Flail Chest: Less Deadly than Originally Thought

Surgical rib fixation in patients with cardiopulmonary disease improves outcomes

INTRODUCTION

The role of rib fixation (RF) in flail chest is debated, and guidelines conditionally recommend RF in highly selected patients. Patients with cardiopulmonary disease (CPD) have traditionally not been deemed surgical candidates. We hypothesize that RF would benefit even high-risk patients with CPD.

METHODS

Adult patients with isolated flail chest and CPD were identified from the Trauma Quality Improvement Program database (2016-2018). Hospital transfers, patients dead within 72 h, penetrating mechanism, concomitant thoracic aortic injury or cancer were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were in-hospital complications, ventilator days, need for tracheostomy, and length of stay. RF patients were propensity score matched (1:1) to non-operative management (NOM) patients. Multivariate regression identified independent risk factors for outcomes.

RESULTS

In this 3 year period, 4614 patients were admitted with flail chest and history of CPD. After exclusions and propensity matching, 544 (12%) underwent analysis (RF n = 272, NOM n = 272). RF patients had a lower mortality compared to NOM patients (1.8% vs 5.5%, p = 0.023) but more likely to develop venous thromboembolic events (5.1% vs 1.85%, p = 0.036), prolonged ventilation (28.4% vs 15.1%, p < 0.001), and tracheostomy (15.4% vs 6.6%, p = 0.001). Multivariate analysis showed RF was independently associated with decreased mortality (OR 0.165, 95% CI 0.037-0.735, p = 0.018) while age > 85 years (OR 145.115, 95% CI 9.721-2166.262) and ventilator-associated pneumonia (OR 8.283, 95% CI 1.375-49.888) were associated with increased mortality.

CONCLUSIONS

RF shows a survival benefit even in high-risk patients with CPD. Patient selection should be individualized but RF should not be excluded based solely on pre-existing conditions.

The Effects of Pulmonary Risk Factors and Combination Thoracic Osseous Fractures on Mortality and Outcomes of Surgical Stabilization of Rib Fractures

BACKGROUND

Rib fixation for traumatic rib fractures is advocated to decrease morbidity and mortality in select patient populations. We intended to investigate the effect of combination osseous thoracic injuries on mortality with the hypothesis that combination injuries will worsen overall mortality and that SSRF will improve outcomes in combination injuries and in high-risk patients.

METHODS

Patients with rib fractures were identified from the Trauma Quality Improvement Project registry from 2019. Patients were then divided into rib fracture(s) alone or in combination with sternal, thoracic vertebra, or scapula fracture. Patients were also categorized into those with COPD and smokers. Patients with AIS >3 outside of thorax were excluded. Patients were subcategorized into those who had rib fixation verse nonoperative management for all subgroups. Analysis was performed to evaluate the efficacy of rib fixation.

RESULTS

A total of 111,066 patients were included for analysis. The overall mortality was 1.4%. Patients with COPD had over double the mortality risk, with an overall mortality of 3.4%. Combination injuries did not appear to increase mortality. SSRF did not decrease mortality; however, the number of patients in this group was too small to complete statistical analysis. The overall complication rate was 0.43%. There was a trend towards an increase in extrapulmonary complications in the group that underwent surgical fixation.

DISCUSSION

Mortality from rib fractures with concomitant osseous thoracic fracture appears to be low. However, mortality is increased in patients with COPD regardless of rib fracture pattern. The number of patients who underwent SSRF was too small to make a statistical comparison.

Favourable outcome in survivors of CPR-related chest wall injuries

BACKGROUND

There is a lack of studies focusing on long-term chest function after chest wall injury due to cardiopulmonary resuscitation (CPR). The purpose of this cross-sectional study was to investigate long-term pain, lung function, physical function, and fracture healing after manual or mechanical CPR and in patients with and without flail chest.

METHODS

Patients experiencing out-of-hospital cardiac arrest between 2013 and 2020 and transported to Sahlgrenska University Hospital were identified. Survivors who had undergone a computed tomography (CT) showing chest wall injury were contacted. Thirty-five patients answered a questionnaire regarding pain, physical function, and quality of life and 25 also attended a clinical examination to measure the respiratory and physical functions 3.9 (SD 1.7, min 2-max 8) years after the CPR. In addition, 22 patients underwent an additional CT scan to evaluate fracture healing.

RESULTS

The initial CT showed bilateral rib fractures in all but one patient and sternum fracture in 69 %. At the time of the follow-up none of the patients had persistent pain, however, two patients were experiencing local discomfort in the chest wall. Lung function and thoracic expansion were significantly lower compared to reference values (FVC 14 %, FEV1 18 %, PEF 10 % and thoracic expansion 63 %) (p < 0.05). Three of the patients had remaining unhealed injuries. Patients who had received mechanical CPR in additional to manual CPR had a lower peak expiratory flow (80 vs 98 % of predicted values) (p=0.030) =0.030) and those having flail chest had less range of motion in the thoracic spine (84 vs 127 % of predicted) (p = 0.019) otherwise the results were similar between the groups.

CONCLUSION

None of the survivors had long-term pain after CPR-related chest wall injuries. Despite decreased lower lung function and thoracic expansion, most patients had no limitations in physical mobility. Only minor differences were seen after manual vs. mechanical CPR or with and without flail chest.

Surgical stabilization of rib fractures for flail chest: Analysis of center-based variability in practice and outcomes

BACKGROUND

Given the lack of high-quality data on patient selection for surgical stabilization of rib fractures (SSRF), significant variability in practice likely exists across trauma centers. We aimed to determine whether centers with a more liberal approach to SSRF had improved outcomes.

METHODS

We performed a retrospective cohort study of adult patients with flail chest admitted to Level I or II trauma centers participating in the American College of Surgeons' Trauma Quality Improvement Program. The primary outcome was hospital mortality; secondary outcomes included discharge status, tracheostomy, duration of mechanical ventilation, and hospital length of stay. Logistic regression was performed to calculate center-level observed/expected rates of SSRF and centers were grouped into quintiles from "most liberal" to "most restrictive." Multivariable regression was used to determine the association between these quintiles and outcomes. We also used an instrumental variable analysis to evaluate the association between SSRF and mortality at the patient level.

RESULTS

Among 23,619 patients with flail chest across 354 centers, 22% underwent SSRF. Center rates of fixation ranged from 0% to 88%. Higher rates of SSRF were not associated with lower mortality overall (highest vs. lowest quintile: odds ratio, 0.86; 95% confidence interval, 0.63-1.17). However, centers with a more liberal approach to SSRF had lower rates of independent status at discharge, higher tracheostomy rates, longer duration of mechanical ventilation, and longer hospital and ICU length of stay. The patient level analysis demonstrated that SSRF as was associated with a 25% lower risk of death.

CONCLUSION

Overall, centers with a liberal approach to SSRF do not show improved outcomes among patients with a flail chest, but have higher resource utilization. Results at the patient level suggest that there is a population likely to benefit but these patients remain to be identified through further research.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Early risk factors for prolonged mechanical ventilation in patients with severe blunt thoracic trauma: A retrospective cohort study

BACKGROUND

A significant proportion of patients with severe chest trauma require mechanical ventilation (MV). Early prediction of the duration of MV may influence clinical decisions. We aimed to determine early risk factors for prolonged MV among adults suffering from severe blunt thoracic trauma.

METHODS

This retrospective, single-center, cohort study included all patients admitted between January 2014 and December 2020 due to severe blunt chest trauma. The primary outcome was prolonged MV, defined as invasive MV lasting more than 14 days. Multivariable logistic regression was performed to identify independent risk factors for prolonged MV.

RESULTS

The final analysis included 378 patients. The median duration of MV was 9.7 (IQR 3.0-18.0) days. 221 (58.5 %) patients required MV for more than 7 days and 143 (37.8 %) for more than 14 days. Male gender (aOR 3.01, 95 % CI 1.63-5.58, p < 0.001), age (aOR 1.40, 95 % CI 1.21-1.63, p < 0.001, for each category above 30 years), presence of severe head trauma (aOR 3.77, 95 % CI 2.23-6.38, p < 0.001), and transfusion of >5 blood units on admission (aOR 2.85, 95 % CI 1.62-5.02, p < 0.001) were independently associated with prolonged MV. The number of fractured ribs and the extent of lung contusions were associated with MV for more than 7 days, but not for 14 days. In the subgroup of 134 patients without concomitant head trauma, age (aOR 1.63, 95 % CI 1.18-2.27, p = 0.004, for each category above 30 years), respiratory comorbidities (aOR 9.70, 95 % CI 1.49-63.01, p = 0.017), worse p/f ratio during the first 24 h (aOR 1.55, 95 % CI 1.15-2.09, p = 0.004), and transfusion of >5 blood units on admission (aOR 5.71 95 % CI 1.84-17.68, p = 0.003) were independently associated with MV for more than 14 days.

CONCLUSIONS

Several predictors have been identified as independently associated with prolonged MV. Patients who meet these criteria are at high risk for prolonged MV and should be considered for interventions that could potentially shorten MV duration and reduce associated complications. Hemodynamically stable, healthy young patients suffering from severe thoracic trauma but no head injury, including those with extensive lung contusions and rib fractures, have a low risk of prolonged MV.

Injury pattern and clinical outcome in patients with and without chest wall injury after cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI.

METHODS

This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied.

RESULTS

Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0-43] vs. 3 [0-22]; p = 0.430), ICU-LOS (3 [0-48] vs. 3 [0-24]; p = 0.427), and H-LOS (5.5 [0-85] vs. 9.0 [1-53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007).

CONCLUSION

Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

A Prospective Observational Study on the Outcome Assessment of Conservative Management Versus Intercostal Drainage (ICD) in Blunt Chest Injury Patients With ≤3 Rib Fractures in a North Indian Tertiary Care Center

Introduction Trauma is the third most common cause of death in all age groups. One out of four trauma patients die due to thoracic injury or its complications. Seventy percent of thoracic traumas are due to blunt injury. This indicates the importance of chest trauma among all traumas. Quick and precise assessment bears paramount importance in deciding life-saving and definitive management. Often, the initial management in blunt injury patients is based on subjective assessment by the attending clinician. A scoring system that provides early identification of the patients at the greatest risk for respiratory failure and more likely to require mechanical ventilation and require prolonged care, as well as those with a higher mortality risk, may allow the early institution of intervention to improve outcomes. Thoracic Trauma Severity Score (TTSS) poses to be a precise tool in directing the management modality to be employed. Methodology This was an observational study including 112 patients of age >12 years, with blunt chest injury, sustaining ≤3 rib fractures, and with a stable chest wall. The patients with penetrating injury, those with blunt chest injury having flail segment, patients in the pediatric age group (<12 years), or polytrauma patients were excluded from our study. Of the 112 patients, 56 had been managed by intercostal drainage (ICD), and the rest (56) had been managed conservatively. Result Road traffic accidents (RTA) were the most common mode of injury in both groups. The percentage of the patients with one, two, and three rib fractures was 57.14%, 32.14%, and 10.71%, respectively, in the ICD group and 85.71%, 7.14%, and 7.14%, respectively, in the conservative management group (p = 0.124). The mean TTSS score was significantly more in the ICD group as compared to the conservative management group in the single rib fracture patients (p = 0.001*), as well as all patients of any number of rib fractures (p < 0.01*) (significance was defined as a value of p less than 0.05 {indicated by an asterisk}). The mean hospital stay was significantly lower in the conservative group as compared to the ICD group (p < 0.01*). The mean SF-36 (outcome) was significantly more in the conservative management group as compared to the ICD group (p = 0.020*). The mean cost of treatment was significantly more in the ICD group as compared to the conservative management group (p < 0.001*). Conclusion In our study, a TTSS (as measured by the primary care surgeon) of >7, across any number of rib fractures, was preferably predictive of management by ICD, while a <7 value was favorable for conservative management. TTSS can be used as an important tool to predict the management modality in blunt chest injury patients with ≤3 rib fractures.

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.

Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review

BACKGROUND

Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days).

METHODS

Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0.

RESULTS

For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia.

CONCLUSION

In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Respiratory Function Tolerance of Rats with Vaying Degrees of Thoracic Volume Reduction

OBJECTIVE

To compare the effects of respiratory function on different degrees of reduced thoracic volume and evaluate the tolerance of rats with reduced thoracic volume, and to assess the feasibility of thoracic volume as a measure of the severity of rib fractures.

METHODS

A total of 24 10-week-old female Sprague-Dawley (SD) rats were randomly divided into four groups (n = 6 in each group) according to the displacement degree of bilateral rib fractures (2, 4, 6, and 8 mm). The respiratory function of the rats（Tidal volume, Inspiration time, Expiration time, Breath rate, Minute volume, Peak inspiration flow) measured via whole-body barometric plethysmography before and after operation for 14 consecutive days. Respiratory function parameters of each group were analyzed. Chest CT scans were performed before and 14 days after operation, after that we reconstructed three-dimensional of the thoracic and lung and measured their volumes by computer software. We calculated the percentage of thoracic and lung volume reduction after operation.

RESULTS

At the 14th day after the operation, the decline of thoracic volume rates of in the 2, 4, 6, and 8 mm groups were 5.20%, 9.01%, 16.67%, and 20.74%, respectively. The 8 mm group showed a significant reduction in lung volume. The postoperative tidal volumes were lower in each of the groups than the baseline values before the operation. The tidal volume of the 2 mm group gradually recovered after the operation and returned to a normal level (1.54 ± 0.07 mL) at 14th day after the operation. The tidal volume of the 4, 6, and 8 mm groups recovered gradually after the operation, but did not return to baseline level at the 14th day. In particular, the tidal volume of the 8 mm group was significantly lower than that of the other groups during the 14 days (1.23 ± 0.12 mL, p < 0.05). There were no significant changes in the inspiratory and expiratory times, peak inspiratory and expiratory flows, respiratory rate, and minute ventilation during the 14 days after the operation in each group.

CONCLUSIONS

Displaced rib fractures lead to thoracic collapse and reduced thoracic volume, which can affect tidal volume in rats. The greater the decrease of thoracic volume, the more obvious the decrease of early tidal volume. The thoracic volume can be used as an objective parameter to evaluate the severity of multiple rib fractures. Early operation to restore thoracic volume may improve early respiratory function. Decreased thoracic volume affected respiratory function and can be compensated and recovered in the long term.

Predicting pneumonia during hospitalization in flail chest patients using machine learning approaches

Objective

Pneumonia is a common pulmonary complication of flail chest, causing high morbidity and mortality rates in affected patients. The existing methods for identifying pneumonia have low accuracy, and their use may delay antimicrobial therapy. However, machine learning can be combined with electronic medical record systems to identify information and assist in quick clinical decision-making. Our study aimed to develop a novel machine-learning model to predict pneumonia risk in flail chest patients.

Methods

From January 2011 to December 2021, the electronic medical records of 169 adult patients with flail chest at a tertiary teaching hospital in an urban level I Trauma Centre in Chongqing were retrospectively analysed. Then, the patients were randomly divided into training and test sets at a ratio of 7:3. Using the Fisher score, the best subset of variables was chosen. The performance of the seven models was evaluated by computing the area under the receiver operating characteristic curve (AUC). The output of the XGBoost model was shown using the Shapley Additive exPlanation (SHAP) method.

Results

Of 802 multiple rib fracture patients, 169 flail chest patients were eventually included, and 86 (50.80%) were diagnosed with pneumonia. The XGBoost model performed the best among all seven machine-learning models. The AUC of the XGBoost model was 0.895 (sensitivity: 84.3%; specificity: 80.0%).Pneumonia in flail chest patients was associated with several features: systolic blood pressure, pH value, blood transfusion, and ISS.

Conclusion

Our study demonstrated that the XGBoost model with 32 variables had high reliability in assessing risk indicators of pneumonia in flail chest patients. The SHAP method can identify vital pneumonia risk factors, making the XGBoost model's output clinically meaningful.

Surgical Rib Fixation in Obese Patients with Isolated Flail Chest Improves Outcomes: A Matched Cohort Study

BACKGROUND

Obesity is associated with adverse outcomes after major operations. The role of operative rib fixation (RF) in obese patients with flail chest is not clear. The presence of other associated injuries may complicate the interpretation of outcomes. This study compared outcomes after RF to nonoperative management (NOM) in obese patients with isolated flail chest injury.

METHODS

Adult obese patients (BMI > 29.9) with flail chest were identified from the Trauma Quality Improvement Program (TQIP) database (2016-2018). Hospital transfers, death within 72 h, and extrathoracic injuries were excluded. RF patients were propensity score matched (1:2) to similar NOM patients. Multivariate regression identified independent factors predicting adverse outcomes.

RESULTS

Overall, 367 patients with isolated flail chest who underwent RF were matched with 734 in the NOM group. After matching, the mortality rate was significantly lower in the RF group (1.4% vs. 3.7%; p < 0.05). RF had longer HLOS (15.7 days vs. 12.8 days; p < 0.05) and ICU LOS (10.1 days vs. 8.6 days; p < 0.05), shorter ventilator days (9.2 days vs. 11.5 days; p < 0.05), and a higher rate of venous thromboembolism (7.1% vs. 3.5%, p < 0.05). On multivariate analysis, RF was associated with decreased mortality (OR 0.27; p < 0.05). Early RF (≤ 72 h) was associated with shorter ICU stay and mechanical ventilation.

CONCLUSION

RF for isolated flail chest in obese patients is associated with decreased mortality and fewer ventilator days. When performed early, fixation decreases the need for prolonged ventilator use and ICU stay. A more aggressive VTE prophylaxis should be considered in patients undergoing RF.

Long term outcomes following rib fracture fixation in patients with major chest trauma

BACKGROUND

Severe chest injuries are associated with significant morbidity and mortality. Surgical rib fixation has become a more commonplace procedure to improve chest wall mechanics, pain, and function. The aim of this study was to characterise the epidemiology and long-term functional outcomes of chest trauma patients who underwent rib fixation in a major trauma centre (MTC).

METHODOLOGY

This was a retrospective review (2014-19) of all adult patients with significant chest injury who had rib fixation surgery following blunt trauma to the chest. The primary outcome was functional recovery after hospital discharge, and secondary outcomes included length of intensive care unit (ICU) and hospital stay, maximum organ support, tracheostomy insertion, ventilator days.

RESULTS

60 patients underwent rib fixation. Patients were mainly male (82%) with median age 52 (range 24-83) years, injury severity score (ISS) of 29 (21-38), 10 (4-19) broken ribs, and flail segment in 90% of patients. Forty-six patients (77%) had a good outcome (GOSE grade 6-8). Patients in the poor outcome group (23%; GOSE 1-5) tended to be older [55 (39-83) years vs. 51 (24-78); p = 0.05] and had longer length of hospital stay [42 (19-82) days vs. 24 (7-90); p<0.01]. Injury severity, rate of mechanical ventilation or organ dysfunction did not affect long term outcome. Nineteen patients (32%) were not mechanically ventilated.

CONCLUSIONS

Rib fixation was associated with good long-term outcomes in severely injured patients. Age was the only predictor of long-term outcome. The results suggest that rib fixation be considered in patients with severe chest injuries and may also benefit those who are not mechanically ventilated but are at risk of deterioration.

The incidence, clinical characteristics, and outcome of polytrauma patients with the combination of pulmonary contusion, flail chest and upper thoracic spinal injury

BACKGROUND

Chest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury.

METHODS

Patients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality.

RESULTS

A total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%).

CONCLUSIONS

Lethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic "lethal triad", there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.

An innovative technique of chest wall stabilization and reconstruction in traumatic flail chest: The figure-of-eight suture with polypropylene mesh and musculofascial flap

Surgical stabilization of the flail chest is challenging and has no established guidelines. Chest wall integrity and stability are the main factors that ensure the protection of intrathoracic organs and an adequate respiratory function. Here, we report a novel chest wall reconstruction technique in a 45-year-old man with a traumatic left flail chest and open pneumothorax diagnosed both clinically and radiographically. Rib approximation and chest wall reconstruction was done using intercostal figure-of-eight suture and polypropylene mesh with vascularized musculofascial flap. The patient improved gradually and was discharged after three weeks of total hospital stay. He returned to regular working after a month with no evidence of respiratory distress or paradoxical chest movement. Follow-up visit at one year revealed no lung hernia or paradoxical chest movement. This is a novel, feasible and cost-effective modification of chest wall reconstruction that can be adopted for thoracic wall repair in case of open flail chest, which needs emergency surgical interventions even in resource constraint settings.

surgical rib fixation in isolated flail chest improves survival

BACKGROUND

The presence of severe associated injuries in flail chest complicates the interpretation of outcomes and the role of rib fixation. This study aimed to examine the impact of fixation in isolated flail chest patients.

METHODS

All patients diagnosed with flail chest injuries were queried from the National Trauma Data Bank (2016-2017). Patients who died within 72 hours, transferred from an outside hospital, had associated thoracic aortic injuries or significant extrathoracic injuries were excluded. Patients with rib fixation were propensity score matched 1:3 with similar patients treated nonoperatively and outcomes were evaluated. Multivariate analysis was used to identify independent predictors for mortality and prolonged mechanical ventilation.

RESULTS

Of 287,947 patients with rib fractures, there were 12,110 (4.2%) patients with flail chest. After exclusion, 5,293 patients with isolated blunt flail chest injuries were included in the analysis. Rib fixation was performed in 575 (10.9%) and 4,718 (89.1%) were managed nonoperatively. After matching, the mortality rate was significantly lower in the fixation group (2.0% vs 5.5%, p= 0.001). On multivariate analysis, rib fixation was associated with improved mortality (OR 0.355, p= 0.002). The timing of operation was not a significant independent risk factor for mortality. However, early fixation (≤72 hours) was associated with a significantly lower need for prolonged ventilation (>7 days).

CONCLUSIONS

Operative fixation in patients with isolated flail chest is associated with improved survival and should be considered liberally. The timing of fixation did not affect mortality, but early fixation was associated with a reduced need for prolonged mechanical ventilation.

Multiple rib fractures: does flail chest matter?

BACKGROUND

Recent studies have reported significant morbidity and mortality in patients with multiple rib fractures, even without flail chest. The aim of this study was to compare the clinical outcome and incidence of associated chest injuries between patients with and without flail chest, with three or more rib fractures.

METHODS

This study included patients with blunt trauma with at least three rib fractures, hospitalised during 2010-2019 in the Hillel Yaffe Medical Center in central Israel (level II trauma centre). Patients with and without radiologically defined flail chest were compared with regard to demographics, Injury Severity Score (ISS), GCS, systolic blood pressure (SBP) on admission, radiological evidence of flail chest, associated chest injuries, length of stay in intensive care unit, length of hospitalisation and mortality.

RESULTS

The study included 407 patients, of which 79 (19.4%) had flail chest. Overall, pneumothorax and haemothorax were more common among patients with flail chest (p<0.05). When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest.

CONCLUSION

In patients with three to five rib fractures, pneumothorax is more common among patients with flail chest. Clinical significance of flail chest in patients with more than six rib fractures is questionable and flail chest may not be a reliable marker for severity of chest injury in patients with more than six fractures.

The Treatment of Rib Fractures : A Single-Center Comparison

BACKGROUND

Rib fractures are a major problem characterized by pain, increased length of stay, and respiratory complications. Treatments include fixation, management with opiates, paraspinous local anesthetic pumps, and intercostal nerve blocks. The aim of this study was to evaluate the use of treatment options and compare clinically relevant outcomes.

METHODS

Patients admitted to a Level 1 trauma center with multiple rib fractures between 2015 and 2019 were screened. We included all participants treated with surgical fixation and/or intercostal nerve block or local anesthetic pump. Patients were case-matched 1:2 by Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) Chest and Head, age, and number of rib fractures. Outcomes assessed were hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, pneumonia, and tracheostomy rates.

RESULTS

We identified 25 patients who received rib fixation and intercostal analgesia. Of these, 14 cases were treated with liposomal bupivaicaine nerve block and 11 by paraspinous catheter block. Fifty control cases treated with opiates were identified. All patients survived to discharge. Cases and controls were approximately equivalent in age, ISS, number of fractured ribs, chest AIS, and head AIS. Rib-plated patients had a lower rate of pneumonia (OR 0.2029, 95% CI 0.0242, 0.09718), decreased average ICU LOS (10.62 vs 6.64, P = .018), and decreased average ventilator days (5.44 vs 1.68, P = .003).

DISCUSSION

Findings suggest more aggressive treatment of rib fractures may decrease ICU LOS, ventilator days, and pneumonia in patients with multiple rib fractures. These findings are in line with current literature; however, more research is needed in this area.