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Tullington JE, Brown LR, Flippin JA, Fu CY, Patel J, Bokhari F. The Effects of Pulmonary Risk Factors and Combination Thoracic Osseous Fractures on Mortality and Outcomes of Surgical Stabilization of Rib Fractures. Am Surg 2024:31348241244627. [PMID: 38569537 DOI: 10.1177/00031348241244627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
BACKGROUND Rib fixation for traumatic rib fractures is advocated to decrease morbidity and mortality in select patient populations. We intended to investigate the effect of combination osseous thoracic injuries on mortality with the hypothesis that combination injuries will worsen overall mortality and that SSRF will improve outcomes in combination injuries and in high-risk patients. METHODS Patients with rib fractures were identified from the Trauma Quality Improvement Project registry from 2019. Patients were then divided into rib fracture(s) alone or in combination with sternal, thoracic vertebra, or scapula fracture. Patients were also categorized into those with COPD and smokers. Patients with AIS >3 outside of thorax were excluded. Patients were subcategorized into those who had rib fixation verse nonoperative management for all subgroups. Analysis was performed to evaluate the efficacy of rib fixation. RESULTS A total of 111,066 patients were included for analysis. The overall mortality was 1.4%. Patients with COPD had over double the mortality risk, with an overall mortality of 3.4%. Combination injuries did not appear to increase mortality. SSRF did not decrease mortality; however, the number of patients in this group was too small to complete statistical analysis. The overall complication rate was 0.43%. There was a trend towards an increase in extrapulmonary complications in the group that underwent surgical fixation. DISCUSSION Mortality from rib fractures with concomitant osseous thoracic fracture appears to be low. However, mortality is increased in patients with COPD regardless of rib fracture pattern. The number of patients who underwent SSRF was too small to make a statistical comparison.
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Affiliation(s)
- Jessica E Tullington
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
- Trauma Surgery Department, OSF HealthCare Saint Francis Medical Center, Peoria, IL, USA
| | - Laura R Brown
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
- Trauma Surgery Department, OSF HealthCare Saint Francis Medical Center, Peoria, IL, USA
| | - J Alford Flippin
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
- Trauma Surgery Department, OSF HealthCare Saint Francis Medical Center, Peoria, IL, USA
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung University, Taoyuan, Taiwan
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jasmine Patel
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
- Trauma Surgery Department, OSF HealthCare Saint Francis Medical Center, Peoria, IL, USA
| | - Faran Bokhari
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
- Trauma Surgery Department, OSF HealthCare Saint Francis Medical Center, Peoria, IL, USA
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van Zyl T, Ho AMH, Klar G, Haley C, Ho AK, Vasily S, Mizubuti GB. Analgesia for rib fractures: a narrative review. Can J Anaesth 2024; 71:535-547. [PMID: 38459368 DOI: 10.1007/s12630-024-02725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/11/2023] [Accepted: 12/27/2023] [Indexed: 03/10/2024] Open
Abstract
PURPOSE Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. SOURCE Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. PRINCIPAL FINDINGS Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. CONCLUSION Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).
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Affiliation(s)
- Theunis van Zyl
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Gregory Klar
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Christopher Haley
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Adrienne K Ho
- Department of Public Health Sciences (Epidemiology), School of Medicine, Queen's University, Kingston, ON, Canada
| | - Susan Vasily
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology & Perioperative Medicine, Queen's University, Kingston General Hospital, Victory 2 Wing, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
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Ye JB, Lee JY, Seok J. Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report. J Int Med Res 2024; 52:3000605241244990. [PMID: 38629496 PMCID: PMC11025438 DOI: 10.1177/03000605241244990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024] Open
Abstract
We present the case of a victim of a motor vehicle accident in his late 60s who suffered from severe torso injuries. He initially presented with abdominal and chest pain, and underwent emergency laparotomy for hemoperitoneum. After surgery, the patient developed pneumonia and septicemia, which were responsive to antibiotics. The patient was treated with mechanical ventilation in the intensive care unit for approximately 10 days and experienced a severe weight loss of approximately 30%, but slowly recovered without dyspnea. Notably, on hospital day 24, he experienced sudden respiratory distress and flail motion of the chest wall in a general ward. This late presentation of flail chest was attributed to non-union at rib fracture sites, and was likely exacerbated by malnutrition and osteomyelitis. Surgical stabilization of rib fractures and excision of the infected rib were successfully performed. The findings from this case highlight the complexity of managing delayed onset of flail chest. The findings from this case suggest the importance of vigilance for late emerging complications in patients with trauma, even when initial symptoms are absent.
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Affiliation(s)
- Jin Bong Ye
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Jin Young Lee
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, South Korea
- Department of Trauma Surgery, College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - Junepill Seok
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, South Korea
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Chungbuk National University, Cheongju, South Korea
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4
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Corrales MA, Bolte JH, Pipkorn B, Markusic C, Cronin DS. Explaining and predicting the increased thorax injury in aged females: age and subject-specific thorax geometry coupled with improved bone constitutive models and age-specific material properties evaluated in side impact conditions. Front Public Health 2024; 12:1336518. [PMID: 38532975 PMCID: PMC10964717 DOI: 10.3389/fpubh.2024.1336518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/05/2024] [Indexed: 03/28/2024] Open
Abstract
Predicting and understanding thorax injury is fundamental for the assessment and development of safety systems to mitigate injury risk to the increasing and vulnerable aged population. While computational human models have contributed to the understanding of injury biomechanics, contemporary human body models have struggled to predict rib fractures and explain the increased incidence of injury in the aged population. The present study enhanced young and aged human body models (HBMs) by integrating a biofidelic cortical bone constitutive model and population-based bone material properties. The HBMs were evaluated using side impact sled tests assessed using chest compression and number of rib fractures. The increase in thoracic kyphosis and the associated change in rib angle with increasing age, led to increased rib torsional moment increasing the rib shear stress. Coupled with and improved cortical bone constitutive model and aged material properties, the higher resulting shear stress led to an increased number of rib fractures in the aged model. The importance of shear stress resulting from torsional load was further investigated using an isolated rib model. In contrast, HBM chest compression, a common thorax injury-associated metric, was insensitive to the aging factors studied. This study proposes an explanation for the increased incidence of thorax injury with increasing age reported in epidemiological data, and provides an enhanced understanding of human rib mechanics that will benefit assessment and design of future safety systems.
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Affiliation(s)
| | - John Henry Bolte
- Injury Biomechanics Research Center, Ohio State University, Columbus, OH, United States
| | - Bengt Pipkorn
- Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
- Autoliv Research, Vårgårda, Sweden
| | - Craig Markusic
- Honda Development & Manufacturing of America, Raymond, OH, United States
| | - Duane S. Cronin
- Department of MME, University of Waterloo, Waterloo, ON, Canada
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5
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Lopez-Melia M, Magnin V, Marchand-Maillet S, Grabherr S. Deep learning for acute rib fracture detection in CT data: a systematic review and meta-analysis. Br J Radiol 2024; 97:535-543. [PMID: 38323515 PMCID: PMC11027249 DOI: 10.1093/bjr/tqae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/16/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Abstract
OBJECTIVES To review studies on deep learning (DL) models for classification, detection, and segmentation of rib fractures in CT data, to determine their risk of bias (ROB), and to analyse the performance of acute rib fracture detection models. METHODS Research articles written in English were retrieved from PubMed, Embase, and Web of Science in April 2023. A study was only included if a DL model was used to classify, detect, or segment rib fractures, and only if the model was trained with CT data from humans. For the ROB assessment, the Quality Assessment of Diagnostic Accuracy Studies tool was used. The performance of acute rib fracture detection models was meta-analysed with forest plots. RESULTS A total of 27 studies were selected. About 75% of the studies have ROB by not reporting the patient selection criteria, including control patients or using 5-mm slice thickness CT scans. The sensitivity, precision, and F1-score of the subgroup of low ROB studies were 89.60% (95%CI, 86.31%-92.90%), 84.89% (95%CI, 81.59%-88.18%), and 86.66% (95%CI, 84.62%-88.71%), respectively. The ROB subgroup differences test for the F1-score led to a p-value below 0.1. CONCLUSION ROB in studies mostly stems from an inappropriate patient and data selection. The studies with low ROB have better F1-score in acute rib fracture detection using DL models. ADVANCES IN KNOWLEDGE This systematic review will be a reference to the taxonomy of the current status of rib fracture detection with DL models, and upcoming studies will benefit from our data extraction, our ROB assessment, and our meta-analysis.
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Affiliation(s)
- Manel Lopez-Melia
- University Centre of Legal Medicine Lausanne-Geneva, Geneva 1206, Switzerland
- University Hospital and University of Geneva, Geneva 1205, Switzerland
| | - Virginie Magnin
- University Centre of Legal Medicine Lausanne-Geneva, Geneva 1206, Switzerland
- University Hospital and University of Geneva, Geneva 1205, Switzerland
- University Hospital and University of Lausanne, Lausanne 1005, Switzerland
| | | | - Silke Grabherr
- University Centre of Legal Medicine Lausanne-Geneva, Geneva 1206, Switzerland
- University Hospital and University of Geneva, Geneva 1205, Switzerland
- University Hospital and University of Lausanne, Lausanne 1005, Switzerland
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Towe CW, Bachman KC, Ho VP, Pieracci F, Worrell SG, Moorman ML, Linden PA, Badrinathan A. Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample. Medicina (Kaunas) 2024; 60:153. [PMID: 38256413 PMCID: PMC10819862 DOI: 10.3390/medicina60010153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/01/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.
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Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Vanessa P Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH 44109, USA
| | - Fredric Pieracci
- Department of Surgery Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80045, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Matthew L Moorman
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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7
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Tetsumoto K, Takayama M, Koyama T, Kayawake H, Saito M, Nakamura K, Takahashi Y, Hamakawa H. Penetrating cardiac injury caused by multiple rib fractures following high-energy trauma: Usefulness of the exploratory video-assisted thoracoscopic surgery. Acute Med Surg 2024; 11:e938. [PMID: 38596161 PMCID: PMC11002335 DOI: 10.1002/ams2.938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/03/2024] [Accepted: 02/25/2024] [Indexed: 04/11/2024] Open
Abstract
Background Penetrating cardiac injuries are usually fatal and associated with poor survival rates. Case Presentation A 69-year-old man was injured in a motor vehicle accident and suffered from left hemothorax and multiple rib fractures near the heart. A comprehensive assessment raised suspicions of lacerated pericardium and myocardial injury. Consequently, a thoracoscopy was performed 9 h after injury. A penetrating cardiac injury was detected and surgically treated via video-assisted thoracoscopic surgery. The patient recovered uneventfully and was discharged on postoperative day 16. Conclusion Exploratory video-assisted thoracoscopic surgery may play a key role in the primary diagnosis of patients with high-energy chest traumas with cardiac injury and simultaneously allow for the appropriate surgical interventions.
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Affiliation(s)
- Keisuke Tetsumoto
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
- Department of Thoracic SurgeryHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Masakazu Takayama
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Tadaaki Koyama
- Department of Cardiovascular SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Hidenao Kayawake
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Masao Saito
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Ken Nakamura
- Department of Cardiovascular SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Yutaka Takahashi
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
| | - Hiroshi Hamakawa
- Department of Thoracic SurgeryKobe City Medical Center General HospitalKobeJapan
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Ladhani HA, Harrell KN, Burlew CC, van Wijck SFM, Smith EF, Coleman JR, Horwood C, Werner NL, Lawless R, Platnick B, Campion E, Moore EE, VanDerPloeg D, Parry JA, Pieracci FM. Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries. Am Surg 2023; 89:5813-5820. [PMID: 37183169 DOI: 10.1177/00031348231175496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- Husayn A Ladhani
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Kevin N Harrell
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Elizabeth F Smith
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
| | - Julia R Coleman
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Chelsea Horwood
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole L Werner
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Lawless
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Barry Platnick
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric Campion
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel VanDerPloeg
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Orthopedic Surgery, Denver Health Hospital and Authority, Denver, CO, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Hospital and Authority, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
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9
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Taylor Z, Miller J, Azani DZ, Patterson B, McCague A. Management of a Flail Chest Caused by Multiple Costosternal Fractures: A Case Report. Cureus 2023; 15:e51082. [PMID: 38274933 PMCID: PMC10808774 DOI: 10.7759/cureus.51082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/23/2023] [Indexed: 01/27/2024] Open
Abstract
Costochondral separation is a rare consequence of blunt thoracic trauma and can lead to life-threatening complications such as a flail chest. The diagnosis of costochondral separation remains challenging due to the obscurity of the condition on chest radiographs. Surgical rib fixation is a viable treatment option and research regarding its effectiveness and long-term benefits is promising but still evolving. Here, we discuss a case of flail chest caused by multiple costosternal fractures definitively managed with surgical rib fixation.
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Affiliation(s)
- Zachary Taylor
- Medicine, College of Osteopathic Medicine of the Pacific - Northwest, Western University of Health Sciences, Lebanon, USA
- General Surgery, Desert Regional Medical Center, Palm Springs, USA
| | - Jeremy Miller
- Surgery, Desert Regional Medical Center, Palm Springs, USA
| | - Danielle Z Azani
- General Surgery, Desert Regional Medical Center, Palm Springs, USA
| | | | - Andrew McCague
- Trauma and Acute Care Surgery, Desert Regional Medical Center, Palm Springs, USA
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10
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Bassiri A, Badrinathan A, Kishawi S, Sinopoli J, Linden PA, Ho VP, Towe CW. Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis. Medicina (Kaunas) 2023; 59:2046. [PMID: 38004095 PMCID: PMC10673139 DOI: 10.3390/medicina59112046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/31/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.
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Affiliation(s)
- Aria Bassiri
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Avanti Badrinathan
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Sami Kishawi
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Jillian Sinopoli
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Philip A. Linden
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
| | - Vanessa P. Ho
- Department of Surgery, Division of Trauma, Critical Care, Burns, and Acute Care Surgery, MetroHealth Medical Center, Cleveland, OH 44109, USA;
| | - Christopher W. Towe
- Department of Surgery, Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA; (A.B.); (A.B.); (S.K.); (J.S.); (P.A.L.)
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11
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Lampridis S, Scarci M. Editorial: Recent advances in the assessment and management of thoracic trauma. Front Surg 2023; 10:1325928. [PMID: 38033526 PMCID: PMC10684930 DOI: 10.3389/fsurg.2023.1325928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023] Open
Affiliation(s)
- Savvas Lampridis
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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12
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Snyder R, Brillhart DB. Pain Control and Point-of-Care Ultrasound: An Approach to Rib Fractures for the Austere Provider. J Spec Oper Med 2023; 23:70-73. [PMID: 37253154 DOI: 10.55460/5ey1-gpam] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 06/01/2023]
Abstract
Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.
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13
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Fearing M, Behzadpour V, House RD, Tarakemeh A, Morey T, Randall J, Vopat B, Darche JP. Rib Stress Fractures and a Novel Muscle-Sparing Rib Fixation Plating in an Elite Tennis Player: A Systematic Review of the Literature and Case Report. Sports Health 2023:19417381231195271. [PMID: 37688535 DOI: 10.1177/19417381231195271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2023] Open
Abstract
A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during a routine overhead movement. The patient was eventually diagnosed with 2 lower rib stress fractures. After unsuccessful conservative management, the player underwent an open reduction and internal fixation and autologous bone grafting of the sixth and seventh ribs with a muscle-sparing approach and was able to return to full competition. We present this case along with a systematic review of the literature regarding rib stress fractures, which included 6 separate online data sources (PubMed, EMBASE, Cochrane, CINAHL, SportDiscus, and Medline). The successful surgical intervention demonstrates a significant option for elite athletes who wish to return to competition but have been unable to with standard of care conservative management of rib stress fractures.
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Affiliation(s)
- Marcus Fearing
- Department of Family Medicine and Sports Medicine, University of Kansas Health System, Kansas City, Kansas
| | - Vafa Behzadpour
- University of Kansas School of Medicine - Wichita Campus, Wichita, Kansas
| | - Richard D House
- Department of Orthopaedic Surgery and Sports Medicine, University of Kansas Health System, Kansas City, Kansas
| | - Armin Tarakemeh
- Department of Orthopaedic Surgery and Sports Medicine, University of Kansas Health System, Kansas City, Kansas)
| | - Tucker Morey
- Department of Orthopaedic Surgery and Sports Medicine, University of Kansas Health System, Kansas City, Kansas
| | - Jeffrey Randall
- Department of Orthopaedic Surgery and Sports Medicine, University of Kansas Health System, Kansas City, Kansas
| | - Bryan Vopat
- Department of Orthopaedic Surgery and Sports Medicine, University of Kansas Health System, Kansas City, Kansas
| | - Jean-Philippe Darche
- Department of Family Medicine and Sports Medicine, University of Kansas Health System, Kansas City, Kansas
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14
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Evans WE, Briese A, Gratton A, Yon JR, Mentzer CJ. Rib Fractures With Concomitant Spinal Fractures May Benefit From Surgical Stabilization. Am Surg 2023; 89:3928-3929. [PMID: 37195634 DOI: 10.1177/00031348231175123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Surgical stabilization of rib fractures has demonstrated benefits in patients with complex thoracic injuries. Limited information exists regarding patients with thoracic injuries and concomitant spinal injuries. We hypothesized that patients who suffer both thoracic cage and spinal fractures and undergo surgical fixation (FIX) will have improved outcomes compared to non-fixation (NFIX) patients. In our retrospective review, adult patients with rib injuries from 2015 to 2019 were pooled from the National Trauma Data Bank. Mortality with FIX rib fractures with spinal fractures decreased by 6.1% vs the NFIX group. Mortality of FIX of rib fractures without spinal fractures decreased by 2.2% vs the NFIX group. Patients with rib fractures with concomitant spinal fracture (RFWSF) are more likely to receive rib FIX than those with rib fractures without spinal fractures. Rib FIX in patients with RFWSF vs those with RFWO facilitates less ventilators days and shorter ICU and hospital length of stay (LOS) as well as decreases mortality.
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Affiliation(s)
- Warren E Evans
- Department of Surgery, Spartanburg Regional Medical Center, Spartanburg, SC, USA
| | - Amanda Briese
- Department of Surgery, Novant Health Regional Medical Center, Wilmington, NC, USA
| | - Austin Gratton
- Department of Surgery, Novant Health Regional Medical Center, Wilmington, NC, USA
| | - James R Yon
- Department of Surgery, Novant Health Regional Medical Center, Wilmington, NC, USA
| | - Caleb J Mentzer
- Department of Surgery, Spartanburg Regional Medical Center, Spartanburg, SC, USA
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15
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Bai J, Sun J, Cheng XG, Liu F, Liu H, Wang X. Construction and Application of Rib Fracture Diagnosis Model Based on YOLOv3 Algorithm. Fa Yi Xue Za Zhi 2023; 39:343-349. [PMID: 37859472 DOI: 10.12116/j.issn.1004-5619.2023.230308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVES The artificial intelligence-aided diagnosis model of rib fractures based on YOLOv3 algorithm was established and applied to practical case to explore the application advantages in rib fracture cases in forensic medicine. METHODS DICOM format CT images of 884 cases with rib fractures caused by thoracic trauma were collected, and 801 of them were used as training and validation sets. A rib fracture diagnosis model based on YOLOv3 algorithm and Darknet53 as the backbone network was built. After the model was established, 83 cases were taken as the test set, and the precision rate, recall rate, F1-score and radiology interpretation time were calculated. The model was used to diagnose a practical case and compared with manual diagnosis. RESULTS The established model was used to test 83 cases, the fracture precision rate of this model was 90.5%, the recall rate was 75.4%, F1-score was 0.82, the radiology interpretation time was 4.4 images per second and the identification time of each patient's data was 21 s, much faster than manual diagnosis. The recognition results of the model was consistent with that of the manual diagnosis. CONCLUSIONS The rib fracture diagnosis model in practical case based on YOLOv3 algorithm can quickly and accurately identify fractures, and the model is easy to operate. It can be used as an auxiliary diagnostic technique in forensic clinical identification.
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Affiliation(s)
- Jie Bai
- Beijing Public Security Bureau, Beijing 100192, China
| | - Jing Sun
- Beijing Jishuitan Hospital Affiliated to Capital Medical University, Beijing 100035, China
| | - Xiao-Guang Cheng
- Beijing Jishuitan Hospital Affiliated to Capital Medical University, Beijing 100035, China
| | - Fan Liu
- Beijing Public Security Bureau, Beijing 100192, China
| | - Hua Liu
- Beijing Public Security Bureau, Beijing 100192, China
| | - Xu Wang
- Key Laboratory of Evidence Law and Forensic Science, Ministry of Education, China University of Political Science and Law, Beijing 100088, China
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16
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Hoepelman RJ, van der Linde RA, Beeres FJ, Beks RB, Sweet AA, Lansink KW, van Wageningen B, Tromp TN, Minervini F, Link BC, van Veelen NM, Hoogendoorn JM, de Jong MB, van Baal MC, Leenen LP, Groenwold RH, Houwert RM, IJpma FF. In patients with combined clavicle and multiple rib fractures, does fracture fixation of the clavicle improve clinical outcomes? A multicenter prospective cohort study of 232 patients. J Trauma Acute Care Surg 2023; 95:249-255. [PMID: 37165478 PMCID: PMC10389406 DOI: 10.1097/ta.0000000000004001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/15/2023] [Accepted: 03/29/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Clavicle and rib fractures are often sustained concomitantly. The combination of injuries may result in decreased stability of the chest wall, making these patients prone to (respiratory) complications and prolonged hospitalization. This study aimed to assess whether adding chest wall stability by performing clavicle fixation improves clinical outcomes in patients with concurrent clavicle and rib fractures. METHODS A prospective multicenter study was performed including all adult patients admitted between January 2018 and March 2021 with concurrent ipsilateral clavicle and rib fractures. Patients treated operatively versus nonoperatively for their clavicle fracture were matched using propensity score matching. The primary outcome was hospital length of stay (HLOS). Secondary outcomes were intensive care unit length of stay, duration of mechanical ventilation, pain, complications, and quality of life at 6 weeks and 12 months of follow-up. RESULTS In total, 232 patients with concomitant ipsilateral clavicle and rib fractures were included. Fifty-two patients (22%) underwent operative treatment of which 39 could be adequately matched to 39 nonoperatively treated patients. No association was observed between clavicle plate fixation and HLOS (mean difference, 2.3 days; 95% confidence interval, -2.1 to 6.8; p = 0.301) or any secondary endpoint. Eight of the 180 nonoperatively treated patients (4%) had a symptomatic nonunion, for which 5 underwent secondary clavicle fixation. CONCLUSION We found no evidence that, in patients with combined clavicle and multiple rib fractures, plate fixation of the clavicle reduces HLOS, pain, or (pulmonary) complications, nor that it improves quality of life. STUDY TYPE Therapeutic/Care Management; Level III.
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17
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Huang ST, Liu LR, Chiu HW, Huang MY, Tsai MF. Deep convolutional neural network for rib fracture recognition on chest radiographs. Front Med (Lausanne) 2023; 10:1178798. [PMID: 37593404 PMCID: PMC10427862 DOI: 10.3389/fmed.2023.1178798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Introduction Rib fractures are a prevalent injury among trauma patients, and accurate and timely diagnosis is crucial to mitigate associated risks. Unfortunately, missed rib fractures are common, leading to heightened morbidity and mortality rates. While more sensitive imaging modalities exist, their practicality is limited due to cost and radiation exposure. Point of care ultrasound offers an alternative but has drawbacks in terms of procedural time and operator expertise. Therefore, this study aims to explore the potential of deep convolutional neural networks (DCNNs) in identifying rib fractures on chest radiographs. Methods We assembled a comprehensive retrospective dataset of chest radiographs with formal image reports documenting rib fractures from a single medical center over the last five years. The DCNN models were trained using 2000 region-of-interest (ROI) slices for each category, which included fractured ribs, non-fractured ribs, and background regions. To optimize training of the deep learning models (DLMs), the images were segmented into pixel dimensions of 128 × 128. Results The trained DCNN models demonstrated remarkable validation accuracies. Specifically, AlexNet achieved 92.6%, GoogLeNet achieved 92.2%, EfficientNetb3 achieved 92.3%, DenseNet201 achieved 92.4%, and MobileNetV2 achieved 91.2%. Discussion By integrating DCNN models capable of rib fracture recognition into clinical decision support systems, the incidence of missed rib fracture diagnoses can be significantly reduced, resulting in tangible decreases in morbidity and mortality rates among trauma patients. This innovative approach holds the potential to revolutionize the diagnosis and treatment of chest trauma, ultimately leading to improved clinical outcomes for individuals affected by these injuries. The utilization of DCNNs in rib fracture detection on chest radiographs addresses the limitations of other imaging modalities, offering a promising and practical solution to improve patient care and management.
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Affiliation(s)
- Shu-Tien Huang
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Liong-Rung Liu
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Hung-Wen Chiu
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Big Data Research Center, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Ming-Yuan Huang
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Ming-Feng Tsai
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
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18
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Singh S, Avinash R, Jaiswal S, Kumari A. Comparison of safety and efficacy of thoracic epidural block and erector spinae plane block for analgesia in patients with multiple rib fractures: A pilot single-blinded, randomised controlled trial. Indian J Anaesth 2023; 67:614-619. [PMID: 37601936 PMCID: PMC10436724 DOI: 10.4103/ija.ija_844_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 04/29/2023] [Accepted: 04/29/2023] [Indexed: 08/22/2023] Open
Abstract
Background and Aims Pain associated with rib fractures is challenging to manage. This pilot trial aimed to assess the efficacy of erector spinae plane block (ESPB) compared with thoracic epidural analgesia (TEA) for controlling pain associated with multiple rib fractures. Methods This randomised, single-blinded, controlled pilot study was conducted on trauma patients who had three or more rib fractures and had been admitted at a tertiary care centre. The study was conducted after receiving ethical approval and trial registration. Patients were randomised into two groups: TEA and ESPB, from February 2019 to February 2020. In the ESPB group, a unilateral or bilateral catheter was inserted in the erector spinae space, and an infusion of 0.125% bupivacaine was started. In the TEA group, the thoracic epidural catheter was inserted, and 0.125% bupivacaine infusion was started. Rescue analgesia using intravenous morphine (0.1 mg/kg) was administered if the Visual Analogue Scale (VAS) score was >3 for 48 hours postoperatively. The primary endpoint was total morphine consumption after administration of ESPB and TEA in patients with a rib fracture. Results Forty patients completed the study, with 20 in each group. Total morphine consumption by patients in the ESPB group was 5.38 ± 2.6 mg per 48 hours, and by those in the TEA group was 5.22 ± 2.11 mg per 48 hours (P = 0.883). Thirty minutes after starting the infusion, mean arterial pressure (MAP) was 64.8 ± 2.1 mmHg in the ESPB group and 57.2 ± 1.3 mmHg in the TEA group (P = 0.00001). Conclusion Total morphine consumption was not statistically different in this pilot trial among the two groups. ESP block may provide similar analgesia with better haemodynamic stability compared to TEA in patients with multiple traumatic rib fractures.
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Affiliation(s)
- Swati Singh
- Department of Anesthesia and Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Raja Avinash
- Department of Anesthesia and Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Shreyas Jaiswal
- Department of Anesthesia and Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Anita Kumari
- Department of Anesthesia and Critical Care, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
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Shandilya S, Roy S, Rai A, Kumar S, Kumar S, Tiwari S, Sonkar AA. A Prospective Observational Study on the Outcome Assessment of Conservative Management Versus Intercostal Drainage (ICD) in Blunt Chest Injury Patients With ≤3 Rib Fractures in a North Indian Tertiary Care Center. Cureus 2023; 15:e42167. [PMID: 37602137 PMCID: PMC10439305 DOI: 10.7759/cureus.42167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Trauma is the third most common cause of death in all age groups. One out of four trauma patients die due to thoracic injury or its complications. Seventy percent of thoracic traumas are due to blunt injury. This indicates the importance of chest trauma among all traumas. Quick and precise assessment bears paramount importance in deciding life-saving and definitive management. Often, the initial management in blunt injury patients is based on subjective assessment by the attending clinician. A scoring system that provides early identification of the patients at the greatest risk for respiratory failure and more likely to require mechanical ventilation and require prolonged care, as well as those with a higher mortality risk, may allow the early institution of intervention to improve outcomes. Thoracic Trauma Severity Score (TTSS) poses to be a precise tool in directing the management modality to be employed. Methodology This was an observational study including 112 patients of age >12 years, with blunt chest injury, sustaining ≤3 rib fractures, and with a stable chest wall. The patients with penetrating injury, those with blunt chest injury having flail segment, patients in the pediatric age group (<12 years), or polytrauma patients were excluded from our study. Of the 112 patients, 56 had been managed by intercostal drainage (ICD), and the rest (56) had been managed conservatively. Result Road traffic accidents (RTA) were the most common mode of injury in both groups. The percentage of the patients with one, two, and three rib fractures was 57.14%, 32.14%, and 10.71%, respectively, in the ICD group and 85.71%, 7.14%, and 7.14%, respectively, in the conservative management group (p = 0.124). The mean TTSS score was significantly more in the ICD group as compared to the conservative management group in the single rib fracture patients (p = 0.001*), as well as all patients of any number of rib fractures (p < 0.01*) (significance was defined as a value of p less than 0.05 {indicated by an asterisk}). The mean hospital stay was significantly lower in the conservative group as compared to the ICD group (p < 0.01*). The mean SF-36 (outcome) was significantly more in the conservative management group as compared to the ICD group (p = 0.020*). The mean cost of treatment was significantly more in the ICD group as compared to the conservative management group (p < 0.001*). Conclusion In our study, a TTSS (as measured by the primary care surgeon) of >7, across any number of rib fractures, was preferably predictive of management by ICD, while a <7 value was favorable for conservative management. TTSS can be used as an important tool to predict the management modality in blunt chest injury patients with ≤3 rib fractures.
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Affiliation(s)
| | - Shubhajeet Roy
- Medical Sciences, King George's Medical University, Lucknow, IND
| | - Anurag Rai
- Thoracic Surgery, King George's Medical University, Lucknow, IND
| | - Suresh Kumar
- General Surgery, King George's Medical University, Lucknow, IND
| | - Shailendra Kumar
- Thoracic Surgery, King George's Medical University, Lucknow, IND
- General Surgery, King George's Medical University, Lucknow, IND
| | - Sandeep Tiwari
- Trauma Surgery, King George's Medical University, Lucknow, IND
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20
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Selvendran S, Cheluvappa R. Management Pathways for Traumatic Rib Fractures-Importance of Surgical Stabilisation. Healthcare (Basel) 2023; 11:healthcare11081064. [PMID: 37107898 PMCID: PMC10138113 DOI: 10.3390/healthcare11081064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/29/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Rib fractures occur in almost half of blunt chest wall trauma victims in Australia. They are associated with a high rate of pulmonary complications, and consequently, with increased discomfort, disability, morbidity, and mortality. This article summarises thoracic cage anatomy and physiology, and chest wall trauma pathophysiology. Institutional clinical strategies and clinical pathway "bundles of care" are usually available to reduce mortality and morbidity in patients with chest wall injury. This article analyses multimodal clinical pathways and intervention strategies that include surgical stabilisation of rib fractures (SSRF) in thoracic cage trauma patients with severe rib fractures, including flail chest and simple multiple rib fractures. The management of thoracic cage injury should include a multidisciplinary team approach with proper consideration of all potential avenues and treatment modalities (including SSRF) to obtain the best patient outcomes. There is good evidence for the positive prognostic role of SSRF as part of a "bundle of care" in the setting of severe rib fractures such as ventilator-dependent patients and patients with flail chest. However, the use of SSRF in flail chest treatment is uncommon worldwide, although early SSRF is standard practice at our hospital for patients presenting with multiple rib fractures, flail chest, and/or severe sternal fractures. Several studies report that SSRF in patients with multiple simple rib fractures lead to positive patient outcomes, but these studies are mostly retrospective studies or small case-control trials. Therefore, prospective studies and well-designed RCTs are needed to confirm the benefits of SSRF in patients with multiple simple rib fractures, as well as in elderly chest trauma patients where there is scant evidence for the clinical outcomes of SSRF intervention. When initial interventions for severe chest trauma are unsatisfactory, SSRF must be considered taking into account the patient's individual circumstances, clinical background, and prognostic projections.
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Affiliation(s)
- Selwyn Selvendran
- Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia
| | - Rajkumar Cheluvappa
- Nursing and Midwifery, Australian Catholic University, Watson, ACT 2602, Australia
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21
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Johnston LR, Nam JJ, Nissen AP, Sleeter JJ, Aden JK, Mills AF, Sams VG. Admission Forced Vital Capacity Adds a Predictive Physiologic Tool to Triage Patients Suffering Rib Fractures: A Prospective Observation Trial. J Spec Oper Med 2023; 23:107-113. [PMID: 36878850 DOI: 10.55460/4dsk-9d0e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Patients with rib fractures are at high risk for morbidity and mortality. This study prospectively examines bedside percent predicted forced vital capacity (% pFVC) in predicting complications for patients suffering multiple rib fractures. The authors hypothesize that increased % pFVC is associated with reduced pulmonary complications. METHODS Adult patients with =3 rib fractures admitted to a level I trauma center, without cervical spinal cord injury or severe traumatic brain injury, were consecutively enrolled. FVC was measured at admission and % pFVC values were calculated for each patient. Patient were grouped by % pFVC <30% (low), 30-49% (moderate), and =50% (high). RESULTS A total of 79 patients were enrolled. Percent pFVC groups were similar except for pneumothorax being most frequent in the low group (47.8% vs. 13.9% and 20.0%, p = .028). Pulmonary complications were infrequent and did not differ between groups (8.7% vs. 5.6% vs. 0%, p = .198). DISCUSSION Increased % pFVC was associated with reduced hospital and intensive care unit (ICU) length of stay (LOS) and increased time to discharge to home. Percent pFVC should be used in addition to other factors to risk stratify patients with multiple rib fractures. Bedside spirometry is a simple tool that can help guide management in resource-limited settings, especially in large-scale combat operations. CONCLUSION This study prospectively demonstrates that % pFVC at admission represents an objective physiologic assessment that can be used to identify patients likely to require an increased level of hospital care.
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22
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Akbaş İ, Dogruyol S, Kocak AO, Dogruyol T, Koçak MB, Gur STA, Cakir Z. Effect of coolant spray on rib fracture pain of geriatric blunt thoracic trauma patients: a randomized controlled trial. Rev Assoc Med Bras (1992) 2023; 69:30-36. [PMID: 36820711 PMCID: PMC9937612 DOI: 10.1590/1806-9282.20220048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/26/2022] [Indexed: 02/19/2023]
Abstract
OBJECTIVE This study aimed to evaluate the effectiveness of cryotherapy in elderly patients with rib fractures due to blunt thoracic trauma. METHODS In this prospective randomized controlled study, geriatric patients were assigned to groups to receive either coolant spray (n=51) or placebo spray (n=50). The visual analog scale scores of all patients were recorded before starting spray application (V0), as well as at 10th (V1), 20th (V2), 30th (V3), 60th (V4), 120th (V5), and 360th (V6) minute. The mean decreases in the visual analog scale scores were calculated. RESULTS The differences between V0 and V1, V0 and V2, V0 and V3, and V0 and V4 mean visual analog scale scores measured in the coolant spray group were found to be significantly higher (p<0.001). In V1, V2, V3, and V4 measurements, the incidence of "clinical effectiveness" in the coolant spray group was significantly higher than in the placebo group (p=0.001). CONCLUSIONS Coolant spray therapy can be used as a component of multimodal therapy to provide adequate analgesia due to rib fractures in geriatric patients.
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Affiliation(s)
- İlker Akbaş
- Kahramanmaras Sutcu Imam University, Department of Emergency Medicine – Kahramanmaras, Turkey.,Corresponding author:
| | - Sinem Dogruyol
- Haydarpasa Numune Training and Research Hospital, Department of Emergency Medicine – Istanbul, Turkey
| | - Abdullah Osman Kocak
- Ataturk University, Faculty of Medicine, Department of Emergency Medicine – Erzurum, Turkey
| | - Talha Dogruyol
- Health Science University Kartal Dr. Lutfi Kirdar Training and Research Hospital, Department of Thoracic Surgery – İstanbul, Turkey
| | | | - Sultan Tuna Akgol Gur
- Ataturk University, Faculty of Medicine, Department of Emergency Medicine – Erzurum, Turkey
| | - Zeynep Cakir
- Ataturk University, Faculty of Medicine, Department of Emergency Medicine – Erzurum, Turkey
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23
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van Veelen NM, Buenter L, Kremo V, Peek J, Leiser A, Kestenholz P, Babst R, Paulus Beeres FJ, Minervini F. Outcomes after fixation of rib fractures sustained during cardiopulmonary resuscitation: A retrospective single center analysis. Front Surg 2023; 10:1120399. [PMID: 36755767 PMCID: PMC9899886 DOI: 10.3389/fsurg.2023.1120399] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023] Open
Abstract
Background Historically rib fractures have been typically treated non-operatively. Recent studies showed promising results after osteosynthesis of rib fractures in trauma patients with flail segments or multiple rib fractures. However, there is a paucity of data on rib fixation after cardiopulmonary resuscitation (CPR). This study evaluated the outcomes of patients who received rib fixation after CPR. Methods Adult patients who received surgical fixation of rib fractures sustained during CPR between 2010 and 2020 were eligible for inclusion in this retrospective study. Outcome measures included complications, quality of life (EQ 5D 5L) and level of dyspnea. Results Nineteen patients were included with a mean age of 66.8 years. The mean number of fractured ribs was ten, seven patients additionally had a sternum fracture. Pneumonia occurred in 15 patients (74%), of which 13 were diagnosed preoperatively and 2 post-operatively. Six patients developed a postoperative pneumothorax, none of which required revision surgery. One patient showed persistent flail chest after rib fixation and required additional fixation of a concomitant sternum fracture. One infection of the surgical site of sternal plate occurred, while no further surgery related complications were reported. Mean EQ-5D-5L was 0.908 and the average EQ VAS was 80. One patient reported persisting dyspnea. Conclusion To date, this is the largest reported cohort of patients who received rib fixation for fractures sustained during CPR. No complications associated with rib fixation were reported whereas one infection after sternal fixation did occur. Current follow-up demonstrated a good long-term quality of life after fixation, warranting further studies on this topic. Deeper knowledge on this subject would be beneficial for a wide spectrum of physicians.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Lea Buenter
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Valérie Kremo
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jesse Peek
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Alfred Leiser
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Peter Kestenholz
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Fabrizio Minervini
- Department of Thoracic Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland,Correspondence: Fabrizio Minervini
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KIM S, NAIK MV, KIRINO Y, SATOH H, TSUZUKI N, INOUE Y, KURODA K, HIDAKA Y. A retrospective analysis for criteria of surgical intervention in Japanese Black calves with respiratory signs caused by perinatal rib fracture. J Vet Med Sci 2023; 85:40-43. [PMID: 36384699 PMCID: PMC9887215 DOI: 10.1292/jvms.22-0332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Medical records of 16 Japanese Black calves with respiratory signs associated with perinatal rib fracture were analyzed, retrospectively, to speculate criteria of surgical intervention for the disease. For this analysis, the severity of respiratory condition was classified into three grades: Grade 1, with no wheezing, Grade 2, with wheezing after excitement but not at rest and Grade 3, with wheezing at rest. Grade 1 (n=3) received only conservative management. Seven of Grade 2 (n=8) and all of Grade 3 (n=5) had surgical management. Clinical outcome was good in all of Grade 1, and the surgical success rate was 83% in other groups. Our result suggests that surgical intervention should be considered for cases with more the severity of Grade 2.
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Affiliation(s)
- Sueun KIM
- Laboratory of Veterinary Surgery, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan
| | - Mrunmayi Vishwanath NAIK
- Laboratory of Veterinary Surgery, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan
| | - Yumi KIRINO
- Laboratory of Veterinary Surgery, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan
| | - Hiroyuki SATOH
- Laboratory of Veterinary Clinical Radiology, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan
| | - Nao TSUZUKI
- Laboratory of Veterinary Surgery, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan
| | - Yoshiyuki INOUE
- Laboratory of Veterinary Surgery, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan
| | - Kohei KURODA
- Laboratory of Veterinary Surgery, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan
| | - Yuichi HIDAKA
- Laboratory of Veterinary Surgery, Department of Veterinary Science, University of Miyazaki, Miyazaki, Japan,Correspondence to: Hidaka Y: , Laboratory of Veterinary Surgery,
University of Miyazaki, 1-1 Gakuen Kibana-dai Nishi, Miyazaki 889-2192, Japan
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Zhang D, Jiao C, Xi S, Wang L, Li R, Zhang Q. Evaluation of surgical outcomes in elderly patients with rib fractures: A single-centre propensity score matching study. Front Surg 2023; 10:1174365. [PMID: 37143770 PMCID: PMC10151702 DOI: 10.3389/fsurg.2023.1174365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
Background Rib fractures are the most common injuries in chest trauma. Compared with younger patients, elderly patients with rib fracture have a higher incidence of complications and mortality. A retrospective study was conducted to investigate the effect of internal fixation compared with conservative treatment on the outcome of rib fracture in elderly patients. Material and methods We used a 1:1 propensity score matching method to perform a retrospective analysis of 703 elderly patients with rib fractures treated in the Thoracic Surgery Department of Beijing Jishuitan Hospital between 2013 and 2020. After matching, the length of hospital stay, death, symptom relief and rib fracture healing were compared between the surgery and the control group. Results The study included 121 patients receiving SSRF in the surgery group and 121 patients receiving conservative treatment in the control group. The length of hospital stay in the surgery group was significantly longer than that in the conservative group (11.39d vs. 9.48d, p = 0.000). After 9 months of follow-up, the fracture healing rate in the surgery group was significantly higher than that in the control group (96.67% vs. 88.89%, p = 0.020). The fracture healing time (p = 0.000), improvement in pain score (p = 0.000) and duration of pain medication use (p = 0.000) were also significantly better in the surgery group than in the control group. Conclusion Compared with conservative treatment, surgical treatment can prolong hospital stay to some extent. However, it has the advantages of more rapid healing and lessened pain. For rib fractures in elderly individuals, surgical treatment is a safe and effective option under strict surgical indications and is recommended.
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Affiliation(s)
- Dong Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Chenbo Jiao
- Health Science Center, Peking University, Beijing, China
| | - Siqi Xi
- Health Science Center, Peking University, Beijing, China
| | - Langran Wang
- Health Science Center, Peking University, Beijing, China
| | - Run Li
- Health Science Center, Peking University, Beijing, China
| | - Qiang Zhang
- Department of Thoracic Surgery, Beijing Jishuitan Hospital, Beijing, China
- Correspondence: Qiang Zhang
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Bolte J, Fibbi C, Tesny AC, Kang YS, Agnew AM, Shurtz BK, Pipkorn B, Rhule H, Moorhouse K. Analysis of injury mechanism and thoracic response of elderly, small female PMHS in near-side impact scenarios. Traffic Inj Prev 2023; 24:S23-S31. [PMID: 37267001 DOI: 10.1080/15389588.2022.2160198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE In 2020, 17% of all crash fatalities were individuals aged 65 years or older. Crash data also revealed that for older occupants, thoracic related injuries are among the leading causes of fatality. Historically, the majority of near-side impact postmortem human subjects (PMHS) studies used a generic load wall to capture external loads that were applied to PMHS. While these data were helpful in documenting biofidelity, they did not represent a realistic response an occupant would undergo in a near-side crash. The objective of this research was to test small, elderly female PMHS in a repeatable, realistic near-side impact crash scenario to investigate current injury criteria as they relate to this vulnerable population. METHOD Ten small, elderly PMHS were subjected to a realistic near-side impact loading condition. The PMHS were targeted to be elderly females age 60+, approximately 5th percentile in height and weight, with osteopenic areal bone mineral density. Each subject was seated on a mass-production seat, equipped with a side airbag and standard three-point restraint with a pretensioner. Other boundary conditions included an intruding driver's side door. PMHS instrumentation included strain gages on ribs 3-10 bilaterally to identify fracture timing. Two chestbands were used to measure chest deflection, one at the level of the axilla and one at the level of the xiphoid process. RESULTS Injuries observed included rib fractures, particularly on the struck side, and in multiple cases a flail chest was observed. Eight of ten subjects resulted in AIS3+ thoracic injuries, despite previously tested ATDs predicting less than a 10% chance of AIS3+ injury. Subjects crossed the threshold for AIS3 injury in the range of only 1% - 9% chest compression. Additionally, mechanisms of injury varied, as some injuries were incurred by door interactions while others came during airbag interactions. CONCLUSIONS This research points to two areas of concern that likely require further analysis: (1) the appropriateness of potentially oversimplified PMHS testing to establish injury thresholds and define injury criteria for complicated crash scenarios; (2) the importance of identifying the precise timing of injuries to better understand the effect of current passive restraint systems.
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Affiliation(s)
- John Bolte
- Injury Biomechanics Research Center, The Ohio State University, Columbus, OH, USA
| | - Clare Fibbi
- Injury Biomechanics Research Center, The Ohio State University, Columbus, OH, USA
| | - Angela C Tesny
- Injury Biomechanics Research Center, The Ohio State University, Columbus, OH, USA
| | - Yun-Seok Kang
- Injury Biomechanics Research Center, The Ohio State University, Columbus, OH, USA
| | - Amanda M Agnew
- Injury Biomechanics Research Center, The Ohio State University, Columbus, OH, USA
| | | | | | - Heather Rhule
- National Highway Traffic Safety Administration, Vehicle Research and Test Center, East Liberty, OH, USA
| | - Kevin Moorhouse
- National Highway Traffic Safety Administration, Vehicle Research and Test Center, East Liberty, OH, USA
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Kang YS, Stammen J, Agnew AM, Baker GH, Pradhan V, Bendig A, Hagedorn A, Moorhouse K, Bolte Iv JH. Thoracic responses and injuries to male postmortem human subjects (PMHS) in rear-facing seat configurations in high-speed frontal impacts. Traffic Inj Prev 2023; 24:S47-S54. [PMID: 37267007 DOI: 10.1080/15389588.2023.2167490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Objective: One potential nonstandard seating configuration for vehicles with automated driving systems (ADS) is a reclined seat that is rear-facing when in a frontal collision. There are limited biomechanical response and injury data for this seating configuration during high-speed collisions. The main objective of this study was to investigate thoracic biomechanical responses and injuries to male postmortem human subjects (PMHS) in a rear-facing scenario with varying boundary conditions.Method: Fourteen rear-facing male PMHS tests (10 previously published and 4 newly tested) were conducted at two different recline angles (25-degree and 45-degree) in 56 km/h frontal impacts. PMHS were seated in two different seats; one used a Fixed D-Ring (FDR) seat belt assembly and one used an All Belts To Seat (ABTS) restraint. For thoracic instrumentation, strain gages were attached to ribs to quantify strain and fracture timing. A chestband was installed at the mid-sternum level to quantify anterior-posterior (AP) chest deflections. Data from the thorax instrumentation were analyzed to investigate injury mechanisms.Results: The PMHS sustained a greater number of rib fractures (NRF) in the 45-degree recline condition (12 ± 7 NRF for ABTS45 and 25 ± 18 NRF for FDR45) than the 25-degree condition (6 ± 4 NRF for ABTS25 and 12 ± 8 NRF for FDR25), despite AP chest compressions in the 45-degree condition (-23.7 ± 9.4 mm for ABTS45 and -39.6 ± 11.9 mm for FDR45) being smaller than the 25-degree condition (-38.9 ± 16.9 mm for ABTS25 and -55.0 ± 4.4 mm for FDR25). The rib fractures from the ABTS condition were not as symmetric as the FDR condition in the 25-degree recline angle due to a belt retractor structure located at one side of the seatback frame. Average peak AP chest compression occurred at 45.7 ± 3.4 ms for ABTS45, 45.6 ± 3.1 ms for FDR45, 46.7 ± 1.9 ms for ABTS25, and 46.9 ± 2.3 ms for FDR25. Average peak seatback resultant force occurred at 43.9 ± 0.9 ms for ABTS45, 44.6 ± 0.8 ms for FDR45, 42.5 ± 0.2 ms for ABTS25, and 41.5 ± 0.5 ms for FDR25. The majority of rib fractures occurred after peak AP chest compression and peak seatback resultant force likely due to the ramping motion of the PMHS, which might create a combined loading (e.g., AP deflection and upward deflection) to the thorax. Although NRF in the 45-degree reclined condition was greater than the 25-degree recline condition, similar magnitudes of rib strains were observed regardless of seat and restraint types, while strain modes varied.Conclusions: The majority of rib fractures occurred after peak AP chest compression and peak seatback force, especially in FDR25, ABTS45, and FDR45, while the PMHS ramped up along the seatback. AP chest compression, seatback load, and strain measured along the rib could not explain the greater NRF in the 45-degree recline conditions. A complex combination of AP chest deflection with upward deflection was discovered as a possible mechanism for rib fractures in PMHS subjected to rear-facing frontal impacts in this study.
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Affiliation(s)
| | - Jason Stammen
- National Highway Traffic Safety Administration, Vehicle Research and Test Center, East Liberty, Ohio
| | | | | | | | | | | | - Kevin Moorhouse
- National Highway Traffic Safety Administration, Vehicle Research and Test Center, East Liberty, Ohio
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Larsson KJ, Iraeus J, Holcombe S, Pipkorn B. Influences of human thorax variability on population rib fracture risk prediction using human body models. Front Bioeng Biotechnol 2023; 11:1154272. [PMID: 37034266 PMCID: PMC10078960 DOI: 10.3389/fbioe.2023.1154272] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/10/2023] [Indexed: 04/11/2023] Open
Abstract
Rib fractures remain a common injury for vehicle occupants in crashes. The risk of a human sustaining rib fractures from thorax loading is highly variable, potentially due to a variability in individual factors such as material properties and geometry of the ribs and ribcage. Human body models (HBMs) with a detailed ribcage can be used as occupant substitutes to aid in the prediction of rib injury risk at the tissue level in crash analysis. To improve this capability, model parametrization can be used to represent human variability in simulation studies. The aim of this study was to identify the variations in the physical properties of the human thorax that have the most influence on rib fracture risk for the population of vehicle occupants. A total of 15 different geometrical and material factors, sourced from published literature, were varied in a parametrized SAFER HBM. Parametric sensitivity analyses were conducted for two crash configurations, frontal and near-side impacts. The results show that variability in rib cortical bone thickness, rib cortical bone material properties, and rib cross-sectional width had the greatest influence on the risk for an occupant to sustain two or more fractured ribs in both impacts. Therefore, it is recommended that these three parameters be included in rib fracture risk analysis with HBMs for the population of vehicle occupants.
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Affiliation(s)
- Karl-Johan Larsson
- Autoliv Research, Vårgårda, Sweden
- Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
- *Correspondence: Karl-Johan Larsson,
| | - Johan Iraeus
- Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Sven Holcombe
- International Center for Automotive Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Bengt Pipkorn
- Autoliv Research, Vårgårda, Sweden
- Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
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Deluca A, Deininger S, Wichlas F, Hofmann V, Amelunxen B, Diepold J, Freude T, Deininger C. Follow-Up Chest X-rays in Minor Chest Trauma with Fewer Than Three Rib Fractures: A Justifiable, Habitual Re-Imaging Industry? Healthcare (Basel) 2022; 10:healthcare10122471. [PMID: 36553995 PMCID: PMC9778125 DOI: 10.3390/healthcare10122471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
Objective: We evaluated the necessity of follow-up chest X-rays (CXRs) to exclude a pneumothorax after 1 week of initial hospital presentation in patients with no signs of respiratory distress and fewer than three rib fractures. Materials and Methods: Adult patients with fewer than three fractured ribs who presented at our Level I trauma center between 2015 and 2017 were evaluated retrospectively. Patients with sternal fractures, who had suffered a polytrauma, or were primarily treated with a chest tube were excluded. The patients' and fractures' characteristics, trauma mechanism, median follow-up time, and the number of required secondary interventions were recorded. Results: This study included 249 patients, 137 (55.0%) of whom were male, with a median age of 64.34 years. In 150 patients (60.2%) one rib was affected, in 99 patients (39.8%) two ribs were affected, with the fractured ribs being true ribs (1-7) in 72 cases (28.9%), false ribs (8-12) in 151 cases (60.6%), and both in 26 cases (10.4%). The affected thorax half was the left side in 124 cases (49.8%) and both thorax halves in 4 cases (1.6%). The median follow-up time was 9 ± 4 days. In the follow-up CXRs, six patients (1.6%) required delayed intervention (tube thoracostomy): one case of hemopneumothorax and five cases of pneumothorax. All of the patients fully recovered. Conclusions: Planned CXR follow-ups revealed only a small number of complications that needed intervention and therefore seem not to be necessary. Symptom-triggered reappearance seems to be more sufficient and economical compared to habitual reimaging.
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Affiliation(s)
- Amelie Deluca
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Susanne Deininger
- Department of Urology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Florian Wichlas
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Valeska Hofmann
- Department of Trauma and Reconstructive Surgery, University of Tübingen, 72076 Tübingen, Germany
| | - Berndt Amelunxen
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Julian Diepold
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Thomas Freude
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian Deininger
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, 5020 Salzburg, Austria
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Paracelsus Medical University, 5020 Salzburg, Austria
- Correspondence:
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Van Wijck SFM, Pieracci FM, Smith EF, Madden K, Moore EE, Wijffels MME, Werner NL. Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe? J Trauma Acute Care Surg 2022; 93:721-6. [PMID: 36121283 DOI: 10.1097/TA.0000000000003790] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions. METHODS This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses. RESULTS A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted β , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted β , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management. CONCLUSION In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Van Wijck SFM, Curran C, Sauaia A, Van Lieshout EMM, Whitbeck SS, Edwards JG, Pieracci FM, Wijffels MME. Interobserver agreement for the Chest Wall Injury Society taxonomy of rib fractures using computed tomography images. J Trauma Acute Care Surg 2022; 93:736-42. [PMID: 36042547 DOI: 10.1097/TA.0000000000003766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In 2020, a universal nomenclature for rib fractures was proposed by the international Chest Wall Injury Society taxonomy collaboration. The purpose of this study is to validate this taxonomy. We hypothesized that there would be at least moderate agreement, regardless of the observers' background. METHODS An international group of independent observers evaluated axial, coronal, and sagittal computed tomography images on an online platform from 11 rib fractures for location (anterior, lateral, or posterior), type (simple, wedge, or complex), and displacement (undisplaced, offset, or displaced) of rib fractures. The multirater κ and Gwet's first agreement coefficient (AC1) were calculated to estimate agreement among the observers. RESULTS A total of 90 observers participated, with 76 complete responses (84%). Strong agreement was found for the classification of fracture location ( κ = 0.83 [95% confidence interval (CI) 0.69-0.97]; AC1, 0.84 [95% CI, 0.81-0.88]), moderate for fracture type ( κ = 0.46 [95% CI, 0.32-0.59]; AC1, 0.50 [95% CI, 0.45-0.55]), and fair for rib fracture displacement ( κ = 0.38 [95% CI, 0.21-0.54], AC1, 0.38 [95% CI, 0.34-0.42]). CONCLUSION Agreement on rib fracture location was strong and moderate for fracture type. Agreement on displacement was lower than expected. Evaluating strategies such as comprehensive education, additional imaging techniques, or further specification of the definitions will be needed to increase agreement on the classification of rib fracture type and displacement as defined by the Chest Wall Injury Society taxonomy. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level IV.
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Kong JS, Lee KH, Kang CY, Choi D, Kim OH. Preventive Effectiveness of Thoracic Side Airbags in Side-Impact Crashes Based on Korea In-Depth Accident Study (KIDAS) Database. Int J Environ Res Public Health 2022; 19:15757. [PMID: 36497831 PMCID: PMC9736127 DOI: 10.3390/ijerph192315757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 06/17/2023]
Abstract
Studies on the effectiveness of thoracic side airbags (tSABs) in preventing thoracic injuries is limited and conflicting. This retrospective observational study aims to evaluate the effectiveness of tSABs in side-impact crashes based on data for motor vehicle occupants (MVOs) who visited an emergency department in Korea. The data were obtained from the Korean In-Depth Accident Study (KIDAS) database for patients treated at Wonju Severance Christian Hospital between January 2011 and April 2020. Of the 3899 patients with road traffic injuries, data for 490 patients were used. The overall frequency of tSAB deployment in side-impact crashes was found to be 8.1%. In the multivariate analysis, elderly age, near-side impact, colliding with fixed objects, non-oblique force, and higher crush extent were found to be factors associated with higher thoracic injuries (Abbreviated Injury Scale ≥ 2). MVOs in crashes with tSAB deployment were at an increased risk of injury compared with MVOs in crashes with no deployment, but no statistical difference was observed [adjusted odds ratios (AORs): 1.65 (0.73-3.73)]. Further, the incidence of lung injury and rib fractures increased with tSAB activation (p < 0.05). These results demonstrate the limited capability of tSABs in preventing thoracic injuries in motor vehicle crashes.
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Affiliation(s)
- Joon Seok Kong
- Center for Automotive Medical Science Institute, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
| | - Kang Hyun Lee
- Center for Automotive Medical Science Institute, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
| | - Chan Young Kang
- Center for Automotive Medical Science Institute, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
| | - Dooruh Choi
- Center for Automotive Medical Science Institute, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
| | - Oh Hyun Kim
- Center for Automotive Medical Science Institute, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea
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Wessell JE, Pereira MP, Eriksson EA, Kalhorn SP. Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case. J Neurosurg Case Lessons 2022; 4:CASE22337. [PMID: 36411547 PMCID: PMC9678797 DOI: 10.3171/case22337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/07/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue. OBSERVATIONS Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery. LESSONS Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.
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Affiliation(s)
| | | | - Evert A. Eriksson
- Surgery, Medical University of South Carolina, Charleston, South Carolina
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Mergan İliklerden D, İliklerden ÜH, Kalaycı T. Traumatic diaphragmatic ruptures: A multidisciplinary study in a tertiary health center. Turk Gogus Kalp Damar Cerrahisi Derg 2022; 30:565-73. [PMID: 36605318 DOI: 10.5606/tgkdc.dergisi.2022.21790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/16/2021] [Indexed: 11/07/2022]
Abstract
Background In this study, we present diagnostic and therapeutic approaches in diaphragmatic rupture cases secondary to trauma and treated using surgical intervention. Methods Between March 2010 and December 2020, a total of 24 patients (23 males, 1 female; mean age: 35.0±13.7 years; range, 18 to 61 years) who were operated for traumatic diaphragm rupture were retrospectively reviewed. Preoperative, intraoperative, and postoperative data of the patients were evaluated. Differences between the groups with and without morbidity were analyzed. Results The mean total length of stay in the hospital was 16.2±10.9 (range, 6 to 56) days. The morbidity rate was 50% (n=12), and the mortality rate was 4.2% (n=1). In the comparison of groups with and without morbidity, three factors were found to be statistically significant: instability at the time of admission (p=0.009), gastrointestinal system perforation regardless of its location (p=0.014), and rib fracture (p=0.027). There was a significant difference in the total length of hospital stay (p=0.045). Conclusion Patients whose condition is unstable at the time of admission to the emergency room and who have gastrointestinal system perforations and rib fractures are more prone to developing morbidity, which prolongs the duration of hospital stay.
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von Kleeck BW, Hostetler Z, Fleischmann K, Weaver AA, Gayzik FS. Age targeted human body models indicate increased thoracic injury risk with aging. Traffic Inj Prev 2022; 23:S74-S79. [PMID: 35862927 DOI: 10.1080/15389588.2022.2097223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The objective of this study is to generate age targeted versions of the male and female Global Human Body Models Consortium (GHBMC) occupant human body models (HBMs), to validate each in frontal impacts, and to assess rib fracture probability of each. METHODS Six age targeted models were developed based on the GHBMC average male and small female occupant models (M50-O v6.0 and F05-O v6.0, respectively). All age targeted models were modified to represent population means for height, weight, shape, and relevant material properties. The thin plate spline method was used to morph models, and material properties were modified using available literature. Validation focused on chest response. Models were evaluated in a rigid body frontal chest impact at 6.7 m/s. Furthermore, the male and female age targeted models were evaluated against published data from 40 km/hr and 30 km/hr frontal sled tests respectively. RESULTS Chest deflections and landmark kinematics reasonably matched the respective corridors in the M50-O and F05-O aged models. Regional probability of rib fracture was assessed using probabilistic methods based on cortex strain. Increasing rib fracture with age was observed in both impacts for both sexes. For the rigid chest impact, the M50-O 70YO resulted in 10 ribs exceeding 50% probability of fracture whereas the younger ages reported 4 to 6 ribs exceeding the same probability. In the same simulation, the F05-O 70YO resulted in 8 regions exceeding 50% probability of rib fracture as opposed to 3 and 0 such regions at the youngest ages. Sled simulation demonstrated similar trends. The 70YO age adjusted models best aligned with the reported extent of fractures from the referenced PMHS studies, which tend to be composed of subjects of advanced age. CONCLUSIONS Age targeted HBMs demonstrated increased fracture probability with age when subjected to equivalent impacts. Gross model kinematics approximate PMHS data but showed little difference between targeted age models. The findings indicate that while gross kinematics are unaffected by age-targeting models, such models can capture trends of increased thoracic injury risk observed in experimental and field studies, and further suggest their potential use to target interventions for vulnerable driving populations, such as older adults.
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Affiliation(s)
- B Wade von Kleeck
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Zach Hostetler
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kevin Fleischmann
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Ashley A Weaver
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - F Scott Gayzik
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Pregler B, Beyer LP, Platz Batista da Silva N, Steer S, Zeman F, Popp D, Stroszczynski C, Müller-Wille R. Assessment of Rib Fracture in Acute Trauma Using Automatic Rib Segmentation and a Curved, Unfolded View of the Ribs: Is There a Saving of Time? J Clin Med 2022; 11. [PMID: 35566629 DOI: 10.3390/jcm11092502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/23/2022] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: The fast and accurate diagnosis of rib fractures in polytrauma patients is important to reduce the mortality rate and relieve long-term pain and complications. Aim: To evaluate the diagnostic accuracy and potential time savings using automatic rib segmentation and a curved, unfolded view for the detection of rib fractures in trauma patients. Methods: The multidetector computed tomography raw data of 101 consecutive polytrauma patients (72 men; mean age 45 years, age range 17 to 84 years) admitted to a university hospital were retrospectively post-processed to generate a curved, unfolded view of the rib cage. No manual corrections were performed. Patients with reconstruction errors and movement artifacts were excluded from further analysis. All fractures were identified and classified by the study coordinator using the original data set. Two readers (reader 1 and reader 2) evaluated the original axial sections and the unfolded view, separately. The fracture locations, fracture type, and reading times were recorded. Sensitivity and specificity were calculated on a per-rib basis using a ratio estimator. Cohen’s Kappa was calculated as an index of inter-rater agreement. Results: 26 of 101 patients (25.7%) were excluded from further analysis owing to breathing artifacts (6.9%) or incorrect centerline computation in the unfolded view (18.8%). In total, 107 (5.9%) of 1800 ribs were fractured in 25 (33%) of 75 patients. The unfolded view had a sensitivity/specificity of 81%/100% (reader 1) and 71%/100% (reader 2) compared to 94%/100% (reader 1; p = 0.002/p = 0.754) and 63%/99% (reader 2; p < 0.001/p = 0.002). The sensitivity (reader 1; reader 2) was poor for buckled fractures (31%; 38%), moderate for undislocated fractures (78%; 62%), and good for dislocated fractures (94%; 90%). The assessment of the unfolded view was performed significantly faster than that of the original layers (19.5 ± 9.4 s vs. 68.6 ± 32.4 s by reader 1 (p < 0.001); 24.1 ± 9.5 s vs. 40.2 ± 12.7 s by reader 2 (p < 0.001)). Both readers demonstrated a very high interobserver agreement for the unfolded view (κ = 0.839) but only a moderate agreement for the original view (κ = 0.529). Conclusion: Apart from a relatively high number of incorrect centerline reconstructions, the unfolded view of the rib cage allows a faster diagnosis of dislocated rib fractures.
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Flaaten N, Dyke G. First rib fracture: Still a marker of trauma severity? Emerg Med Australas 2022; 34:808-811. [PMID: 35445531 DOI: 10.1111/1742-6723.13983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 03/27/2022] [Accepted: 04/01/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE First rib fractures (FRFs) have historically been a marker for severe trauma and poor outcomes. The aim of the present study was to assess whether an association still exists between a fractured first rib and global trauma scores suffered by the patient, examine mortality rates and identify other commonly associated injuries. METHODS This retrospective study examined records collected from patients from the Rockhampton Hospital with a traumatic FRF from July 2015 to June 2020. Patient demographics, mortality rate and injuries sustained were compiled. The Injury Severity Score (ISS) was utilised and calculated for each patient. Analysis was conducted to determine associations between trauma scores and FRFs. RESULTS In total, 545 patients had a rib fracture with 48 patients identified as having an FRF. Median age was 50 years. Thirty-seven (77%) were male. The most common mechanism of FRF was motor vehicle/motorbike accidents (71%). Fifty percent of patients with an observed FRF had the highest global ISS of very severe, with 13% severe, 22% moderate and 15% mild. No patients died from their injuries. Of those with an FRF, 79% experienced fractures other than ribs, 75% had other rib fractures and 52% had chest injuries. CONCLUSIONS A larger than expected proportion of FRFs were not associated with severe trauma scores or high mortality. These findings suggest that patients with an FRF may have a greater chance of surviving their traumatic FRF than previously reported. Clinicians should be aware of the potential for severity and specific associated injuries when treating a patient with FRFs.
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Affiliation(s)
- Nordan Flaaten
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Surgery, Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Garry Dyke
- Department of Surgery, Rockhampton Hospital, Rockhampton, Queensland, Australia
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Kozanlı F, Güler Ö. Effect of the presence of rib fracture on mortality and morbidity in blunt thoracic traumas. ULUS TRAVMA ACIL CER 2022; 28:440-446. [PMID: 35485510 PMCID: PMC10443126 DOI: 10.14744/tjtes.2020.55710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/23/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to determine the effect of the presence of rib fracture on mortality and morbidity in blunt thoracic trauma (BTT). METHODS Records of patients aged over 18 and admitted with BTT between January 2017 and October 2019 dates were ret-rospectively evaluated. Only patients with both BTT and rib fracture were included in the study. Age, gender, trauma mechanism, additional organ injuries, and need for intensive care unit of patients were identified. The total length of hospital stay, length of stay in the intensive care unit, treatment modalities, need for mechanical ventilator; blood and blood products, complications, and mortality rates for patients were recorded. RESULTS One hundred eighty-six (73.8%) and 66 (26.2%) of 252 included patients were male and female, respectively. The most commonly seen trauma mechanism was motor vehicle accidents (51.4%). The mean age of patients was 52±12 (18-91). We identified that there was a significant association between hemothorax and non-thoracic additional organ injuries (p=0.024). There was no significant association between pneumothorax and additional organ injuries (p=0.067). The number of fractured ribs was significantly different between cases with and without hemothorax (p<0.001). There was also a significant difference between cases with and without pneumothorax in terms of the number of broken ribs (p<0.039). There was a significant difference between cases undergone thoracotomy and cases who did not undergo thoracotomy in terms of mean length of stay in the hospital (p<0.001). There was a positive correlation between the number of broken ribs and length of stay in the hospital (r=320, p<0.001). CONCLUSION Increased number of rib fracture in BTTs increases morbidity and length of stay in the hospital.
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Affiliation(s)
- Fatoş Kozanlı
- Department of Thoracic Surgery, Kahramanmaraş Sütçü İmam University Faculty of Medicine, Kahramanmaraş-Turkey
| | - Özlem Güler
- Department of Emergency Medicine, Kahramanmaraş Sütçü İmam University Faculty of Medicine, Kahramanmaraş-Turkey
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Karatasakis A, Sarikaya B, Liu L, Gunn ML, Kudenchuk PJ, Gatewood MO, Maynard C, Sayre MR, Counts CR, Carlbom DJ, Edwards RM, Branch KRH. Prevalence and Patterns of Resuscitation-Associated Injury Detected by Head-to-Pelvis Computed Tomography After Successful Out-of-Hospital Cardiac Arrest Resuscitation. J Am Heart Assoc 2022; 11:e023949. [PMID: 35043689 PMCID: PMC9238478 DOI: 10.1161/jaha.121.023949] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients resuscitated from out-of-hospital circulatory arrest (OHCA) frequently have cardiopulmonary resuscitation injuries identifiable by computed tomography, although the prevalence, types of injury, and effects on clinical outcomes are poorly characterized. Methods and Results We assessed the prevalence of resuscitation-associated injuries in a prospective, observational study of a head-to-pelvis sudden-death computed tomography scan within 6 hours of successful OHCA resuscitation. Primary outcomes included total injuries and time-critical injuries (such as organ laceration). Exploratory outcomes were injury associations with mechanical cardiopulmonary resuscitation and survival to discharge. Among 104 patients with OHCA (age 56±15 years, 30% women), 58% had bystander cardiopulmonary resuscitation, and total cardiopulmonary resuscitation time was 15±11 minutes. The prevalence of resuscitation-associated injury was high (81%), including 15 patients (14%) with time-critical findings. Patients with resuscitation injury were older (58±15 versus 46±13 years; P<0.001), but had otherwise similar baseline characteristics and survival compared with those without. Mechanical chest compression systems (27%) had more frequent sternal fractures (36% versus 12%; P=0.009), including displaced fractures (18% versus 1%; P=0.005), but no difference in survival (46% versus 41%; P=0.66). Conclusions In patients resuscitated from OHCA, head-to-pelvis sudden-death computed tomography identified resuscitation injuries in most patients, with nearly 1 in 7 with time-critical complications, and one-half with extensive rib-cage injuries. These data suggest that sudden-death computed tomography may have additional diagnostic utility and treatment implications beyond evaluating causes of OHCA. These important findings need to also be taken in context of the certain fatal outcome without resuscitation efforts. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03111043.
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Affiliation(s)
| | - Basar Sarikaya
- Department of Radiology University of Washington Seattle WA
| | - Linda Liu
- Division of Cardiology University of Washington Seattle WA
| | - Martin L Gunn
- Department of Radiology University of Washington Seattle WA
| | | | - Medley O Gatewood
- Department of Emergency Medicine University of Washington Seattle WA
| | - Charles Maynard
- Department of Health Services School of Public Health and Community Medicine University of Washington Seattle WA
| | - Michael R Sayre
- Department of Emergency Medicine University of Washington Seattle WA
| | | | - David J Carlbom
- Division of Pulmonary Critical Care, and Sleep Medicine University of Washington Seattle WA
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Wiedl A, Förch S, Otto A, Lisitano L, Rau K, Nachbaur T, Mayr E. Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up. Geriatr Orthop Surg Rehabil 2021; 12:21514593211058969. [PMID: 34868724 PMCID: PMC8637372 DOI: 10.1177/21514593211058969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/16/2021] [Accepted: 10/22/2021] [Indexed: 11/08/2022] Open
Abstract
Background Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare. The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up. Methods Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters. Results Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases. Discussion This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years. Conclusion Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.
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Affiliation(s)
- Andreas Wiedl
- Abteilung für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Stefan Förch
- Abteilung für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Alexander Otto
- Abteilung für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Leonard Lisitano
- Abteilung für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Kim Rau
- Abteilung für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Thilo Nachbaur
- Abteilung für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Edgar Mayr
- Abteilung für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
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Yahn CA, McNally AP, Deivert K, Fraga T, Sharaf Alddin RA, Martyak MT, Collins JN. Outcomes of Trauma Patients with Flail Chest and Surgical Rib Stabilization. Am Surg 2021; 88:810-812. [PMID: 34806413 DOI: 10.1177/00031348211056260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The goal of this project was to describe the current practices of this institution and identify which patients benefit from surgical stabilization of rib fractures (SSRF). A total of 1429 trauma patients admitted to our Level 1 center with rib fractures between January 1, 2014 and June 22, 2020 were retrospectively reviewed. Flail chest was observed in 43 (3.01%) patients. Surgical stabilization of rib fractures was pursued in 27 of all patients (1.89%). Twenty-four flail chest patients required intubation (ETT). Nineteen were not intubated (NoET). Of the ETT group, 8 underwent SSRF and 16 did not. Those who had SSRF had a shorter ventilator LOS (7.1 vs 15.7 d) and ICU LOS (9.8 vs 11.9 d). Surgical stabilization of rib fractures has shown success in managing flail chest. In intubated patients with flail chest, fixation seems to decrease ICU stays and the duration of ventilation. We believe we need to perform SSRF on more patients with flail chest.
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Affiliation(s)
- Colten A Yahn
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Alexander P McNally
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Kyle Deivert
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Tyler Fraga
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Reem A Sharaf Alddin
- Healthcare Analytics and Delivery Science Institute (HADSI), 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Michael T Martyak
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jay N Collins
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
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Prins JTH, Leasia K, Dull MB, Lawless RA, Platnick KB, Werner NL, Wijffels MME, Moore EE, Pieracci FM. Surgical Site Infection after Surgical Stabilization of Rib Fractures: Rare But Morbid. Surg Infect (Larchmt) 2021; 23:5-11. [PMID: 34762547 DOI: 10.1089/sur.2021.165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: Although surgical stabilization for rib fractures (SSRF) has been adopted widely over the past decade, little information is available regarding the prevalence and outcomes of post-operative surgical site infection (SSI). We hypothesized that SSI after SSRF is uncommon but morbid. Patients and Methods: Patients undergoing SSRF at a level 1 trauma center from 2010-2020 were reviewed. The primary outcome was the prevalence of SSI, documented by clinical examination, radiography, systemic markers of infection, and microbiology. Results: Of 228 patients undergoing SSRF, 167 (73.2%) were male, the median age was 53 years (P25-P75; 41-63 years), injury severity score (ISS) was 19 (P25-P75, 13-26), with a median of eight fractured ribs (P25-P75, 6-11). All stabilization plates were titanium. SSRF was typically performed on post-injury day one (P25-P75, 0-2 days) after trauma. All patients received antibiotic agents within 30 minutes of incision, and a median of four ribs (P25-P75, 3-6) were repaired. Four (1.8%) patients developed an SSI and all underwent implant removal. Two patients required implant removal within 30 days (on post-operative day seven and 17) and two for chronic infection at seven and 17 months after SSRF. The causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) bacteria in all patients. After implant removal, three patients received intravenous and oral antibiotic agents, ranging from two to six weeks, without recurrent infection. No patient required additional SSRF. Conclusions: Surgical site infection after SSRF is rare but morbid and can become symptomatic within one week to 17 months. Implant removal results in complete recovery.
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Affiliation(s)
- Jonne T H Prins
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Kiara Leasia
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Matthew B Dull
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Ryan A Lawless
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
| | - K Barry Platnick
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Nicole L Werner
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Mathieu M E Wijffels
- Trauma Research Unit, Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ernest E Moore
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Hospital & Authority, University of Colorado School of Medicine, Denver, Colorado, USA
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King S, Smith L, Harper C, Beam Z, Heidel E, Carico G, Wahler K, Daley B. Intravenous Lidocaine for Rib Fractures: Effect on Pain Control and Outcome. Am Surg 2021; 88:734-739. [PMID: 34732060 DOI: 10.1177/00031348211050838] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multimodal analgesia in rib fractures (RFs) is designed to maximize pain control while minimizing narcotics. Prior research with intravenous lidocaine (IVL) efficacy produced conflicting results. We hypothesized IVL infusion reduces opioid utilization and pain scores. METHODS A retrospective review of RF patients at an ACS-verified Level I trauma center from April 2018 to 2/2020 was conducted. Patients (pts) stratified as receiving IVL vs no IVL. Initial lidocaine dose: 1 mg/kg/hr with a maximum of 3 mg/kg/hr. Duration of infusion: 48 h. Pain quantified by the Stanford Pain Score system (PS). Bivariate and multivariate analyses of variables were performed on SPSS, version 21 (IBM Corp). RESULTS 414 pts met inclusion criteria: 254 males and 160 females. The average age for the non-IVL = 67.4 ± 15.2 years vs IVL = 58.3 ± 17.1 years (P < .001). There were no statistically significant differences between groups for ISS, PS for initial 48 h, and ICU length of stay (LOS). There was a difference in morphine equivalents per hour: non-IVL = 1.25 vs IVL = 1.72 (P = .004) and LOS non-IVL = 10.2+/-7.6 vs IVL = 7.82+/-4.94. By analyzing IVL pts in a crossover comparison before and after IVL, there was reduction in opiates: 3.01 vs 1.72 (P < .001) and PS: 7.0 vs 4.9 (P < .001). Stanford Pain Score system reduction in the IVL = 48.3 ± 23.9%, but less effective in narcotic dependency (27 ± 22.9%, P = .035); IVL pts had hospital cost reduction: $82,927 vs $118,202 (P < .01). DISCUSSION In a crossover analysis, IVL is effective for reduction of PS and opiate use and reduces hospital LOS and costs. Patient age may confound interpretation of results. Our data support IVL use in multimodal pain regimens. Future prospective study is warranted.
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Affiliation(s)
- Sarah King
- 12324Department of Surgery, East Tennessee State University Quillen College of Medicine, Johnson City, TN, USA
| | - Lou Smith
- Department of Surgery, 21823University of Tennessee Medical Center, Knoxville, TN, USA
| | - Christopher Harper
- 12325Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Zachary Beam
- Department of Surgery, 21823University of Tennessee Medical Center, Knoxville, TN, USA
| | - Eric Heidel
- Department of Surgery, 21823University of Tennessee Medical Center, Knoxville, TN, USA
| | - Genevieve Carico
- Department of Surgery, 21823University of Tennessee Medical Center, Knoxville, TN, USA
| | - Kelsey Wahler
- Department of Surgery, 21823University of Tennessee Medical Center, Knoxville, TN, USA
| | - Brian Daley
- Department of Surgery, 21823University of Tennessee Medical Center, Knoxville, TN, USA
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Aalberg JJ, Johnson BP, Hojman HM, Rattan R, Arabian S, Mahoney EJ, Bugaev N. Readmission following surgical stabilization of rib fractures: Analysis of incidence, cost, and risk factors using the Nationwide Readmissions Database. J Trauma Acute Care Surg 2021; 91:361-368. [PMID: 33852561 PMCID: PMC8373660 DOI: 10.1097/ta.0000000000003227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) has become increasingly common for the treatment of traumatic rib fractures; however, little is known about related postoperative readmissions. The aims of this study were to determine the rate and cost of readmissions and to identify patient, hospital, and injury characteristics that are associated with risk of readmission in patients who underwent SSRF. The null hypotheses were that readmissions following rib fixation were rare and unrelated to the SSRF complications. METHODS This is a retrospective analysis of the 2015 to 2017 Nationwide Readmission Database. Adult patients with rib fractures treated by SSRF were included. Univariate and multivariate analyses were used to compare patients readmitted within 30 days with those who were not, based on demographics, comorbidities, and hospital characteristics. Financial information examined included average visit costs and national extrapolations. RESULTS A total of 2,522 patients who underwent SSRF were included, of whom 276 (10.9%) were readmitted within 30 days. In 36.2% of patients, the reasons for readmissions were related to complications of rib fractures or SSRF. The rest of the patients (63.8%) were readmitted because of mostly nontrauma reasons (32.2%) and new traumatic injuries (21.1%) among other reasons. Multivariate analysis demonstrated that ventilator use, discharge other than home, hospital size, and medical comorbidities were significantly associated with risk of readmission. Nationally, an estimated 2,498 patients undergo SSRF each year, with costs of US $176 million for initial admissions and US $5.9 million for readmissions. CONCLUSION Readmissions after SSRF are rare and mostly attributed to the reasons not directly related to sequelae of rib fractures or SSRF complications. Interventions aimed at optimizing patients' preexisting medical conditions before discharge should be further investigated as a potential way to decrease rates of readmission after SSRF. LEVEL OF EVIDENCE Epidemiological study, level III.
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Affiliation(s)
- Jeffrey J Aalberg
- From the Tufts University School of Medicine (J.J.A.); Division of Trauma and Acute Care Surgery, Department of Surgery (B.P.J., H.M.H., S.A., E.J.M., N.B.), Tufts Medical Center, Boston, Massachusetts; and Division of Trauma Surgery and Critical Care (R.R.), DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
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Arborelius UP, Rocksén D, Gustavsson J, Günther M. Pulmonary hypoxia and venous admixture correlate linearly to the kinetic energy from porcine high velocity projectile behind armor blunt trauma. Exp Lung Res 2021; 47:323-333. [PMID: 34278891 DOI: 10.1080/01902148.2021.1950869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose. Behind armor blunt trauma (BABT) is a non-penetrating injury caused by the rapid deformation of body armor, by a projectile, which may in extreme circumstances cause death. The understanding of the mechanisms is still low, in relation to what is needed for safety threshold levels. High velocity projectile BABT causes immediate and severe hypoxia by increased venous admixture (Q's/Q't), but it is not known whether the level of hypoxia correlates to the kinetic energy (Ek) of the projectile.Materials and Methods. We constructed a 65 mm BABT-simulator to measure the Ek absorbed by the thorax. The simulator was validated to 7.62 mm high velocity BABT (swine with removed organs) for 7.62 mm (n = 7) and 65 mm (n = 12). Physiological measurements during 60 minutes were performed in 40 anesthetized swine in groups control (n = 9), 7.62 mm (n = 7), 65 mm weight variation (n = 24), 65 mm speed variation (n = 12, included in the weight variation group). New calculations were done for a previously studied group of 7.62 mm with backing (n = 9).Results. 65 mm BABT simulation and 7.62 mm BABT had similar back-face signatures (24 mm), and maximum thoracic impression speed (24-34 m/s). Back-face signatures correlated linearly to Ek (R2=0.20). Rib fractures had a 50% likelihood at back-face signature 23.0 mm (95% CI 18.5 to 29.0 mm, area under ROC curve 0.93). Ek correlated linearly to pO2 (R2=0.34, p = 0.0026) and venous admixture (R2=0.37, p = 0.0046). The extrapolated Ek at 5 minutes for pO2=0 kPa was 587 J and for venous admixture = 100% 574 J.Conclusions. Hypoxia and venous admixture correlated linearly to Ek, allowing for a calculated predicted lethal Ek to ≥574 J, which should be verified in survival studies. Lethality predictions from lung physiology is an alternative to clay impressions and may facilitate the development of ballistic safety equipment and new BABT safety criteria.Supplemental data for this article is available online at https://doi.org/10.1080/01902148.2021.1950869 .
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Affiliation(s)
- Ulf P Arborelius
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - David Rocksén
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Neuroscience Section of Experimental Traumatology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Section of Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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Larsson KJ, Blennow A, Iraeus J, Pipkorn B, Lubbe N. Rib Cortical Bone Fracture Risk as a Function of Age and Rib Strain: Updated Injury Prediction Using Finite Element Human Body Models. Front Bioeng Biotechnol 2021; 9:677768. [PMID: 34109166 PMCID: PMC8181138 DOI: 10.3389/fbioe.2021.677768] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/27/2021] [Indexed: 11/13/2022] Open
Abstract
To evaluate vehicle occupant injury risk, finite element human body models (HBMs) can be used in vehicle crash simulations. HBMs can predict tissue loading levels, and the risk for fracture can be estimated based on a tissue-based risk curve. A probabilistic framework utilizing an age-adjusted rib strain-based risk function was proposed in 2012. However, the risk function was based on tests from only twelve human subjects. Further, the age adjustment was based on previous literature postulating a 5.1% decrease in failure strain for femur bone material per decade of aging. The primary aim of this study was to develop a new strain-based rib fracture risk function using material test data spanning a wide range of ages. A second aim was to update the probabilistic framework with the new risk function and compare the probabilistic risk predictions from HBM simulations to both previous HBM probabilistic risk predictions and to approximate real-world rib fracture outcomes. Tensile test data of human rib cortical bone from 58 individuals spanning 17-99 years of ages was used. Survival analysis with accelerated failure time was used to model the failure strain and age-dependent decrease for the tissue-based risk function. Stochastic HBM simulations with varied impact conditions and restraint system settings were performed and probabilistic rib fracture risks were calculated. In the resulting fracture risk function, sex was not a significant covariate-but a stronger age-dependent decrease than previously assumed for human rib cortical bone was evident, corresponding to a 12% decrease in failure strain per decade of aging. The main effect of this difference is a lowered risk prediction for younger individuals than that predicted in previous risk functions. For the stochastic analysis, the previous risk curve overestimated the approximate real-world rib fracture risk for 30-year-old occupants; the new risk function reduces the overestimation. Moreover, the new function can be used as a direct replacement of the previous one within the 2012 probabilistic framework.
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Affiliation(s)
- Karl-Johan Larsson
- Autoliv Research, Vårgårda, Sweden.,Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Amanda Blennow
- Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Johan Iraeus
- Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Bengt Pipkorn
- Autoliv Research, Vårgårda, Sweden.,Division of Vehicle Safety, Department of Mechanics and Maritime Sciences, Chalmers University of Technology, Gothenburg, Sweden
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Kaiume M, Suzuki S, Yasaka K, Sugawara H, Shen Y, Katada Y, Ishikawa T, Fukui R, Abe O. Rib fracture detection in computed tomography images using deep convolutional neural networks. Medicine (Baltimore) 2021; 100:e26024. [PMID: 34011107 PMCID: PMC8137061 DOI: 10.1097/md.0000000000026024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/26/2021] [Indexed: 01/05/2023] Open
Abstract
To evaluate the rib fracture detection performance in computed tomography (CT) images using a software based on a deep convolutional neural network (DCNN) and compare it with the rib fracture diagnostic performance of doctors.We included CT images from 39 patients with thoracic injuries who underwent CT scans. In these images, 256 rib fractures were detected by two radiologists. This result was defined as the gold standard. The performances of rib fracture detection by the software and two interns were compared via the McNemar test and the jackknife alternative free-response receiver operating characteristic (JAFROC) analysis.The sensitivity of the DCNN software was significantly higher than those of both Intern A (0.645 vs 0.313; P < .001) and Intern B (0.645 vs 0.258; P < .001). Based on the JAFROC analysis, the differences in the figure-of-merits between the results obtained via the DCNN software and those by Interns A and B were 0.057 (95% confidence interval: -0.081, 0.195) and 0.071 (-0.082, 0.224), respectively. As the non-inferiority margin was set to -0.10, the DCNN software is non-inferior to the rib fracture detection performed by both interns.In the detection of rib fractures, detection by the DCNN software could be an alternative to the interpretation performed by doctors who do not have intensive training experience in image interpretation.
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Affiliation(s)
- Masafumi Kaiume
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Arakawa-ku
- Department of Radiology, Graduate School of Medicine, University of Tokyo, Bunkyo-ku
| | - Shigeru Suzuki
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Arakawa-ku
| | - Koichiro Yasaka
- Department of Radiology, The Institute of Medical Science, The University of Tokyo, Minato-ku, Tokyo, Japan
| | - Haruto Sugawara
- Department of Radiology, The Institute of Medical Science, The University of Tokyo, Minato-ku, Tokyo, Japan
| | - Yun Shen
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Arakawa-ku
| | - Yoshiaki Katada
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Arakawa-ku
| | - Takuya Ishikawa
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Arakawa-ku
| | - Rika Fukui
- Department of Radiology, Tokyo Women's Medical University Medical Center East, Arakawa-ku
| | - Osamu Abe
- Department of Radiology, Graduate School of Medicine, University of Tokyo, Bunkyo-ku
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Kao PY, Ben-Arie E, Lu TY, Ho WC, Lee YC, Lin YS, Chen CK, Chen JX, Huang TM, Chen FP. Acupuncture for blunt chest trauma: A protocol for a double-blind randomized control trial. Medicine (Baltimore) 2021; 100:e25667. [PMID: 33950945 PMCID: PMC8104233 DOI: 10.1097/md.0000000000025667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Blunt chest trauma (BCT) accounts for up to 65% of polytrauma patients. In patients with 0 to 2 rib fractures, treatment interventions are typically limited to oral analgesics and breathing exercises. Patients suffering from BCT experience symptoms of severe pain, poor sleep, and inability to perform simple daily life activities for an extended period of time thereafter. In this trial, we aim to investigate the efficacy of acupuncture as a functional and reliable treatment option for blunt chest trauma patients. METHODS The study is designed as a double-blind randomized control trial. We will include 72 patients divided into 2 groups; the acupuncture group (Acu) and placebo group (Con). The acupuncture group will receive true acupuncture using a uniquely designed press tack needle. The control group will receive placebo acupuncture treatment through the use of a similarly designed press tack needle without the needle element. The acupoints selected for both groups are GB 34, GB 36, LI 4, LU 7, ST 36, and TH 5. Both groups will receive 1 treatment only following the initial visit to the medical facility and upon diagnosis of BCT. Patient outcome measurements include: Numerical Rating Scale, Face Rating Scale, respiratory function flowmeter, Verran Snyder-Halpern sleep scale, and the total amount of allopathic medication used. Follow-up time will be scheduled at 4 days, 2 weeks, and lastly 3 months. EXPECTED OUTCOME The results of this study can potentially provide a simple and cost-effective analgesic solution to blunt chest trauma patients. This novel study design can serve as supporting evidence for future double-blind studies within the field of acupuncture. OTHER INFORMATION The study will be conducted in the thoracic surgical department and acupuncture department in China Medical University Hospital, Taichung, Taiwan. The study will be conducted on blunt chest trauma patients and is anticipated to have minimum risk of adverse events. Enrollment of the patients and data collection will start from March 2020. Study completion time is expected in March 2022. PROTOCOL REGISTRATION (CMUH109-REC1-002), (NCT04318496).
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Affiliation(s)
- Pei-Yu Kao
- Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, Taichung
- Institute of Traditional Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Eyal Ben-Arie
- Graduate Institute of Acupuncture Science, China Medical University
| | - Ting-Yu Lu
- Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - Wen-Chao Ho
- Department of Public Health, China Medical University
| | - Yu-Chen Lee
- Graduate Institute of Acupuncture Science, China Medical University
- Department of Acupuncture, China Medical University Hospital, Taichung
| | - Yu-Sen Lin
- Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - Chien-Kuang Chen
- Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - Jian-Xun Chen
- Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - Tzu-Min Huang
- Division of Thoracic Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - Fang-Pey Chen
- Institute of Traditional Medicine, School of Medicine, National Yang-Ming University, Taipei
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Matic KJ, Cheluvappa R, Selvendran S. Surgical Stabilisation of Traumatic Rib Fractures with Chronic, Residual Type A Aortic Dissection. Healthcare (Basel) 2021; 9:healthcare9040392. [PMID: 33915874 PMCID: PMC8066594 DOI: 10.3390/healthcare9040392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/23/2021] [Accepted: 03/23/2021] [Indexed: 11/16/2022] Open
Abstract
Surgical stabilisation of rib fractures (SSRF) reduces morbidity and mortality. However, its impact in complicated cases, particularly those with underlying thoracic pathologies, is of continued interest. Electronic records were retrospectively reviewed after obtaining informed consent from the patient. This case report details a patient with chronic, residual, Stanford Type A aortic dissection (AD) who had multiple left-sided rib fractures with a flail segment after being struck by a bicycle. The preoperative computed tomography (CT) of the patient's chest showed that the sixth posterior rib fracture location was just ~13 mm from the false lumen of the aorta. As the patient had poor respiratory output and persistent pain, SSRF was not performed on the posterior sections. However, the anterior third to seventh rib fractures were plated. The patient recovered fully, with reduced pain and improved respiratory function. This is the first report describing the benefits of SSRF with AD or major thoracic pathologies. Further research into the benefits of SSRF in specific thoracic pathologies may lead to improved patient outcomes. This may require the creation of profiles of patient cohorts with relevant clinical history to determine if SSRF may benefit patients with specific thoracic pathologies.
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Affiliation(s)
- Kieran J. Matic
- Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia; (K.J.M.); (S.S.)
| | - Rajkumar Cheluvappa
- Australian Catholic University, Watson, ACT 2602, Australia
- Correspondence: ; Tel.: +61-0406-0406-20
| | - Selwyn Selvendran
- Department of Surgery, St George Hospital, Kogarah, NSW 2217, Australia; (K.J.M.); (S.S.)
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Schnekenburger M, Mathew J, Fitzgerald M, Hendel S, Sekandarzad MW, Mitra B. Regional anaesthesia for rib fractures: A pilot study of serratus anterior plane block. Emerg Med Australas 2021; 33:788-793. [PMID: 33511786 DOI: 10.1111/1742-6723.13724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/17/2020] [Accepted: 01/01/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Rib fractures are not only painful but are associated with morbidity and mortality, especially in older patients. The serratus anterior plane block (SAPB) is a plane block distant from major neurovascular bundles and may provide anaesthesia to a substantial area of the hemithorax. This pilot study was designed to assess if the SAPB can be safely and efficiently incorporated to the trauma reception workflow of an adult, level 1 trauma centre. METHODS A convenience sample of 20 adult patients with at least two or more unilateral rib fractures received a SAPB performed by an emergency physician in addition to their standard analgesic regime. Time to perform the procedure, the number of attempts and complications were recorded as feasibility measures. Secondary outcome was the safety of the block. Numerical pain scores at pre-determined time points over 4 h, the diagnosis of hospital-acquired pneumonia, hospital length of stay and mortality at hospital discharge were collected to provide pilot data on effectiveness. RESULTS The median time to perform the procedure was 5.5 (interquartile range 4.6-10) mins with a range of 2-10.5 min. Most (16; 80%) SAPBs were completed in a single attempt. There were no documented complications. Median pain scores reduced from 6.5 (6-8) and were maintained at 3 (2-5) at 4 h after the SAPB. CONCLUSIONS The present study demonstrated the feasibility of ultrasound-guided SAPB among patients with multiple rib fractures in the ED. No complications were observed. Further prospective evaluation of analgesic effects in a larger cohort is indicated.
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Affiliation(s)
- Marc Schnekenburger
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia
| | - Simon Hendel
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mir Wais Sekandarzad
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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