A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture

Conservative Treatment of Empyema Formation Following Intrathoracic Rib Fixation With Antibiotics and Tissue Plasminogen Activator/Dornase

Rib plating is a recommended intervention for patients with multiple rib fractures or flail chest to improve shortness of breath, significantly reduce pain, and shorten the length of hospital stay. Here, we report a unique and extremely rare finding in a patient with empyema following intrathoracic rib fixation. A 32-year-old male with a history of alcohol use disorder presented to the emergency department trauma bay after a motor vehicle accident. Computed tomography (CT) showed right hemopneumothorax and fourth to ninth rib fractures with displacement. The right fifth and sixth ribs were then plated using a titanium RibFix bridge, implanted intrathoracically along the posterior surface of the ribs. On postoperative day 11, the patient developed an empyema and a CT-guided drainage catheter was placed into the collection. The patient was given a 3-day course of tissue plasminogen activator (tPA) and DNase for the treatment of his empyema. On postoperative day 15, a repeat CT scan demonstrated significant improvement in the empyema with evidence of abscess resolution. Antibiotics were discontinued after a total of 7 days and the patient was discharged on postoperative day 20. This case report contributes information to the management of complications in intrathoracic rib fixation.

Prognostic factors for outcomes following surgical stabilization of rib fractures: A review of the literature

Rib fractures are a common injury following blunt thoracic trauma, often resulting in high levels of morbidity and mortality. With the ageing global population, the incidence of rib fractures is expected to increase, posing a significant burden on healthcare systems worldwide. With advancements in surgical techniques and pioneering research on the topic the use of surgical stabilisation of rib fractures (SSRF) has increased significantly over the past two decades. However, the relationship between certain prognostic factors and patient outcomes following surgery is still contested and there lacks a consensus on definitive indications for the operation. This literature review presents the current research on SSRF outcomes for; patients with flail chest injuries and multiple-non flail rib fractures, optimal timing between injury and operation, and patient age. This article contributes to the ongoing dialogue surrounding chest wall trauma management and may be drawn upon to aid future research and develop clinical practice guidelines.

Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis

BACKGROUND

Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients.

METHODS

Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8).

RESULTS

Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004).

CONCLUSION

In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Rib Fixation for Multiple Rib Fractures: Healthcare Professionals Perceived Barriers and Facilitators to Clinical Implementation

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is associated with improved respiratory symptoms and shorter intensive care admission in patients with flail chest. For multiple rib fractures, the benefit of SSRF remains a topic of debate. This study investigated barriers and facilitators of healthcare professionals to SSRF as treatment for multiple traumatic rib fractures.

METHODS

Dutch healthcare professionals were asked to complete an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators of SSRF. If ≥ 20% of participants responded negatively, the item was considered a barrier, and if ≥ 80% responded positively, the item was considered a facilitator.

RESULTS

Sixty-one healthcare professionals participated; 32 surgeons, 19 non-surgical physicians, and 10 residents. The median experience was 10 years (P₂₅-P₇₅ 4-12). Sixteen barriers and two facilitators for SSRF in multiple rib fractures were identified. Barriers included lack of knowledge, experience, evidence on (cost-)effectiveness, and the implication of more operations and higher medical costs. Facilitators were the assumption that SSRF alleviates respiratory problems and the feeling that surgeons are supported by colleagues for SSRF. Non-surgeons and residents reported more and several different barriers than surgeons (surgeons: 14; non-surgical physicians: 20; residents: 21; p < 0.001).

CONCLUSION

For adequate implementation of SSRF in patients with multiple rib fractures, implementation strategies should address the identified barriers. Especially, improved clinical experience and scientific knowledge of healthcare professionals, and high-level evidence on the (cost-) effectiveness of SSRF potentially increase its use and acceptance.

Comparison of surgical stabilization of rib fractures vs epidural analgesia on in-hospital outcomes

INTRODUCTION

Surgical stabilization of rib fractures (SSRF) improves functional outcomes compared to controls, partly due to reduction in pain. We investigated the impact of early SSRF on pulmonary complications, mortality, and length of stay compared to non-operative analgesia with epidural analgesia (EA).

METHODS

Retrospective cohort study of the Trauma Quality Improvement Program (TQIP) 2017 dataset for adults with rib fractures, excluding those with traumatic brain injury or death within twenty-four hours. Early SSRF and EA occurred within 72 h, and we excluded those who received both or neither intervention. Our primary outcome was a composite of pulmonary complications including acute respiratory distress syndrome (ARDS) or ventilator-associated pneumonia (VAP). Additional outcomes included unplanned endotracheal intubation, in-hospital mortality, and hospital and intensive care unit (ICU) length of stay (LOS) for those surviving to discharge. Multiple logistic and linear regressions were controlled for variables including age, sex, flail chest (FC), injury severity, additional procedures, and medical comorbidities.

RESULTS

We included 1,024 and 1,109 patients undergoing early SSRF and EA, respectively. SSRF patients were more severely injured with higher rates of FC (42.8 vs 13.3%, p<0.001), Injury Severity Score (ISS) > 16 (56.9 vs 36.1%, p<0.001), and Abbreviated Injury Scale (AIS) Thorax > 3 (33.3 vs 12.2%, p<0.001). Overall, 49 (2.3%) of patients developed ARDS or VAP, 111 (5.2%) required unplanned intubation, and 58 (2.7%) expired prior to discharge. On multivariable analysis, SSRF was not associated with the primary composite outcome (OR: 1.65, 95%CI: 0.85-3.21). Early SSRF significantly predicted decreased risk of unplanned intubation (OR:0.59, 95%CI: 0.38-0.92) compared with early EA alone, however, was not a significant predictor of in-hospital mortality (OR: 1.27, 95%CI: 0.68-2.39). SSRF was associated with significantly longer hospital (Exp(β): 1.06, 95%CI: 1.00-1.12, p = 0.047) and ICU LOS (Exp(β): 1.17, 95%CI: 1.08-1.27, p<0.001).

CONCLUSIONS

Aside from unplanned intubation, we observed no statistically significant difference in the adjusted odds of in-hospital pulmonary morbidity or mortality for patients undergoing early SSRF compared with early EA. Chest wall injury patients may benefit from referral to trauma centers where both interventions are available and appropriate surgical candidates may receive timely intervention.

Retrospective study of consecutive rib fracture patients treated by open reduction internal fixation in a single major trauma centre, UK

INTRODUCTION

Rib fractures are a common presentation in both patients presenting with high impact poly-trauma and as a result of low energy falls in the elderly. This injury can lead to various complications including prolonged hospital admission, pneumonia, need for ventilation and in admission to intensive care unit. There is much controversy around the management of this injury in the literature, with favourable outcomes for patients treated non-operatively as well as surgically.

METHODS

We collated a database for all rib fracture fixations between 2014 and 2019 that took place at the major trauma centre in Liverpool. The decision to undergo surgical fixation was after discussion with multidisciplinary team at trauma meeting. Following British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs), these injuries should ideally be operated on within 48 h.

RESULTS

Overall, a total of 220 patients were included in the study (143 male and 77 female). 142 (64%) patients were operated on within 48 h of admission. A total of 101 (45%) patients required admission to ITU. Those in the early surgical fixation group had a statistically significant decrease in their hospital length of stay (12.8 days compared to 15.5 days, p=<0.001). Mean length of ITU stay was shorter in the early surgical group with no statistical significance (p = 0.1). Those patients that required mechanical ventilation in turn stayed in hospital for a longer period compared to those who did not (p=<0.001). There is no statistical difference in survival between the 2 patient groups (p = 0.3).

DISCUSSION

To our knowledge, this is the largest data set published in the rib fracture fixation cohort. Our results agree with previous studies which have demonstrated that those who undergo ORIF tend require fewer days of hospital stay, less ventilatory support and overall have better outcomes in terms of pain when compared to those treated non-operatively. Our study adds that patients who receive treatment within 48-hours as per BOAST guidelines have better outcomes, specifically reducing hospital length of stay by nearly 4 days (p = 0.014).

CONCLUSION

Early surgical fixation of rib fractures leads to significantly favoured outcomes.

Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-Analysis

BACKGROUND

Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse.

METHODS

A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality.

RESULTS

Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation.

CONCLUSIONS

Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.

Management of Advanced Aged Patients with Rib Fractures: Current Evidence and Review of the Literature

Elderly patients (age > 60 years old) represent the majority of the victims of major trauma, and rib fractures account for 10% of all trauma admissions. Due to the growing interest in surgical rib fixation and the lack of evidence on the best treatment available, we aimed to compare the conservative and operative approaches among the elderly population with multiple rib fractures. The systematic review identified seven eligible studies from over 321 papers collected through the database screening process. The mortality rate, considered the primary outcome, was higher in the conservative-treated group than the operatively-treated patients (8.3% vs. 3%). Considering the secondary outcomes investigated, the overall intensive care unit stay and in-hospital length of stay were longer in the operatively-treated patients (6.3 and 13.3 vs. 4.7 and 7.7, respectively). Conversely, the operative treatment showed favorable results regarding the pneumonia complication rate (5.8% vs. 9.6%), while the duration of mechanical ventilation was similar for both treatments. Surgical stabilization of rib fractures in the elderly population appears to be associated with a survival advantage and avoiding pulmonary complications. However, the individual contribution of operative and conservative treatment in reducing morbidity and mortality in the elderly with multiple rib fractures remains unclear.

Long-term pulmonary function, thoracic pain, and quality of life in patients with one or more rib fractures

BACKGROUND

Long-term outcomes after rib fractures and the effect of treatment modality or chest wall injury severity on these outcomes remains uncertain. This retrospective cohort study evaluated the long-term pulmonary function, thoracic pain, and quality of life in patients admitted with rib fractures.

METHODS

Patients admitted with rib fractures between January 1, 2012, and December 1, 2019, were included. Data on long-term outcomes were collected during one follow-up visit. Patients were stratified by chest wall injury severity (one or two rib fractures, ≥3 rib fractures, or a flail chest) and treatment modality (surgical stabilization of rib fractures [SSRF] or nonoperative management). Multivariable analysis was performed to compare outcomes after SSRF with nonoperative treatment in patients with three or more rib fractures.

RESULTS

In total, 300 patients were included. The median follow-up was 39 months (P25-P75, 18-65 months). At follow-up, the corrected forced vital capacity returned to 84.7% (P25-P75, 74.3-93.7) and the forced expiratory volume in 1 second to 86.3% (P25-P75, 75.3-97.0) of the predicted reference values. Quality of life was determined using the Short Form-12 version 2 and EuroQoL-5D-5L. The Short Form-12 version 2 physical and mental component summary were 45 (P25-P75, 38-54) and 53 (P25-P75, 43-60), respectively. The EuroQoL-5D-5L utility score was 0.82 (P25-P75 0.66-0.92) and visual analog scale score 75 (P25-P75 70-85). This indicated a quality of life within normal population ranges. Moderate to severe thoracic pain was reported by 64 (21.3%) patients. Long-term outcomes returned to values within population ranges and were similar across chest wall injury severity and for patients treated with SSRF or nonoperatively.

CONCLUSION

While long-term pulmonary function and quality of life recover to values considered normal, subjective thoracic complaints, such as pain and dyspnea, remain frequently present following rib fractures. No effect of chest wall injury severity or treatment modality on long-term outcomes was demonstrated.

LEVEL OF EVIDENCE

Therapeutic, level III.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021)

Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.

Chest wall stabilization and rib fixation using a nitinol screwless system in selected patients after blunt trauma: long-term results in a single-centre experience

 

OBJECTIVES

First experiences with rib fixation using nitinol, in terms of reliability and morbidity, influence on pain control and quality of life (QOL), in a large series of selected patients after blunt chest trauma.

METHODS

Data of all patients who had undergone rib fixation by the use of nitinol were retrospectively analysed in terms of indications, morbidity and in-hospital mortality. Pain status and health-related QOL were assessed preoperatively, when possible, at discharge and at 1, 3, 6 and 12 months post-surgery using visual analogous scale and short form 12 questionnaires.

RESULTS

From September 2017 to April 2019, 70 patients underwent rib fixation using the nitinol device, of which 47 (67%) had dislocated, painful fractures, 6 (8.5%) had flail chest injuries, 6 (8.5%) were emergencies with haemodynamical instability and 11 (16%) had pseudoarthrosis. Morbidity was 21% without wound infection; in-hospital mortality was 3%. Fracture of the material occurred in 6% of the patients during the first year, but removal of the material was not required. Analysis of the pain score showed a statistically significant decrease in pain for both the whole collective and the group with a series of dislocated and painful fractured ribs (P < 0.001, Tukey contrast on the linear mixed-effects models). Assessment of health-related QOL revealed a significant improvement in the physical score for the mid- and long-term analysis.

CONCLUSIONS

Our results suggest that rib fixation using the nitinol device is reliable, associated with an acceptable morbidity, while significantly decreasing pain and improving health-related QOL.

The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures

BACKGROUND

Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic.

METHODS

A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated.

RESULTS

The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations.

CONCLUSION

Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.

Early Outcomes of Surgical Stabilisation of Traumatic Rib Fractures: Single-Center Review With a Real-World Evidence Perspective

BACKGROUND

Randomized controlled trials have demonstrated that surgical stabilization of rib fractures (SSRF) in selected trauma patients is associated with potential benefits. This study evaluates the real-world outcomes of SSRF since its implementation at Westmead Hospital, Australia. We hypothesize these outcomes to be similar to that reported by best-evidence in the literature.

MATERIALS AND METHODS

A retrospective analysis of data on all consecutive SSRF performed between January 2013 to December 2018 was completed.

RESULTS

Sixty-three patients (54 male; average age 55.9 ± 14.1 y) with median ISS 24 (IQR 17;30) underwent SSRF. Thirty-seven patients were admitted to Intensive Care Unit (ICU), with median ICU length of stay (LOS) 10.0 (5.0-17.0) d. Median hospital LOS was 15.5 (10.0-24.8) d. Fifty-five (87.3%) patients did not have any surgery-specific complications. The highest observed surgical morbidity was wound infection (n = 4, 4.7%). There was one mortality after rib fixation that was not related to surgery. SSRF within 3 d of hospital presentation in ventilated patients with flail chest was associated with significantly reduced median ICU LOS (3.0 [2.0;4.0] versus 10.0 [9.3;13.0] d; P = 0.03). Early (2013-2015) versus late (2015-2018) phase SSRF implementation demonstrated no significant difference in outcome variables.

CONCLUSION

Experience with SSRF demonstrates early outcomes similar to best-evidence in the existing literature. As a quality assurance tool, ongoing evaluation of real-world data is needed to ensure that outcomes remain consistent with benchmarks available from best-evidence.

Race and Insurance Status are Associated With Different Management Strategies After Thoracic Trauma

INTRODUCTION

Health-care disparities based on race and socioeconomic status among trauma patients are well-documented. However, the influence of these factors on the management of rib fractures following thoracic trauma is unknown. The aim of this study is to describe the association of race and insurance status on management and outcomes in patients who sustain rib fractures.

METHODS

The Trauma Quality Improvement Program database was used to identify adult patients who presented with rib fractures between 2015 and 2016. Patient demographics, injury severity, procedures performed, and outcomes were evaluated. Multivariate logistic regression analysis was used to determine the effect of race and insurance status on mortality and the likelihood of rib fixation surgery and epidural analgesia for pain management.

RESULTS

A total of 95,227 patients were identified. Of these, 2923 (3.1%) underwent rib fixation. Compared to White patients, Asians (AOR: 0.57, P = 0.001), Blacks or African-Americans (AA) (AOR: 0.70, P < 0.001), and Hispanics/Latinos (HL) (AOR: 0.78, P < 0.001) were less likely to undergo rib fixation surgery. AA patients (AOR: 0.67, P = 0.004), other non-Whites (ONW) (AOR: 0.61, P = 0.001), and HL (AOR 0.65, P = 0.006) were less likely to receive epidural analgesia. Compared to privately insured patients, mortality was higher in uninsured patients (AOR: 1.72, P < 0.001), Medicare patients (AOR: 1.80, P < 0.001), and patients with other non-private insurance (AOR: 1.23, P < 0.001).

CONCLUSIONS

Non-White race is associated with a decreased likelihood of rib fixation and/or epidural placement, while underinsurance is associated with higher mortality in patients with thoracic trauma. Prospective efforts to examine the socioeconomic disparities within this population are warranted.

Operative versus nonoperative treatment of multiple simple rib fractures: A systematic review and meta-analysis

PURPOSE

Surgical rib stabilization in flail chest is proven to be beneficial over nonoperative treatment in terms of rate of pneumonia, Intensive Care (IC) length of stay (ICLOS) and mechanical ventilation days. The aim of this systematic review and meta-analysis was to evaluate the effect of operative versus nonoperative treatment on the occurrence of pneumonia and other relevant clinical outcomes in patients with multiple simple rib fractures.

METHODS

A search was performed in Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. The primary outcome was the occurrence of pneumonia. Secondary outcomes were duration of mechanical ventillation, ICLOS, hospital length of stay (HLOS), mortality, and wound infections. Publication bias was assessed using funnel plots for the outcome measures and random-effect models were used when heterogeneity of data on outcome measures was significant (I²≥40%).

RESULTS

The search resulted in 592 unique records, of which 14 studies on 13 cohorts were included. The 14 studies comprised five prospective and nine retrospective cohort studies with a cumulative total of 4565 patients. Meta-analysis showed a significant decrease of the occurrence of pneumonia (n=2659 patients; risk ratio, RR=0.66; 95% confidential interval [CI] 0.49 to 0.90; p=0.008), mortality (n=4456 patients; RR=0.32; 95% CI 0.19 to 0.54; p<0.001), and HLOS (n=648 patients; mean difference, MD=-5.78 days; 95% CI -10.40 to -1.15; p=0.01) in favor of operative treatment. No effect of operative treatment was found for the duration of mechanical ventilation (n=113 patients; MD=-6.01 days; 95% CI =-19.61 to 7.59; p=0.39), or ICLOS (n=524 patients; MD=-2.93 days; 95% CI -8.65 to 2.80; p=0.32). The postoperative wound infection rate ranged from 0 to 9.4%.

CONCLUSION

Surgical treatment of multiple simple rib fractures may result in a significant reduction of pneumonia, mortality, and hospital length of stay. A reducing effect of treatment on the duration of mechanical ventilation and IC length of stay, was not demonstrated. However, due to nonstandard or absent definitions of outcome measures as well as heterogenous patient groups and the observational design of studies, results must be interpreted with caution and high-quality studies are needed.

Quantifying the expense of deferring surgical stabilization of rib fractures: Operative management of rib fractures is associated with significantly lower charges

INTRODUCTION

Surgical stabilization of rib fractures (SSRF) remains a relatively controversial operation, which is often deferred because of concern about expense. The objective of this study was to determine the charges for SSRF versus medical management during index admission for rib fractures. We hypothesize that SSRF is associated with increased charge as compared with medical management.

METHODS

This is a retrospective chart review of a prospectively maintained database of patients with ≥3 displaced rib fractures admitted to a level 1 trauma center from 2010 to 2019. Patients who underwent SSRF (operative management [OM]) were compared with those managed medically (nonoperative management [NOM]). The total hospital charge between OM and NOM was compared with univariate analysis, followed by backward stepwise regression and mediation analysis.

RESULTS

Overall, 279 patients were included. The majority (75%) were male, the median age was 54 years, and the median Injury Severity Scale score (ISS) was 21. A total of 182 patients underwent OM, whereas 97 underwent NOM. Compared with NOM, OM patients had a lower ISS (18 vs. 22, p = 0.004), less traumatic brain injury (14% vs. 31%, p = 0.0006), shorter length of stay (10 vs. 14 days, p = 0.001), and decreased complications. After controlling for the differences between OM and NOM patients, OM was significantly associated with decreased charges (β = US $35,105, p = 0.01). Four other predictors, with management, explained 30% of the variance in charge (R = 0.30, p < 0.0001): scapular fracture (β = US $471,967, p < 0.0001), ISS per unit increase (β = US $4,139, p < 0.0001), long bone fracture (β = US $52,176, p = 0.01), bilateral rib fractures (β = US $34,392, p = 0.01), and Glasgow Coma Scale per unit decrease (β = US $17,164, p < 0.0001). The difference in charge between NOM and OM management was most strongly, although only partially, mediated by length of stay.

CONCLUSION

Our analysis found that OM, as compared with NOM, was independently associated with decreased hospital charges. These data refute the prevailing notion that SSRF should be withheld because of concerns for increased cost.

LEVEL OF EVIDENCE

Economic, level II.

Pulsed Ultrasounds Reduce Pain and Disability, Increasing Rib Fracture Healing, in a Randomized Controlled Trial

INTRODUCTION

Rib fractures are an important health issue worldwide, with significant, pain, morbidity, and disability for which only symptomatic treatment exists.

OBJECTIVES

Based on our previous experimental model, the objective of the current study was to assess for the first time whether pulsed ultrasound (PUS) application could have beneficial effects on humans.

METHODS

Prospective, double-blinded, randomized, controlled trial of 51 patients. Four were excluded, and 47 were randomized into the control group (N = 23) or PUS group (N = 24). The control group received a PUS procedure without emission, and the PUS group received 1 Mhz, 0.5 W/cm2 for 1 min/cm2. Pain level, bone callus healing rate, physical and work activity, pain medication intake, and adverse events were blindly evaluated at baseline and one, three, and six months.

RESULTS

There were no significant differences at baseline between groups. PUS treatment significantly decreased pain by month 1 (P = 0.004), month 3 (P = 0.005), and month 6 (P = 0.025), significantly accelerated callus healing by month 1 (P = 0.013) and month 3 (P < 0.001), accelerated return to physical activity by month 3 (P = 0.036) and work activity (P = 0.001) by month 1, and considerably reduced pain medication intake by month 1 (P = 0.057) and month 3 (P = 0.017). No related adverse events were found in the PUS group.

CONCLUSIONS

This study is the first evidence that PUS treatment is capable of improving rib fracture outcome, significantly accelerating bone callus healing, and decreasing pain, time off due to both physical activity and convalescence period, and pain medication intake. It is a safe, efficient, and low-cost therapy that may become a new treatment for patients with stable rib fractures.

Rib fracture displacement worsens over time

PURPOSE

Rib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time.

METHODS

Retrospective review of all RF patients from 2016-2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1-2, 3-6, 7-10, 11-12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002.

RESULTS

78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13-27) with Chest Abbreviated Injury Score of 3 (IQR, 3-4). Median time between CT1 and CT2 was 6 days (IQR, 3-12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11-12 in all planes (p < 0.002).

CONCLUSION

RF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly.

Surgical fixation of rib fractures decreases intensive care length of stay in flail chest patients

Background

Nonoperative treatment is currently the standard therapy for rib fractures. However, there is a trend towards surgical fixation from conservative management over the last decade. While surgical fixation of rib fractures has shown promising results, its impact on the clinical results remains unclear based on the current literature. As such, the present study aims to compare the short-term outcomes of multiple rib fracture patients treated by surgical fixation with traditional conservative management.

Methods

Data for patients with multiple (three or more) rib fractures admitted to our department between January 2012 and January 2019 were retrospectively collected and analyzed. Propensity score matched patients were compared between those treated with surgical rib fixation and those of nonoperatively treated. Primary outcomes were hospital length of stay for multiple rib fracture patients, and intensive care unit (ICU) length of stay for flail chest patients. Secondary outcomes included in hospital mortality, ICU usage rate, duration of ventilator support, ventilator usage rate, and pneumonia.

Results

The study included 1,201 patients with mean age of 50.1±12.7 years, of whom 954 (79.4%) were male. The average number of rib fractures was 6.3±2.4, with a mean injury severity score of 20.5±7.3. Among them, 563 (46.9%) patients had surgical rib fixation and 638 (53.1%) patients received nonoperative treatment. There were 191 patients with a flail chest, 133 (69.6%) had operative rib fixation and 58 (30.4%) were nonoperatively treated. After propensity score match, the hospital length of stay was not significantly differed between surgery and conservative management in multiple rib fracture patients (10.7±3.4 vs. 10.2±3.8 days, P=0.067), nor were the secondary outcomes, in terms of in hospital mortality (0.9% vs. 1.1%, P=0.704), ICU usage rate (12.3% vs. 12.9%, P=0.820), duration of ventilator support (100.1±13.9 vs. 99.8±20.7 hours, P=0.822), ventilator usage rate (12.0% vs. 12.9%, P=0.732), and pneumonia (24.3% vs. 24.9%, P=0.861). For patients with a flail chest, shorter ICU length of stay was found to be associated with surgical rib fixation comparing with nonoperative treatment (5.5±1.9 vs. 6.7±2.1 days, P=0.011). No secondary outcomes such as in hospital mortality (4.4% vs. 4.4%, P=1.000), ICU usage rate (20.0% vs. 22.2%, P=0.796), duration of ventilator support (113.1±20.4 vs. 131.2±19.5 hours, P=0.535), ventilator usage rate (20.0% vs. 20.0%, P=1.000), pneumonia (28.9% vs. 31.1%, P=0.818) were significant different between the operative and nonoperative groups.

Conclusions

Surgical rib fixation results in a shorter ICU length of stay in patients with a flail chest, and a comparable outcome for patients with multiple rib fractures when compared with nonoperative treatment.

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.

Clinical management of rib fractures and methods for prevention of pulmonary complications: A review

Rib fractures are common injuries associated with significant morbidity and mortality, largely due to pulmonary complications. Despite equivocal effectiveness data, incentive spirometers are widely utilized to reduce pulmonary complications in the postoperative setting. Few studies have evaluated the effectiveness of incentive spirometry after rib fracture. Multiple investigations have demonstrated incentive spirometry to be an important screening tool to identify high-risk rib fracture patients who could benefit from aggressive, multidisciplinary pulmonary complication prevention strategies. This review evaluates the epidemiology of rib fractures, their associated pulmonary complications, along with the evidence for optimizing their clinical management through the use of incentive spirometry, multimodal analgesia, and surgical fixation.

The ideal methods for the management of rib fractures

The clinical treatment choices for multiple rib fractures and flail chest are controversial. For example, among conservative treatment and surgical treatment, different studies have different conclusions and recommendations. Furthermore, early clinical research was mainly focused on the treatment of flail chest due to its severity. Nowadays, the treatment for multiple rib fractures patients without a flail chest is drawing an increased clinical interest. However, we are facing many challenges for the treatment of rib fractures, such as insufficient understanding of the available treatment options, lack of clinical research, lack of the internationally recognized clinical indication for the surgical stabilization of rib fractures (SSRF), and the constant controversies and debates in terms of treatment options, surgery timing, and surgical techniques. All these challenges make it difficult to select the most appropriated clinical decisions for the proper treatment of a rib fracture, resulting in a seriously hindered development of novel rib fractures treatment choices. The concepts and ideas for traditional rib fractures treatment are relatively old, and even have some misunderstandings or errors. With the emergence of more and more research, the understandings of the rib fractures treatment has gradually improved; for example, the benefits provided to patients under the open reductions and internal fixation of fractures treatment. In this article, we outlined the new concepts in rib fractures treatment, which mainly included four parts, damage control, pain management, fixation selection, and quality of life. We hope these concepts help practitioners better manage rib fracture patients.

Surgical Management of Multiple Rib Fractures Reduces the Hospital Length of Stay and the Mortality Rate in Major Trauma Patients: A Comparative Study in a UK Major Trauma Center

OBJECTIVES

To investigate and assess the effectiveness of surgical fixation of rib fractures in complex traumatic chest injuries compared with traditional nonoperative management.

DESIGN

Retrospective observational comparative study.

SETTING

Level 1 Major Trauma Centre in North West England.

PATIENTS/PARTICIPANTS

A total of 83 patients who were admitted urgently to our hospital after major trauma, between August 2012 and March 2015, and fulfilled the criteria for surgical fixation of their multiple rib fractures. Patients who had concomitant nonsurvivable injuries or did not consent for surgery were excluded.

INTERVENTION

Open reduction and internal fixation (ORIF) of multiple rib fractures and flail chest segments versus traditional nonoperative management.

MAIN OUTCOME MEASUREMENTS

The primary outcome of interest was the total hospital length of stay (LOS). Secondary outcomes included the incidence of intensive care unit (ICU) admission and the incidence of respiratory complications such as hospital-acquired pneumonia, need for mechanical ventilation, and/or tracheotomy. The mortality rate was also investigated.

RESULTS

A total of 83 patients were included, 47 of these in the ORIF group and 36 in the non-ORIF group. The mean hospital LOS for patients in the non-ORIF group was 30.41 days (SD 30.1). This was markedly reduced in the ORIF group to a mean of 14.53 days (SD 11.7), with the difference being statistically significant (P < 0.01). Twenty-eight patients (77.7%) in the nonoperatively managed group required admission to the ICU compared with a significantly lower 48.9% (23 patients) in the ORIF group (P < 0.01). The incidence of respiratory complications was lower in the ORIF group but this difference was not statistically significant. The mortality rate was 2.1% for the group that was treated surgically compared with 13.9% for the conservative group (P < 0.05).

CONCLUSIONS

Surgical fixation of multiple displaced rib fractures reduced the total hospital LOS and the overall mortality in our major trauma patients and decreased the incidence of ICU admission.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Surgery Reduce the Risk of Complications Among Patients with Multiple Rib Fractures? A Meta-analysis

BACKGROUND

Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial.

QUESTIONS/PURPOSES

The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores.

METHODS

We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed.

RESULTS

The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470).

CONCLUSIONS

This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study

BACKGROUND

Over the years, a trend has evolved towards operative treatment of flail chest although evidence is limited. Furthermore, little is known about operative treatment for patients with multiple rib fractures without a flail chest. The aim of this study was to compare rib fixation based on a clinical treatment algorithm with nonoperative treatment for both patients with a flail chest or multiple rib fractures.

METHODS

All patients with ≥ 3 rib fractures admitted to one of the two contributing hospitals between January 2014 and January 2017 were retrospectively included in this multicenter cohort study. One hospital treated all patients nonoperatively and the other hospital treated patients with rib fixation according to a clinical treatment algorithm. Primary outcome measures were intensive care length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. To control for potential confounding, propensity score matching was applied.

RESULTS

A total of 332 patients were treated according to protocol and available for analysis. The mean age was 56 (SD 17) years old and 257 (77%) patients were male. The overall mean Injury Severity Score was 23 (SD 11) and the average number of rib fractures was 8 (SD 4). There were 92 patients with a flail chest, 37 (40%) had rib fixation and 55 (60%) had non-operative treatment. There were 240 patients with multiple rib fractures, 28 (12%) had rib fixation and 212 (88%) had non-operative treatment. For both patient groups, after propensity score matching, rib fixation was not associated with intensive care unit length of stay (for flail chest patients) nor with hospital length of stay (for multiple rib fracture patients), nor with the secondary outcome measures.

CONCLUSION

No advantage could be demonstrated for operative fixation of rib fractures. Future studies are needed before rib fixation is embedded or abandoned in clinical practice.

Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis

Purpose

The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.

Methods

MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy.

Results

Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I² = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies.

Conclusions

Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.

Electronic supplementary material

The online version of this article (10.1007/s00068-018-1020-x) contains supplementary material, which is available to authorized users.

Development of a blunt chest injury care bundle: An integrative review

BACKGROUND

Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes.

OBJECTIVE

To review and integrate the BCI management interventions to inform the development of a BCI care bundle.

METHODS

A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle.

RESULTS

Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation.

CONCLUSIONS

The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.

Using 3-Dimensional Modeling to Customize Titanium Plates for Repair of Chest Wall Trauma

BACKGROUND

Open reduction and internal fixation of rib fractures is recommended to decrease mortality, shorten the duration of mechanical ventilation, and lower hospital length of stay. Prosthetic titanium plates are frequently used to repair chest wall trauma, and are typically contoured to the patient's anatomy at the time of implant in the operating room. We describe the use of 3-dimensional (3D) digitally corrected rapid prototyping to generate a model of a patient's skeletal anatomy for the purposes of preoperative customization of standard titanium plates for fixation of rib fractures.

METHODS

A computed tomography imaging Digital Imaging and Communication in Medicine data set was segmented. Rib fractures were virtually realigned using the mirrored normal anatomy as a guide. The model was printed and used to customize titanium rib fixation plates prior to the procedure.

RESULTS

Preoperative shaping of 5 titanium plates using the final 3D model required a total of 5.65 minutes. Surgical fixation of 4 of the patient's 5 fractures was accomplished using the titanium plates that were preoperatively shaped using our 3D model.

DISCUSSION

We demonstrate successful use of a digitally rendered model to preoperatively customize standard titanium rib fixation plates. Compared with intraoperative contouring of rib fixation plates, we believe that this approach facilitates repair of complex rib fractures, saving time in the operating room. We believe this technique can improve the accuracy of reductions, increase the ease and efficiency of these procedures, and afford benefits in reducing surgical stress on patients who have already suffered significant trauma.

Traumatic thoracic rib cage hernias: Operative management and proposal for a new anatomic-based grading system

BACKGROUND

Traumatic Rib Cage Hernias (TRCH) requiring operative repair are rare and there is currently no literature to guiding surgical management.

METHODS

Perioperative review of TRCH over 32 years. Five operative grades were developed based on extent of tissue/bone damage, size, and location.

RESULTS

Twenty-four patients (20 blunt, 4 penetrating) underwent operative repair. Lung was the herniated organ in 88% with a median of 4 rib fractures and average size of 60.25 cm. Types of operation were well clustered by assigned TRCH grade. The majority required mesh (75%) and/or rib plating (79%). Complex tissue flap reconstruction was required in 10%. Full range-of-motion was maintained in 88% with79% returning to pre-injury activity levels. Five patients had continued pain at final follow up (mean = 7months).

CONCLUSION

The size and degree of injury has important implications in the optimal surgical management of TRCHs. These operative grades effectively direct surgical care for these rare and complex injuries.

Evidence-Based Care of Geriatric Trauma Patients

The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.

Magnitude of rib fracture displacement predicts opioid requirements

INTRODUCTION

It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients.

METHODS

Adult blunt RF patients undergoing computed tomography (CT) of the chest admitted to an urban Level 1 trauma center (2007-2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), nondisplaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioid requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics.

RESULTS

There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 patients (91%). Compared to DRF (mean, 1.7 RF per patient) and NDRF patients (2.4 RF per patient), those with CRF (6.8 RF per patient) were older and had more RF per patient and a higher Injury Severity Score (ISS) and MED (251 vs 53 and 105 mg, respectively, p < 0.0001 and p = 0.0045). They also more frequently received patient-controlled analgesia. Patients with displaced RF had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p < 0.0001) and the number of RF (p < 0.0001). Every 5-mm increase in total displacement predicted a 6.3% increase in mean MED (p = 0.0035), while every additional RF predicted an 11.2% increase in MED (p = 0.0001). These associations included adjustment for age, ISS, and presence of chest tubes.

CONCLUSION

The magnitude of RF displacement and the number of RF predicted opioid requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

[Ribs osteosynthesis in patients with isolated and combined chest trauma]

INTRODUCTION

Rapid methods of costal fractures fixation using special costal plates are becoming more common.

AIM

To evaluate the efficacy of ribs osteosynthesis in patients with isolated and combined chest trauma.

MATERIAL AND METHODS

It is presented an experience of surgical treatment of patients with costal fractures in case of isolated (30) and combined (29) chest injury. System for ribs osteosynthesis was used predominantly in surgical tactics.

RESULTS

Immediate surgical results were analyzed. Most patients had increase of blood gas parameters, oxygenation in the postoperative period. In case of isolated chest injury mean duration of mechanical ventilation was 1.3±1.1, incidence of complications - 3.3%, mortality rate - 0%. In group of combined injuries those indexes were 4.6±3.05, 13.8% and 13.8% respectively.

CONCLUSION

The method of ribs osteosynthesis in patients with isolated and combined chest trauma showed high efficiency.

Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability

PURPOSE

Stabilizing techniques of flail chest injuries usually need wide approaches to the chest wall. Three main regions need to be considered when stabilizing the rib cage: median-anterior with dissection of pectoral muscle; lateral-axillary with dissection of musculi (mm) serratus, externus abdominis; posterior inter spinoscapular with division of mm rhomboidei, trapezius and latissimus dorsi. Severe morbidity due to these invasive approaches needs to be considered. This study discusses possibilities for minimized approaches to the shown regions.

METHOD

Fifteen patients were stabilized by locked plate osteosynthesis (MatrixRib^®) between May 2012 and April 2014 and prospectively followed up. Flail chest injuries were managed through limited incisions to the anterior, the lateral, and the posterior parts of the chest wall or their combinations. Each approach was 4-10 cm using Alexis^® retractor.

RESULTS

One minimized approach offered sufficient access at least to four ribs posterior and laterally, four pairs of ribs anterior in all cases. There was no need to divide latissimus dorsi muscle. Trapezius und rhomboid muscles were only limited divided, whereas a subcutaneous dissection of serratus and abdominis muscles was necessary. A follow-up showed sufficient consolidation.

COMPLICATIONS

pneumothorax (2) and seroma (2).

CONCLUSION

Minimized approaches allow sufficient stabilization of severe dislocated rib fractures without extensive dissection or division of the important muscles. Keeping the arm and, thus, the scapula mobile is very important for providing the largest reachable surface of the rib cage through each approach.

Pitfalls associated with open reduction and internal fixation of fractured ribs

Rib fracture is exceedingly common and remains a leading cause of death in patients with chest injury. Probability of death increases by 19% with each broken rib, and the probability of death increases further with age. Treatment is centered on pain control and early mobilization to provide adequate pulmonary hygiene. Multimodality interventions, such as incentive spirometry, postural changes, and coughing, are pivotal in minimizing the risk of pneumonia and death. Recently, many studies have found mortality benefit to operation fixation (ORIF) of ribs in select patients. However, this procedure remains underutilized partly due to lack of familiarity with its technique and pitfalls by trauma surgeons, in particular. Whereas there are publications on operative technique, there are no studies describing pitfalls associated with this procedure. The purpose of this paper is to describe pitfalls on the technical aspects of ORIF of the ribs based on the medical literature where possible and based on our experience in instances where peer reviewed evidence is lacking. The paper is not meant to serve as a protocol for managing rib fractures.

Potential Benefits of Rib Fracture Fixation in Patients with Flail Chest and Multiple Non-flail Rib Fractures

The purpose of this study is to evaluate the potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures versus conventional treatment modalities. A retrospective reviewed study compared 86 cases which received surgical treatment between June 2009 and May 2013 to 76 cases which received conservative treatment between January 2006 and May 2009. The patients were divided into the flail chest (n = 38) and multiple non-flail rib fracture groups (n = 124). In the flail chest group, the mechanical ventilation time, ICU monitoring time, tracheostomies, thoracic deformity, and impaired pulmonary function and return to full-time employment were compared. In the multiple non-flail rib fracture group, fracture healing, visual analog scale (VAS) pain score, inpatient length of stay, atelectatic, pulmonary complications, and normal activity-returning time were compared. Patients in the flail chest operative fixation group had significantly shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic deformity and impaired pulmonary function, and more returned to full-time employment. Patients in the multiple non-flail rib fracture operative fixation had shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections. This study demonstrates the potential benefits of surgical stabilization of flail chest and multiple non-flail rib fractures with plate fixation. When compared with conventional conservative management, operatively managed patients demonstrated improved clinical outcomes.

Successful management of severe flail chest via early operative intervention

A review on the role of open reduction and internal fixation of flail chest injuries is presented. A 37-year-old woman involved in a motorcycle crash sustained comminuted rib fractures on her right 3rd through 12th ribs. On postinjury day 2, the patient's fifth through ninth ribs were surgically reduced and plated. Later that same day, the patient was successfully weaned from mechanical ventilation and experienced a rapid improvement in incentive spirometry volumes. Further studies are needed to definitively determine the benefits of rib plating versus conventional treatment. Through our case, we are able to demonstrate successful management of pain and chest wall instability associated with flail chest through the use of rib plating.

Better short-term efficacy of treating severe flail chest with internal fixation surgery compared with conservative treatments

Background

The objective of the study is to provide evidence for selecting the best treatment approach for severe flail chest by comparing surgical and conservative treatments.

Methods

This is a retrospective study in which 32 patients with severe flail chest were treated in the Fujian Provincial Hospital (China) between July 2007 and July 2012 with surgical internal rib fixation (n = 17) or conservative treatments (n = 15). Mechanical ventilation time, intensive care unit (ICU) stay time, pulmonary infection, antibiotic treatment duration, acute physiology and chronic health evaluation II (APACHE II) scores 7 and 14 days after trauma, rate of tracheostomy, and rate of endotracheal re-intubation were compared.

Results

One patient died in the conservative treatment group. Better short-term outcomes were observed in the surgery group, such as total mechanical ventilation time (10.5 ± 3.7 vs. 13.7 ± 4.4 days, P = 0.03), ICU stay (15.9 ± 5.0 vs. 19.6 ± 5.0 days, P = 0.05), pulmonary infection rate (58.8 % vs. 93.3 %, P = 0.02), and APACHE II scores on the 14th day (6.5 ± 3.8 vs. 10.1 ± 4.7, P = 0.02). No difference was observed in the therapeutic time of antibiotics, rate of tracheostomy, and the rate of endotracheal re-intubation between the two groups.

Conclusions

Results suggest that internal fixation surgery resulted in better outcomes in the management of severe flail chest compared with conservative treatments.

Blunt chest wall trauma: A review

Blunt chest wall trauma accounts for a large proportion of all trauma presentations to the Emergency Departments in the United Kingdom and has a high reported incidence of morbidity and mortality. The difficulty in the assessment and management of this patient group arises from the possibility that the patient may develop potentially life-threatening complications up to approximately 72 h post-injury, even in patients who have sustained what is initially considered a minor injury. Limited consensus currently exists in the literature regarding optimal assessment or management strategies for this patient group. The aim of this review is to provide an overview of current research investigating the optimal assessment and management strategies for the blunt chest wall trauma patient.