Investigation of the relationship of the number, localization, and displacement of rib fractures with intrathoracic structures and abdominal solid organ complications using computed tomography

Physiologic parameters and radiologic findings can predict pulmonary complications and guide management in traumatic rib fractures

BACKGROUND

Traumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures.

METHODS

This is a single-center retrospective review (2015-2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC.

RESULTS

A total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS.

CONCLUSION

VC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study.

Characteristics of rib fracture patients who require chest computed tomography in the emergency department

BACKGROUND

The disadvantages and complications of computed tomography (CT) can be minimized if CT is performed in rib fracture patients with high probability of intra-thoracic and intra-abdominal injuries and CT is omitted in rib fracture patients with low probability of intra-thoracic and intra-abdominal injuries. This study aimed to evaluate the factors that can identify patients with rib fractures with intra-thoracic and intra-abdominal injuries in the emergency department among patients with rib fracture.

METHODS

This retrospective observational study included adult patients (age ≥ 18 years) diagnosed with rib fracture on chest radiography prior to chest CT due to blunt chest trauma in the emergency department who underwent chest CT from January 2016 to February 2021. The primary outcomes were intra-thoracic and intra-abdominal injuries that could be identified on a chest CT. Multivariate logistic regression analysis was performed.

RESULTS

Among the characteristics of rib fractures, the number of rib fractures was greater (5.0 [3.0-7.0] vs. 2.0 [1.0-3.0], p < 0.001), bilateral rib fractures were frequent (56 [20.1%] vs. 12 [9.8%], p = 0.018), and lateral and posterior rib fracture was more frequent (lateral rib fracture: 160 [57.3%] vs. 25 [20.5%], p < 0.001; posterior rib fracture: 129 [46.2%] vs. 21 [17.2%], p < 0.001), and displacement was more frequent (99 [35.5%] vs. 6 [6.6%], p < 0.001) in the group with intra-thoracic and intra-abdominal injuries than in the group with no injury. The number of rib fractures (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.16-1.78; p = 0.001), lateral rib fracture (aOR, 2.80; 95% CI, 1.32-5.95; p = 0.008), and posterior rib fracture (aOR, 3.18; 95% CI, 1.45-6.94; p = 0.004) were independently associated with intra-thoracic and intra-abdominal injuries. The optimal cut-off for the number of rib fractures on the outcome was three. The number of rib fractures ≥ 3 (aOR, 3.01; 95% CI, 1.35-6.71; p = 0.007) was independently associated with intra-thoracic and intra-abdominal injuries.

CONCLUSION

In patients with rib fractures due to blunt trauma, those with lateral or posterior rib fractures, those with ≥ 3 rib fractures, and those requiring O₂ supplementation require chest CT to identify significant intra-thoracic and intra-abdominal injuries in the emergency department.

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.