The financial burden of rib fractures: National estimates 2007 to 2016

Analgesia for rib fractures: a narrative review

PURPOSE

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach.

SOURCE

Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts.

PRINCIPAL FINDINGS

Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities.

CONCLUSION

Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Comparative study of wound outcomes and surgical strategies: Internal fixation versus external stabilization in rib fracture patients with traumatic chest wounds

The clinical management of traumatic chest incisions accompanied by rib fractures presents the formidable challenge. The study was carried out to compare the outcomes of auscultatory triangle internal fixation (ATIF) and external fixation (EF) in such injuries. From June 2019 to June 2022, 105 patients with multiple rib fractures participated in the cohort study in which they were divided into two groups: 53 patients underwent ATIF and 52 patients underwent EF. The incidence of surgical site infection, wound healing time, incidence of wound dehiscence, number of dressing changes, pain as measured by the visual analogue scale (VAS), duration of hospitalization, period of return to work, pulmonary complications and functionality of the upper limbs as assessed by the Disability of Arm, Shoulder, and Hand (DASH) questionnaire were among the parameters evaluated. In comparison with EF, ATIF demonstrated the decreased incidence of wound dehiscence (1.9% vs. 9.6%) (p < 0.05), surgical site infection (3.8 vs. 11.5) and wound healing time (12.3 ± 2.1 vs. 18.5 ± 3.7 days) (p < 0.05). Furthermore, during their ATIF treatment, patients required fewer changes of dressing (3.5 ± 0.8 vs. 5.7 ± 1.2) and demonstrated enhanced pain management, reduced hospital stays and expedited return to work (p < 0.05). ATIF group demonstrated enhancements in both upper limb functionality and post-operative pulmonary function (p < 0.05). The utilization of ATIF as opposed to EF for the treatment of traumatic chest wounds accompanied by rib fractures yields superior outcomes in terms of wound healing, infection reduction and restoration of pulmonary and upper limb functionality.

Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries

INTRODUCTION

The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries.

PATIENTS AND METHODS

In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups.

RESULTS

Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups.

CONCLUSIONS

SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

Does the timing of surgery affect outcomes in young and middle-aged patients undergoing surgical stabilization of rib fractures? Feedback was based on real data from physicians, patients, and family caregivers

BACKGROUND

There is a general clinical consensus that early surgical stabilization of rib fractures (SSRF, ≤ 48-72 h after admission) can benefit patients, and this is only regarding the surgeon's opinions. This study assessed the true outcomes of young and middle-aged patients at different surgical timings.

METHODS

This retrospective cohort study was conducted among patients aged 30-55 years who were hospitalized with a diagnosis of isolated rib fractures and underwent SSRF between July 2017 and September 2021. The patients were divided into early (≤ 3 days), mid- (4-7 days) and late (8-14 days) groups, according to the interval (days) between surgery and injury date. The impact of different surgical timings on clinical outcomes, patients, and families was assessed by comparing SSRF-related data during hospitalization and follow-up studies of clinicians, patients themselves, and family caregivers 1-2 months after surgery.

RESULTS

In this study, 155 complete patient data were finally included, including 52, 64, and 39 patients in the early, mid, and late groups, respectively. Length of operation, preoperative closed chest drainage rate, length of hospital stay, intensive care unit length of stay, duration of invasive mechanical ventilation in the early group were lower than those in the intermediate and late groups. Additionally, hemothorax and excess pleural fluid incidence after SSRF was lower in the early group than in the intermediate and late groups. Postoperative follow-up results showed that patients in the early group had higher SF-12 physical component summary scores and shorter duration of absence from work. Family caregivers had lower Zarit Burden Interview scores than those in the mid- and late groups.

CONCLUSION

From the experience of our institution's SSRF, early surgery is safe and offers additional potential benefits for young and middle-aged patients and families with isolated rib fractures.

Delayed hemothorax readmissions after rib fracture in blunt trauma patients

Background

Rib fractures are the most common traumatic injury. Hemothorax is one of the widespread complications associated with a rib fracture and occurs in 10-37 % of all rib fractures. Delayed hemothorax (DHTX) is defined as an accumulation of blood within the pleural cavity. Although there is extensive literature on hemothorax, there is limited literature on rib fractures and DHTX readmissions. The objective of this study was to identify potential risk factors for DHTX readmission and examine descriptive information on readmission.

Methods

Using the 2016-2019 National Readmission Database (NRD), patients that experienced an admission with a blunt traumatic rib fracture were included. It was determined if the patients experienced DHTX by screening for an admission containing an ICD-10 code for hemothorax within 30 days after an admission containing a ICD-10 code for rib fracture. Univariable and multivariable analysis was performed to determine independent risk factors associated with DHTX readmission. Additionally, information on the clinical and financial characteristics of DHTX readmissions were examined.

Results

A total of 242,071 patients were included, of whom 635 experienced DHTX readmission ≤30 days after discharge. Diagnosed with hemothorax on the index admission had the largest odds ratio for DHTX readmission (7.43 [6.14-8.99], P < 0.001). Complications found during DHTX readmission included acute respiratory failure (16.9 %), sepsis (6.9 %), and empyema (4.3 %). Treatment mainly consisted of pleural drainage (62.2 %) and video-assisted thoracoscopic surgery (VATS) evacuation of hemothorax (10.1 %).

Conclusion

Patients admitted for a rib fracture have a low incidence for DHTX readmission within 30 days. However, multivariable analysis has demonstrated some risk and protective factors associated with DHTX readmission. Further studies should focus on exploring these risk factors to screen for potential DHTX readmission and/or protective factors to decrease the change for DHTX readmission.