Rib fractures in trauma patients: does operative fixation improve outcome?

The therapeutic value of vacuum external fixation in polytrauma patients with multiple ribs fracture

BACKGROUND

Multiple displaced rib fractures often result in a poor prognosis. Open reduction and internal fixation has been shown to provide benefits for patients with displaced rib fractures and flail chest. Nevertheless, for patients who are unwilling or unsuitable for surgery, the therapeutic options are limited. We developed a novel plastic vacuum device for rib fractures external stabilization. This study aims to compare the therapeutic efficacy of this device against a traditional chest strap in polytrauma patients with multiple rib fractures.

METHODS

A retrospective investigation was conducted on polytrauma patients with multiple rib fractures admitted to our trauma center between March 2020 and March 2023. Patients were categorized into two groups: vacuum external fixation and chest strap. Comparative analysis was conducted on baseline parameters, injury characteristics, and clinical outcomes between the two groups.

RESULTS

In this study, 54 patients were included, with 28 receiving chest strap and 26 undergoing vacuum external fixation. Results showed that, at 3 days and 7 days postintervention, the vacuum external fixation group had significantly lower visual analog scale scores during deep breathing and coughing (P < .05). Vacuum external fixation also reduced pleural drainage duration and volume, as well as lowered the risk of pneumonia and other complications (P < .05). Furthermore, the vacuum external fixation group demonstrated notable improvements in vital capacity, tidal volume, blood-gas test results, and a shorter hospital length of stay.

CONCLUSIONS

According to the study findings, vacuum external fixation appears to offer benefits to patients with multiple rib fractures, potentially reducing the risk of complications and improving overall clinical outcomes.

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.

A Retrospective Two-Year Review of the Outcomes of Surgical Rib Fixation Following Chest Wall Injury by the Multidisciplinary Chest Wall Injury Group in a Major Trauma Centre and the Change in Outcomes as the Service Has Developed

Aims All English major trauma centres (MTCs) offer rib fixation, which the National Institute for Health and Care Excellence (NICE) guidance indicates in patients with multiple rib fractures or a flail segment; however, the data does not identify the appropriate patients. Our aims were to establish improvements in outcomes following rib fixation at our trust and then determine if the rib fixation service has improved. Methods We performed a matched cohort study whereby 32 patients who underwent rib fixation were independently matched with conservatively managed patients. We then performed a retrospective re-audit to compare outcomes with the matched cohort study. The outcomes analysed were mortality, critical care length of stay (LOS) and total hospital LOS. Results Our initial study revealed a 33.4% reduction in mortality in patients over 55 years. There was also a reduction in average total hospital LOS by 4.5 days in patients under 55 years when comparing rib fixation to conservative management. The results also revealed an average of 4.1 days from admission to operation, 12.7 days of critical care LOS and 29.1 days of total hospital LOS. The re-audit showed improvements in all outcomes. Time from admission to fixation was reduced to 2.1 days, critical care LOS was reduced to 7.5 days and total hospital LOS was reduced to 20.7 days. Conclusions Reduced mortality and LOS reinforce evidence that rib fixation improves outcomes. The re-audit shows that patients are identified for fixation sooner, which is important as the evidence has not identified optimal time for fixation. LOS further decreased in our re-audit, which indicates that earlier fixation results in patients avoiding the sequelae of rib fractures.

The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial

INTRODUCTION

Multiple rib fractures (≥ 3 displaced rib fractures and/or flail chest) are severe chest trauma with high morbidity and mortality. Rib fixation has become the first choice for multiple rib fracture treatment. However, the timing of surgical rib fixation is unclear.

MATERIALS AND METHODS

The present study explored whether early rib fracture fixation can improve the outcome of multiple rib fractures. The present research included patients who were hospitalized in three Jiangsu hospitals following diagnosis with multiple rib fractures. Patients received early rib fracture fixation (≤ 48 h) or delayed rib fracture fixation (> 48 h) utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures included hospital length of stay, intensive care unit (ICU) stay, mechanical ventilation, inflammatory cytokine levels, infection marker levels, infection, and mortality.

RESULTS

A total of 403 individuals were classified into two groups, namely, the early group (n = 201) and the delayed group (n = 202). Patients belonging to the two groups had similar baseline clinical data, and there were no statistically significant differences between them. Early rib fracture fixation greatly decreased the length of stay in the ICU (4.63 days vs. 6.72 days, p < 0.001), overall hospital stay (10.15 days vs. 12.43 days, p < 0.001), ventilation days (3.67 days vs. 4.55 days, p < 0.001), and hospitalization cost (6900 USD vs. 7600 USD, p = 0.008). Early rib fracture fixation can decrease inflammatory cytokine levels and infection marker levels, prevent hyperinflammation and improve infection in patients with multiple rib fractures. The timing of rib fracture fixation does not influence the surgical procedure time, operative blood loss, 30-day all-cause mortality, or surgical site infection.

CONCLUSION

The findings from the present research indicated that early rib fracture fixation (≤ 48 h) is a safe, rational, effective and economical strategy and worth clinical promotion.

Evaluation of surgical outcomes in elderly patients with rib fractures: A single-centre propensity score matching study

Background

Rib fractures are the most common injuries in chest trauma. Compared with younger patients, elderly patients with rib fracture have a higher incidence of complications and mortality. A retrospective study was conducted to investigate the effect of internal fixation compared with conservative treatment on the outcome of rib fracture in elderly patients.

Material and methods

We used a 1:1 propensity score matching method to perform a retrospective analysis of 703 elderly patients with rib fractures treated in the Thoracic Surgery Department of Beijing Jishuitan Hospital between 2013 and 2020. After matching, the length of hospital stay, death, symptom relief and rib fracture healing were compared between the surgery and the control group.

Results

The study included 121 patients receiving SSRF in the surgery group and 121 patients receiving conservative treatment in the control group. The length of hospital stay in the surgery group was significantly longer than that in the conservative group (11.39d vs. 9.48d, p = 0.000). After 9 months of follow-up, the fracture healing rate in the surgery group was significantly higher than that in the control group (96.67% vs. 88.89%, p = 0.020). The fracture healing time (p = 0.000), improvement in pain score (p = 0.000) and duration of pain medication use (p = 0.000) were also significantly better in the surgery group than in the control group.

Conclusion

Compared with conservative treatment, surgical treatment can prolong hospital stay to some extent. However, it has the advantages of more rapid healing and lessened pain. For rib fractures in elderly individuals, surgical treatment is a safe and effective option under strict surgical indications and is recommended.

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.

Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma—A Matched-Pairs Analysis of the German Trauma Registry

Purpose

In severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay.

Methods

Data from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS)  ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3–10 days after trauma.

Results

After the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226).

Conclusions

We were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.

Isolated Thoracic Injury Patients With Rib Fractures Undergoing Rib Fixation Have Improved Mortality

BACKGROUND

Despite a lack of consensus recommendations for surgical stabilization of rib fractures (SSRF), SSRF has increased over the past decade. Outcomes of patients with isolated thoracic injuries undergoing SSRF are unknown. We hypothesized adult trauma patients with isolated thoracic injuries and rib fractures undergoing SSRF would have a decreased risk of mortality and in-hospital respiratory complications compared with those not undergoing SSRF.

MATERIALS AND METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for patients presenting with a rib fracture. Patients who died in the emergency department or within 24-h, as well as those with a grade>1 for abbreviated injury scale of the head, face, neck, spine, abdomen, and extremities, were excluded. A multivariable logistic regression analysis was performed.

RESULTS

From 60,000 patients with isolated thoracic injuries and rib fractures, 688 (1.1%) underwent SSRF. Compared with patients without SSRF, those undergoing SSRF had a similar median age (P = 0.83) and higher injury severity score (P < 0.001). Patients undergoing SSRF had a longer length of stay (P < 0.001), higher rate of acute respiratory distress syndrome (P < 0.001), unplanned intubation (P < 0.001), and pneumonia (P < 0.001) but lower rate of mortality (0.9% versus 1.7%, P = 0.084). After adjusting for confounding variables, patients undergoing SSRF had a decreased associated risk of mortality (OR 0.40, P = 0.036) compared with those not undergoing SSRF.

CONCLUSIONS

The risk of mortality in trauma patients with isolated thoracic injuries and rib fractures is lower when undergoing SSRF despite being associated with a higher rate of respiratory complications during their increased length of stay.

Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: A meta-analysis of randomized controlled trials

BACKGROUND

There are still controversies between surgical treatment and conservative treatment for multiple rib fractures (MRFs). No consensus has been reached concerning the indications and timing of surgery. In this meta-analysis, we aimed to determine the optimal treatment for MRFs.

METHODS

Six databases (PubMed, Medline, Embase, Cochrane, Cnki, Wanfang Database) were retrieved for all eligible randomized controlled trials (RCTs) published before January 2020. MRFs were treated either with operative reduction and internal fixation or conservative treatment. The pertinent data were retrieved. The quality of RCTs was evaluated by the modified Jadad rating scale and meta-analysis was performed using RevMan 5.3 software.

RESULTS

Seven RCTs involving 538 MRFs patients (260 were treated surgically vs. 278 conservatively) were included in this meta-analysis. Compared with conservative treatment, surgical treatment resulted in shorter length of hospital stay (WMD -8.48; 95% CI -11.34 to -5.63; P < 0.001), length of ICU stay (WMD -5.72; 95% CI -7.31 to -4.13; P < 0.001) and duration of mechanical ventilation (WMD -4.93; 95% CI -8.79 to -1.07; P = 0.01), with a lower risk of complications including pneumonia (RR 0.40; 95% CI 0.30 to 0.53; P < 0.001) and chest wall deformity (RR 0.07; 95% CI 0.03 to 0.14; P < 0.001). The sensitivity analysis carried out by excluding one study with significant heterogeneity showed that the rate of tracheostomy was lower in the surgical group than in the conservative group (RR 0.44; 95% CI 0.28 to 0.71; P = 0.0008).

CONCLUSIONS

For patients with MRFs, surgical treatment resulted in faster recovery, a lower risk of complications and better prognosis than conservative treatment.

Stability of Surgical Rib Fixation Hardware after Repeat Chest Trauma

Surgical management of rib fractures has long been a controversial topic, but improvements in rib plating technology have led to a recent increase in interest among surgeons. Unfortunately, follow-up data are limited in patients following rib fracture plating. We present a unique case of an adult male who had multiple ribs plated for symptomatic rib fracture nonunions and developed periprosthetic fractures following repeat trauma several months later. A 57-year-old male with a history of trauma was treated for symptomatic nonunion of several left lateral ribs with surgical rib fixation. He tolerated the procedure well and had significant improvement in his symptoms on follow-up. Several months later, he was hit by a motor vehicle while riding his bicycle. He was found to have flail chest with lateral segmental rib fractures of the first through second ribs, posterior periprosthetic fractures of the seventh through tenth ribs, and lateral fractures of the eleventh and twelfth ribs. The rib plating hardware was completely intact, except for a single displaced seventh rib screw. To our knowledge, this is the first case report of repeat chest trauma following rib plating. Interestingly, the patient developed posterior periprosthetic fractures, and hardware was completely intact except for a single screw that was displaced. The goal of this report is to describe the unique fracture pattern of a flail chest with prior rib plating and to describe potential revision plating techniques and complications that surgeons may encounter in the management of trauma patients with prior rib plating.

Thoracic trauma: a descriptive review of 4168 consecutive cases in East China

Thoracic trauma in China was scarcely reported. This study aimed to summarize the clinical profiles and to analyze the management approaches of patients with traumatic thoracic injury.Data for consecutive patients with thoracic trauma from January 2003 to January 2018 were retrospectively collected and analyzed. Patients' profiles and clinical outcomes were compared between those patients treated with a dedicated thoracic trauma team and those without.The study included 4168 patients with mean age of 49.0 years, of whom 82.1% were male. Traffic accident accounted for 42.7% of the injuries. Most of the patients (66.8%) had rib fractures. Associated injuries were present in 48.3% of the patients; of them 86.0% were extremity fractures. Majority of the patients were managed without surgical procedures other than tube thoracostomy (33.2%). ICU service was needed in 12.0% of the patients. Patients treated with thoracic trauma team were older (53.59 ± 16.8 year vs 45.1 ± 18.0 year, P < .001), less male (78.3% vs 85.2%, P < .001), with higher injury severity scores (17.5 ± 10.1 vs 13.7 ± 8.2, P < .001), required more ventilator support (48.3% vs 25.3%, P < .001) and underwent more tube thoracostomy and other surgeries (43.8% vs 24.2%, and 34.4% vs 14.1%, respectively, all P < .001), yet with a shorter hospital stay (11.7 ± 9.0 days vs 12.7 ± 8.8 days, P < .001), and numerically lower ICU usage and mortality when compared to those without.Thoracic trauma in China usually affects mid-age males. Traffic accident is the top one etiology. The most common type of thoracic injuries is rib fracture. Associated injuries occur frequently. Nonoperative treatment and tube thoracostomy are effective for majority of the patients. A multidisciplinary approach with a dedicated thoracic trauma team could improve the treatment for these patients.

Development of a socket-type rib coaptation device made of poly-L-lactide fibers: feasibility study in a canine model

Background

Costal coaptation pins made of poly-L-lactide (PLA) are clinically available for fixing surgically divided ribs. However, the clinical results of such rib fixation have not been completely satisfactory. We aimed to develop a new rib coaptation socket system and explore its clinical applicability.

Methods

We surgically divided three consecutive ribs of each beagle dog, and rib coaptation sockets were implanted to stabilize each rib. Fifteen 3-dimensional (3D)-printed and 30 PLA fiber knitted sockets were implanted in five and ten dogs, respectively, to stabilize the artificially divided ribs. Mechanical analysis of the sockets and radiographical examination of costal fixation were performed to evaluate the effectiveness of the newly developed socket system for rib stabilization.

Results

All 15 ribs with 3D-printed sockets had displaced 1 month after the operation. Three ribs in one dog with implanted PLA fiber knitted sockets were displaced radiographically after 1 month, and the grade of displacement remained unchanged after 6 months. The remaining 27 ribs fixed with PLA fiber knitted sockets did not show any displacement.

Conclusions

The PLA fiber knitted rib coaptation socket system was sufficiently durable for the stabilization of divided ribs with biocompatibility. This promising finding can be applied for clinical stabilization of divided ribs.

Chest wall stabilization in trauma patients: why, when, and how?

Blunt trauma to the chest wall and rib fractures are remarkably frequent and are the basis of considerable morbidity and possible mortality. Surgical remedies for highly displaced rib fractures, especially in cases of flail chest, have been undertaken intermittently for more than 50 years. Rib-specific plating systems have started to be used in the last 10 years. These have ushered in the modern era of rib repair with chest wall stabilization (CWS) techniques that are safer, easier to perform, and more efficient. Recent consensus statements have sought to define the indications and contraindications, as well as the when, the how, and the technical details of CWS. Repair should be considered for patients who have three or more displaced rib fractures or a flail chest, whether or not mechanical ventilation is required. Additional candidates include patients who fail non-operative management irrespective of fracture pattern and those with rib fractures who need thoracic procedures for other reasons. Traditionally, unstable spine fracture and severe traumatic brain injury are definite contraindications. Pulmonary contusion's role in the decision to perform CWS remains controversial. A range of rib-specific plating systems are now commercially available.