of pneumonia and a longer LOS in patients aged 45 and older, despite their lower overall injury severity when compared to patients under 45. Patients aged 45–64 showed a LOS and rate of pneumonia similar to patients aged 65 and older, adding evidence to the growing literature that suggests increased complications after age 45.

Management guidelines for patients with rib fractures often include age 65 and older as a trigger for increased level of care.[[23,24]] Although the literature points to age as a continuous variable with respect to risk, it is still often necessary to choose an age cut-off for the purpose of patient decision-making and clinical guidelines. This study adds to the literature suggesting a younger age should be considered in these clinical guidelines, given patients over age 45 have outcomes more closely aligned with patients over age 65, rather than those aged <45. This is highlighted in this study by pneumonia rates of 23% and 19% in patients aged 45–65 and >65 respectively, compared with 3% in patients aged <45.

Multiple studies from trauma centres have examined the relationship between age and outcomes in patients with rib fractures. Different age cut-offs have been used, including ages 45, 50, 60, 65 and 70.[[11–22]] There is strong evidence that patients aged 65 and older have higher mortality rates and worse outcomes, with growing evidence to suggest adverse outcomes starts at a younger age.[[11–22]] Two large retrospective studies have concordant results: both showed stepwise increases in morbidity and mortality in patients aged 45 and older compared to patients aged <45.[[20,33]] Two small single institution studies, similar to this study, have investigated adverse outcomes starting at a younger age with an age cut-off of 45. The findings are in line with this study, which has shown increased morbidity, in the form of respiratory complications, in patients aged 45 and older.[[19,21]]

The mortality rate of 2% found in this study is similar to that of other studies also focused on isolated thoracic trauma.[[19,21]] Rib fracture mortality is consistently quoted in the literature as ranging from 3–20%. However, this high mortality rate is largely due to associated injuries, with rib fractures being a marker of injury severity rather than the proximate cause of death.[[10]] The low mortality rate in this study is therefore likely due to the exclusion of patients with major head or abdominal injuries. The high rates of pneumonia in this study are also in line with literature reporting rates ranging from 6–31% in patients with rib fractures.[[11,20]]

This study is limited by its sample size and retrospective methodology. The relatively small sample size potentially obscures clinically relevant, significant differences in parameters that are known to have low rates between groups, including a difference in mortality found in studies with greater power.[[20,33]] However, the sample is contemporary and all patients were individually reviewed with a reasonable follow-up time allowed. The results of this study are in line with recent publications and add further evidence to the growing body of work that suggests a younger inflection point for adverse outcomes. It is likely that these findings are generalisable to a large number of provincial centres throughout New Zealand. Larger prospective studies are needed to confirm these findings, but consideration should be given to using local data to drive changes in guidelines if needed.

Conclusion

This study found higher rates of pneumonia and an increased LOS in patients aged 45 and older despite their lower overall injury severity when compared to patients under the age of 45. Patient aged 45–64 had outcomes similar to patients aged >65, in keeping with literature that suggests adverse outcomes increase in patients aged 45 and older. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Summary

Abstract

Aim

Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

Method

A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old.

Results

170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome.

Conclusion

This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45–64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Author Information

Matthew J McGuinness: MBChB; General Surgical Registrar, Department of General Surgery, Northland District Health Board. Liam Ryan Ferguson: Medical student, University of Auckland. Imogen Watt: Medical student, University of Auckland. Christopher Harmston: FRCS(Eng), FRACS; Consultant Colorectal and General Surgeon, Department of General Surgery, Northland District Health Board; Honorary Associate Professor, University of Auckland.

Acknowledgements

Correspondence

Matthew J McGuinness, Department of General Surgery, Whangārei Hospital, Manu Road, Whangarei 0148, New Zealand

Correspondence Email

Matt@McGuinness.net.nz

Competing Interests

Nil.

1) Christey GR. Trauma care in New Zealand: it's time to move ahead. World J Surg. 2008;32(8):1618-21.

2) Corporation MoHaAC. Injury-related Health Loss: A report from teh New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006-2016. In: Health Mo, editor. Wellington.

3) Wanek S, Mayberry JC. Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin. 2004;20(1):71-81.

4) Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent). 2013;26(2):120-3.

5) Te Hononga Whētuki ā-Motu National Trauma Network [Internet]. Annual report 2016-2017: New Zealand Major Trauma Registry & National Clinical Network; 2017.  Available from: www.majortrauma.nz/assets/Publication-Resources/Annual-reports.

6) Martin 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(6):1159-65.

7) Peek 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. 2020.

8) Brasel 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(1):200-3.

9) Galvagno SM, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, et al. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936-51.

10) Bankhead-Kendall B, Radpour S, Luftman K, Guerra E, Ali S, Getto C, et al. Rib Fractures and Mortality: Breaking the Causal Relationship. Am Surg. 2019;85(11):1224-7.

11) Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib Fractures in the Elderly. Journal of Trauma and Acute Care Surgery. 2000;48(6):1040-7.

12) Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478-85.

13) Van Vledder MG, Kwakernaak V, Hagenaars T, Van Lieshout EMM, Verhofstad MHJ, Group SWNTRS. Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study. Eur J Trauma Emerg Surg. 2019;45(4):575-83.

14) Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23(3):374-8.

15) Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R, Stombaugh HA. Perils of rib fractures. Am Surg. 2008;74(4):310-4.

16) Svennevig JL, Bugge-Asperheim B, Geiran OR, Vaage J, Pillgram-Larsen J, Fjeld NB, et al. Prognostic factors in blunt chest trauma. Analysis of 652 cases. Ann Chir Gynaecol. 1986;75(1):8-14.

17) Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133-8.

18) Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. 2004;52(5):805-8.

19) Holcomb JB, McMullin NR, Kozar RA, Lygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003;196(4):549-55.

20) Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures: relationship with pneumonia and mortality. Crit Care Med. 2006;34(6):1642-6.

21) Testerman GM. Adverse outcomes in younger rib fracture patients. South Med J. 2006;99(4):335-9.

22) Harrington DT, Phillips B, Machan J, Zacharias N, Velmahos GC, Rosenblatt MS, et al. Factors associated with survival following blunt chest trauma in older patients: results from a large regional trauma cooperative. Arch Surg. 2010;145(5):432-7.

23) Witt 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(1):e000064.

24) Sahr SM, Webb ML, Renner CH, Sokol RK, Swegle JR. Implementation of a rib fracture triage protocol in elderly trauma patients. J Trauma Nurs. 2013;20(4):172-5; quiz 6-7.

25) Goodyear-Smith F, Ashton T. New Zealand health system: universalism struggles with persisting inequities. Lancet. 2019;394(10196):432-42.

26) Poppitt SD, Silvestre MP, Liu A. Etiology of Obesity Over the Life Span: Ecologic and Genetic Highlights from New Zealand Cohorts. Curr Obes Rep. 2014;3(1):38-45.

27) Civil I, Twaddle B. Trauma care systems in New Zealand. Injury. 2003;34(9):740-4.

28) Te Hononga Whētuki ā-Motu National Trauma Network [Internet]. Australia New Zealand Trauma Registry: Management of the Severely Injured. Annual Report. 2017-2018. Available from: www.majortrauma.nz/assets/Publication-Resources/Publications.

29) Association for the Advancement of Automotive Medicine. Abbreviated Injury Scale: 2015 Revision (6 ed.), (2018).

30) Schluter PJ. The Trauma and Injury Severity Score (TRISS) revised. Injury. 2011;42(1):90-6.

31) Baker SP, O'Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-96.

32) Starts NZ [Internet]. New Zealand population statistics 2020. Available from: www.stats.govt.nz/topics/population.

33) Lien YC, Chen CH, Lin HC. Risk factors for 24-hour mortality after traumatic rib fractures owing to motor vehicle accidents: a nationwide population-based study. Ann Thorac Surg. 2009;88(4):1124-30.

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Trauma is an important cause of mortality in New Zealand. It is the leading cause of death between the ages of 1 and 34 and the fifth largest cause of health loss across all age groups.[[1,2]] Thoracic trauma is second only to head and spinal cord injuries as the cause of death in trauma patients.[[3,4]] In New Zealand over 40% of patients presenting with major trauma have thoracic injuries with most of these patients having rib fractures.[[5]]

Rib fractures occur commonly in hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax.[[6,7]] The pain from rib fractures and associated underlying pulmonary pathology may lead to impaired gas exchange and increase the risk of pneumonia and respiratory failure.[[8]] Rib fractures are associated with a significant mortality rate ranging from 3% to 13% and up to 20% in elderly patients.[[8,9]] Although rib fractures are a marker of injury severity and rarely the proximate cause of death, there are a group of patients with isolated thoracic injury that are also at risk of morbidity and mortality directly related to rib fractures. This is especially true in the elderly, who poorly tolerate the subsequent respiratory failure and pneumonia.[[10]] Mortality in young patients with rib fractures is generally attributed to associated injuries.

There is strong evidence that elderly patients, usually defined as 65 and older, have worse outcomes and a higher mortality rate compared with younger patients with isolated thoracic trauma. There is, however, evolving evidence to suggest the inflection point for adverse outcomes starts at a younger age.[[11–22]] Despite this, current clinical guidelines for management of patients with rib fractures mainly include age 65 and older as a trigger for increased level of care in patients with rib fractures.[[23,24]]

The care of trauma patients in New Zealand poses certain unique challenges. New Zealand is geographically diverse and patients often travel large distances to access care. There are high rates of co-morbidity, including obesity and diabetes, and significant inequities in care and outcomes for Māori, Pacific Islanders and low-income populations.[[25–27]] A large proportion of trauma care for patients in New Zealand occurs outside of major trauma centres: this is a key difference to much of the published literature on rib fractures, which is predominantly based on studies from large trauma centres.[[28]] There are no previous studies in New Zealand that have addressed age and its association with outcomes in patients with rib fractures.

The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

Methods

A retrospective study was performed of patients admitted to all hospitals in Northland District Health Board (NDHB) between 1 January 2018 and 31 December 2019. NDHB includes Whangārei Hospital, Dargaville Hospital, Kaitaia Hospital, Bay of Island Hospital and Rawene Hospital. Data were collected from the NDHB’s data warehouse, which was searched to identify patients admitted with rib fractures. Inclusion criteria were patients aged 16 and older with one or more radiologically proven rib fractures sustained secondary to blunt trauma. Exclusion criteria were delayed presentation >48 hours after injury, penetrating trauma, intubation for reason other than thoracic trauma, injury as a result of cardiopulmonary resuscitation or an Abbreviated Injury Scale score >2 in the head or abdomen to remove the impact of polytrauma on management and outcomes of rib fractures.[[29]] Radiological confirmation of a rib fracture was based on a consultant radiologist’s report of either a computer tomography scan or a chest x-ray. NDHB’s electronic medical records were accessed to review injury characteristics, hospital management and outcomes. Number of rib fractures and associated injuries were collected from consultant radiology reports and electronic records. Injury Severity Score (ISS) and Trauma and Injury Severity Score (TRISS) were retrospectively calculated where possible from radiology reports and clinical notes.[[30,31]] Hospital discharge summaries and representation notes were reviewed to determine rates of complications. Patients were followed for six months after their index admission.

The primary outcomes of interest were rates of complications associated with rib fractures and length of stay (LOS). The secondary outcomes of interest were mortality, intensive care unit (ICU) admission rates and rates of intubation.

Data were entered into IBM SPSS for analysis. Median and interquartile range (IQR) were calculated for number of rib fractures, LOS, TRISS and ISS. Non-parametric data were tested with a Mann-Whitney U test. Nominal data was tested using a Chi-square or Fischer’s exact test.

This study was deemed out of scope by the New Zealand Health and Disability Ethics Committee. Locality approval was gained from NDHB and the project guidance was given by a representative from the Northland Māori Health Directorate.

Results

Demographics

One hundred and seventy patients who met study criteria were identified. Fifty-two (31%) were female and 118 (69%) were male. One hundred and four (61%) were New Zealand European, 49 (29%) were Māori and 17 (10%) were other ethnicities. Median age was 60 (IQR 21). The study population was stratified by age into three groups: 59 patients (35%) were >65 years old, 77 (45%) were aged 45 to 65 and 34 (20%) were aged <45. Demographic difference between groups is outlined in Table 1. The difference found between ethnicities was expected and aligned with ethnicity-specific age structures.[[32]] The incidence was calculated at 75/100,000 people per year based on the 2018 Northland census data.[[32]]

Table 1: Demographics by age group.

Injury characteristics

The injury characteristics are outlined in Table 2. The mechanism of injury was significantly different between groups. Road traffic crash (RTC) was the most common mechanism in patients <45 and 45–65, and a fall from height <2m was the most common mechanism in patients >65. Patients aged <45 sustained more severe injuries, evidenced by significantly more severe ISS and TRISS and higher rates of pulmonary contusions, pneumothoraces and clavicular fractures. There was a significant difference in number of flail segments between groups, with the highest rate in patients aged 45–65, and a significant difference in the number of patients with bilateral rib fractures, with the highest rates in patients aged >65.

Table 2: Injury characteristics by age group.

Hospital management

Hospital management is outlined in Table 3. A significant difference in the admitting services was found between groups, with 20% of patients aged >65 admitted to general medicine. Regional block use, paracetamol use and placement of a chest drain and rib plating was similar across groups. There was a significantly higher rate of patient-controlled analgesia (PCA) and ketamine use in patients aged 45–65 and significantly less use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients >65.

Table 3: Hospital management by age group.

Primary and secondary outcomes

The primary and secondary outcomes are outlined in Table 4. Patients aged <45 had a significantly shorter LOS and significantly lower rates of pneumonia compared to patients aged 45 and older. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome (ARDS).

Table 4: Outcomes by age group.

Discussion

This study shows increased rates of pneumonia and a longer LOS in patients aged 45 and older, despite their lower overall injury severity when compared to patients under 45. Patients aged 45–64 showed a LOS and rate of pneumonia similar to patients aged 65 and older, adding evidence to the growing literature that suggests increased complications after age 45.

Management guidelines for patients with rib fractures often include age 65 and older as a trigger for increased level of care.[[23,24]] Although the literature points to age as a continuous variable with respect to risk, it is still often necessary to choose an age cut-off for the purpose of patient decision-making and clinical guidelines. This study adds to the literature suggesting a younger age should be considered in these clinical guidelines, given patients over age 45 have outcomes more closely aligned with patients over age 65, rather than those aged <45. This is highlighted in this study by pneumonia rates of 23% and 19% in patients aged 45–65 and >65 respectively, compared with 3% in patients aged <45.

Multiple studies from trauma centres have examined the relationship between age and outcomes in patients with rib fractures. Different age cut-offs have been used, including ages 45, 50, 60, 65 and 70.[[11–22]] There is strong evidence that patients aged 65 and older have higher mortality rates and worse outcomes, with growing evidence to suggest adverse outcomes starts at a younger age.[[11–22]] Two large retrospective studies have concordant results: both showed stepwise increases in morbidity and mortality in patients aged 45 and older compared to patients aged <45.[[20,33]] Two small single institution studies, similar to this study, have investigated adverse outcomes starting at a younger age with an age cut-off of 45. The findings are in line with this study, which has shown increased morbidity, in the form of respiratory complications, in patients aged 45 and older.[[19,21]]

The mortality rate of 2% found in this study is similar to that of other studies also focused on isolated thoracic trauma.[[19,21]] Rib fracture mortality is consistently quoted in the literature as ranging from 3–20%. However, this high mortality rate is largely due to associated injuries, with rib fractures being a marker of injury severity rather than the proximate cause of death.[[10]] The low mortality rate in this study is therefore likely due to the exclusion of patients with major head or abdominal injuries. The high rates of pneumonia in this study are also in line with literature reporting rates ranging from 6–31% in patients with rib fractures.[[11,20]]

This study is limited by its sample size and retrospective methodology. The relatively small sample size potentially obscures clinically relevant, significant differences in parameters that are known to have low rates between groups, including a difference in mortality found in studies with greater power.[[20,33]] However, the sample is contemporary and all patients were individually reviewed with a reasonable follow-up time allowed. The results of this study are in line with recent publications and add further evidence to the growing body of work that suggests a younger inflection point for adverse outcomes. It is likely that these findings are generalisable to a large number of provincial centres throughout New Zealand. Larger prospective studies are needed to confirm these findings, but consideration should be given to using local data to drive changes in guidelines if needed.

Conclusion

This study found higher rates of pneumonia and an increased LOS in patients aged 45 and older despite their lower overall injury severity when compared to patients under the age of 45. Patient aged 45–64 had outcomes similar to patients aged >65, in keeping with literature that suggests adverse outcomes increase in patients aged 45 and older. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Summary

Abstract

Aim

Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand.

Method

A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old.

Results

170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome.

Conclusion

This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45–64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Author Information

Matthew J McGuinness: MBChB; General Surgical Registrar, Department of General Surgery, Northland District Health Board. Liam Ryan Ferguson: Medical student, University of Auckland. Imogen Watt: Medical student, University of Auckland. Christopher Harmston: FRCS(Eng), FRACS; Consultant Colorectal and General Surgeon, Department of General Surgery, Northland District Health Board; Honorary Associate Professor, University of Auckland.

Acknowledgements

Correspondence

Matthew J McGuinness, Department of General Surgery, Whangārei Hospital, Manu Road, Whangarei 0148, New Zealand

Correspondence Email

Matt@McGuinness.net.nz

Competing Interests

Nil.

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2) Corporation MoHaAC. Injury-related Health Loss: A report from teh New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006-2016. In: Health Mo, editor. Wellington.

3) Wanek S, Mayberry JC. Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin. 2004;20(1):71-81.

4) Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent). 2013;26(2):120-3.

5) Te Hononga Whētuki ā-Motu National Trauma Network [Internet]. Annual report 2016-2017: New Zealand Major Trauma Registry & National Clinical Network; 2017.  Available from: www.majortrauma.nz/assets/Publication-Resources/Annual-reports.

6) Martin 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(6):1159-65.

7) Peek 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. 2020.

8) Brasel 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(1):200-3.

9) Galvagno SM, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, et al. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016;81(5):936-51.

10) Bankhead-Kendall B, Radpour S, Luftman K, Guerra E, Ali S, Getto C, et al. Rib Fractures and Mortality: Breaking the Causal Relationship. Am Surg. 2019;85(11):1224-7.

11) Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib Fractures in the Elderly. Journal of Trauma and Acute Care Surgery. 2000;48(6):1040-7.

12) Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478-85.

13) Van Vledder MG, Kwakernaak V, Hagenaars T, Van Lieshout EMM, Verhofstad MHJ, Group SWNTRS. Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study. Eur J Trauma Emerg Surg. 2019;45(4):575-83.

14) Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23(3):374-8.

15) Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R, Stombaugh HA. Perils of rib fractures. Am Surg. 2008;74(4):310-4.

16) Svennevig JL, Bugge-Asperheim B, Geiran OR, Vaage J, Pillgram-Larsen J, Fjeld NB, et al. Prognostic factors in blunt chest trauma. Analysis of 652 cases. Ann Chir Gynaecol. 1986;75(1):8-14.

17) Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133-8.

18) Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF. Rib fractures in the elderly: a marker of injury severity. J Am Geriatr Soc. 2004;52(5):805-8.

19) Holcomb JB, McMullin NR, Kozar RA, Lygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003;196(4):549-55.

20) Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures: relationship with pneumonia and mortality. Crit Care Med. 2006;34(6):1642-6.

21) Testerman GM. Adverse outcomes in younger rib fracture patients. South Med J. 2006;99(4):335-9.

22) Harrington DT, Phillips B, Machan J, Zacharias N, Velmahos GC, Rosenblatt MS, et al. Factors associated with survival following blunt chest trauma in older patients: results from a large regional trauma cooperative. Arch Surg. 2010;145(5):432-7.

23) Witt 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(1):e000064.

24) Sahr SM, Webb ML, Renner CH, Sokol RK, Swegle JR. Implementation of a rib fracture triage protocol in elderly trauma patients. J Trauma Nurs. 2013;20(4):172-5; quiz 6-7.

25) Goodyear-Smith F, Ashton T. New Zealand health system: universalism struggles with persisting inequities. Lancet. 2019;394(10196):432-42.

26) Poppitt SD, Silvestre MP, Liu A. Etiology of Obesity Over the Life Span: Ecologic and Genetic Highlights from New Zealand Cohorts. Curr Obes Rep. 2014;3(1):38-45.

27) Civil I, Twaddle B. Trauma care systems in New Zealand. Injury. 2003;34(9):740-4.

28) Te Hononga Whētuki ā-Motu National Trauma Network [Internet]. Australia New Zealand Trauma Registry: Management of the Severely Injured. Annual Report. 2017-2018. Available from: www.majortrauma.nz/assets/Publication-Resources/Publications.

29) Association for the Advancement of Automotive Medicine. Abbreviated Injury Scale: 2015 Revision (6 ed.), (2018).

30) Schluter PJ. The Trauma and Injury Severity Score (TRISS) revised. Injury. 2011;42(1):90-6.

31) Baker SP, O'Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-96.

32) Starts NZ [Internet]. New Zealand population statistics 2020. Available from: www.stats.govt.nz/topics/population.

33) Lien YC, Chen CH, Lin HC. Risk factors for 24-hour mortality after traumatic rib fractures owing to motor vehicle accidents: a nationwide population-based study. Ann Thorac Surg. 2009;88(4):1124-30.

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