Rib fixation in geriatric trauma: Mortality benefits for the most vulnerable patients

Surgical stabilization of rib fractures in anticoagulated patients: Proceed with caution?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is increasingly performed, however the outcome of patients undergoing SSRF while on pre-injury antithrombotic therapy remains unknown. We compared surgical variables and outcomes of patients who were and were not on antithrombotic therapy. We hypothesize pre-injury anticoagulation is associated with delay in SSRF and worse outcomes.

METHODS

For this retrospective cohort study, we queried the Chest Injury International Database, for patients undergoing SSRF between 08/2018 and 03/2022. Antithrombotic therapy was categorized into antiplatelet and anticoagulant use. Primary outcome was time from admission to SSRF. Secondary outcomes included SSRF duration and complications. Numerical data were presented as median (IQR), categorical data as number (%). Inverse probability weighting was used to control for confounding.

RESULTS

Two hundred and eighteen SSRF patients were included, 25 (11 %) were on antithrombotic therapy. These patients were older (72 years, (65-80) versus 57 years, (43-66); p < 0.001) with lower ISS (14, (10-20) versus 21, (14-30); p = 0.002). Time from admission to SSRF was comparable (2 days, (1-4) versus 2 days, (1-4); p = 0.37) as was operative time (154 mins, (120.0-212.0) versus 177 mins, (143.0-210.0); p = 0.34). Patients using antithrombotics had fewer ICU-free days (24 (22-26) versus 28 (23-28); p = 0.003) but more ventilator free days (28, (28-28) versus 27 (27-28); p < 0.008). After adjusting for confounding, pre-injury anticoagulation was not significantly associated with delayed SSRF (Relative Risk, RR=1.37, 95 % CI 0.30-6.24), operative time (RR=1.07, 95 % CI0.88-1.31), IFD <=28 (RR=2.05, 95 %CI:0.33-12.67), VFD<=27 (RR=0.71, 95 %CI:0.15-3.48) or complications (RR=0.55, 95 % CI0.06-5.01).

CONCLUSION

Pre-injury antithrombotic drug use neither delayed SSRF nor impacted operative time in patients requiring SSRF and was not associated with increased risk of complications. Our data suggest SSRF can be safely performed without delay in patients who use anticoagulation pre-injury.

LEVEL OF EVIDENCE

IV.

STUDY TYPE

Therapeutic/care management.

Age-Neutral Surgical Stabilization of Rib Fractures: Breaking the Ageism Barrier

INTRODUCTION

Surgical stabilization of rib fractures (SSRF) is associated with lower rates of mortality and fewer complications. This study evaluates whether the decision to undergo SSRF is associated with age, race, ethnicity, and insurance status and assesses associated clinical outcomes.

METHODS

This retrospective analysis included patients ≥45 y old with rib fractures who underwent SSRF in the Trauma Quality Improvement Program from 2016 to 2020. Race, ethnicity, and insurance statuses were collected. Age in years was dichotomized into two groups: 45-64 and 65+. Outcomes included ventilator-associated pneumonia, unplanned endotracheal intubation, acute respiratory distress syndrome, in-hospital mortality, failure to rescue (FTR) after major complications, and FTR after respiratory complications. Logistic regression models were fit to evaluate outcomes, controlling for gender, body mass index, Injury Severity Score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking.

RESULTS

Two thousand eight hundred thirty-nine patients aged 45-64 and 1828 patients aged 65+ underwent SSRF. No significant difference in clinical outcomes was noted between these groups. Analysis showed that the association of SSRF with ventilator-associated pneumonia, unplanned intubation, acute respiratory distress syndrome, in-hospital mortality, FTR after a major complication, or FTR after a respiratory complication did not vary by age (P > 0.05). Black (odds ratio [OR] 0.67; 95% confidence interval [CI]: 0.59-0.77; P < 0.001), Hispanic (OR 0.80; 95% CI: 0.71-0.91; P < 0.001), and Medicaid (OR = 0.85; 95% CI = 0.76-0.95; P = 0.005) patients were less likely to receive SSRF.

CONCLUSIONS

No differences in clinical outcomes were measured between adults aged 45-64 and ≥65 who underwent SSRF. Older age should not preclude patients from receiving SSRF. Further work is needed to improve underutilization in Black, Hispanic and Medicaid patients.

Surgical stabilization of rib fractures: The impact of volume and the need for standardized indications

INTRODUCTION

We aimed to examine impact of trauma center (TC) surgical stabilization of rib fracture (SSRF) volume on outcomes of patients undergoing SSRF.

METHODS

Blunt rib fracture patients who underwent SSRF were included from ACS-TQIP2017-2021. TCs were stratified according to tertiles of SSRF volume:low (LV), middle, and high (HV). Outcomes were time to SSRF, respiratory complications, prolonged ventilator use, mortality.

RESULTS

16,872 patients were identified (LV:5470,HV:5836). Mean age was 56 years, 74% were male, median thorax-AIS was 3. HV centers had a lower proportion of patients with flail chest (HV41% vs LV50%), pulmonary contusion (HV44% vs LV52%) and had shorter time to SSRF(HV58 vs LV76 ​h), less respiratory complications (HV3.2% vs LV4.5%), prolonged ventilator use (HV15% vs LV26%), mortality (HV2% vs LV2.6%) (all p ​< ​0.05). On multivariable regression analysis, HV centers were independently associated with reduced time to SSRF(β ​= ​-18.77,95%CI ​= ​-21.30to-16.25), respiratory complications (OR ​= ​0.67,95%CI ​= ​0.49-0.94), prolonged ventilator use (OR ​= ​0.49,95%CI ​= ​0.41-0.59), but not mortality.

CONCLUSIONS

HV SSRF centers have improved outcomes, however, there are variations in threshold for SSRF and indications must be standardized.

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Therapeutic/Care Management.

Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity matched analysis

BACKGROUND

Surgical stabilization of rib fractures (SSRF) improves outcomes in chest wall trauma. Geriatric patients are particularly vulnerable to poor outcomes; yet, this population is often excluded from SSRF studies. Further delineating patient outcomes by age is necessary to optimize care for the aging trauma population.

METHODS

A retrospective cohort study was conducted examining outcomes among patients aged 40+ for whom an SSRF consult was placed between 2017 and 2022 at a level 1 trauma center. Patients were categorized into geriatric (65+) and adult (40-64), as well as 80 years and older (80+) and 79 and younger (40-79). Patient outcomes were assessed comparing non-operative and operative management of chest wall trauma. Propensity matched analysis was performed to evaluate mortality differences between adult and geriatric patients who did and did not undergo SSRF.

RESULTS

A total of 543 patients had an SSRF consult. Of these, 227 were 65+, and 73 were 80+. A total of 129 patients underwent SSRF (24 %). The percentage of patients undergoing SSRF did not vary between 40 and 64 and 65+ (23.7 % and 23.6 %, respectively, p = 0.97) or 40-79 and 80+ (24.0 vs 21.9, p = 0.69). Patients undergoing SSRF had higher chest injury burden and were more likely to require mechanical ventilation and ICU level care on admission. Overall, in-hospital mortality rate was 4.6 %. Among patients who underwent SSRF, mortality rate did not significantly differ between 65+ and 40-64 (7.8% vs 2.7 %, p = 0.18) or 80+ and 40-79 (6.3% vs 4.6 %, p = 0.77). This remained true in propensity matched analysis.

CONCLUSION

Geriatric and octogenarian patients with rib fractures underwent SSRF at similar rates and achieved equivalent outcomes to their younger counterparts. SSRF did not differentially affect mortality outcomes based on age group in propensity matched analysis. SSRF is safe for geriatric patients including octogenarians.

Together is better - RibScore and SCARF in the prediction of pulmonary complications and association with SSRF

BACKGROUND

Optimal treatment of patients with rib fractures requires identification of those patients at risk of pulmonary complications. It is also important to determine which patients would benefit from Surgical Stabilisation of Rib Fractures (SSRF). This study aims to validate two scoring systems (RibScore and SCARF score) in predicting complications and association with SSRF in an Australian trauma population. Clinical observation suggests that complications and criteria for SSRF is associated with anatomical and physiological factors. Therefore it is hypothesized that utilisation of an anatomical (RibScore) and physiological (SCARF) in conjunction will have improved predictive ability.

METHOD

Retrospective cohort study of rib fracture patients admitted to an Australian Level I trauma centre from Jan 2017 to Jan 2021. RibScore and SCARF score were calculated. Multivariate logistic regression was performed to determine risk factors associated with complications and SSRF, as well the scoring systems' ability via ROC AUC.

RESULTS

1157 patients were included. Higher median RibScore (1vs0; p < 0.001) and SCARF score (3vs1, p < 0.001) was associated with development of complications. Similarly for SSRF, RibScore (3vs0; p < 0.001), SCARF score (3vs1; p < 0.001) were higher. On multivariate analysis, increasing RibScore and SCARF score were associated with an increased risk of respiratory failure, pneumonia, death, and SSRF. The sensitivity for a patient with a high risk score in either RibScore or SCARF increased to 96.3 % in identifying pulmonary complications (from 66.7 % in RibScore and 88 % in SCARF, when used individually) and 91.9 % in identifying association with SSRF (from 86.5 % in RibScore and 70.3 % in SCARF).

CONCLUSION

RibScore and SCARF score demonstrate predictive ability for complications and SSRF in an Australian trauma rib fracture population. Combining a radiological score with a clinical scoring system demonstrates improved sensitivity over each score individually for identifying patients at risk of complications from rib fractures, those who may require SSRF, and those who are low risk.

STUDY TYPE

Retrospective Cohort Study LEVEL OF EVIDENCE: Level III.

Management of Blunt Chest Trauma

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

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.

Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review

Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.

Surgical stabilization of rib fractures is associated with better return on investment for a health care institution than nonoperative management

BACKGROUND

Surgical stabilization of rib fractures (SSRFs) continues to gain popularity due to patient benefits. However, little has been produced regarding the economic benefits of SSRF and its impact on hospital metrics such as Vizient. The aim of this study was to explore these benefits hypothesizing SSRF will demonstrate positive return on investment (ROI) for a health care institution.

METHODS

This is a retrospective review of all rib fracture patients over 5 years at our Level I trauma center. Patients were grouped into SSRF versus nonoperative management. Basic demographics were obtained including case mix index (CMI). Outcomes included narcotic requirements in morphine milliequivalents prior to discharge, mortality, and discharge disposition. Furthermore, actual hospital length of stay (ALOS) versus Vizient expected length of stay were compared between cohorts. Contribution margin (CM) was also calculated. Independent t-test, paired t-test, and linear regression analysis were performed, and significance set at p < 0.05.

RESULTS

A total of 1,639 patients were included; 230 (14%) underwent SSRF. Age, gender, and Injury Severity Score were similar. Surgical stabilization of rib fracture patients had more ribs fractured (7 vs. 4; p < 0.001) and more patients with flail chest (43.5% vs. 6.7%; p < 0.001). Surgical stabilization of rib fracture patients also had a significantly higher CMI (4.33 vs. 2.78; p = 0.001). Narcotic requirements and mortality were less in the SSRF cohort; 155 versus 246 morphine milliequivalents ( p < 0.001) and 1.7% versus 7.1% ( p = 0.003), respectively. Surgical stabilization of rib fracture patients were more likely to be discharged home (70.4% vs. 63.7%; p = 0.006). Surgical stabilization of rib fracture patients demonstrated shorter ALOS where nonoperative management patients demonstrated longer ALOS compared with Vizient expected length of stay. Contribution margins for SSRF patients were significantly higher and linear regression analysis showed a CM $1,128.14 higher per patient undergoing SSRF ( p < 0.001).

CONCLUSION

Patients undergoing SSRF demonstrate a significant ROI for a health care organization. Despite SSRF patients having a higher CMI, they were able to be discharged sooner than expected by Vizient calculations resulting in better a CM.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis

BACKGROUND

Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI.

METHODS

We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017-2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours).

RESULTS

Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (β) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001-0.023), longer hospital LOS (β = 0.053; p < 0.001; 95% CI, 0.042-0.064), prolonged ICU LOS (β = 0.032; p < 0.001; 95% CI, 0.025-0.038), and more ventilator days (β = 0.026, p < 0.001; 95% CI, 0.020-0.032).

CONCLUSION

In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

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.

In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF.

METHODS

A retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days.

RESULTS

50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days.

CONCLUSION

In this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.

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.

Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis

BACKGROUND

Treatment for multiple rib fractures includes surgical stabilization of rib fractures (SSRF) or nonoperative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates versus NOM. Our study evaluated postoperative outcomes for multiple rib fracture patients following SSRF versus NOM in a real-world, all-comer study design.

METHODS

Multiple rib fracture patients with inpatient admissions in the PREMIER hospital database from October 1, 2015, to September 30, 2020, were identified. Outcomes included discharge disposition, and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, Abbreviated Injury Scale and Injury Severity Scores, and provider characteristics were determined for all patients. Patients were excluded from the cohort if they had a thorax Abbreviated Injury Scale score of <2 (low severity patient) or a Glasgow Coma Scale score of ≤8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting so that all patient data were kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links.

RESULTS

A total of 203,450 patients were included, of which 200,580 were treated with NOM and 2,870 with SSRF. Compared to NOM, patients with SSRF had higher rates of home discharge (62% SSRF vs. 58% NOM) and lower rates of lung-related readmissions (3 months, 3.1% SSRF vs. 4.0% NOM; 12 months, 6.2% SSRF vs. 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF versus NOM was 1.166 (95% confidence interval [CI], 1.073-1.266; p = 0.0002). Similarly, ORs for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF versus NOM (OR [3 months], 0.764 [95% CI, 0.606-0.963]; p = 0.0227 and OR [12 months], 0.799 [95% CI, 0.657-0.971]; p = 0.0245).

CONCLUSION

Surgical stabilization of rib fractures results in greater odds of home discharge and lower rates of lung-related readmissions compared with NOM at 12 months of follow-up.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Surgical and perioperative management of flail chest with titanium plates: a French cohort series from a thoracic referral center

BACKGROUND

The development of titanium claw plates has made rib osteosynthesis easy to achieve and led to a renewed interest for this surgery. We report the management of patients referred to the intensive care unit (ICU) of a referral center for surgical rib fracture fixation (SRFF) after chest trauma.

METHODS

We performed a retrospective observational cohort study describing the patients' characteristics and analyzing the determinants of postoperative complications.

RESULTS

From November 2013 to December 2016, 42 patients were referred to our center for SRFF: 12 patients (29%) had acute respiratory failure, 6 of whom received invasive mechanical ventilation. The Thoracic Trauma Severity Score (TTSS) was 11.0 [9-12], with 7 [5-9] broken ribs and a flail chest in 92% of cases. A postoperative complication occurred in 18 patients (43%). Five patients developed ARDS (12%). Postoperative pneumonia occurred in 11 patients (26%). Two patients died in the ICU. In multivariable analysis, the Thoracic Trauma Severity Score (TTSS) (OR = 1.89; CI 95% 1.12-3.17; p = 0.016) and the Simplified Acute Physiology Score II without age (OR = 1.17; CI 95% 1.02-1.34; p = 0.024) were independently associated with the occurrence of a postoperative complication.

CONCLUSION

The TTSS score appears to be accurate for determining thoracic trauma severity. Short and long-term benefit of Surgical Rib Fracture Fixation should be assessed, particularly in non-mechanically ventilated patients.

Rib fractures in the elderly population: a systematic review

BACKGROUND

Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates.

METHODS

Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered.

RESULTS

Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%).

CONCLUSION

It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.

Non-operative vs. operative treatment for multiple rib fractures after blunt thoracic trauma: a multicenter prospective cohort study

BACKGROUND

Patients with multiple rib fractures without a clinical flail chest are increasingly being treated with rib fixation; however, high-quality evidence to support this development is lacking.

METHODS

We conducted a prospective multicenter observational study comparing rib fixation to non-operative treatment in all patients aged 18 years and older with computed tomography confirmed multiple rib fractures without a clinical flail chest. Three centers performed rib fixation as standard of care. For adequate comparison, the other three centers performed only non-operative treatment. As such clinical equipoise formed the basis for the comparison in this study. Patients were matched using propensity score matching.

RESULTS

In total 927 patients with multiple rib fractures were included. In the three hospitals that performed rib fixation, 80 (14%) out of 591 patients underwent rib fixation. From the nonoperative centers, on average 71 patients were adequately matched to 71 rib fixation patients after propensity score matching. Rib fixation was associated with an increase in hospital length of stay (HLOS) of 4.9 days (95%CI 0.8-9.1, p = 0.02) and a decrease in quality of life (QoL) measured by the EQ5D questionnaire at 1 year of 0.1 (95% CI - 0.2-0.0, p = 0.035) compared to non-operative treatment. A subgroup analysis of patients who received operative care within 72 h showed a similar decrease in QoL. Up to 22 patients (28%) who underwent surgery experienced implant-related irritation.

CONCLUSIONS

We found no benefits and only detrimental effects associated with rib fixation. Based on these results, we do not recommend rib fixation as the standard of care for patients with multiple rib fractures.

TRIAL REGISTRATION

Registered in the Netherlands Trial Register NTR6833 on 13/11/2017.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Surgical Timing and Complications of Rib Fixation for Rib Fractures in Geriatric Patients

Rib fractures (RF) are a common injury that cause significant morbidity and mortality, especially in geriatric patients. RF fixation could shorten hospital stay and improve survival. The aim of this retrospective study was to evaluate the clinical impact and proper surgical timing of RF fixation in geriatric patients. We reviewed all the medical data of patients older than 16 years old with RF from the trauma registry database between January 2017 and December 2019 in Chang Gung Memorial Hospital. A total of 1078 patients with RF were enrolled, and 87 patients received RF fixation. The geriatric patients had a higher chest abbreviated injury scale than the non-geriatric group (p = 0.037). Univariate analysis showed that the RF fixation complication rates were significantly related to the injury severity scores (Odds ratio 1.10, 95% CI 1.03–1.20, p = 0.009) but not associated with age (OR 0.99, 95% CI 0.25–3.33, p = 0.988) or the surgical timing (OR 2.94, 95% CI 0.77–12.68, p = 0.122). Multivariate analysis proved that only bilateral RF was an independent risk factor of complications (OR 6.60, 95% CI 1.38–35.54, p = 0.02). RF fixation can be postponed for geriatric patients after they are stabilized and other lethal traumatic injuries are managed as a priority.

Operative Rib Fixation at a Rural Trauma Center

INTRODUCTION

Operative rib fixation is becoming more common in the management of rib fractures, with studies showing benefits of surgery in decreasing time on mechanical ventilation, ICU and total hospital length of stay, and mortality. This paper will review the data from our institution to determine if these benefits were seen in our trauma population.

METHODS

A retrospective review of the institution's trauma database was conducted, including operative patients (n = 36), control patients (nonoperative patients from October 2018 to October 2019, n = 207), and selected control patients based on similar injury severity score range as operative patients (n = 181). Data reviewed included time on mechanical ventilation, ICU and total hospital length of stay, and disposition at discharge, including mortalities. Operative complications were also reviewed.

RESULTS

The operative group had a higher ISS compared to both controls, longer average time on mechanical ventilation, longer average ICU and total hospital length of stay, and a higher percentage of patients discharged to inpatient facilities. However, the operative group had lower mortality compared to the control groups. The operative group had 3 surgical site infections requiring readmission and hardware removal.

DISCUSSION

Unlike other studies, our operative patients did not see improvements in time on mechanical ventilation, ICU and total hospital length of stay, or disposition at discharge, but did see a mortality benefit. Confounding factors include higher average ISS in the operative group, and over-sedation in the ICU. Data collection is ongoing, and refinements are being made to perioperative and ICU management to minimize these confounding variables.

The role of acute care surgeons in treating rib fractures-a retrospective cohort study from a single level I trauma center

BACKGROUND

Rib fractures are the most common thoracic injury in patients who sustained blunt trauma, and potentially life-threatening associated injuries are prevalent. Multi-disciplinary work-up is crucial to achieving a comprehensive understanding of these patients. The present study demonstrated the experience of an acute care surgery (ACS) model for rib fracture management from a single level I trauma center over 13 years.

METHODS

Data from patients diagnosed with acute rib fractures from January 2008 to December 2020 were collected from the trauma registry of Chang Gung Memorial Hospital (CGMH). Information, including patient age, sex, injury mechanism, Abbreviated Injury Scale (AIS) in different anatomic regions, injury severity score (ISS), index admission department, intensive care unit (ICU) length of stay (LOS), total admission LOS, mortality, and other characteristics of multiple rib fracture, were analyzed. Patients who received surgical stabilization of rib fractures (SSRF) were analyzed separately, and basic demographics and clinical outcomes were compared between acute care and thoracic surgeons.

RESULTS

A total of 5103 patients diagnosed with acute rib fracture were admitted via the emergency department (ED) of CGMH in the 13-year study period. The Department of Trauma and Emergency Surgery (TR) received the most patients (70.8%), and the Department of Cardiovascular and Thoracic Surgery (CTS) received only 3.1% of the total patients. SSRF was initiated in 2017, and TR performed fixation for 141 patients, while CTS operated for 16 patients. The basic demographics were similar between the two groups, and no significant differences were noted in the outcomes, including LOS, LCU LOS, length of indwelling chest tube, or complications. There was only one mortality in all SSRF patients, and the patient was from the CTS group.

CONCLUSIONS

Acute care surgeons provided good-quality care to rib fracture patients, whether SSRF or non-SSRF. Acute care surgeons also safely performed SSRF. Therefore, we propose that the ACS model may be an option for rib fracture management, depending on the deployment of staff in each institute.

A decade of surgical stabilization of rib fractures: the effect of study year on patient selection, operative characteristics, and in-hospital outcome

BACKGROUND

Many centers now perform surgical stabilization of rib fractures (SSRF). This single center study aimed to investigate temporal trends by year in patient selection, operative characteristics, and in-hospital outcomes We hypothesized that, over time, patient selection, time to SSRF, operative time, and in-hospital outcomes varied significantly.

METHODS

A retrospective review of a prospectively maintained SSRF database (2010 to 2020) was performed. Patients were stratified by year in which they underwent SSRF. The primary outcome was operative time, defined in minutes from incision to closure. Secondary outcomes were patient and operative characteristics, and in-hospital outcomes. Multivariable regression analyses were performed to assess for temporal trends, corrected for confounders. The outcomes ventilator-, Intensive Care Unit-, and hospital-free days (VFD, IFD, and HFD, respectively) were categorized based on the group's medians, and complications were combined into a composite outcome.

RESULTS

In total, 222 patients underwent SSRF on a median of one day after admission (P₂₅-P₇₅, 0-2). Patients had a median age of 54 years (P₂₅-P₇₅, 42-63), ISS of 19 (P₂₅-P₇₅, 13-26), RibScore of 3 (P₂₅-P₇₅, 2-5), and sustained a median of 8 fractured ribs (P₂₅-P₇₅, 6-11). In multivariable analysis, increasing study year was associated with an increase in operative time (p<0.0001). In addition, study year was associated with a significantly reduced odds of complications (Odds ratio [OR], 0.76; 95% Confidence Interval [95% CI], 0.63-0.92; p=0.005), VFD < 28 days (OR, 0.77; 95% CI, 0.65-0.92; p=0.003), IFD < 24 days (OR, 0.77; 95% CI, 0.66-0.91; p=0.002), and HFD < 18 days (OR, 0.64; 95% CI, 0.53-0.76; p<0.0001).

CONCLUSION

In-hospital outcomes after SSRF improved over time. Unexpectedly, operative time increased. The reason for this finding is likely multifactorial and may be related to patient selection, onboarding of new surgeons, fracture characteristics, and minimally invasive exposures. Due to potential for confounding, study year should be accounted for when evaluating outcomes of SSRF.

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.

Extubation of the potentially difficult airway in the intensive care unit

PURPOSE OF REVIEW

Extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10-20% patients further associated with significant morbidity and mortality. This review serves to highlight recent advancements and guidance on approaching extubation for patients at risk for difficult or failed extubation (DFE).

RECENT FINDINGS

Recent literature including closed claim analysis, meta-analyses, and national society guidelines demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an extubation strategy have been described as potential methods to decrease occurrence of DFE.

SUMMARY

Extubation in the ICU remains an elective decision and patients found to be at risk should be further optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be operationalized utilizing easily reproducible strategies, with airway experts present to guide decision making and assist in reintubation if needed.

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.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

Purpose

Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients.

Methods

A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern.

Results

In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11–0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, − 2.96 days; 95% CI − 5.70 to − 0.23; p = 0.034).

Conclusion

In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Surgical Stabilization of Rib Fractures Improves Outcomes in the Geriatric Patient Population

Introduction

Rib fractures in the ≥65-year-old population have been shown to strongly influence mortality and pneumonia rates. There is a growing body of evidence demonstrating improvements in the geriatric patient’s survival statistics and respiratory performances after surgical stabilization of rib fractures (SSRF). We have observed a strong survival and complication avoidance trend in geriatric patients who undergo SSRF. The purpose of our study was to evaluate the outcomes of geriatric patients with rib fractures treated with SSRF compared to those who only receive conservative therapies.

Methods

We performed a retrospective review of our trauma registry analyzing outcomes of patients ≥65 years with rib fractures. Patients admitted from 2015 to 2019 receiving SSRF (RP group) were compared to a nonoperative controls (NO group) admitted during the same time. Bilateral fractures were excluded. Independent variables analyzed = ISS, mortalities, hospital days, ICU days, pleural space complications, and readmissions. Follow-up was 60 days after discharge. Group comparison was performed using Kolmogorov-Smirnov, Shapiro-Wilk, and Mann-Whitney U tests.

Results

257 patients were analyzed: 172 in the NO group with mean age of 75 (65-10) and 85 in the RP group with mean age of 74 (65-96). Mean ISS = 13 (1-38) for the NO group and 20 (9-59) for the RP group ( P < .001). Mean hospital days = 8 (1-39) and 15 (3-49) in NO and RP groups, respectively. Mean ICU days = 10 (1-32) and 8 (1-11) in NO and RP groups, respectively. Deaths, pneumonia, readmissions, and pleural effusions in the NO group were statistically significant ( P < .01). Analysis of complications revealed 4 RP patients (4.7%) with respiratory complications out to 60 days and 65 NO patients (37.8%) ( P < .001).

Conclusions

Surgical stabilization of rib fractures appears to be associated with a survival advantage and an avoidance of respiratory-related complications in the ≥65-year-old patient population.

What is the optimal timing to perform surgical stabilization of rib fractures?

The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.

The Cheshire & Merseyside Collaborative trainee-led on-call service: a review of safety and efficiency

AIM

To assess safety and efficiency of the Cheshire & Merseyside Collaborative, the largest trainee led on-call service in the UK, based on discrepancy rates and time taken to issue reports.

MATERIALS & METHODS

All studies reported by the collaborative in a 4-week period were evaluated for discrepancy and the time taken to issue a report. These figures were compared against the Royal College of Radiologists (RCR) guidelines and a recent national audit of discrepancy rates. The time taken to report was measured against the National Institute of Health and Clinical Excellence (NICE) and Trauma Audit Research Network (TARN) guidelines.

RESULTS

The overall discrepancy rates for the collaborative were 2.5% for minor discrepancies and 2% for major discrepancies, which is within the RCR standard. The median time taken to issue a report was 30 min, which is within the NICE and TARN 1-h targets.

CONCLUSIONS

The Cheshire & Merseyside Collaborative can be deemed a safe and efficient way of delivering an out-of-hours radiology service.

What's new in trauma 2020

Throughout the past 2020, the pandemic COVID-19 has caused a big global shock, meanwhile it brought a great impact on the public health network. Trauma emergency system faced a giant challenge and how to manage trauma under the pandemic of COVID-19 was widely discussed. However, the trauma treatment of special population (geriatric patients and patients taking anticoagulant drugs) has received inadequate attention. Due to the high mortality following severe traumatic hemorrhage, hemostasis and trauma-induced coagulopathy are the important concerns in trauma treatment. Sepsis is another topic should not be ignored when we talking about trauma. COVID-19 itself is a special kind of sepsis, and it may even be called as serious systemic infection syndrome. Sepsis has been become a serious problem waiting to be solved urgently no matter in the fields of trauma, or in intensive care and infection, etc. This article reviewed the research progress in areas including trauma emergency care, trauma bleeding and coagulation, geriatric trauma and basic research of trauma within 2020.