Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study

[Specialised Intensive Care Treatment Concepts for Severe Chest Trauma]

This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.

Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients

BACKGROUND

Optimal treatment (i.e., nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment.

METHODS

The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with 1-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life.

RESULTS

Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic nonunion. The median HLOS was 7 days (4-13 days), and median intensive care unit length of stay was 2 days (1-5 days). Mean 5-Level Quality of Life Questionnaire index value was 0.83 ± 0.18 1 year after trauma. Polytrauma patients had a median HLOS of 10 days (6-18 days), a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 days (5-15 days), a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12).

CONCLUSION

Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after 1 year. Future studies evaluating the benefit of operative stabilization should use contemporary outcomes to establish the therapeutic margin of rib fixation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Predictors of opioid use for rib fractures in a regional Australian hospital

BACKGROUND

Rib fractures (RFs) are the leading type of single serious injury in New South Wales trauma patients. Uncontrolled pain drives the sequelae of atelectasis, pneumonia, respiratory failure, and death in severe cases. Opioids are the mainstay of management; however, they carry numerous adverse effects. Understanding patient or injury factors which predict opioid requirement is important to tailor management. Existing evidence is limited to metropolitan trauma centres (MTCs).

METHODS

We conducted an observational, retrospective, single-centre cohort study of all admissions to Albury Wodonga Health diagnosed with one or more RFs and discharged between January 1st, 2017, and December 31st, 2022, inclusive. Data collected included demographics, injury characteristics, and management, including analgesia. LASSO regression was performed to determine predictors of average daily opioid use for the first five days of admission in oral morphine equivalents (mg). R2 and root mean square error (RMSE) were calculated to assess model performance.

RESULTS

We included 624 patients. LASSO selected number of RFs, fracture displacement score, pulmonary contusion, new injury severity score, age, chest tube use, chronic pain history, opioid history and upper or middle lateral RF location categories as predictors. Sex, middle anterior, middle posterior, and lower RF location categories were excluded by LASSO. The out of sample R2 was 28.6 %. On the scale of log OME, the RMSE was 1.08.

CONCLUSION

The model is effective at identifying predictors of opioid use in this regional centre, which are similar to those described in evidence from MTCs. However, the low R2 with wide prediction intervals limits its utility on an individual level.

Investigating the link between frailty and outcomes in geriatric patients with isolated rib fractures

Background

Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures.

Methods

All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding.

Results

A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001].

Conclusion

There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.

[Bilateral thoracic trauma-"double the trouble"?]

BACKGROUND

Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma.

OBJECTIVE

The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two.

MATERIAL AND METHODS

In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome.

RESULTS

A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors.

CONCLUSION

Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

A clinical study on the surgical treatment of simple multiple rib fractures in older adult patients

Background

The treatment of simple rib fractures in older adults can be divided into surgical treatment and nonsurgical treatment, with indications for surgery presently being unclear. This study was conducted to determine whether older adult individuals with simple multiple rib fractures can benefit from surgical treatment.

Methods

A single-center, retrospective study was conducted. All 880 registry-identified patients aged ≥60 years who were admitted to Beijing Jishuitan Hospital with blunt rib fractures between 2013 to 2020 were included. They were divided into 2 groups according to whether internal fixation was performed. After screening of inclusion and exclusion criteria and propensity score matching, there were 226 patients, 113 of whom were placed in the operation group and 113 in the nonoperation group. The demographic characteristics, underlying diseases, number of rib fractures, hospital stay, intensive care unit (ICU) hospital stay, mechanical ventilation duration, fracture comorbidities on admission, pain index, and fracture healing condition were analyzed using chi-squared test and independent samples t test.

Results

The pain score and fracture healing time were significantly improved in the operation group (P<0.05), while the duration of painkiller use was significantly shorter in the operation group (P=0.009). However, there was no significant differences in mortality, the incidence of bone nonunion, length of stay in the ICU, or duration of mechanical ventilation between the 2 groups.

Conclusions

For patients in the clinical study, internal fixation surgery could reduce fracture healing time and minimize the use of painkillers. Surgical treatment was determined to be safe, as it did not increase the mortality of the older adult patients. For older patients with simple rib fractures who have no contraindications to surgery, internal fixation surgery is recommended.

Performing Advanced Trauma Life Support (ATLS) across Borders: Midterm Follow-Up of the Aeromedical Evacuation after Civilian Bus Accident at Madeira

On 17 April 2019, a coach with tourists from Germany crashed in Madeira, requiring repatriation by the German Air Force. The Advanced Trauma Life Support (ATLS) concept was the central component of patient care. Data in Madeira were collected through a structured interview. The analysis of the Aeromedical Evacuation was based on intensive care transport records. In Germany, all available medical data sheets were reviewed for data collection. Quality of life (HRQoL) was evaluated by the 12-item Short Form Health Survey (SF-12). Twenty-eight prehospital patients were transported to the Level III Trauma Center in Funchal (Madeira). Five operative procedures were performed. Fifteen patients were eligible for Aeromedical Evacuation (AE). In the second hospital phase in Germany, in total 82 radiological images and 9 operations were performed. Hospital stay lasted 11 days (median, IQR 10-18). Median follow-up (14 of 15 patients) was 16 months (IQR 16-21). Eighty percent (8 out of 10) showed an increased risk for post-traumatic stress disorder (PTSD). Six key findings were identified in this study: divergent injury classification, impact of AE mission on health status, lack of communication, need of PTSD prophylaxis, patient identification, and media coverage. Those findings may improve AE missions in the future, e.g., when required after armed conflicts.

Predictors of long-term survival in 5,680 patients admitted to a UK major trauma centre with thoracic injuries

INTRODUCTION

The long-term outcomes of chest trauma are largely unknown. We sought to determine the predictors of in-hospital and long-term survival in patients admitted to a major trauma centre (MTC) with chest injuries and to evaluate spatial patterns of injury in our network area.

METHODS

Retrospective analysis of data collected on the National Trauma Audit Research Network (TARN) database using multivariate analysis and Cox regression analysis. Spatial analysis was performed using ArcGis 10.7.1.

RESULTS

Some 5,680 patients were admitted with chest trauma between December 1999 and December 2019. Median patient age was 45 years and the median Injury Severity Score (ISS) was 20. The proportion of patients who had an operation was 39.8%. Age, blood transfusion, head injury, shock, emergency thoracotomy and heart disease were predictors of hospital mortality (p < 0.05). However, having an operation on concomitant injuries was protective. ISS and Glasgow Coma Score were discriminators of in-hospital mortality (C-indices 0.76 and 0.80, respectively). The 10-year survival values for patients who survived to discharge from hospital and who were aged <40, 50, 60, 70, 80 and >80 years were 99%, 93%, 95%, 87%, 75% and 43%, respectively. Preadmission lung disease and alcohol/drug misuse were poor predictors of long-term survival (p < 0.05). Hotspot analysis revealed the areas with the highest incidents were all close to the MTC.

CONCLUSIONS

The MTC is geographically central to areas with high numbers of trauma incidents. Although emergency thoracotomy was a predictor of poor in-hospital outcomes, having surgery for concomitant injuries improved outcomes. Patients surviving to discharge have good long-term survivals.

A qualitative descriptive study exploring clinicians' perspectives of the management of older trauma care in rural Australia

BACKGROUND

For older trauma patients who sustain trauma in rural areas, the risk of adverse outcomes associated with advancing age, is compounded by the challenges encountered in rural healthcare such as geographic isolation, lack of resources, and accessibility. Little is known of the experience and challenges faced by rural clinicians who manage trauma in older adults. An understanding of stakeholders' views is paramount to the effective development and implementation of a trauma system inclusive of rural communities. The aim of this descriptive qualitative study was to explore the perspectives of clinicians who provide care to older trauma patients in rural settings.

METHOD

We conducted semi-structured interviews of health professionals (medical doctors, nurses, paramedics, and allied health professionals) who provide care to older trauma patients in rural Queensland, Australia. A thematic analysis consisting of both inductive and deductive coding approaches, was used to identify and develop themes from interviews.

RESULTS

Fifteen participants took part in the interviews. Three key themes were identified: enablers of trauma care, barriers, and changes to improve trauma care of older people. The resilience of rural residents, and breadth of experience of rural clinicians were strengths identified by participants. The perceived systemic lack of resources, both material and in the workforce, and fragmentation of the health system across the state were barriers to the provision of trauma care to older rural patients. Some changes proposed by participants included tailored education programs that would be taught in rural centres, a dedicated case coordinator for older trauma patients from rural areas, and a centralised system designed to streamline the management of older trauma patients coming from rural regions.

CONCLUSIONS

Rural clinicians are important stakeholders who should be included in discussions on adapting trauma guidelines to the rural setting. In this study, participants formulated pertinent and concrete recommendations that should be weighed against the current evidence, and tested in rural centres.

Thoracic injuries in trauma patients: epidemiology and its influence on mortality

BACKGROUND

Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality.

METHODS

Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality.

RESULTS

A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3).

CONCLUSION

Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

Older trauma patients with isolated chest injuries have low rates of complications

INTRODUCTION

The number of older adults hospitalised for injury is growing rapidly. The population-adjusted incidence of isolated thoracic injuries in older adults is also growing. While some older adults are at high risk of post-traumatic complications, not all older adults will need treatment in a major trauma service (MTS). The aim of this study was to characterise older patients with isolated chest injuries, determine the rates of post-traumatic complications, including respiratory failure and pneumonia, and the factors associated with the risk of developing these complications.

PATIENTS AND METHODS

This was a retrospective review of patients aged 65 years and over with isolated chest trauma, from January 2007 to June 2017, using data from the Victorian State Trauma Registry. Patient characteristics and rates of complications were compared between patients with 1. isolated rib fractures, and 2. complex chest injury. Multivariable logistic regression was used to identify predictors of respiratory failure, and pneumonia.

RESULTS

The study population comprised 5401 patients aged 65 years or more, with isolated chest injuries. Two-thirds (65%) of all patients had isolated rib fractures, and 58% of patients (n = 3156) were directly admitted to a non-major trauma centre. Complications were uncommon, with 5.45% of all patients (n = 295) having pneumonia and 3.2% (n = 175) having respiratory failure. Factors associated with increased risk of pneumonia and respiratory failure included advancing age, smoking, chronic obstructive pulmonary disease, congestive heart failure, and more severe and complex chest injury. The adjusted odds of complications were lowest amongst patients not classified as major trauma and receiving definitive treatment in non-MTS.

DISCUSSION

Our findings suggest that rates of complications in older patients with isolated chest trauma in this study were low, and that there is a large group of patients with isolated, uncomplicated rib fractures, who may not need to be treated in a major trauma centre. Further work should be undertaken to appropriately risk stratify and manage older adults with isolated chest trauma.

Risk factors that predict mortality in patients with blunt chest wall trauma: an updated systematic review and meta-analysis

BACKGROUND

Over the last 10 years, research has highlighted emerging potential risk factors for poor outcomes following blunt chest wall trauma. The aim was to update a previous systematic review and meta-analysis of the risk factors for mortality in blunt chest wall trauma patients.

METHODS

A systematic review of English and non-English articles using MEDLINE, Embase and Cochrane Library from January 2010 to March 2022 was completed. Broad search terms and inclusion criteria were used. All observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. Where sufficient data were available, ORs with 95% CIs were calculated using a Mantel-Haenszel method. Heterogeneity was assessed using the I² statistic.

RESULTS

73 studies were identified which were of variable quality (including 29 from original review). Identified risk factors for mortality following blunt chest wall trauma were: age 65 years or more (OR: 2.11; 95% CI 1.85 to 2.41), three or more rib fractures (OR: 1.96; 95% CI 1.69 to 2.26) and presence of pre-existing disease (OR: 2.86; 95% CI 1.34 to 6.09). Other new risk factors identified were: increasing Injury Severity Score, need for mechanical ventilation, extremes of body mass index and smoking status. Meta-analysis was not possible for these variables due to insufficient studies and high levels of heterogeneity.

CONCLUSIONS

The results of this updated review suggest that despite a change in demographics of trauma patients and subsequent emerging evidence over the last 10 years, the main risk factors for mortality in patients sustaining blunt chest wall trauma remained largely unchanged. A number of new risk factors however have been reported that need consideration when updating current risk prediction models used in the ED.

PROSPERO REGISTRATION NUMBER

CRD42021242063. Date registered: 29 March 2021. https://www.crd.york.ac.uk/PROSPERO/%23recordDetails.

The Surgical Timing and Complications of Rib Fixation for Rib Fractures in Geriatric Patients

Rib fractures (RF) are a common injury that cause significant morbidity and mortality, especially in geriatric patients. RF fixation could shorten hospital stay and improve survival. The aim of this retrospective study was to evaluate the clinical impact and proper surgical timing of RF fixation in geriatric patients. We reviewed all the medical data of patients older than 16 years old with RF from the trauma registry database between January 2017 and December 2019 in Chang Gung Memorial Hospital. A total of 1078 patients with RF were enrolled, and 87 patients received RF fixation. The geriatric patients had a higher chest abbreviated injury scale than the non-geriatric group (p = 0.037). Univariate analysis showed that the RF fixation complication rates were significantly related to the injury severity scores (Odds ratio 1.10, 95% CI 1.03–1.20, p = 0.009) but not associated with age (OR 0.99, 95% CI 0.25–3.33, p = 0.988) or the surgical timing (OR 2.94, 95% CI 0.77–12.68, p = 0.122). Multivariate analysis proved that only bilateral RF was an independent risk factor of complications (OR 6.60, 95% CI 1.38–35.54, p = 0.02). RF fixation can be postponed for geriatric patients after they are stabilized and other lethal traumatic injuries are managed as a priority.

Surgical stabilization of serial rib fractures is advantageous in patients with relevant traumatic brain injury

Purpose

To evaluate the clinical benefit of surgical stabilization of rib fractures (SSRF) in polytrauma patients with serial rib fractures.

Methods

Retrospective single-center cohort analysis in trauma patients. Serial rib fracture was defined as three consecutive ribs confirmed by chest computer tomography (CT). Study cohort includes 243 patients that were treated conservatively and 34 patients that underwent SSRF. Demographic patient data, trauma mechanism, injury pattern, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and hospital course were analyzed. Two matched pair analyses stratified for ISS (32 pairs) and GCS (25 pairs) were performed.

Results

The majority of patients was male (74%) and aged 55 ± 20 years. Serial rib fractures were associated with more than 6 broken ribs in average (6.3 ± 3.7). Other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). Visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). Average ISS was 22 ± 7.3. Overall hospital stay was 15.9 and ICU stay 7.4 days. In hospital, mortality was 13%. SSRF did not improve hospital course or postoperative complications in the complete study cohort. However, patients with a significantly reduced GCS (7.6 ± 5.3 vs 11.22 ± 4.8; p = 0.006) benefitted from SSRF. Matched pair analysis stratified for GCS showed shorter ICU stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003).

Conclusion

Patients with serial rib fractures and simultaneous moderate or severe traumatic brain injury benefit from surgical stabilization of rib fractures.

Is surgical rib fixation in patients aged more than 65 years old associated with worse outcomes compared to younger patients? A retrospective single-center study

BACKGROUND

There is no robust data regarding rib fixation in elderly patients. The aim of this study is to compare the postoperative outcomes of patients aged less and more than 65 years old.

METHODS

Patients operated from January 2012 to December 2018 were retrospectively analyzed. The following data were collected: age, sex, comorbidities, smoking habit, Injury Severity Score (ISS), number of fractured ribs, indication for surgery, associated injuries, time from trauma to surgery, number of fixed ribs, intrathoracic injuries, duration of intubation, ICU stay, postoperative cardiopulmonary complications, blood transfusion, overall and 30-day mortality, length of stay.

RESULTS

There was no difference regarding the ISS (p = 0.09), the number of rib fractures (p = 0.291), the indication for surgery, the number of fixed ribs (p = 0.819), the ICU stay (p = 0.096), the postoperative intubation duration (p = 0.059), the cardiopulmonary complications (p = 0.273) and perioperative blood transfusions (p = 0.34). Elderly patients presented more postoperative cognitive complications (p < 0.001). There was no difference in terms of overall mortality (p = 0.06) and 30-day mortality (p = 0.69). Elderly patients stayed longer in the hospital (p < 0.001).

CONCLUSIONS

The outcomes of rib fixation in the elderly patients are comparable to younger patients. However, elderly patients experience more frequently postoperative cognitive complications and their hospitalizations are longer.

Rib Fracture Frailty Index: A risk stratification tool for geriatric patients with multiple rib fractures

BACKGROUND

Rib fractures are consequential injuries for geriatric patients (age, ≥65 years). Although age and injury patterns drive many rib fracture management decisions, the impact of frailty-which baseline conditions affect rib fracture-specific outcomes-remains unclear for geriatric patients. We aimed to develop and validate the Rib Fracture Frailty (RFF) Index, a practical risk stratification tool specific for geriatric patients with rib fractures. We hypothesized that a compact list of frailty markers can accurately risk stratify clinical outcomes after rib fractures.

METHODS

We queried nationwide US admission encounters of geriatric patients admitted with multiple rib fractures from 2016 to 2017. Partitioning around medoids clustering identified a development subcohort with previously validated frailty characteristics. Ridge regression with penalty for multicollinearity aggregated baseline conditions most prevalent in this frail subcohort into RFF scores. Regression models with adjustment for injury severity, sex, and age assessed associations between frailty risk categories (low, medium, and high) and inpatient outcomes among validation cohorts (odds ratio [95% confidence interval]). We report results according to Transparent Reporting of Multivariable Prediction Model for Individual Prognosis guidelines.

RESULTS

Development cohort (n = 55,540) cluster analysis delineated 13 baseline conditions constituting the RFF Index. Among external validation cohort (n = 77,710), increasing frailty risk (low [reference group], moderate, high) was associated with stepwise worsening adjusted odds of mortality (1.5 [1.2-1.7], 3.5 [3.0-4.0]), intubation (2.4 [1.5-3.9], 4.7 [3.1-7.5]), hospitalization ≥5 days (1.4 [1.3-1.5], 1.8 [1.7-2.0]), and disposition to home (0.6 [0.5-0.6], 0.4 [0.3-0.4]). Locally weighted scatterplot smoothing showed correlations between increasing RFF scores and worse outcomes.

CONCLUSION

The RFF Index is a practical frailty risk stratification tool for geriatric patients with multiple rib fractures. The mobile app we developed may facilitate rapid implementation and further validation of RFF Index at the bedside.

LEVEL OF EVIDENCE

Prognostic study, level III.

Geriatric All-Terrain Vehicle Trauma: An Unhelmeted and Severely Injured Population

BACKGROUND

All-terrain vehicle (ATV) use is widespread, however, little is known about injury patterns and outcomes in geriatric patients. We hypothesized that geriatric patients would have distinct and more severe injuries than non-geriatric adults after ATV trauma.

METHODS

A retrospective cohort study was performed using the National Trauma Databank comparing non-geriatric (18-64) and geriatric adults (≥65) presenting after ATV trauma at Level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, and outcomes data were collected, including injury severity score (ISS), abbreviated injury scale (AIS) score, discharge disposition, and mortality. We performed univariate statistical tests between cohorts and multiple logistic regression models to assess for risk factors associated with severe injury (ISS>15) and mortality.

RESULTS

23,568 ATV trauma patients were identified, of whom 1,954 (8.3%) were geriatric. Geriatric patients had higher rates of severe injury(29.2 v 22.5%,p<0.0001), and thoracic (55.2 v 37.8%,p<0.0001) and spine (31.5 v 26.0%,p<0.0001) injuries, but lower rates of abdominal injuries (14.6 v 17.9%,p<0.001) as compared to non-geriatric adults. Geriatric patients had overall lower head injury rates (39.2 v 42.1%,p=0.01), but more severe head injuries (AIS>3) (36.2 vs 30.2%,p<0.001). Helmet use was significantly lower in geriatric patients (12.0 v 22.8%,p<0.0001). On multivariate analysis age increased the odds for both severe injury (OR 1.50, 95% CI 1.31-1.72, p<0.0001) and mortality (OR 5.07, 95% CI 3.42-7.50, p<0.0001).

CONCLUSIONS

While severe injury and mortality after ATV trauma occurred in all adults, geriatric adults suffered distinct injury patterns and were at greater risk for severe injury and mortality.

A retrospective study comparing analgesic efficacy of ultrasound-guided serratus anterior plane block versus intravenous fentanyl infusion in patients with multiple rib fractures

Background and Aims

Inadequately managed pain due to multiple rib fractures (MRFs) can lead to atelectasis, pneumonia, prolonged ICU stay thereby leads to significant morbidity, morbidity and cost of treatment. Opioids, non-steroidal anti-inflammatory drugs and regional anaesthesia techniques like thoracic epidural or paravertebral blocks, intercostal nerve blocks are used to manage pain. Serratus anterior plane block (SAPB) is an ultrasound (US) guided interfascial plane block which has been used in managing pain due to MRFs. In this retrospective study, we compared analgesic efficacy and 24 hr fentanyl consumption in patients with MRFs who were managed with continuous SAPB versus patients who were managed with fentanyl infusion alone.

Material and Methods

After Institutional Ethics Committee approval, we retrospectively collected data of 72 patients (38 in SAPB group and 34 in fentanyl group). Demographic data, VAS scores and 24 hrs fentanyl consumption was analysed in both groups.

Results

There were statistically significant lower pain scores in patients of SAPB group when compared to that of fentanyl group (p=0.001) and in 24 hrs fentanyl consumption in patients who received continuous SAPB versus that in fentanyl group(p=0.001). No complications were observed in patients who received US guided SAPB.

Conclusion

US guided SAPB is an opioid sparing, effective interfascial plane block which is safe and should be considered early in all patients who sustain MRFs. Continuous SAPB by placing a catheter can provide pain relief for longer duration, facilitate early mobilization, physiotherapy and early ICU discharge.

What is the optimal timing to perform surgical stabilization of rib fractures?

The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.

Mechanism of injury, injury patterns and associated injuries in patients operated for chest wall trauma

PURPOSE

Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms of injury (MOI), injury patterns, and associated injuries in patients who undergo surgery for chest wall trauma.

METHODS

This was a retrospective study of trauma patients with multiple rib fractures and unstable thoracic cage injuries who were managed surgically at Sahlgrenska University Hospital during the period September 2010-September 2017. The MOI, injury severity score (ISS), new injury severity score (NISS), thoracic and associated injuries were recorded. Patients were categorized according to age (years): groups I (15‒44), II (45‒64) and III ( > 64). Unstable thoracic cage injuries were classified as sternal, anterior, lateral and posterior flail chest.

RESULTS

Two hundred and eleven trauma patients with a mean age (years) of 58.2 ± 15.6, mean ISS 23.6 ± 11.0, and mean NISS 34.1 ± 10.6 were included in the study. Traffic accidents were the most common MOI in Group I (62%) and falls in Group III (59%). The most common flail segments were lateral and posterior. Sternal and anterior flail segments were more common with bilateral injuries and traffic accidents, particularly frontal collisions. Injuries in at least three body regions were also more associated with traffic accidents. Diaphragmatic injury was seen in 18% of patients who underwent thoracotomy.

CONCLUSIONS

The MOI associated with multiple rib fractures differs according to the age of the patient and is associated with different chest wall injury patterns and extra-thoracic injuries.

Outcomes of rib fractures in the geriatric population: A 5-year retrospective, single-institution, Australian study

BACKGROUND

Surgical rib fixation in the general population can decrease morbidity, including length of stay and ventilator days. Elderly rib fractures convey high rates of morbidity and mortality, and it is unclear whether this population benefits from operative management.

METHODS

A single-centre, retrospective study at a Level 1 Australasian trauma centre was conducted. Registry-identified patients aged ≥70 years, admitted to hospital with blunt trauma-induced rib fractures, were included. Outcome measures included demographics, pre-morbid function, acute length of stay, intensive care unit admission, injury characteristics, management and complications.

RESULTS

A total of 920 presentations were identified, with 295 meeting the inclusion criteria. Falls accounted for majority (n = 148/295, 50.2%), with a median Injury Severity Score of 10 (inter-quartile range [IQR] 10-14). Severe chest trauma occurred overall in 80% (n = 243/294) and all operative patients (n = 15/15). Conservative management was used in 95% (n = 280/295). Patient-controlled analgesia was common (n = 177/295, 60.0%) and regional techniques increased in the surgical approach (n = 12/15, 80.0%) compared with conservative approach (n = 71/280, 25.4%). Despite longer acute length of stay (12 days, IQR 9-15), operative management resulted in similar complications (26.7% vs. 30.4%) and no deaths. Operative intervention was significantly associated with increased number of fractures (p < 0.001), flail segment (p = 0.001) and higher chest Abbreviated Injury Score (p < 0.001); however, it was not significantly associated with age (p = 0.90), comorbidities (0.91) or anticoagulation (p = 0.51).

CONCLUSION

Surgical management of rib fractures in the elderly was performed without increased complications within this centre's multimodal approach. Standard indications for rib fixation may be applicable in the elderly population, whilst comorbidities, age and anticoagulation use alone may not be adequate reasons to withhold surgical rib fixation.

Trends in incidence rate, health care use, and costs due to rib fractures in the Netherlands

PURPOSE

This study aimed to examine population-based trends in the incidence rate, health care consumption, and work absence with associated costs in patients with rib fractures.

METHODS

A retrospective nationwide epidemiologic study was performed with data from patients with one or more rib fractures presented or admitted to a hospital in the Netherlands between January 1, 2015 and December 31, 2018 and have been registered in the Dutch Injury Surveillance System (DISS) or the Hospital Discharge Registry (HDR). Incidence rates were calculated using data from Statistics Netherlands. The associated direct health care costs, costs for lost productivity, and years lived with disability (YLD) were calculated using data from a questionnaire.

RESULTS

In the 4-year study period, a total of 32,124 patients were registered of which 19,885 (61.9%) required hospitalization with a mean duration of 7.7 days. The incidence rate for the total cohort was 47.1 per 100,000 person years and increased with age. The mean associated direct health care costs were €6785 per patient and showed a sharp increase after the age of 75 years. The mean duration of work absence was 44.2 days with associated mean indirect costs for lost productivity of €22,886 per patient. The mean YLD was 0.35 years and decreased with age.

CONCLUSION

Rib fractures are common and associated with lengthy HLOS and work absenteeism as well as high direct and indirect costs which appear to be similar between patients with one or multiple rib fractures and mostly affected by admitted patients and age.

Midterm outcome after posterior stabilization of unstable Midthoracic spine fractures in the elderly

Background

The evidence for the treatment of midthoracic fractures in elderly patients is weak. The aim of this study was to evaluate midterm results after posterior stabilization of unstable midthoracic fractures in the elderly.

Methods

Retrospectively, all patients aged ≥65 suffering from an acute unstable midthoracic fracture treated with posterior stabilization were included. Trauma mechanism, ASA score, concomitant injuries, ODI score and radiographic loss of reduction were evaluated. Posterior stabilization strategy was divided into short-segmental stabilization and long-segmental stabilization.

Results

Fifty-nine patients (76.9 ± 6.3 years; 51% female) were included. The fracture was caused by a low-energy trauma mechanism in 22 patients (35.6%). Twenty-one patients died during the follow-up period (35.6%). Remaining patients (n = 38) were followed up after a mean of 60 months. Patients who died were significantly older (p = 0.01) and had significantly higher ASA scores (p = 0.02). Adjacent thoracic cage fractures had no effect on mortality or outcome scores. A total of 12 sequential vertebral fractures occurred (35.3%). The mean ODI at the latest follow up was 31.3 ± 24.7, the mean regional sagittal loss of reduction was 5.1° (± 4.0). Patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral fractures during follow-up (p = 0.03).

Conclusion

Unstable fractures of the midthoracic spine are associated with high rates of thoracic cage injuries. The mortality rate was rather high. The majority of the survivors had minimal to moderate disabilities. Thereby, patients treated with long segmental stabilization had a significantly lower rate of sequential vertebral body fractures during follow-up.

Geriatric Snowmobile Trauma: Longer Courses After Similar Injuries

BACKGROUND

Snowmobiling is a popular activity that leads to geriatric trauma admissions; however, this unique trauma population is not well characterized. We aimed to compare the injury burden and outcomes for geriatric versus nongeriatric adults injured riding snowmobiles.

MATERIALS AND METHODS

A retrospective cohort study was performed using the National Trauma Databank comparing nongeriatric (18-64) and geriatric adults (≥65) presenting after snowmobile-related trauma at level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, injury, and outcome data were collected and compared. A multivariate logistic regression model assessed for risk factors associated with severe injury (Injury Severity Score >15). Analysis was also performed using chi square, analysis of variance, and Kruskal-Wallis testing.

RESULTS

A total of 2471 adult patients with snowmobile trauma were identified; 122 (4.9%) were geriatric. Rates of severe injury (Injury Severity Score >15) were similar between groups, 27.5% in geriatric patients and 22.5% in nongeriatric adults (P = 0.2). Geriatric patients experienced higher rates of lower extremity injury (50.4 versus 40.3%, P = 0.03), neck injury (4.1 versus 1.4%, P = 0.02), and severe spine injury (20.6 versus 7.0%, P = 0.004). Geriatric patients had longer hospitalizations (5 versus 3 d, P < 0.0001), rates of discharge to a facility (36.8% versus 12%, P < 0.0001), and higher mortality (4.1 versus 0.6%, P < 0.0001). Geriatric age did not independently increase the risk for severe injury.

CONCLUSIONS

Geriatric age was not a significant predictor of severe injury after snowmobile trauma; however, geriatric patients suffered unique injuries, had longer hospitalizations, had higher rates of discharge to a facility, and had higher mortality. Tailored geriatric care may improve outcomes in this unique sport-related trauma population.

The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients

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.

Rib fractures after blunt thoracic trauma in patients with normal versus diminished bone mineral density: a retrospective cohort study

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.

Patterns of serial rib fractures after blunt chest trauma: An analysis of 380 cases

Rib fractures represent the most common bone fracture, occurring in 10-20% of all blunt trauma patients and leading to concomitant injuries of the inner organs in severe cases. The purpose of this study was to identify specific serial rib fracture patterns after blunt chest trauma. 380 serial rib fracture cases were investigated. Fractures were assigned to five different locations within the transverse plane. Rib level, fracture type, and dislocation grades were recorded and related to the cause of accident. In total, 3735 rib fractures were identified (9.8 per patient). 54% of the rib fractures were detected on the left thorax. Rib fracture distribution exhibited a hotspot at rib levels 4 to 7 in the lateral and posterolateral segments. On average, most rib fractures occurred in crush/burying injuries (15.8, n = 13) and pedestrian accidents (12.8, n = 13), least in car/truck accidents (8.9, n = 75). In the car/truck accident group, 47% of all rib fractures were in the lateral segment, in case of frontal collision (n = 24) even 60%. Fall injuries (n = 141) entailed mostly posterolateral rib fractures (35%). In case of falls >3 m (n = 45), 48% more rib fractures were detected on the left thorax. In cardiopulmonary resuscitation related serial rib fractures (n = 33), 70% of all rib fractures were located anterolaterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all rib fractures were dislocated (15% ≥ rib width). Serial rib fractures showed distinct fracture patterns depending on the cause of accident. When developing a serial rib fracture classification system, data regarding patterns, fracture types, dislocation grades, and associated fractures should be included.

Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial

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.

The importance of increased awareness for delirium in elderly patients with rib fractures after blunt chest wall trauma: a retrospective cohort study on risk factors and outcomes

BACKGROUND

Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma.

METHODS

A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months.

RESULTS

Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance.

CONCLUSION

Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.