Taxonomy of Multiple Rib Fractures: Results of the Chest Wall Injury Society International Consensus Survey

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There is a need to standardize rib fracture definitions to aid clinical communication and facilitate research. The Chest Wall Injury Society (CWIS) initiated efforts to reach consensus in several areas pertaining to rib fixation in 2016. We have performed an international Delphi consensus exercise to seek consensus for rib fracture definitions.


All definitions regarding displacement, fracture line characterisation, fragmentation, associations between neighbouring ribs, anatomical sectors, flail chest and sternal (anterior) flail chest were retrieved from the literature, trial protocols, research theses, conference proceedings and personal correspondence. Experts to include in the exercise were identified from authorship, CWIS members, clinical trial chief investigators, and major trauma centre leads. Online questionnaires were circulated. An International Review Committee (IRC) was established and standard Delphi consensus methods agreed. An a priori consensus threshold was set at 80%. Results of each round were collated and analysed by the IRC. Where consensus was not reached, the IRC determined iterative refinements to the question design for the subsequent round, in keeping with the tenets of the Delphi method: anonymity, iteration, controlled feedback, and group response.


There were 113 respondents from 18 countries. Consensus was gained in 9 of 14 domains. Four definitions were agreed upon with regards to individual fracture characterization, fracture displacement and associations between neighbouring ribs. Two definitions were agreed upon regarding the localisation of fractures by anatomical sector and three definitions were agreed upon for flail chest.


This consensus exercise has resulted in the creation of a standardized nomenclature for rib fracture classification, which has broad clinical and research applicability. Where consensus has not been reached, a framework for clinical recording has been proposed and further evaluation in clinical studies indicated. This will allow standard reporting of cases within surgical units and standard taxonomy for design, analysis and interpretation of clinical trials.