Prognostic Factors and Clinical Outcomes of Surgical Treatment of Major Thoracic Trauma

BACKGROUND

Major thoracic trauma represents a life-threatening condition, requiring a prompt multidisciplinary approach and appropriate pathways for effective recovery. While acute morbidity and mortality are well-known outcomes in thoracic-traumatized patients, long-term quality of life in patients surviving surgical treatment has not been widely investigated before.

METHODS

Between November 2016 and November 2023, thirty-two consecutive patients were operated on because of thoracic trauma. Age, sex, comorbidities, location and extent of thoracic trauma, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), Organ Injury Scale (OIS), intra and extrathoracic organ involvement, mechanism of injury, type of surgical procedure, postoperative complications, ICU and total length of stay, immediate clinical outcomes and long-term quality of life-by using the EQ-5D-3L scale and Numeric Rate Pain Score (NPRS)-were collected for each patient Results: Results indicated no significant difference in EQOL.5D3L among patients with thoracic trauma based on AIS (p = 0.55), but a significant difference was observed in relation to ISS (p = 0.000011).

CONCLUSIONS

ISS is correlated with the EQOL.5D3L questionnaire on long-term quality of life, representing the best prognostic factor-in terms of long-term quality of life-in patients surviving major thoracic trauma surgical treatment.

Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients

BACKGROUND

Optimal treatment (i.e., nonoperative or operative) for patients with multiple rib fractures remains debated. Studies that compare treatments are rationalized by the alleged poor outcomes of nonoperative treatment.

METHODS

The aim of this prospective international multicenter cohort study (between January 2018 and March 2021) with 1-year follow-up, was to report contemporary outcomes of nonoperatively treated patients with multiple rib fractures. Including 845 patients with three or more rib fractures. Primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay (HLOS), (pulmonary) complications, and quality of life.

RESULTS

Mean age was 57.7 ± 17.0 years, median Injury Severity Score was 17 (13-22) and the median number of rib fractures was 6 (4-8). In-hospital mortality rate was 1.5% (n = 13), 112 (13.3%) patients had pneumonia and four (0.5%) patients developed a symptomatic nonunion. The median HLOS was 7 days (4-13 days), and median intensive care unit length of stay was 2 days (1-5 days). Mean 5-Level Quality of Life Questionnaire index value was 0.83 ± 0.18 1 year after trauma. Polytrauma patients had a median HLOS of 10 days (6-18 days), a pneumonia rate of 17.6% (n = 77) and mortality rate of 1.7% (n = 7). Elderly patients (≥65 years) had a median HLOS of 9 days (5-15 days), a pneumonia rate of 19.7% (n = 57) and mortality rate of 4.1% (n = 12).

CONCLUSION

Overall, nonoperative treatment of patients with multiple rib fractures shows low mortality and morbidity rate and good quality of life after 1 year. Future studies evaluating the benefit of operative stabilization should use contemporary outcomes to establish the therapeutic margin of rib fixation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

3D-printed external fixation guide combined with video-assisted thoracoscopic surgery for the treatment of flail chest: a technical report and case series

Background

Flail chest is a common and serious traumatic condition in thoracic surgery. The treatment of flail chest often includes open reduction and internal fixation, which is relatively traumatic, complicated, and expensive. As three-dimensional (3D) printing technology is widely used in the clinical field, the application of 3D-printed products to chest trauma will become a new treatment option. To date, the use of 3D-printed external fixation guides for flail chests has not been reported. Thus, we aimed to assess the short-term efficacy of a new technology that treated flail chests with an individualized 3D-printed external fixation guide combined with video-assisted thoracoscopic surgery (VATS).

Patients and methods

A retrospective analysis was performed on patients with flail chest treated with this new technique at our center from January 2020 to December 2022. The following parameters were included: operative time, thoracic tube extraction time, intensive care unit time, thoracic volume recovery rate, visual analog scale score 1 month postoperatively, and postoperative complication rate. All patients were followed up for at least 3 months.

Results

Five patients (mean age: 45.7 years) were enrolled; they successfully underwent surgery without chest wall deformity and quickly returned to daily life. The average number of rib fractures was 8.4; all patients had lung contusion, hemopneumothorax, and anomalous respiration. The abnormal breathing of all patients was completely corrected on postoperative day 1, and the chest wall was stable. One case experienced mild loosening of the 3D-printed guide postoperatively; however, the overall stability was not affected. The other four cases did not experience such loosening because we replaced the ordinary silk wire with a steel wire. All cases were discharged from the hospital 2 weeks postoperatively and returned to normal life 1 month after the removal of the 3D-printed guide on average. Only one case developed a superficial wound infection postoperatively, and no perioperative death occurred.

Conclusions

The 3D-printed external fixation guide combined with video-assisted thoracoscopic surgery is a novel technique in the treatment of flail chest and is safe, effective, feasible, and minimally invasive, with satisfactory clinical efficacy.

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.

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.

Treatment and outcome in combined scapula and rib fractures: a retrospective study

PURPOSE

The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies.

METHODS

All adult (≥ 18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed.

RESULTS

A total of 223 patients were admitted with concurrent ipsilateral rib and scapula fractures. A total of 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only, and seven patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax and revision surgery) between groups.

CONCLUSION

Injury severity resulted in different treatment modalities. As a result, different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible; however, the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.

Surgical fixation of rib fractures improves 30-day survival after significant chest injury : an analysis of ten years of prospective registry data from England and Wales

AIMS

The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries.

METHODS

A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy.

RESULTS

A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001).

CONCLUSION

SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729-735.

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.

Complete Video-assisted Thoracoscopic Surgery for Rib Fractures: A Series of 35 Cases

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) for internal fixation of rib fracture is a promising approach for treating rib fractures and flail chest. Currently, the standard practice is to make one or several incisions on the chest wall, which will inevitably aggravate the original trauma.

METHODS

We retrospectively analyzed the data of patients with rib fractures who were treated with memory alloy for internal fixation by complete VATS using a thoracoscopic transthoracic memory alloy rib coaptation board and an implantation tool through the clip applier method or the puncture, traction and suspension method at our hospital from October 2016 to June 2019.

RESULTS

There were 35 patients, of whom 12 had traumatic flail chest injury, and 23 had simple multiple rib fractures. Of the 23 patients with multiple rib fractures, 9 had fracture ends in the scapular or paravertebral region, and 14 had fracture ends located in the anterior or lateral chest walls. All surgeries were performed with complete VATS, and it showed quick recovery and good thoracic appearance and function, with no complications for all patients. Follow-up for 6-24 months revealed no detachment of the internal fixation device.

CONCLUSIONS

Internal memory alloy fixation with complete VATS for the treatment of rib fractures is a simple and minimally invasive method, which enables fixing fractured ribs internally while treating thoracic trauma with a thoracoscope.

Utilization of Percentage of Predicted Forced Vital Capacity to Stratify Rib Fracture Patients: An Updated Clinical Practice Guideline

BACKGROUND

Rib fractures are the most common injuries diagnosed after blunt thoracic trauma and are a source of significant morbidity and mortality. Early identification of at-risk patients and initiation of effective analgesia are keys to mitigating complications from these injuries. Multiple tools exist to predict pulmonary decompensation after rib fractures; however, none has found a widespread acceptance. A clinical practice guideline (CPG) utilizing Forced vital capacity (FVC) has been in place at a single institution. The goal of this study is to update the CPG to use percentage of predicted FVC (FVC%) instead of FVC to triage patients with rib fractures.

MATERIALS AND METHODS

A retrospective study of 266 patients with rib fractures was conducted. Patients were divided into 3 groups based on FVC of <1000 mL, 1001-1500 mL, or >1500 mL for analysis. Data were analyzed with analysis of variance, and Youden's J Index was used to identify inflection points.

RESULTS

Patients in the high-risk category were more likely to be women, older than 65 years, admitted to the intensive care unit (ICU), transferred to the ICU, require intubation, and have overall longer hospital and ICU stays. The updated CPG triage cutoffs for admission to ICU, stepdown, and floor were redefined as FVC% values of <25%, 25-45%, and >45%, respectively.

DISCUSSION

The updated CPG using FVC% may more accurately identify patients with compromised physiology and be a better tool to help predict patients who are at risk for decompensation following rib fractures. A validation study for the updated CPG is in progress.

A model for evaluating the biomechanics of rib fracture fixation

INTRODUCTION

High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation.

METHODS

One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes.

FINDINGS

Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating.

INTERPRETATION

This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.

Traumatic rib fractures: a marker of severe injury. A nationwide study using the National Trauma Data Bank

Background

In recent years, there has been increasing interest in the treatment of patients with rib fractures. However, the current literature on the epidemiology and outcomes of rib fractures is outdated and inconsistent. Furthermore, although it has been suggested that there is a large heterogeneity among patients with traumatic rib fractures, there is insufficient literature reporting on the outcomes of different subgroups.

Methods

A retrospective cohort study using the National Trauma Data Bank was performed. All adult patients with one or more traumatic rib fractures or flail chest who were admitted to a hospital between January 2010 and December 2016 were identified by the International Classification of Diseases Ninth Revision diagnostic codes.

Results

Of the 564 798 included patients with one or more rib fractures, 44.9% (n=2 53 564) were patients with polytrauma. Two per cent had open rib fractures (n=11 433, 2.0%) and flail chest was found in 4% (n=23 388, 4.1%) of all cases. Motor vehicle accidents (n=237 995, 51.6%) were the most common cause of rib fractures in patients with polytrauma and flail chest. Blunt chest injury accounted for 95.5% (n=5 39 422) of rib fractures. Rib fractures in elderly patients were predominantly caused by high and low energy falls (n=67 675, 51.9%). Ultimately, 49.5% (n=2 79 615) of all patients were admitted to an intensive care unit, of whom a quarter (n=146 191, 25.9%) required invasive mechanical ventilatory support. The overall mortality rate was 5.6% (n=31 524).

Discussion

Traumatic rib fractures are a marker of severe injury as approximately half of patients were patients with polytrauma. Furthermore, patients with rib fractures are a very heterogeneous group with a considerable difference in epidemiology, injury characteristics and in-hospital outcomes. Worse outcomes were predominantly observed among patients with polytrauma and flail chest. Future studies should recognize these differences and treatment should be evaluated accordingly.

Level of evidence

II/III.

Current status and research progress of minimally invasive surgery for flail chest

Chest trauma accounts for ~13.5% of all traumas, and direct death from chest trauma accounts for 20–25% of all traumatic deaths. Chest trauma is the second cause of death from trauma. Frequent rib fractures, especially in patients with flail chest, often cause severe pain, chest wall softening, abnormal breathing and severe lung contusion and laceration, usually requiring thoracic surgery. In recent years, the open reduction and internal fixation treatment of rib fractures with flail chest has achieved satisfactory results, and some surgical indications have reached consensus. A number of scholars and medical centers have demonstrated the practicality and cost-effectiveness of rib fixation in flail chest, including the small incidence of pulmonary complications, the short ICU mechanical ventilation time, and the reduction of digestive tract inhibition. Open reduction and internal fixation of rib fractures involves multiple ribs. Conventional rib fractures require a large incision to achieve satisfactory exposure. Chest wall muscles, blood vessels and nerves (long thoracic and thoracodorsal nerves) are injured, resulting in a high infection rate of the incision and postoperative dysfunctions, such as limited upper limb, shoulder and back function, and long time numbness on the affected side of the chest. Therefore, the damage of muscles and nerves caused by conventional surgical methods limits the development of such surgical technique. Although the video-assisted thoracoscopic technique has become a necessary technical means for the treatment of thoracic trauma and has been applied to thoracic exploration and hemostasis, there is no report on the application of open reduction and internal fixation for rib fracture. The difficulty lies in the tightly combined bony thorax and the soft tissue of the chest wall. Therefore, experts have explored a variety of minimally invasive surgical methods for the flail chest. The current status and research progress of minimally invasive surgery for thoracic surgery are reviewed.

The evaluation of pulmonary function after rib fixation for multiple rib fractures and flail chest: a retrospective study and systematic review of the current evidence

PURPOSE

The primary aim of this retrospective cohort study was to evaluate the pulmonary function after rib fixation for patients with multiple rib fractures and flail chest. Secondary, a systematic review was performed to give an overview of the current literature and to allow comparison with our results.

METHODS

All adult (≥ 18 years) patients who underwent rib fixation for multiple rib fractures or flail chest between 2010 and 2018 and who received a control pulmonary function test during the postoperative follow-up at our level-1 trauma center were retrospectively reviewed. Secondary, the PubMed, EMBASE and Cochrane databases were searched to identify studies reporting on the pulmonary function after rib fixation. The primary outcome parameters were the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), FEV₁/FVC ratio, maximum vital capacity (VC_max), total lung capacity (TLC), residual volume (RV), and RV/TC ratio.

RESULTS

Of the 103 patients who underwent rib fixation, a total of 61 (59%) patients underwent a pulmonary function test in our hospital and were ultimately included. In the majority of patients all pulmonary function parameters fell within the normal range of the reference values. Obstructive impairment was predominantly seen in patients with pre-existing chronic obstructive pulmonary disease (COPD). Patients with multiple rib fractures had better recovery compared to those with a flail chest. The systematic review included a total of 15 studies and showed comparable results.

CONCLUSION

The present study demonstrates that rib fixation for multiple rib fractures or flail chest results in adequate recovery of the pulmonary function within 3 months after surgery. In addition, based on the current literature, further gradual improvement to maximum pulmonary values appears to occur during the first 12 months after rib fixation.

Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol

INTRODUCTION

A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures.

METHODS AND ANALYSIS

In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest.

ETHICS AND DISSEMINATION

The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication.

TRIAL REGISTRATION NUMBER

NTR6833.

Functional Outcomes After Muscle-Sparing Fixation of Flail Chest Injuries

OBJECTIVES

To present outcomes in a multicenter review of a large number of flail chest patients.

DESIGN

Retrospective case series.

SETTING

One urban Level I and 1 urban Level II trauma center.

PATIENTS/PARTICIPANTS

Fifty-two adult patients who underwent treatment of their flail chest injury with locking plate and screw constructs through muscle-sparing approaches, followed for a minimum of 1 year postoperatively.

RESULTS

All patients went on to successful union, with complication rates in line with recent published norms. Periscapular strength returned to greater than 90% of the noninjured side by 3 months postoperatively and to within a mean of 95% of the noninjured side by 6 months postoperatively. Glenohumeral range of motion similarly improved over this same interval.

CONCLUSIONS

Use of anatomically designed modern locking plate and screw fixation constructs with muscle-sparing approaches results in efficient return to function and restoration of shoulder function and strength as compared with the noninjured shoulder.

LEVEL OF EVIDENCE

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

Flail Chest: Less Deadly than Originally Thought

INTRODUCTION

Flail chest is considered a highly morbid condition with reported mortality ranging from 10 to 20%. It is often associated with other severe injuries, which may complicate management and interpretation of outcomes. The physiologic impact and prognosis of isolated flail chest injury is poorly defined.

METHODS

This is a National Trauma Databank study. All patients from 1/2007 to 12/2014 admitted with flail chest were extracted. Patients with head or abdominal AIS ≥3, dead on arrival, or transferred, were excluded. Primary outcome was mortality; secondary outcomes were need for mechanical ventilation and pneumonia.

RESULTS

Of the 1,047,519 patients with blunt chest injury, 14,718 (1.4%) patients presented with flail chest, and 8098 (0.77%) met inclusion criteria. The most commonly associated intrathoracic injuries were hemothorax (57.9%) and lung contusions (63.0%), while sternal fracture (8.8%) and cardiac contusion (2.5%) were less common. In total, 29.8% of patients required mechanical ventilation, and 11.2% developed pneumonia. Overall mortality was 5.6%. On multivariable analysis, age >65 and need for mechanical ventilation were independent risk factors for mortality (OR 6.02, 3.75, respectively, p < 0.001). Independent predictors for mechanical ventilation included cardiac or pulmonary contusion and sternal fractures (OR 3.78, 2.38, 2.29, respectively, p < 0.001). Need for mechanical ventilation was an independent predictor of pneumonia (OR 13.18, p < 0.001).

CONCLUSIONS

Mortality in isolated flail chest is much lower than previously reported. Fewer than 30% of patients require mechanical ventilation. Need for mechanical ventilation, however, is independently associated with mortality and pneumonia. Age >65 is an independent risk factor for adverse outcomes, and these patients may benefit by more aggressive monitoring and treatment.

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.

Outcome Analysis of Surgical Stabilization of Rib Fractures in Trauma Patients

OBJECTIVES

To compare outcomes in patients with rib fractures (RFX) who underwent surgical stabilization of rib fractures (SSRF) to those treated nonoperatively.

DESIGN

Retrospective cohort study.

SETTING

Two Level 1 Trauma Centers.

PATIENTS

One hundred seventy-four patients with multiple RFX divided into 2 groups: patients with surgically stabilized RFX (n = 87) were compared with nonoperatively managed patients in the matched control group (MCG) (n = 87).

INTERVENTION

SSRF.

OUTCOME MEASUREMENTS

Age, sex, injury severity score, RFX, mortality, hospital length of stay (HLOS) and intensive care unit length of stay (ICULOS), duration of mechanical ventilation (DMV), co-injuries, and time to surgery. Patients were further stratified by presence or absence of flail chest and pulmonary contusion (PC).

RESULTS

Flail chest, displaced RFX, and PC were present significantly more often in SSRF patients compared with the MCG. Mortality was lower in SSRF group. HLOS and ICULOS were longer in SSRF group compared with the corresponding MCG patients regardless of timing to surgery (P < 0.01 for all). SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV to MCG patients with flail chest (P > 0.3 for all). SSRF patients without flail chest had significantly longer HLOS and ICULOS than MCG patients without flail chest (P < 0.001 for both). Presence of PC did not affect lengths of stay.

CONCLUSIONS

SSRF patients had reduced mortality compared with nonoperatively managed patients. HLOS, ICULOS, and DMV were longer in SSRF patients than in MCG. When flail chest was present, lengths of stay were comparable. PC did not seem to affect the surgical outcome.

LEVEL OF EVIDENCE

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

Injury patterns among pedestrians using assistive mobility devices

INTRODUCTION

As the population ages, growing numbers of individuals are turning to assisted mobility devices (AMDs) to maintain independence. These devices often place users in a seated position. Like ambulatory pedestrians, pedestrians seated in an AMD are at risk for involvement in an automobile versus pedestrian crash. The purpose of this study is to compare the injury pattern and comorbidities of standing pedestrians struck by an automobile versus those of seated pedestrians.

METHODS

The Arizona State Trauma Registry was queried for pedestrians struck by an automobile between 2010 and 2015. Using ICD 9 and 10 codes as well as other available documentation, seated pedestrians were identified and matched based on age and gender to standing pedestrians. Presence of co-morbidities, injury pattern, Injury Severity Score (ISS), hospital length of stay (LOS), and mortality were compared between the two groups.

RESULTS

There were 70 seated pedestrians identified, matched to 140 standing pedestrians. Co-morbidities were present in 89% of seated pedestrians vs 66% of standing pedestrians (p = 0.002). Functional dependence was more prevalent in the seated pedestrians (21% vs 1%, p = 0.004). There were not significant differences in the proportion of AIS injuries by body region. However, within the thoracic region, seated pedestrians were more likely to suffer pulmonary contusions: 14% vs 4%, p = 0.05.

CONCLUSIONS

The injury pattern for seated pedestrians differs slightly from that of standing pedestrians struck by an automobile. However, seated pedestrians are more likely to have co-morbid conditions that may complicate care. These findings are important when caring for the injured pedestrian and performing injury prevention outreach.

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.

Long-term follow-up after rib fixation for flail chest and multiple rib fractures

Purpose

Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures.

Methods

All adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone.

Results

Of the 864 patients admitted with ≥ 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18–34) and 21 (IQR 16–29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62–1) and 0.79 (0.62–0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal.

Conclusions

We show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.

Electronic supplementary material

The online version of this article (10.1007/s00068-018-1009-5) contains supplementary material, which is available to authorized users.

Flail Chest: Influence on Length of Stay and Mortality in Blunt Chest Injury

Flail chest is used as one of the indicators for rib fixation, which is being performed more frequently. Radiologic and clinical flail chest are not clearly differentiated in published studies and the relationship between radiologic flail chest (RFC) and outcomes are not clearly established. Our study was designed to evaluate the relationship of RFC to outcomes in patients with severe blunt chest injury. Adult patients with severe blunt chest injury admitted between January 1, 2014, and June 30, 2016, were identified retrospectively. Three hundred and eighty-three patients were studied and mortality rate was not significantly different in patients with an RFC diagnosis (5.88%) compared with patients without RFC (3.83%), P = 0.50. Length of stay (LOS) in patients with and without RFC were compared and patients with RFC were found to have a statistically significant increase in both hospital and intensive care unit LOS (P = 0.0178, P < 0.0017). Multivariate analysis confirmed RFC as an independent predictor of increased LOS when compared with the number of rib fractures and displacements. Our study suggests that RFC may drive inappropriate use of rib fixation. This questions the justification of liberal rib fixation based on the perceived high mortality rate of modern flail chest diagnoses.

Early Surgical Stabilization of Complex Chest Wall Injuries Improves Short-Term Patient Outcomes

BACKGROUND

This study aimed to assess the outcome of patients undergoing internal fixation of complex rib fractures in a U.K. major trauma center.

METHODS

A retrospective analysis was performed on all patients undergoing operative fixation of rib fractures from March 2014 to May 2016. Outcome measures included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, infection, and mortality.

RESULTS

One hundred and two patients (66 male patients and 36 female patients, with a median age of 62 years) underwent rib fracture fixation during the study period. The causes of trauma were road traffic accidents in 39 patients (38%), a fall from a substantial height in 38 patients (37%), and a fall down stairs in 21 patients (21%). Thirty-eight patients (37%) had isolated chest trauma, and 64 patients (63%) had additional injuries. Fifty-three patients (52%) required ICU admission with a mean ICU stay of 4.7 days (range, 1 to 34 days). The median hospital length of stay was 10.6 days (range, 3 to 51 days). Patients with additional injuries (p = 0.01) and those requiring mechanical ventilation (p < 0.0001) stayed significantly longer. Sixty-five patients (64%) underwent rib fixation within 48 hours of the injury, and 37 patients (36%) underwent the surgical procedure after 48 hours. A surgical procedure within 48 hours resulted in a shorter ICU stay (p = 0.01), fewer cases of pneumonia (p = 0.001), reduced duration of mechanical ventilation (p = 0.03) and fewer tracheostomies (p = 0.02), and shorter hospital length of stay (11.5 compared with 17.3 days; p = 0.008).

CONCLUSIONS

Surgical stabilization of multiple rib fractures may improve the outcome in patients with multiple injuries and isolated chest wall trauma. Early surgical fixation leads to shorter length of stay and better outcomes.

LEVEL OF EVIDENCE

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

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

PURPOSE OF REVIEW

Renewed interest in surgical fixation of rib fractures has emerged. However, conservative treatment is still preferred at most surgical departments. We wanted to evaluate whether operative treatment of rib fractures may benefit severely injured patients.

RECENT FINDINGS

Several studies report a reduction in mechanical ventilation time, ICU length of stay (LOS), hospital LOS, pneumonia, need for tracheostomy, pain and costs in operatively treated patients with multiple rib fractures compared with patients treated nonoperatively. Although patient selection and timing of the operation seem crucial for successful outcome, no consensus exists. Mortality reduction has only been shown in a few studies. Most studies are retrospective cohort and case-control studies. Only four randomized control trials exist.

SUMMARY

Conservative treatment, consisting of respiratory assistance and pain control, is still the treatment of choice in the vast majority of patients with multiple rib fractures. In selected patients, operative fixation of fractured ribs within 72 h postinjury may lead to better outcome. More randomized control trials are needed to further determine who benefits from surgical fixation of rib fractures.

Operative Stabilization of Flail Chest Injuries Reduces Mortality to That of Stable Chest Wall Injuries

OBJECTIVE

To determine the prevalence, management and outcomes of patients with flail chest injuries, compared to patients without flail chest injuries (single rib fractures and multiple rib fractures without a flail segment).

DESIGN

Retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Ontario residents over the age of 16 years who had been admitted to hospital with a chest wall injury from 2004 to 2015 were identified using administrative health care databases.

MAIN OUTCOME MEASUREMENTS

Outcomes included treatment modalities such as rate of surgical repair, days on mechanical ventilation, days in the intensive care unit, days in hospital, rate of chest tube placement; and rates of complication, including pneumonia, tracheostomy, readmission, and death.

RESULTS

In total 117,204 patients with fractures of the chest wall were identified. Of the entire cohort, 1.5% of them had a flail chest injury, 41% had multiple rib fractures, and 58% had single rib fractures. Patients with flail chest injuries had significantly worse outcomes compared to patients with multiple rib fractures in all categories (P < 0.0001). Similarly, patients with multiple rib fractures had significantly worst outcomes compared with patients with single rib fractures (P < 0.0001). Only 4.5% of patients with flail chest injuries were treated surgically, however, the number increased from 1% before 2010 to 10% after 2010 (P < 0.0001). After adjustment for potential confounders, patients with flail chest injuries treated surgically had a reduced risk of early mortality compared to those treated nonoperatively (OR 0.16, P = 0.019).

CONCLUSIONS

Surgical stabilization of flail chest injuries has increased significantly in recent years. The results of this study provide preliminary evidence that the increasing rate of surgical intervention may be warranted by reducing mortality.

LEVEL OF EVIDENCE

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

Favorable Outcomes in Blunt Chest Injury with Noninvasive Bi-Level Positive Airway Pressure Ventilation

Recent clinical research in patients with blunt chest injury has focused on the benefits of surgical fixation of rib fractures. Noninvasive ventilation (NIV) has been demonstrated to prevent the need for intubation and ventilation in posttraumatic respiratory failure. The preemptive use of NIV in patients with rib fractures has not been extensively studied. Our study evaluated the outcomes of patients with ≥3 rib fractures and hospitalized for ≥ 4 days. Seventy-one patients treated with NIV were compared with 270 patients without NIV. NIV patients were older (65.8 vs 56.5 years) had more rib fractures (6.25 vs 5.32) and a higher body mass index (31 vs 27.8) than the comparison group, P < 0.05, but did not have an increased mortality or incidence of respiratory failure. NIV patients did have a statistically significant increase in length of stay compared to control (12.8 vs 8.8, P < 0.05). In the total sample, worse clinical outcomes were associated with older age, increased number of and bilateral rib fractures, higher Injury Severity Score, lower Glasgow Coma Scale, and higher body mass index. Outcomes in the most severely injured group of patients treated with NIV were comparable to other studies using surgical fixation of rib fractures and epidural pain control.

Acute forces required for fatal compression asphyxia: A biomechanical model and historical comparisons

Background Fatalities from acute compression have been reported with soft-drink vending machine tipping, motor vehicle accidents, and trench cave-ins. A major mechanism of such deaths is flail chest but the amount of force required is unclear. Between the range of a safe static chest compression force of 1000 N (102 kg with earth gravity) and a lethal dynamic force of 10-20 kN (falling 450 kg vending machines), there are limited quantitative human data on the force required to cause flail chest, which is a major correlate of acute fatal compression asphyxia. Methods We modeled flail chest as bilateral fractures of six adjacent ribs. The static and dynamic forces required to cause such a ribcage failure were estimated using a biomechanical model of the thorax. The results were then compared with published historical records of judicial "pressing," vending machine fatalities, and automobile safety cadaver testing. Results and conclusion The modeling results suggest that an adult male requires 2550 ± 250 N of chest-applied distributed static force (260 ± 26 kg with earth gravity) or 4050 ± 320 N of dynamic force to cause flail chest from short-term chest compression.

Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis

OBJECTIVES

Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis.

METHODS

This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis.

RESULTS

Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY.

CONCLUSIONS

Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation.

LEVEL OF EVIDENCE

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

Blunt thoracic trauma: recent advances and outstanding questions

PURPOSE OF REVIEW

The treatment of blunt thoracic injuries is complex and evolving. The aim of this review is to focus on what is new with ventilation for blunt chest trauma as well as an update on the current management strategies for blunt aortic injury and rib fractures.

RECENT FINDINGS

Early use of noninvasive ventilation appears to be well tolerated in select hemodynamically stable blunt trauma patients. For those patients requiring intubation, airway pressure release ventilation is an excellent mode to decrease the risk of posttraumatic acute lung injury. Endovascular repair of blunt thoracic aortic injuries provides benefit over open repair and, if possible, delayed repair confers a mortality advantage. Despite its increasing use, there continue to be conflicting results about the role of surgical rib fixation for the treatment of flail chest.

SUMMARY

Blunt thoracic injuries are commonly treated in the ICU and a solid knowledge of mechanical ventilation strategies (both noninvasive and invasive) is essential. Blunt thoracic aortic injuries require early diagnosis and aggressive blood pressure management. Not all such injuries need operative repair but those that do benefit from an endovascular approach. The management of flail chest includes early aggressive multimodal analgesia, adequate oxygen, and ventilatory support. Surgical rib fixation should be considered in select patients.

Clinical Outcomes of Surgical Stabilization of Flail Chest Injury

INTRODUCTION

Recent reported success in surgical stabilization of flail chest has been described in small series, but scant evidence exists for this procedure in the orthopaedic literature.

METHODS

We reviewed 88 consecutive patients who underwent surgical stabilization of flail chest, along with 88 consecutive patients with flail chest who underwent traditional closed management before initiation of our algorithm change to surgical management.

RESULTS

Surgical stabilization of flail chest injuries led to statistically significant decreases in hospital length of stay, ventilator-dependency time, pneumonia, tracheostomy, and mortality rate. In addition, the presence of pulmonary contusion did not eliminate the significant improvements in the aforementioned variables.

DISCUSSION

Surgical stabilization of flail chest with modern techniques and implants provides significant improvements in both mortality and short-term outcomes. Although pulmonary contusion decreased overall outcomes across both cohorts, this factor did not alter the ability of rib fixation to improve outcomes.

Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest

BACKGROUND

Open reduction and internal fixation (ORIF) of fractured ribs for flail chest is safe and effective but who is most likely to benefit is unknown. Our purpose is to compare ORIF with nonoperative management (NOM) in polytrauma patients.

METHODS

Albany Medical Center Hospital Trauma Registry was queried for adult patients with flail chest admitted over 7 years.

RESULTS

Eighty-six patients with radiographic flail chest were identified who met inclusion criteria. The 41 ORIF and 45 NOM patients had similar demographics and injury severity. Hospital length of stay and intensive care unit length of stay were significantly longer in the ORIF group than that of the NOM group. There was a trend toward longer time on the ventilator in the ORIF group.

CONCLUSIONS

In this retrospective study, patients treated by ORIF had longer hospitalization and ventilator duration. Future studies should be designed to optimally identify patients who are most likely to benefit from ORIF.

Critical Care for the Patient With Multiple Trauma

Trauma remains the leading cause of death worldwide and the leading cause of death in those less than 44 years old in the United States. Admission to a verified trauma center has been shown to decrease mortality following a major injury. This decrease in mortality has been a direct result of improvements in the initial evaluation and resuscitation from injury as well as continued advances in critical care. As such, it is vital that intensive care practitioners be familiar with various types of injuries and their associated treatment strategies as well as their potential complications in order to minimize the morbidity and mortality frequently seen in this patient population.