101
|
The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients. J Trauma Acute Care Surg 2020; 87:1260-1268. [PMID: 31425473 DOI: 10.1097/ta.0000000000002480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients. METHODS Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve. RESULTS Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage. CONCLUSION Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2. LEVEL OF EVIDENCE Prognostic study, level II.
Collapse
|
102
|
Characteristics of hardware failure in patients undergoing surgical stabilization of rib fractures: A Chest Wall Injury Society multicenter study. J Trauma Acute Care Surg 2020; 87:1277-1281. [PMID: 31107433 DOI: 10.1097/ta.0000000000002373] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) is increasingly used for severe rib fractures/flail chest. There are no reports discussing mechanisms of failure of implanted hardware, its clinical presentation, or consequences. The purpose of this study was to evaluate the incidence, presenting signs, and clinical sequela of hardware failure after SSRF. METHODS A multicenter, retrospective study was performed by a group of surgeons with a large SSRF case volume. All cases with known hardware failure from January 1, 2010, to December 31, 2017, were included. The surgeon's experience at the time of hardware implantation, specific implant used, number of failures the surgeon had experienced with the same system, and time from implantation to hardware failure were recorded. Additionally, patient demographics, including age, comorbid conditions, and number and location of rib fractures were recorded. Symptomatology associated with hardware failure and need for explant and/or reimplantation of hardware was also recorded. Nonparametric statistical tests were used to compare cohorts. RESULTS Of 1,224 patients who underwent SSRF, 38 patients with 233 rib fractures and 279 fracture segments experienced hardware failure and were enrolled in the study. Twelve patients presented more than 3 months following injury. Median age was 54 years old and 34% were active smokers. One hundred forty-four plates were implanted with a median of four plates per patient. Median number of SSRF cases by each surgeon was 100 (range, 1-280). Fractures and hardware failure were most frequent in the anterolateral/lateral region. Hardware failure was mostly due to screw migration and plate fracture. Hardware failure was asymptomatic in 40% and presented as pain in 42% of cases. Fifty-five percent of the cases required explantation of hardware, and only 10% required SSRF again. There was no difference between the acute and chronic fracture cohorts. CONCLUSION Hardware failure after SSRF is rare and often asymptomatic. When present, it rarely requires redo SSRF. LEVEL OF EVIDENCE Therapeutic, level V.
Collapse
|
103
|
Staggers JR, Dennis PB, Eriksson EA. Stability of Surgical Rib Fixation Hardware after Repeat Chest Trauma. J Emerg Trauma Shock 2020; 13:84-87. [PMID: 32395057 PMCID: PMC7204963 DOI: 10.4103/jets.jets_67_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/20/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022] Open
Abstract
Surgical management of rib fractures has long been a controversial topic, but improvements in rib plating technology have led to a recent increase in interest among surgeons. Unfortunately, follow-up data are limited in patients following rib fracture plating. We present a unique case of an adult male who had multiple ribs plated for symptomatic rib fracture nonunions and developed periprosthetic fractures following repeat trauma several months later. A 57-year-old male with a history of trauma was treated for symptomatic nonunion of several left lateral ribs with surgical rib fixation. He tolerated the procedure well and had significant improvement in his symptoms on follow-up. Several months later, he was hit by a motor vehicle while riding his bicycle. He was found to have flail chest with lateral segmental rib fractures of the first through second ribs, posterior periprosthetic fractures of the seventh through tenth ribs, and lateral fractures of the eleventh and twelfth ribs. The rib plating hardware was completely intact, except for a single displaced seventh rib screw. To our knowledge, this is the first case report of repeat chest trauma following rib plating. Interestingly, the patient developed posterior periprosthetic fractures, and hardware was completely intact except for a single screw that was displaced. The goal of this report is to describe the unique fracture pattern of a flail chest with prior rib plating and to describe potential revision plating techniques and complications that surgeons may encounter in the management of trauma patients with prior rib plating.
Collapse
Affiliation(s)
- Jackson Rucker Staggers
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick B Dennis
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Evert A Eriksson
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
104
|
Abstract
More than 45% of polytraumatized patients in Germany suffer from severe thoracic trauma. Due to the urgent time factor (e.g. respiratory insufficiency and severe bleeding), a structured procedure in the diagnostics and treatment according to the advanced trauma life support (ATLS) criteria is necessary both prehospital and in the emergency room in order to provide the patient with adequate care. If a patient is stable or can be stabilized there is the option of using extended diagnostics, such as whole body computer tomography (CT) scanning with contrast medium, to select a treatment that is optimally adapted to the injury pattern. This can be performed by open surgery, minimally invasive surgery and interventional radiologically/endoscopically and depends on the injured organ as well as the extent of the injury. This means that only an interdisciplinary approach guarantees optimal care for patients with thoracic trauma.
Collapse
|
105
|
Fokin AA, Hus N, Wycech J, Rodriguez E, Puente I. Surgical Stabilization of Rib Fractures: Indications, Techniques, and Pitfalls. JBJS Essent Surg Tech 2020; 10:e0032. [PMID: 32944413 PMCID: PMC7478329 DOI: 10.2106/jbjs.st.19.00032] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Rib fractures are a common thoracic injury that is encountered in 20% to 39% of patients with blunt chest trauma and is associated with substantial morbidity and mortality1,2. Traditionally, the majority of patient with rib fractures have been managed nonoperatively. Recently, the utilization of surgical stabilization of rib fractures has increased considerably because the procedure has shown improved outcomes3-5.
Collapse
Affiliation(s)
- Alexander A Fokin
- Delray Medical Center, Delray Beach, Florida.,Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Nir Hus
- Delray Medical Center, Delray Beach, Florida.,Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Joanna Wycech
- Delray Medical Center, Delray Beach, Florida.,Broward Health Medical Center, Fort Lauderdale, Florida
| | - Eugenio Rodriguez
- Delray Medical Center, Delray Beach, Florida.,Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Ivan Puente
- Delray Medical Center, Delray Beach, Florida.,Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida.,Broward Health Medical Center, Fort Lauderdale, Florida.,Florida International University Herbert Wertheim College of Medicine, Miami, Florida
| |
Collapse
|
106
|
Dorman JR, Clarke PTM, Simpson RB, Edwards JG. Testing the clinical validity of the Bemelman Rib Fracture Management Guideline. Interact Cardiovasc Thorac Surg 2020; 30:597-599. [PMID: 31971227 DOI: 10.1093/icvts/ivz317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/06/2019] [Accepted: 12/19/2019] [Indexed: 11/13/2022] Open
Abstract
Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89-0.9995) and 0.83 (0.70-0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76-0.92) and 0.98 (0.85-0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.
Collapse
Affiliation(s)
- Jessica R Dorman
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,The Medical School, University of Sheffield, Sheffield, UK
| | - Peter T M Clarke
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,The Medical School, University of Sheffield, Sheffield, UK
| | - Rosalind B Simpson
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,The Medical School, University of Sheffield, Sheffield, UK
| | - John G Edwards
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
107
|
Bauman ZM, Grams B, Yanala U, Shostrom V, Waibel B, Evans CH, Cemaj S, Schlitzkus LL. Rib fracture displacement worsens over time. Eur J Trauma Emerg Surg 2020; 47:1965-1970. [PMID: 32219487 PMCID: PMC7223740 DOI: 10.1007/s00068-020-01353-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/16/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Rib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time. METHODS Retrospective review of all RF patients from 2016-2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1-2, 3-6, 7-10, 11-12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002. RESULTS 78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13-27) with Chest Abbreviated Injury Score of 3 (IQR, 3-4). Median time between CT1 and CT2 was 6 days (IQR, 3-12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11-12 in all planes (p < 0.002). CONCLUSION RF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly.
Collapse
Affiliation(s)
- Zachary Mitchel Bauman
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA.
| | - Benjamin Grams
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Ujwal Yanala
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Valerie Shostrom
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Brett Waibel
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Charity Hassie Evans
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Samuel Cemaj
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| | - Lisa Lynn Schlitzkus
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE, 68198-3280, USA
| |
Collapse
|
108
|
Xiao X, Zhang S, Yang J, Wang J, Zhang Z, Chen H. Surgical fixation of rib fractures decreases intensive care length of stay in flail chest patients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:216. [PMID: 32309363 PMCID: PMC7154414 DOI: 10.21037/atm.2020.01.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Nonoperative treatment is currently the standard therapy for rib fractures. However, there is a trend towards surgical fixation from conservative management over the last decade. While surgical fixation of rib fractures has shown promising results, its impact on the clinical results remains unclear based on the current literature. As such, the present study aims to compare the short-term outcomes of multiple rib fracture patients treated by surgical fixation with traditional conservative management. Methods Data for patients with multiple (three or more) rib fractures admitted to our department between January 2012 and January 2019 were retrospectively collected and analyzed. Propensity score matched patients were compared between those treated with surgical rib fixation and those of nonoperatively treated. Primary outcomes were hospital length of stay for multiple rib fracture patients, and intensive care unit (ICU) length of stay for flail chest patients. Secondary outcomes included in hospital mortality, ICU usage rate, duration of ventilator support, ventilator usage rate, and pneumonia. Results The study included 1,201 patients with mean age of 50.1±12.7 years, of whom 954 (79.4%) were male. The average number of rib fractures was 6.3±2.4, with a mean injury severity score of 20.5±7.3. Among them, 563 (46.9%) patients had surgical rib fixation and 638 (53.1%) patients received nonoperative treatment. There were 191 patients with a flail chest, 133 (69.6%) had operative rib fixation and 58 (30.4%) were nonoperatively treated. After propensity score match, the hospital length of stay was not significantly differed between surgery and conservative management in multiple rib fracture patients (10.7±3.4 vs. 10.2±3.8 days, P=0.067), nor were the secondary outcomes, in terms of in hospital mortality (0.9% vs. 1.1%, P=0.704), ICU usage rate (12.3% vs. 12.9%, P=0.820), duration of ventilator support (100.1±13.9 vs. 99.8±20.7 hours, P=0.822), ventilator usage rate (12.0% vs. 12.9%, P=0.732), and pneumonia (24.3% vs. 24.9%, P=0.861). For patients with a flail chest, shorter ICU length of stay was found to be associated with surgical rib fixation comparing with nonoperative treatment (5.5±1.9 vs. 6.7±2.1 days, P=0.011). No secondary outcomes such as in hospital mortality (4.4% vs. 4.4%, P=1.000), ICU usage rate (20.0% vs. 22.2%, P=0.796), duration of ventilator support (113.1±20.4 vs. 131.2±19.5 hours, P=0.535), ventilator usage rate (20.0% vs. 20.0%, P=1.000), pneumonia (28.9% vs. 31.1%, P=0.818) were significant different between the operative and nonoperative groups. Conclusions Surgical rib fixation results in a shorter ICU length of stay in patients with a flail chest, and a comparable outcome for patients with multiple rib fractures when compared with nonoperative treatment.
Collapse
Affiliation(s)
- Xiangzhi Xiao
- Department of Thoracic Surgery, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai 201700, China
| | - Shengchao Zhang
- Department of Thoracic Surgery, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai 201700, China
| | - Juhua Yang
- Department of Thoracic Surgery, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai 201700, China
| | - Jian Wang
- Department of Thoracic Surgery, Xuhui Branch of Zhongshan Hospital, Fudan University, Shanghai 200031, China
| | - Zhilong Zhang
- Department of Thoracic Surgery, Xuhui Branch of Zhongshan Hospital, Fudan University, Shanghai 200031, China
| | - Hao Chen
- Department of Thoracic Surgery, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai 201700, China.,Department of Thoracic Surgery, Xuhui Branch of Zhongshan Hospital, Fudan University, Shanghai 200031, China
| |
Collapse
|
109
|
Ingoe HM, Eardley W, McDaid C, Rangan A, Lawrence T, Hewitt C. Epidemiology of adult rib fracture and factors associated with surgical fixation: Analysis of a chest wall injury dataset from England and Wales. Injury 2020; 51:218-223. [PMID: 31690496 DOI: 10.1016/j.injury.2019.10.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/03/2019] [Accepted: 10/14/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Chest wall trauma is commonly seen in patients admitted with both high and low-energy transfer injury. Whilst often associated with other injuries, it is also seen in isolation following simple falls in the older patient. Fixation of the chest wall grows in popularity as part of optimising patient care, particularly in terms of critical care stay. There is currently no description of the epidemiology of these injuries at a national level; nor has there been identification of factors that predict which of these patients undergoes surgery. METHODS The United Kingdom Trauma Audit & Research Network (TARN) database was analysed for the period April 2016 to 30th May 2017 for all adult patients presenting with a rib or sternal fracture. Characteristics of the population were described and a binary logistic regression model constructed to explore the influences of several explanatory variables on whether fixation was performed. RESULTS Of 16,638 patients with chest wall trauma, 402 underwent fixation. Most chest wall injury patients were admitted under three specialties (orthopaedics (19.1%), emergency medicine (16.6%) and general surgery (17.7%)). The odds of fixation in unilateral flail chest was 107.51 (p <0.0001), in bilateral flail or combined complexsternal fracture 47.63 (p = 0.007) and in 3 or more non-flail ribs 15.62 (p<0.0001) when compared to less than three non-flail rib fractures. The odds of fixation was higher in an MTC (p<0.0001) compared to a non-specialist hospital. The odds of fixation was higher in older patients (1.02, p<0.0001) and the more severely injured (1.02, p<0.0001). CONCLUSION There is considerable variation nationally in the management of chest wall trauma. Injury type, patient age and care setting contribute to decision making in fracture fixation. This unique national dataset characterises for the first time the nature of contemporary chest wall trauma management and should help inform the design of future research on this topic.
Collapse
Affiliation(s)
- Helen Ma Ingoe
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD; The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW.
| | - William Eardley
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD; The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW.
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD.
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD; The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW; NDORMS, University of Oxford, research supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC).
| | - Tom Lawrence
- Trauma and Audit Research Network, Manchester Medical Academic Health Sciences Centre, University of Manchester, The Mayo Building, Salford Royal Hospital, Salford M6 8HD.
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, ARRC Building, University of York, Heslington, York, YO10 5DD.
| |
Collapse
|
110
|
Prins JTH, Van Lieshout EMM, Reijnders MRL, Verhofstad MHJ, Wijffels MME. Rib fractures after blunt thoracic trauma in patients with normal versus diminished bone mineral density: a retrospective cohort study. Osteoporos Int 2020; 31:225-231. [PMID: 31828365 PMCID: PMC7010612 DOI: 10.1007/s00198-019-05219-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/30/2019] [Indexed: 11/22/2022]
Abstract
This study aimed to evaluate rib fracture rate as well as rib fracture characteristics after thoracic trauma in patients with normal versus diminished bone mineral density (BMD). A retrospective cohort study of persons aged 50 years or older presenting to the Emergency Department after sustaining blunt thoracic trauma between July 1, 2014, and December 31, 2017, was performed. Patient and trauma characteristics and DXA scan results were collected. Rib fracture rate and characteristics were evaluated on a radiograph and/or CT scan of the thorax. In total, 119 patients were included for analysis. Fifty-eight of them (49%) had a diminished BMD. In the remaining 61, the BMD was normal. The diminished BMD group experienced rib fractures more often than the normal BMD group (n = 43 (74%) versus n = 31 (51%); p = 0.014). Patients with diminished BMD suffered low-energy trauma more frequently than the normal BMD group (21 (36%) versus 11 patients (15%), respectively (p = 0.011)). Rib fracture characteristics such as the median number of rib fractures, concomitant intrathoracic injury rate, and rib fracture type distribution were not different between the groups. The rate of rib fractures after blunt thoracic trauma was significantly higher in patients with diminished BMD than in patients with a normal BMD. Differences in number and location of rib fractures between groups could not be proven. When assessing patients aged 50 years or older presenting to the hospital after substantial blunt thoracic trauma, the presence of diminished BMD should be taken into account and the presence of rib fractures should be investigated with appropriate diagnostic procedures. Diminished bone mineral density (i.e., osteopenia or osteoporosis) is associated with increased fracture risk. This study evaluated if diminished BMD increases the rib fracture risk. Patients with diminished BMD have a higher risk of sustaining rib fractures after substantial blunt thoracic trauma, which implicates a lower threshold for CT imaging of the chest.
Collapse
Affiliation(s)
- J T H Prins
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - E M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - M R L Reijnders
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - M M E Wijffels
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| |
Collapse
|
111
|
Simpson RB, Dorman JR, Hunt WJ, Edwards JG. Multiple rib fractures: A novel and prognostic CT-based classification system. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619895683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The accepted classification for multiple rib fractures is binary: flail chest or not. There is a wide spectrum of morphology with subsequent variation in the impact on chest wall mechanics and clinical outcomes. As the practice of surgical stabilisation of rib fractures evolves, there is a need for a better taxonomy. The aim of this study was to create a data-driven radiological classification system for multiple rib fractures, prognostic of both complications and surgical stabilisation of rib fracture. Methods The radiological pattern of injury was assessed for cases undergoing surgical stabilisation of rib fracture (n = 48) over a five-year period and a consecutive sample of non-operative controls (n = 48). Every rib fracture (n = 1032) was assessed on CT scans for location, displacement and comminution. An iterative classification system was developed and tested for inter-observer agreement and outcome prediction. Results The fractures occurred in a ‘series’ (≥3 consecutive ribs at a similar location) in 72% of cases: these were more likely to be displaced (p < 0.001). Variables included in the classification were the anatomical pattern (presence, length and overlap of series) and degree of displacement. The classification was prognostic for complications (p < 0.001), discriminated for fixation (C = 0.907) and had acceptable inter-observer agreement (k = 0.50). Conclusions The Sheffield Multiple Rib Fracture Classification derived categories of short/long series, and short/long flail chest, with sub-division according to the presence of displacement. It was prognostic for clinical outcomes and of surgical fixation. It may facilitate communication, comparison of outcomes and selection for management protocols.
Collapse
Affiliation(s)
- Rosalind B Simpson
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - Jessica R Dorman
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - William J Hunt
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - John G Edwards
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| |
Collapse
|
112
|
A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma Acute Care Surg 2019; 88:249-257. [DOI: 10.1097/ta.0000000000002559] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
113
|
Xia H, Zhu D, Li J, Sun Z, Deng L, Zhu P, Zhang Y, Li X, Wang D. Current status and research progress of minimally invasive surgery for flail chest. Exp Ther Med 2019; 19:421-427. [PMID: 31885692 PMCID: PMC6913304 DOI: 10.3892/etm.2019.8264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/25/2019] [Indexed: 01/27/2023] Open
Abstract
Chest trauma accounts for ~13.5% of all traumas, and direct death from chest trauma accounts for 20–25% of all traumatic deaths. Chest trauma is the second cause of death from trauma. Frequent rib fractures, especially in patients with flail chest, often cause severe pain, chest wall softening, abnormal breathing and severe lung contusion and laceration, usually requiring thoracic surgery. In recent years, the open reduction and internal fixation treatment of rib fractures with flail chest has achieved satisfactory results, and some surgical indications have reached consensus. A number of scholars and medical centers have demonstrated the practicality and cost-effectiveness of rib fixation in flail chest, including the small incidence of pulmonary complications, the short ICU mechanical ventilation time, and the reduction of digestive tract inhibition. Open reduction and internal fixation of rib fractures involves multiple ribs. Conventional rib fractures require a large incision to achieve satisfactory exposure. Chest wall muscles, blood vessels and nerves (long thoracic and thoracodorsal nerves) are injured, resulting in a high infection rate of the incision and postoperative dysfunctions, such as limited upper limb, shoulder and back function, and long time numbness on the affected side of the chest. Therefore, the damage of muscles and nerves caused by conventional surgical methods limits the development of such surgical technique. Although the video-assisted thoracoscopic technique has become a necessary technical means for the treatment of thoracic trauma and has been applied to thoracic exploration and hemostasis, there is no report on the application of open reduction and internal fixation for rib fracture. The difficulty lies in the tightly combined bony thorax and the soft tissue of the chest wall. Therefore, experts have explored a variety of minimally invasive surgical methods for the flail chest. The current status and research progress of minimally invasive surgery for thoracic surgery are reviewed.
Collapse
Affiliation(s)
- Honggang Xia
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China.,School of Medical Engineering and Translational Medicine, Tianjin 300000, P.R. China
| | - Deqing Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Jing Li
- Teaching and Research Division, Tianjin Medical College, Tianjin 300000, P.R. China
| | - Zhongyi Sun
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Limin Deng
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Pengzhi Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Yongmin Zhang
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Xuan Li
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| | - Dongbin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital Affiliated to Tianjin University, Tianjin 300000, P.R. China
| |
Collapse
|
114
|
El-Akkawi AI, de Paoli FV, Andersen G, Højsgaard A, Christensen TD. A case of severe flail chest with several dislocated sterno-chondral fractures. Int J Surg Case Rep 2019; 65:52-56. [PMID: 31689628 PMCID: PMC6838885 DOI: 10.1016/j.ijscr.2019.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/19/2019] [Accepted: 10/22/2019] [Indexed: 11/27/2022] Open
Abstract
Surgical stabilization of flail chest lead to fast weaning from mechanical ventilation. Plates can be used for stabilization of sterno-costal dehiscence. Cartilage reconstruction of a CT scan can reveal the true severity of the trauma.
Introduction Flail chest is diagnosed clinically by the presence of paradox movement of a segment of the thoracic wall during spontaneous breathing. Radiographic finding confirming a clinical flail chest are fractures of three or more consecutive ribs or costal cartilages in two or more places. Surgical stabilization is associated with a reduced length of hospital stay, time with mechanical ventilation and risk of respiratory complications. Presentation of case A trauma patient had a Computed Tomography (CT) scan showing multiple costa fractures, sternal fracture, manubrium fracture, sternal displacement and dehiscence of the sternal-costal attachment. The severity of the trauma was visualized after performing a cartilage reconstruction of the trauma CT scan. The patient underwent surgery, using fixation plates to stabilize the thoracic cage, and was then weaned quickly from mechanical ventilation. Discussion This case indicates, that if a patient has a severe flail chest recognized clinically, but not radiologically, a reconstruction of cartilage can reveal the true severity of the trauma. Indeed, the patient in this case experienced a positive outcome from surgery. However, such a procedure demands correct timing and experience in surgical stabilization of the thoracic wall. Furthermore, the injury required accurate planning with the involved personal before surgery. Conclusion Surgical stabilization of advanced flail chest with concomitant sternal fracture, seems to be a safe procedure, that might reduce the need of mechanical ventilation and the length of stay at the Intensive Care Unit (ICU). Furthermore, cartilage reconstruction of the trauma CT scan can potentially identify a severe flail chest, that might be missed on regular 3D bone reconstruction.
Collapse
Affiliation(s)
- Ali Imad El-Akkawi
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, DK - 8200 Aarhus N, Denmark.
| | - Frank Vincenzo de Paoli
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, DK - 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University Hospital, DK - 8200 Aarhus N, Denmark; Department of Biomedicine, Aarhus University, DK - 8000 Aarhus C, Denmark
| | - Gratien Andersen
- Department of Radiology, Aarhus University Hospital, DK - 8200 Aarhus N, Denmark
| | - Anette Højsgaard
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, DK - 8200 Aarhus N, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, DK - 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University Hospital, DK - 8200 Aarhus N, Denmark
| |
Collapse
|
115
|
Makey IA, Jacob S, El-Sayed Ahmed MM, Pham S, Landolfo K, Thomas M. Latissimus muscle sparing approach to subscapular rib fracture plating. Trauma Case Rep 2019; 24:100247. [PMID: 31872020 PMCID: PMC6911933 DOI: 10.1016/j.tcr.2019.100247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/28/2019] [Accepted: 09/19/2019] [Indexed: 11/25/2022] Open
Abstract
Surgical stabilization of fractured ribs has been shown to improve trauma related outcomes, however the procedure itself can be a source of morbidity. This report details two cases of latissimus dorsi muscle sparing sub-scapular multi-rib fracture plating. We combined several techniques to make this possible. The first technique was use of a vertical skin incision along the anterior border of the latissimus muscle. The second was the use of a mammary retractor to provide adequate and sustained retraction of the latissimus and scapula. The third was utilization of a right angle screwdriver to allow placement of the posterior screws. Sparing the latissimus muscle for sub-scapular fractures is possible but requires planning and extra equipment to perform. Minimizing rib fixation related morbidity makes it a more appealing treatment.
Collapse
Affiliation(s)
- Ian A Makey
- Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Samuel Jacob
- Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | - Si Pham
- Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Kevin Landolfo
- Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| |
Collapse
|
116
|
Regional analgesia for patients with traumatic rib fractures: A narrative review. J Trauma Acute Care Surg 2019; 88:e22-e30. [DOI: 10.1097/ta.0000000000002524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
117
|
Schulz-Drost S, Ekkernkamp A, Stengel D. [Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]. Unfallchirurg 2019; 121:605-614. [PMID: 30073550 DOI: 10.1007/s00113-018-0532-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed. OBJECTIVE A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options. MATERIAL AND METHODS Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed. RESULTS AND DISCUSSION Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.
Collapse
Affiliation(s)
- S Schulz-Drost
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland.
| | - A Ekkernkamp
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
| | - D Stengel
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
| |
Collapse
|
118
|
Su YH, Yang SM, Ko HJ. Diagnosis and management of a trapped lung or diaphragm by fractured ribs: analysis of patients undergoing rib fracture repair. BMC Surg 2019; 19:123. [PMID: 31462238 PMCID: PMC6714410 DOI: 10.1186/s12893-019-0581-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are few reports regarding a lung or diaphragm trapped by a fractured rib. This study aimed to describe the clinical presentations, diagnosis, and management of these intrathoracic pathologies. METHODS We retrospectively reviewed the database at our institute for patients with rib fractures who underwent thoracoscope-assisted surgical stabilization of rib fracture (SSRF). We analyzed the demographic data, mechanism of trauma, presentations, operative findings, and subsequent management strategies. RESULTS A total of 38 consecutive patients who underwent SSRF were analyzed. Three patients had a trapped lung and one had a trapped diaphragm. Abnormal radiographic findings were observed in 50% of cases. The median waiting time for surgery was 25 days. Surgery was indicated for intractable dynamic pain following conservative treatment. A definitive diagnosis was made during thoracoscopic exploration. Thoracoscopic repair and resection were used for trapped lungs and thoracoscopic release for a trapped diaphragm. We subsequently performed SSRF for unhealed rib fractures. CONCLUSION As per our analysis, the incidence of a trapped lung or diaphragm was 10.5%. If a patient presents with persistent intractable dynamic pain, thoracoscopic exploration with concurrent SSRF may be a feasible and effective treatment option.
Collapse
Affiliation(s)
- Ying-Hao Su
- Department of Orthopaedics, National Taiwan University Hospital Hsin-Chu Branch, 25, Lane 442, Sec 1, Jingguo Rd, Hsinchu City, 30059, Taiwan
| | - Shun-Mao Yang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, 25, Lane 442, Sec 1, Jingguo Rd, Hsinchu city, 30059, Taiwan
| | - Huan-Jang Ko
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, 25, Lane 442, Sec 1, Jingguo Rd, Hsinchu city, 30059, Taiwan.
| |
Collapse
|
119
|
Beks RB, de Jong MB, Sweet A, Peek J, van Wageningen B, Tromp T, IJpma F, Wouters R, Lansink K, Bemelman M, van Baal M, Hoogendoorn J, Saltzherr T, Groenwold R, Leenen L, Houwert RM. Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol. BMJ Open 2019; 9:e023660. [PMID: 31462458 PMCID: PMC6720131 DOI: 10.1136/bmjopen-2018-023660] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/15/2019] [Accepted: 06/07/2019] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER NTR6833.
Collapse
Affiliation(s)
- Reinier B Beks
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Arthur Sweet
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Jesse Peek
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | | | - Tjarda Tromp
- Trauma Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Frank IJpma
- Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Roderick Wouters
- Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Koen Lansink
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Mike Bemelman
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Mark van Baal
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | | | - Teun Saltzherr
- Trauma Surgery, Medisch Centrum Haaglanden, Den Haag, The Netherlands
| | | | - Luke Leenen
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | | |
Collapse
|
120
|
Kaufman E, Shiroff A. Chronic pain associated with costal margin rupture. Trauma Surg Acute Care Open 2019; 4:e000347. [PMID: 31423465 PMCID: PMC6688708 DOI: 10.1136/tsaco-2019-000347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 11/23/2022] Open
Affiliation(s)
- Elinore Kaufman
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Adam Shiroff
- Department of Surgery, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
121
|
Wijffels MME, Prins JTH, Polinder S, Blokhuis TJ, De Loos ER, Den Boer RH, Flikweert ER, Pull Ter Gunne AF, Ringburg AN, Spanjersberg WR, Van Huijstee PJ, Van Montfort G, Vermeulen J, Vos DI, Verhofstad MHJ, Van Lieshout EMM. Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial. World J Emerg Surg 2019; 14:38. [PMID: 31384292 PMCID: PMC6668138 DOI: 10.1186/s13017-019-0258-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/22/2019] [Indexed: 12/22/2022] Open
Abstract
Background Multiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures. Methods The proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months. Discussion With favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures. Trial registration www.trialregister.nl, NTR7248. Registered May 31, 2018.
Collapse
Affiliation(s)
- Mathieu M E Wijffels
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jonne T H Prins
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Suzanne Polinder
- 2Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Taco J Blokhuis
- 3Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Erik R De Loos
- 4Department of Surgery, Zuyderland Medisch Centrum, P.O. Box 5500, 6130 MB Sittard-Geleen, The Netherlands
| | - Roeland H Den Boer
- 5Department of Surgery, Spaarne Gasthuis, P.O. Box 417, 2000 AK Haarlem, The Netherlands
| | - Elvira R Flikweert
- 6Department of Surgery, Deventer Ziekenhuis, P.O. Box 5001, 7400 GC Deventer, The Netherlands
| | | | - Akkie N Ringburg
- 8Department of Surgery, Ikazia Ziekenhuis, P.O. Box 5009, 3008 AA Rotterdam, The Netherlands
| | | | - Pieter J Van Huijstee
- Department of Surgery, Haga Ziekenhuis, P.O. Box 40551, 2504 LN The Hague, The Netherlands
| | - Gust Van Montfort
- 11Department of Surgery, Catharina Ziekenhuis, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - Jefrey Vermeulen
- 12Department of Surgery, Maasstad Ziekenhuis, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands
| | - Dagmar I Vos
- 13Department of Surgery, Amphia Ziekenhuis, P.O. Box 90158, 4800 RK Breda, The Netherlands
| | - Michael H J Verhofstad
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- 1Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| |
Collapse
|
122
|
A Statewide Assessment of Rib Fixation Patterns Reveals Missed Opportunities. J Surg Res 2019; 244:205-211. [PMID: 31299437 DOI: 10.1016/j.jss.2019.06.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/23/2019] [Accepted: 06/11/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rib fractures are a common consequence of traumatic injury and can result in significant debilitation. Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments. However, commercial rib fixation has only recently become clinically prevalent, and we hypothesize that significant variability exists in its utilization based on injury pattern and trauma center. METHODS The Pennsylvania Trauma System Foundation database was queried for all multiple rib fracture patients occurring statewide in 2016 and 2017. Demographics including the presence of flail and the occurrence of rib fixation was abstracted. Outcomes were compared between the fixation group and all other rib fracture patients. Deidentified treating trauma center was used to elicit center-level disparities. RESULTS During the study period, there were 12,910 patients with multiple rib fractures, of which 135 had flail segments. 57 patients underwent rib fixation, and 10 of which had a flail segment. Compared with the nonoperative cohort, those who underwent rib fixation were younger (52.5 versus 61.5, P = 0.0009), similar in gender (68% versus 62% male, P = 0.373), and race (80% versus 86% White, P = 0.239). The rib fixation group had higher Injury Severity Scores (19.4 versus 15.4 P = 0.0011). The timing of rib fixation was most frequent within 1 wk of injury but extended out through 3 wk; the occurrence of pulmonary complications had a similar distribution. The frequency of rib fixation rates within trauma centers was not associated with rib fracture patient volume, and 37.1% of multiple rib fracture patients were cared for at centers that did not perform rib fixation. CONCLUSIONS Rib fixation is infrequently used at trauma centers in Pennsylvania. It is used more frequently in nonflail injuries, and its use may be associated with the occurrence of pulmonary complications. Significant center-level variation exists in rib fixation rates among multiple fractured patients. A significant number of patients are cared for at centers that do not perform rib fixation. Further research is needed to illicit better-defined indications for operative fixation, and opportunities exist to further the penetrance of this practice to all trauma centers.
Collapse
|
123
|
|
124
|
Fokin A, Wycech J, Chin Shue K, Stalder R, Lozada J, Puente I. Tracheostomy in trauma patients with rib fractures. Eur J Trauma Emerg Surg 2019; 47:965-974. [PMID: 31119319 DOI: 10.1007/s00068-019-01149-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Patients with rib fractures (RF) may require prolonged mechanical ventilation and tracheostomy. Indications for tracheostomy in trauma patients with RF remain debatable. The goal was to delineate characteristics of patients who underwent tracheostomy due to thoracic versus extra-thoracic causes, such as maxillofacial-mandibular injury (MFM), traumatic brain injury (TBI), and cervical vertebrae trauma (CVT), and to analyze clinical outcomes. The predictive values of chest trauma scoring systems for tracheostomy were also evaluated. We hypothesized that tracheostomized patients were more severely injured with more ribs fractured and had more pulmonary co-injuries. METHODS Retrospective review included 471 patients with RF admitted to two Level 1 trauma centers. Patients with tracheostomy (n = 124, 26.3%) were compared to patients with endotracheal intubation (n = 347, 73.7%). Analyzed variables included age, gender, injury severity score (ISS), Glasgow Coma Scale, number of ribs fractured, total fractures of ribs, prevalence of bilateral rib fractures, flail chest, clavicle fractures, MFM, TBI, CVT, co-injuries, comorbidities, RF treatment options, hospital length of stay (HLOS), intensive care unit LOS (ICULOS), duration of mechanical ventilation (DMV). RESULTS Tracheostomized compared to intubated patients had statistically higher ISS, more ribs fractured, total fractures of the ribs, bilateral and clavicle fractures, MFM, spine, chest, and orthopedic co-injuries and longer HLOS, ICULOS and DMV. Tracheostomy for thoracic reasons was performed in 64 patients (51.6%) and for extra-thoracic reasons in 60 patients (48.4%). Mean tracheostomy timing was 9.9 days and was significantly shorter in the extra-thoracic compared to the thoracic group (8.0 versus 11.6 days, p < 0.001). All chest trauma scoring system values were significantly higher in tracheostomized patients. Predictive values of scoring systems for tracheostomy increased in patients with thoracic trauma only. CONCLUSIONS A quarter of mechanically ventilated patients with RF required tracheostomy. Tracheostomized compared to intubated patients were more severely injured with more ribs fractured and were intubated longer. An increased amount of RF was associated with an increase in tracheostomies, especially for thoracic reasons.
Collapse
Affiliation(s)
- Alexander Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA.
| | - Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA
| | - Kyle Chin Shue
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA
| | - Ryan Stalder
- Wake Forest University, 1834 Wake Forest Rd, Winston-Salem, NC, 27109, USA
| | - Jose Lozada
- Division of Trauma and Critical Care Services, Broward Health Medical Center, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA.,Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA.,Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, 11200 SW 8th St, Miami, FL, 33199, USA
| |
Collapse
|
125
|
Pieracci FM, Leasia K, Whitbeck S. Barriers to conducting a multi-center randomized controlled trial of surgical stabilization of rib fractures (and how to overcome them). J Thorac Dis 2019; 11:S1049-S1060. [PMID: 31205762 DOI: 10.21037/jtd.2018.12.126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical stabilization of rib fractures (SSRF) has become a standardized procedure, routinely performed at trauma centers over the last 40 years, however, it remains a controversial practice. Multicenter, randomized controlled trials (RCT) would provide compelling evidence in the efficacy of SSRF but there are theoretical obstacles involved with execution and design of this type of investigation. Through the systematic review of current literature on the topics of SSRF for flail and non-fail patterns, medical device industry conflicts of interests, working with international review boards (IRB), the surveyed opinions of surgeons, and through the experience gained from conducting a multicenter RCT on SSRF, it was possible to identify the major barriers that come with successful implementation of this type of study. In identifying these obstacles, it was then possible to propose their solutions, specifically to the issues that make the effort underpowered, underfunded, understaffed, with not enough time for completion. These barriers can be overcome with understanding, up front, that a mutlicenter RCT of SSRF will involve a multi-year and multi-hundred thousand dollar commitment, with support from parent organizations, and a dedicated, full-time research staff (and the solutions of how to overcome them). These barriers stem from poor planning which result specifically in an effort that is underpowered, under funded, under staffed, with not enough time for completion.
Collapse
Affiliation(s)
- Fredric M Pieracci
- Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, Denver, CO, USA
| | - Kiara Leasia
- Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, Denver, CO, USA
| | | |
Collapse
|
126
|
Cheema FA, Chao E, Buchsbaum J, Giarra K, Parsikia A, Stone ME, Kaban JM. State of Rib Fracture Care: A NTDB Review of Analgesic Management and Surgical Stabilization. Am Surg 2019. [DOI: 10.1177/000313481908500523] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thoracic analgesia plays a key role in management and outcomes of rib fractures and can generally be broken down into oral or parenteral medication administration and regional analgesia. Surgical stabilization of rib fractures (SSRF) may be an underused resource in the management of rib fractures. This study describes recent trends in rib fracture management and outcomes. National Trauma Data Bank datasets from 2008 to 2014 were reviewed. Patients with three or more rib fractures were identified, and the frequencies of epidural analgesia (EA), other regional analgesia, and SSRF were analyzed. Those older than 65 years were more likely to be admitted to the ICU but had shorter ICU length of stay, lower intubation, and need for tracheostomy rates. In addition, those older than 65 years had about 2.5 times higher mortality (6.3% vs 2.6%, P < 0.001). EA was used in only 3 per cent of the population and more commonly in the older than 65 years group (3.7% vs 2.8%, P < 0.001). Regardless of age, SSRF was more commonly performed when compared with the placement of EA (5.8% vs 3%). This difference was even greater in the younger than 65 years group, where 7 per cent underwent SSRF. Utilization of EA remains low nationally. SSRF should be considered not only for chest wall stabilization but also as an analgesic modality in selected patients. A more complete accounting of analgesic care in rib fracture patients is needed to allow a more detailed analysis of analgesia for rib fracture–related pain to elucidate optimal treatment.
Collapse
Affiliation(s)
| | - Edward Chao
- Department of Surgery, Jacobi Medical Center, Bronx, New York
| | | | - Katie Giarra
- Department of Surgery, Jacobi Medical Center, Bronx, New York
| | - Afshin Parsikia
- Department of Surgery, Jacobi Medical Center, Bronx, New York
| | - Melvin E. Stone
- Department of Surgery, Jacobi Medical Center, Bronx, New York
| | - Jody M. Kaban
- Department of Surgery, Jacobi Medical Center, Bronx, New York
| |
Collapse
|
127
|
Pieracci FM. Completely thoracoscopic surgical stabilization of rib fractures: can it be done and is it worth it? J Thorac Dis 2019; 11:S1061-S1069. [PMID: 31205763 DOI: 10.21037/jtd.2019.01.70] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Surgical stabilization of rib fractures (SSRF) is now a common operation at most high-volume trauma centers. Increased experience with the procedure has spawned a variety of technical modifications to minimize incision length, muscle division, scapular retraction, and general tissue trauma. The ultimate example of such a minimally invasive approach is completely thoracoscopic SSRF, which refers to using a video-assisted thoracoscopic surgery (VATS) technique to both reduce and fixate rib fractures in an intra-thoracic fashion. The benefits of thoracoscopic SSRF may be divided broadly into those that relate to the repair of the rib fractures themselves, and those that relate to adjuncts to rib fracture repair. With respect to the former, theoretical benefits include improved visualization of rib fractures (particularly in posterior and sub-scapular locations), minimization of trauma to overlying muscles and nerves, minimization of trauma to intra-thoracic structures, and elimination of palpable plates. With respect to the latter, theoretical advantages include evacuation of retained hemothorax, guided placement of loco-regional anesthesia and chest tubes, and identification and repair of associated, intra-thoracic injuries. A VATS may also aid in trainee education. Despite these theoretical benefits, early attempts at thoracoscopic SSRF have been limited by both user inexperience and inadequate instrumentation. Furthermore, there are currently no data comparing the efficacy of completely thoracoscopic SSRF to either contemporary, minimally-invasive, extra-thoracic SSRF or non-operative management.
Collapse
Affiliation(s)
- Fredric M Pieracci
- University of Colorado Health Sciences Center, Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, Denver, CO, USA
| |
Collapse
|
128
|
He Z, Zhang D, Xiao H, Zhu Q, Xuan Y, Su K, Liao M, Tang Y, Xu E. The ideal methods for the management of rib fractures. J Thorac Dis 2019; 11:S1078-S1089. [PMID: 31205765 DOI: 10.21037/jtd.2019.04.109] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The clinical treatment choices for multiple rib fractures and flail chest are controversial. For example, among conservative treatment and surgical treatment, different studies have different conclusions and recommendations. Furthermore, early clinical research was mainly focused on the treatment of flail chest due to its severity. Nowadays, the treatment for multiple rib fractures patients without a flail chest is drawing an increased clinical interest. However, we are facing many challenges for the treatment of rib fractures, such as insufficient understanding of the available treatment options, lack of clinical research, lack of the internationally recognized clinical indication for the surgical stabilization of rib fractures (SSRF), and the constant controversies and debates in terms of treatment options, surgery timing, and surgical techniques. All these challenges make it difficult to select the most appropriated clinical decisions for the proper treatment of a rib fracture, resulting in a seriously hindered development of novel rib fractures treatment choices. The concepts and ideas for traditional rib fractures treatment are relatively old, and even have some misunderstandings or errors. With the emergence of more and more research, the understandings of the rib fractures treatment has gradually improved; for example, the benefits provided to patients under the open reductions and internal fixation of fractures treatment. In this article, we outlined the new concepts in rib fractures treatment, which mainly included four parts, damage control, pain management, fixation selection, and quality of life. We hope these concepts help practitioners better manage rib fracture patients.
Collapse
Affiliation(s)
- Zhe He
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Dongsheng Zhang
- Department of Thoracic Surgery, Shijiazhuang Third Hospital, Shijiazhuang 050011, China
| | - Haiping Xiao
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Qihang Zhu
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Yiwen Xuan
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Kai Su
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Ming Liao
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Yong Tang
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China
| | - Enwu Xu
- Department of Thoracic Surgery, General Hospital of Southern Theater Command, PLA, Guangzhou 510010, China.,Southern Medical University, Guangzhou 510515, China
| |
Collapse
|
129
|
Ashley DW, Drahos A, Fitzgerald M, Christie DB. Chest wall stabilization and rib plating in 15-year-old male adolescent after blunt thoracic trauma. J Thorac Dis 2019; 11:S1100-S1102. [PMID: 31205768 DOI: 10.21037/jtd.2018.10.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Dennis W Ashley
- Department of Trauma Surgery and Critical Care, Medical Center of Central Georgia, Navicent Health Systems, Mercer University School of Medicine, Macon, GA, USA
| | - Andrew Drahos
- Department of Trauma Surgery and Critical Care, Medical Center of Central Georgia, Navicent Health Systems, Mercer University School of Medicine, Macon, GA, USA
| | - Michael Fitzgerald
- Department of Trauma Surgery and Critical Care, Medical Center of Central Georgia, Navicent Health Systems, Mercer University School of Medicine, Macon, GA, USA
| | - D Benjamin Christie
- Department of Trauma Surgery and Critical Care, Medical Center of Central Georgia, Navicent Health Systems, Mercer University School of Medicine, Macon, GA, USA
| |
Collapse
|
130
|
Su YH, Yang SM, Huang CH, Ko HJ. Early versus late surgical stabilization of severe rib fractures in patients with respiratory failure: A retrospective study. PLoS One 2019; 14:e0216170. [PMID: 31022284 PMCID: PMC6483262 DOI: 10.1371/journal.pone.0216170] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/14/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The timing of surgical stabilization of rib fractures remains controversial. We hypothesized that early surgical stabilization (within 3 days of injury) can improve clinical outcome in patients with severe rib fractures and respiratory failure. The aim of this study was to analyze the impact of early surgical stabilization of rib fractures on the perioperative results, clinical outcomes, and medical costs of patients with severe rib fractures and respiratory failure. Methods This was a retrospective comparative study based on a prospectively collected database at a single institute. Patients with severe rib fractures and respiratory failure who underwent surgical stabilization were classified into early (within 3 days of injury) and late (more than 3 days after injury) groups. Outcome measures included operation time, duration of mechanical ventilation, intensive care unit stay, hospital stay, complication rate, mortality rate, and medical cost. Results A total of 33 patients were enrolled (16 and 17 in the early and late groups, respectively). The demographics, trauma mechanism, associated injuries, and severity of trauma were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (median 36 vs. 90 hours, p = 0.03), intensive care unit stay (median 123 vs. 230 hours, p = 0.004), and hospital stay (median 12 vs. 18 days, p = 0.005); and lower National Health Insurance costs (median 6,617 vs. 10,017 US dollars, p = 0.031). The early group tended to have lower rates of morbidity and mortality, but the difference was not statistically significant. Conclusion Early surgical stabilization of rib fractures in selected patients may significantly shorten their duration of mechanical ventilation, and intensive care unit and hospital stays, while incurring less medical costs.
Collapse
Affiliation(s)
- Ying-Hao Su
- Department of Orthopedics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
| | - Shun-Mao Yang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
| | - Chun-Hsiung Huang
- Division of Trauma Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
| | - Huan-Jang Ko
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu City, Taiwan
- * E-mail:
| |
Collapse
|
131
|
Taxonomy of multiple rib fractures: Results of the chest wall injury society international consensus survey. J Trauma Acute Care Surg 2019; 88:e40-e45. [DOI: 10.1097/ta.0000000000002282] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
132
|
Zhang S, Tang M, Ma J, Yang J, Qin X, Jin W, Qian J, Li F, Cheng Y, Chen H. Thoracic trauma: a descriptive review of 4168 consecutive cases in East China. Medicine (Baltimore) 2019; 98:e14993. [PMID: 30946326 PMCID: PMC6456143 DOI: 10.1097/md.0000000000014993] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Thoracic trauma in China was scarcely reported. This study aimed to summarize the clinical profiles and to analyze the management approaches of patients with traumatic thoracic injury.Data for consecutive patients with thoracic trauma from January 2003 to January 2018 were retrospectively collected and analyzed. Patients' profiles and clinical outcomes were compared between those patients treated with a dedicated thoracic trauma team and those without.The study included 4168 patients with mean age of 49.0 years, of whom 82.1% were male. Traffic accident accounted for 42.7% of the injuries. Most of the patients (66.8%) had rib fractures. Associated injuries were present in 48.3% of the patients; of them 86.0% were extremity fractures. Majority of the patients were managed without surgical procedures other than tube thoracostomy (33.2%). ICU service was needed in 12.0% of the patients. Patients treated with thoracic trauma team were older (53.59 ± 16.8 year vs 45.1 ± 18.0 year, P < .001), less male (78.3% vs 85.2%, P < .001), with higher injury severity scores (17.5 ± 10.1 vs 13.7 ± 8.2, P < .001), required more ventilator support (48.3% vs 25.3%, P < .001) and underwent more tube thoracostomy and other surgeries (43.8% vs 24.2%, and 34.4% vs 14.1%, respectively, all P < .001), yet with a shorter hospital stay (11.7 ± 9.0 days vs 12.7 ± 8.8 days, P < .001), and numerically lower ICU usage and mortality when compared to those without.Thoracic trauma in China usually affects mid-age males. Traffic accident is the top one etiology. The most common type of thoracic injuries is rib fracture. Associated injuries occur frequently. Nonoperative treatment and tube thoracostomy are effective for majority of the patients. A multidisciplinary approach with a dedicated thoracic trauma team could improve the treatment for these patients.
Collapse
Affiliation(s)
| | - Meiwen Tang
- Department of Hematology
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, China
| | | | | | | | - Wei Jin
- Department of Thoracic Surgery
| | - Jin Qian
- Department of Respiration
- Emergency Department, Zhongshan Hospital Qingpu Branch
| | - Feng Li
- Department of Hematology
- Department of Hematology
| | - Yunfeng Cheng
- Department of Hematology
- Department of Hematology
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, China
| | | |
Collapse
|
133
|
Lodhia JV, Konstantinidis K, Papagiannopoulos K. Surgical management of multiple rib fractures/flail chest. J Thorac Dis 2019; 11:1668-1675. [PMID: 31179112 DOI: 10.21037/jtd.2019.03.54] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Rib fractures in the setting of trauma carries a high morbidity and mortality. Forty-three percent of patients presenting with trauma will have rib fractures. Fifty-five percent of patients, greater than 60 years of age, who die following chest trauma, have isolated rib fractures. Mortality associated with rib fractures starts to increase from the age of 45. Rib fixation is being utilised more for the management of rib fractures. Following the review of literature, we propose a pathway for the management of both simple rib fractures and flail segments. Furthermore, we review the various methods of rib fixation, discussing the advantages and disadvantages of each.
Collapse
Affiliation(s)
- Joshil Vinod Lodhia
- Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Konstantinos Konstantinidis
- Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kostas Papagiannopoulos
- Department of Thoracic Surgery, St. James University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
134
|
Abstract
OBJECTIVES To compare outcomes in patients with rib fractures (RFX) who underwent surgical stabilization of rib fractures (SSRF) to those treated nonoperatively. DESIGN Retrospective cohort study. SETTING Two Level 1 Trauma Centers. PATIENTS One hundred seventy-four patients with multiple RFX divided into 2 groups: patients with surgically stabilized RFX (n = 87) were compared with nonoperatively managed patients in the matched control group (MCG) (n = 87). INTERVENTION SSRF. OUTCOME MEASUREMENTS Age, sex, injury severity score, RFX, mortality, hospital length of stay (HLOS) and intensive care unit length of stay (ICULOS), duration of mechanical ventilation (DMV), co-injuries, and time to surgery. Patients were further stratified by presence or absence of flail chest and pulmonary contusion (PC). RESULTS Flail chest, displaced RFX, and PC were present significantly more often in SSRF patients compared with the MCG. Mortality was lower in SSRF group. HLOS and ICULOS were longer in SSRF group compared with the corresponding MCG patients regardless of timing to surgery (P < 0.01 for all). SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV to MCG patients with flail chest (P > 0.3 for all). SSRF patients without flail chest had significantly longer HLOS and ICULOS than MCG patients without flail chest (P < 0.001 for both). Presence of PC did not affect lengths of stay. CONCLUSIONS SSRF patients had reduced mortality compared with nonoperatively managed patients. HLOS, ICULOS, and DMV were longer in SSRF patients than in MCG. When flail chest was present, lengths of stay were comparable. PC did not seem to affect the surgical outcome. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
135
|
Patel B, L. Hung G, Wullschleger M. Surgical rib fixation: Does increase case volume lead to improved outcomes? ACTA ACUST UNITED AC 2019. [DOI: 10.4103/jctt.jctt_4_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
136
|
Xia H, Zhu P, Li J, Zhu D, Sun Z, Deng L, Zhang Y, Wang D. Thoracoscope combined with internal support system of chest wall in open reduction and internal fixation for multiple rib fractures. Exp Ther Med 2018; 16:4650-4654. [PMID: 30542416 PMCID: PMC6257545 DOI: 10.3892/etm.2018.6817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/29/2018] [Indexed: 01/01/2023] Open
Abstract
This study aimed to investigate the feasibility of applying thoracoscope combined with internal support system of chest wall (ISSW) in minimally invasive internal fixation for rib fracture on patients with multiple rib fractures. A total of 84 patients undergoing open reduction and internal fixation for rib fracture from January 2017 to December 2017 in the Department of Cardiothoracic Surgery, Tianjin Hospital were selected into the study, and retrospective analyses were carried out. The clinical data, pain score, operating time, intraoperative blood loss, indwelling time of thoracic tube, total drainage volume of thoracic tube for 3 days after operation, indwelling time of wound drainage tube, total drainage volume of wound drainage tube, length of stay, hospitalization costs, postoperative complications, C-reactive protein (CRP) and pulmonary function of patients in the groups were compared. The patients were followed up for prognosis for 2–4 months via re-examination, and chest numbness at 1 month after operation was recorded. Compared with that (145.27±18.80 min) in the traditional group, the operating time in the minimally invasive group (112.20±21.40 min) was shorter (p<0.05). The total drainage volume of wound drainage tube was 145.75±61.03 ml in the minimally invasive group and 248.91±93.95 ml in the traditional group (p<0.05). In addition, the chest numbness at 1 month after operation (11.8%) in the minimally invasive group was better than that (34.00%) in the traditional group (p<0.05). Postoperative pain score, CRP and pulmonary function tests were also significantly different between the two groups (p<0.05). The results indicated that the application of thoracoscope combined with ISSW in minimally invasive internal fixation for rib fracture can effectively improve the prognosis of patients and reduce the length of stay and adverse reactions, and has high economic benefits, which is worthy of promotion and use in clinical practice.
Collapse
Affiliation(s)
- Honggang Xia
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Pengzhi Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Jing Li
- Department of Nursing, Tianjin Medical College, Tianjin 300222, P.R. China
| | - Deqing Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Zhongyi Sun
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Limin Deng
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Yongmin Zhang
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| | - Dongbin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, P.R. China
| |
Collapse
|
137
|
Moskowitz EE, Garabedian L, Hardin K, Perkins-Pride E, Asfaw M, Preslaski C, Leasia KN, Lawless R, Burlew CC, Pieracci F. A double-blind, randomized controlled trial of gabapentin vs. placebo for acute pain management in critically ill patients with rib fractures. Injury 2018; 49:1693-1698. [PMID: 29934099 DOI: 10.1016/j.injury.2018.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/02/2018] [Accepted: 06/02/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Achieving adequate pain control for rib fractures remains challenging; prescription of alternatives to narcotics is imperative to curtail the current opioid epidemic. Although gabapentin has shown promise following elective thoracic procedures, its efficacy in patients with rib fractures remains unstudied. We hypothesized that gabapentin, as compared to placebo, would both improve acute pain control and decrease narcotic use among critically ill patients with rib fractures. MATERIALS AND METHODS Adult patients admitted to the trauma surgery service from November 2016 - November 2017 at an urban, Level I trauma center with one or more rib fractures were randomized to either gabapentin 300 mg thrice daily or placebo for one month following their injury. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings during the index admission, as well as and one-month quality of life survey data were abstracted. RESULTS Forty patients were randomized. The groups were well matched with respect to age, gender, prior narcotic use, tobacco use, and prior respiratory disease. Although the median RibScore did not differ between groups, the gabapentin group had a higher median number of ribs fractured as compared to the placebo group (7 vs. 5, respectively). Degree of pulmonary contusion and injury severity score were similar between groups. Use of loco-regional anesthetic modalities did not differ between groups. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings were similar between both groups. No benefit was observed when adding gabapentin to a multi-modal analgesic regimen for rib fractures. There were no instances of pneumonia, respiratory failure, or mortality in either group. Hospital and intensive care unit length of stay were similar between groups. Both overall and chest-specific quality of life was equivalent between groups at one month follow-up. CONCLUSIONS In this group of critically ill patients with rib fractures, gabapentin did not improve acute outcomes for up to one month of treatment.
Collapse
Affiliation(s)
- Eliza E Moskowitz
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Lucin Garabedian
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Kimberly Hardin
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Emily Perkins-Pride
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Menilik Asfaw
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Candice Preslaski
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Kiara N Leasia
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Ryan Lawless
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Clay Cothren Burlew
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| | - Fredric Pieracci
- Denver Health Medical Center University of Colorado School of Medicine, United States.
| |
Collapse
|
138
|
Udekwu P, Roy S, McIntyre S, Farrell M. Flail Chest: Influence on Length of Stay and Mortality in Blunt Chest Injury. Am Surg 2018. [DOI: 10.1177/000313481808400940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Flail chest is used as one of the indicators for rib fixation, which is being performed more frequently. Radiologic and clinical flail chest are not clearly differentiated in published studies and the relationship between radiologic flail chest (RFC) and outcomes are not clearly established. Our study was designed to evaluate the relationship of RFC to outcomes in patients with severe blunt chest injury. Adult patients with severe blunt chest injury admitted between January 1, 2014, and June 30, 2016, were identified retrospectively. Three hundred and eighty-three patients were studied and mortality rate was not significantly different in patients with an RFC diagnosis (5.88%) compared with patients without RFC (3.83%), P = 0.50. Length of stay (LOS) in patients with and without RFC were compared and patients with RFC were found to have a statistically significant increase in both hospital and intensive care unit LOS (P = 0.0178, P < 0.0017). Multivariate analysis confirmed RFC as an independent predictor of increased LOS when compared with the number of rib fractures and displacements. Our study suggests that RFC may drive inappropriate use of rib fixation. This questions the justification of liberal rib fixation based on the perceived high mortality rate of modern flail chest diagnoses.
Collapse
Affiliation(s)
- Pascal Udekwu
- From the WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Sara Roy
- From the WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Sarah McIntyre
- From the WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Meagan Farrell
- From the WakeMed Health and Hospitals, Raleigh, North Carolina
| |
Collapse
|
139
|
Bauman ZM, Cemaj S, Schlitzkus LL. Taking the bull by the horns: Patient trampled by bull requiring surgical fixation of multiple rib fractures including rib 11. Trauma Case Rep 2018; 16:12-15. [PMID: 30186934 PMCID: PMC6123322 DOI: 10.1016/j.tcr.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2018] [Indexed: 11/30/2022] Open
Abstract
Rib fractures are a serious problem in thoracic trauma resulting in high morbidity and mortality. Surgical stabilization in the management of rib fractures is gaining more popularity and recognition as outcomes continue to show positive results, however, there is still hesitancy among the trauma community to recommend this intervention. Although there still remains questions as to which patients to provide surgical stabilization to in the non-flail rib fracture patient population, surgical stabilization of rib fractures have been shown to be extremely beneficial in those patients with flail chest and should be strongly considered in this patient population, especially if they require ventilatory support. Here we present a 62-year-old female with severe chest wall deformity from 21 rib fractures after being trampled by a bull. This included a flail segment and a severely angulated 11th rib fracture piercing through the lung into the retroperitoneum. Furthermore, we also introduce a new technique for stabilization of rib fractures that are more posterior. Given the fact we surgically intervened early in our patient with severe chest wall trauma, she had a very favorable outcome, allowing her to be discharged from the hospital in a timely fashion with minimal overall morbidity.
Collapse
Affiliation(s)
- Zachary M Bauman
- Department of Emergency General Surgery, Trauma and Critical Care Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, United States of America
| | - Samuel Cemaj
- Department of Emergency General Surgery, Trauma and Critical Care Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, United States of America
| | - Lisa L Schlitzkus
- Department of Emergency General Surgery, Trauma and Critical Care Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, United States of America
| |
Collapse
|
140
|
Mitev K, Neziri D, Stoicovski E, Mitrev Z. Surgical plate fixation of multiple rib fractures: a case report. J Med Case Rep 2018; 12:150. [PMID: 29807546 PMCID: PMC5972397 DOI: 10.1186/s13256-018-1683-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/07/2018] [Indexed: 11/29/2022] Open
Abstract
Background The healthcare system in developing countries is limited; particularly, medical specialties such as emergency and trauma medicine are underdeveloped. Consequently, trauma injuries sustained in traffic accidents result in chronic morbidity more often than similar cases in developed countries. Multiple rib fractures induce significant patient morbidity. Current international guidelines recommend a multidisciplinary, surgery-based treatment approach to achieve optimal clinical benefit. Case presentation We admitted a 41-year-old Albanian man to our emergency department following a pedestrian-vehicle accident 5 days earlier. He presented with severe upper thoracic pain, chest deformity, dyspnea, tachycardia, subcutaneous emphysema, and hematoma. Chest radiography pointed to hypoventilated lung fields and a minor pleural effusion. Computed tomographic scans indicated displaced fractures of right lateral ribs 5 –11, hyperdensity regions from bone fragments, and pulmonary contusion. The treatment consisted of surgical fixation of ribs 7–10 using titanium reconstruction plates and cortical locking screws. The patient’s clinical condition rapidly improved postoperatively. Follow-up at 6 weeks confirmed a full return to preoperative daily activities and a high quality of life. Conclusions In this case report, we present a novel and promising development in the field of trauma medicine in the Republic of Macedonia. Trauma injuries can be treated via advanced multidisciplinary medical care according to international standards, allowing optimal health recovery.
Collapse
Affiliation(s)
- Konstantin Mitev
- Department of Orthopedic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia. .,Faculty of Medical Sciences, University Goce Delchev, Shtip, Republic of Macedonia.
| | - Dashurie Neziri
- Department of Orthopedic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia
| | - Emil Stoicovski
- Department of Orthopedic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia
| | - Zan Mitrev
- Department of Thoracic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia
| |
Collapse
|
141
|
Early results after operatively versus non-operatively treated flail chest: a retrospective study focusing on outcome and complications. Eur J Trauma Emerg Surg 2018; 46:539-547. [PMID: 29785655 PMCID: PMC7280328 DOI: 10.1007/s00068-018-0961-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/29/2018] [Indexed: 12/22/2022]
Abstract
Purpose Flail chest was traditionally treated non-operatively using mechanical ventilation and pain control. In order to reduce the occurrence of ventilation-associated complications and long-term disability, operative rib fixation is becoming a proven standard therapy for these patients. However, the consequences of the surgical complications may influence success rates negatively. The aim of this study was to compare the outcome of flail chest treatment by surgical rib fixation with non-operative treatment, with special focus on the impact of surgical complications. Methods A retrospective case series of operatively treated flail chest patients was compared with non-operatively treated patients. Patients’ injury and treatment characteristics and outcome parameters (e.g., duration of mechanical ventilation, length of Intensive Care stay (ICLOS) and hospital length of stay (HLOS), mortality, surgery-related complications and pneumonia) were collected from the patients’ medical files. Crude and matched-pairs analyses were performed in SPSS. Results Twenty-three operatively and 47 non-operatively treated patients were enrolled. Operatively treated patients required significantly shorter mechanical ventilation; median 4 days versus 12 days for the non-operative group (p = 0.011). The matched-pairs analysis also showed a lower pneumonia rate (35% versus 80%; p = 0.035) and a shorter HLOS (median 21 versus 23 days; p = 0.028) in the operative group. No significant differences in duration of ICLOS, and occurrence of other injury-related adverse events were found between both groups.
Seven surgery-related complications occurred, of which three required invasive solutions. Conclusions Operative fixation of a flail chest in trauma patients results in a lower rate of pneumonia, less mechanical ventilation days and shorter hospital stay, compared with non-operative treatment, but at the cost of surgery-related complications requiring invasive solutions in some cases.
Collapse
|
142
|
Schulz-Drost S, Langenbach A. Reply to the letter to the editor "Minimized approaches to the posterolateral chest wall in the fixation of rib fracture" by Yih-Wen Tarng, Yi-Pin Chou, Tung-Ho Wu, Hsing-Lin Lin. Eur J Trauma Emerg Surg 2018; 44:485-486. [PMID: 29691596 DOI: 10.1007/s00068-018-0952-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 03/30/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Stefan Schulz-Drost
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
- Department of Trauma and Orthopedic Surgery, BG Hospital Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.
| | - Andreas Langenbach
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| |
Collapse
|
143
|
de Campos JRM, White TW. Chest wall stabilization in trauma patients: why, when, and how? J Thorac Dis 2018; 10:S951-S962. [PMID: 29744222 DOI: 10.21037/jtd.2018.04.69] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Blunt trauma to the chest wall and rib fractures are remarkably frequent and are the basis of considerable morbidity and possible mortality. Surgical remedies for highly displaced rib fractures, especially in cases of flail chest, have been undertaken intermittently for more than 50 years. Rib-specific plating systems have started to be used in the last 10 years. These have ushered in the modern era of rib repair with chest wall stabilization (CWS) techniques that are safer, easier to perform, and more efficient. Recent consensus statements have sought to define the indications and contraindications, as well as the when, the how, and the technical details of CWS. Repair should be considered for patients who have three or more displaced rib fractures or a flail chest, whether or not mechanical ventilation is required. Additional candidates include patients who fail non-operative management irrespective of fracture pattern and those with rib fractures who need thoracic procedures for other reasons. Traditionally, unstable spine fracture and severe traumatic brain injury are definite contraindications. Pulmonary contusion's role in the decision to perform CWS remains controversial. A range of rib-specific plating systems are now commercially available.
Collapse
Affiliation(s)
| | - Thomas W White
- Trauma and Surgical Critical Care, Intermountain Medical Center, Salt Lake City, Utah, USA
| |
Collapse
|
144
|
A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures. J Trauma Acute Care Surg 2018; 84:1-10. [DOI: 10.1097/ta.0000000000001729] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
145
|
Kane ED, Jeremitsky E, Bittner KR, Kartiko S, Doben AR. Surgical Stabilization of Rib Fractures: A Single Institution Experience. J Am Coll Surg 2017; 226:961-966. [PMID: 29180034 DOI: 10.1016/j.jamcollsurg.2017.11.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/14/2017] [Accepted: 11/14/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Use of surgical stabilization of rib fractures (SSRF) has increased. Despite compelling small studies, many centers still struggle with determining criteria for intervention. We investigated the benefit of SSRF in our patients compared with nonoperative (NonOp) National Trauma Databank (NTDB) controls, specifically in the older population. STUDY DESIGN We performed a retrospective comparison of trauma patients with ≥3 and >5 rib fractures, who underwent SSRF at a tertiary care level I trauma center, with nonoperatively managed NTDB controls from equivalent level I centers between 2007 and 2014. The main outcomes measures included mortality, pneumonia, length of stay (LOS), ICU LOS, ventilator use, and tracheostomy rates. RESULTS Overall, SSRF patients were older, had a higher percentage of respiratory disease, and higher Injury Severity Scores (ISS). Despite more respiratory disease in SSRF patients vs NonOp (p < 0.0001), there was no difference in ventilator usage. Results of SSRF included decreases in mortality (12%, p = 0.008) and pneumonia (13%, p < 0.001) compared with NonOp on propensity score matching. On subgroup analysis of patients 65 years of age or older, ISS was higher in the SSRF group. Mortality was significantly lower for SSRF vs NonOp, even with higher frequency of respiratory disease within the group (p < 0.001). CONCLUSIONS Patients who underwent SSRF at our institution had improved outcomes despite a higher percentage of respiratory disease, compared with patients who were managed nonoperatively nationwide. Mortality rates improved for patients aged 65 and older, suggesting that this patient population may benefit more from SSRF.
Collapse
Affiliation(s)
- Erica D Kane
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA.
| | - Elan Jeremitsky
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| | - Katharine R Bittner
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| | - Susan Kartiko
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| | - Andrew R Doben
- Department of Surgery, University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA
| |
Collapse
|
146
|
Reduced invasive and muscle-sparing operative approaches to the posterolateral chest wall provide an excellent accessibility for the operative stabilization! Eur J Trauma Emerg Surg 2017; 44:471-481. [DOI: 10.1007/s00068-017-0877-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
|
147
|
Abstract
The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.
Collapse
Affiliation(s)
- Steven E Brooks
- Geriatric Trauma Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Department of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA; Pediatric Intensive Care Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Department of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA.
| | - Allan B Peetz
- Emergency General Surgery, Division of Trauma, Surgical Critical Care, Vanderbilt University Medical Center, Medical Arts Building Suite 404, 1211 21st Avenue South, Nashville, TN 37212, USA
| |
Collapse
|
148
|
|
149
|
Indications for surgical stabilization of rib fractures in patients without flail chest: surveyed opinions of members of the Chest Wall Injury Society. INTERNATIONAL ORTHOPAEDICS 2017; 42:401-408. [DOI: 10.1007/s00264-017-3612-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 08/09/2017] [Indexed: 10/19/2022]
|
150
|
Udekwu P, Patel S, Farrell M, Vincent R. Favorable Outcomes in Blunt Chest Injury with Noninvasive Bi-Level Positive Airway Pressure Ventilation. Am Surg 2017. [DOI: 10.1177/000313481708300722] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent clinical research in patients with blunt chest injury has focused on the benefits of surgical fixation of rib fractures. Noninvasive ventilation (NIV) has been demonstrated to prevent the need for intubation and ventilation in posttraumatic respiratory failure. The preemptive use of NIV in patients with rib fractures has not been extensively studied. Our study evaluated the outcomes of patients with ≥3 rib fractures and hospitalized for ≥ 4 days. Seventy-one patients treated with NIV were compared with 270 patients without NIV. NIV patients were older (65.8 vs 56.5 years) had more rib fractures (6.25 vs 5.32) and a higher body mass index (31 vs 27.8) than the comparison group, P < 0.05, but did not have an increased mortality or incidence of respiratory failure. NIV patients did have a statistically significant increase in length of stay compared to control (12.8 vs 8.8, P < 0.05). In the total sample, worse clinical outcomes were associated with older age, increased number of and bilateral rib fractures, higher Injury Severity Score, lower Glasgow Coma Scale, and higher body mass index. Outcomes in the most severely injured group of patients treated with NIV were comparable to other studies using surgical fixation of rib fractures and epidural pain control.
Collapse
Affiliation(s)
- Pascal Udekwu
- WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Sahill Patel
- WakeMed Health and Hospitals, Raleigh, North Carolina
| | | | | |
Collapse
|