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Rib fractures are still a relevant and frequently occurring injury associated with a significant morbidity and mortality. Six percent of all hospitalized trauma patients appeared to sustain one or more fractured ribs and the absolute incidence rate of rib fractures requiring hospital admission among the Dutch population was 29 per 100,000 person-years. Furthermore, we found that the incidence rate of rib fractures in the elderly was even higher with 72 per 100,000 person-years, which illustrates the high clinical impact of rib fractures on the elderly population. Hence, given the considerable morbidity and mortality of rib fractures in these patients, it could be argued that rib fractures may impose the largest burden of disease after hip fractures in the elderly trauma patient. Furthermore, with the increasing aging population, it is to be expected that the incidence of elderly patients with fractured ribs requiring clinical care will increase. Pain associated with rib fractures can be severe and disabling. More importantly, it is well known that ineffective pain management significantly increases the likelihood of developing pulmonary complications, which is caused by several mechanisms. First, the thoracic pain associated with rib fractures may lead to hypoventilation, consequently resulting in ineffective coughing, retention of secretions, and ultimately, atelectasis. Second, rib fractures can compromise the integrity of the chest wall, which may alter the normal breathing mechanism, especially in patients suffering from a clinical flail chest. Third, the frequently encountered concomitant injuries to the lungs, such as a pulmonary contusion or hemothorax, may negatively affect the pulmonary gas exchange. As such, in order to reduce the risk of pulmonary complications, prompt evaluation and adequate pain management has traditionally been considered as the cornerstones in the treatment of rib fractures. While non-operative treatment has traditionally been the golden standard in rib fracture treatment, it comes with several challenges and as such new treatment strategies are still being explored. In the modern-day clinical practice, the use of rib fixation has rapidly increased over the last years and it is expected that this trend will continue as it has been received with great enthusiasm in many trauma centers. Although previous randomized controlled trials reported a significant positive treatment effect of surgical fixation, the available evidence mainly focused on patients suffering from a clinical flail chest, instead of all patients with multiple rib fractures, which thus limits its generalizability. Despite rib fixation showing promising results in selected patients, there is a growing debate about the exact indication and patient selection for this operation, as there is no consensus as to which patients would benefit. Besides, while important in the decision-making process, the long-term outcomes and complication risk of surgical fixation have received little attention.

This meta-analysis compares functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radial fractures in adults., Key Points Question What outcomes are associated with operative vs nonoperative treatment of distal radius fractures in adults? Findings This meta-analysis of 2254 unique participants in 23 unique studies showed that operative treatment of distal radius fractures improved the medium-term Disabilities of the Arm, Shoulder and Hand questionnaire score and grip strength compared with nonoperative treatment in adults, with no difference in overall complication rate. Meaning These findings suggest that operative treatment might be preferred for distal radius fractures., Importance No consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift. Objectives To compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults. Data Sources The PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception to June 15, 2019, for studies comparing operative vs nonoperative treatment of distal radius fractures. Study Selection Randomized clinical trials (RCTs) and observational studies reporting on the following: acute distal radius fracture with operative treatment (internal or external fixation) vs nonoperative treatment (cast immobilization, splinting, or bracing); patients 18 years or older; and functional outcome. Studies in a language other than English or reporting treatment for refracture were excluded. Data Extraction and Synthesis Data extraction was performed independently by 2 reviewers. Effect estimates were pooled using random-effects models and presented as risk ratios (RRs) or mean differences (MDs) with 95% CIs. Data were analyzed in September 2019. Main Outcomes and Measures The primary outcome measures included medium-term functional outcome measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the overall complication rate after operative and nonoperative treatment. Results A total of 23 unique studies were included, consisting of 8 RCTs and 15 observational studies, that described 2254 unique patients. Among the studies that presented sex data, 1769 patients were women [80.6%]. Overall weighted mean age was 67 [range, 22-90] years). The RCTs included 656 patients (29.1%); observational studies, 1598 patients (70.9%). The overall pooled effect estimates the showed a significant improvement in medium-term (≤1 year) DASH score after operative treatment compared with nonoperative treatment (MD, −5.22 [95% CI, −8.87 to −1.57]; P = .005; I2 = 84%). No difference in complication rate was observed (RR, 1.03 [95% CI, 0.69-1.55]; P = .87; I2 = 62%). A significant improvement in grip strength was noted after operative treatment, measured in kilograms (MD, 2.73 [95% CI, 0.15-5.32]; P = .04; I2 = 79%) and as a percentage of the unaffected side (MD, 8.21 [95% CI, 2.26-14.15]; P = .007; I2 = 76%). No improvement in medium-term DASH score was found in the subgroup of studies that only included patients 60 years or older (MD, −0.98 [95% CI, −3.52 to 1.57]; P = .45; I2 = 34%]), compared with a larger improvement in medium-term DASH score after operative treatment in the other studies that included patients 18 years or older (MD, −7.50 [95% CI, −12.40 to −2.60]; P = .003; I2 = 77%); the difference between these subgroups was statically significant (test for subgroup differences, P = .02). Conclusions and Relevance This meta-analysis suggests that operative treatment of distal radius fractures improves the medium-term DASH score and grip strength compared with nonoperative treatment in adults, with no difference in overall complication rate. The findings suggest that operative treatment might be more effective and have a greater effect on the health and well-being of younger, nonelderly patients.