Radiographic rib fracture nonunion and association with fracture classification in adults with multiple rib fractures without flail segment: A multicenter prospective cohort study

BACKGROUND

Rib fracture nonunion is a probable cause of chronic pain following chest trauma, although its prevalence remains unknown. The aims of this study were to determine rib fracture nonunion prevalence following nonoperative management and to determine if presence of nonunion was associated with the number of rib fractures, or the rib fracture classification of anatomical location, type, and displacement.

METHODS

This multicenter prospective cohort study included trauma patients with three or more fractured ribs but without a flail segment, who participated in the nonoperative management group of the FixCon trial between January 2019 and June 2022. The number and classification of rib fractures were assessed on trauma chest CT. Chest CTs conducted six months post-trauma were evaluated for the presence of nonunion. Radiological characteristics of nonunions were compared with normally healed rib fractures using the Mann-Whitney U, χ2 test, and Fisher's exact test as appropriate. A generalized linear model adjusted for multiple observations per patient when assessing the associations between nonunion and fracture characteristics.

RESULTS

A total of 68 patients were included with 561 post-traumatic fractures in 429 ribs. Chest CT after six months revealed nonunions in 67 (12 %) rib fractures in 29 (43 %) patients with a median of 2 (P25-P75 1-3) nonunions per patient. Nonunion was most commonly observed in ribs seven to 10 (20-23 %, p < 0.001, adjusted p = 0.006). Nonunion occurred in 14 (5 %) undisplaced, 22 (19 %) offset, and 20 (23 %) displaced rib fractures (p < 0.001). No statistically significant association between rib fracture type and nonunion was found.

CONCLUSIONS

Forty-three percent of patients with multiple rib fractures had radiographic nonunion six months after trauma. Fractures in ribs seven to 10 and dislocated fractures had an increased risk of rib fracture nonunion.

The application of electrical impedance tomography and surgical outcomes of thoracoscope-assisted surgical stabilization of rib fractures in severe chest trauma

Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fractures. More studies have claimed that early video-assisted thoracoscopic surgery with surgical stabilization of rib fractures (SSRF) results in a good prognosis in patients with major trauma. This study aimed to verify the outcomes in patients with chest trauma whether SSRF was performed. Consecutive patients who were treated in a medical center in Taiwan, for traumatic events between January 2015 and June 2020, were retrospectively reviewed. This study focused on patients with major trauma and thoracic injuries, and they were divided into groups based on whether they received SSRF. We used electrical impedance tomography (EIT) to evaluate the change of ventilation conditions. Different scores used for the evaluation of trauma severity were also compared in this study. Among the 8396 patients who were included, 1529 (18.21%) had major trauma with injury severity score > 16 and were admitted to the intensive care unit initially. A total of 596 patients with chest trauma were admitted, of whom 519 (87%) survived. Younger age and a lower trauma score (including injury severity scale, new injury severity score, trauma and injury severity score, and revised trauma score) account for better survival rates. Moreover, 74 patients received SSRF. They had a shorter intensive care unit (ICU) stay (5.24, p = 0.045) and better performance in electrical impedance tomography (23.46, p < 0.001). In patients with major thoracic injury, older age and higher injury survival scale account for higher mortality rate. Effective surgical stabilization of rib fractures shortened the ICU stay and helped achieve better performance in EIT. Thoracoscope-assisted rib fixation is suggested in severe trauma cases.

Clinical effect of the internal fixation for rib fracture with single utility port complete video-assisted thoracoscopic surgery

BACKGROUNDS

The internal fixation for rib fracture with single-operation-port (two ports) complete video-assisted thoracoscopic surgery (VATS) is a promising surgical approach for treating multiple rib fractures. The study aimed to investigate the minimally invasive surgical procedure's clinical effect in treating multiple rib fractures.

METHODS

Seventy-three patients with multiple rib fractures were divided into two groups according to surgical procedure. In the study group, 42 patients were operated on with the internal fixation of rib fracture with single-operation-port complete VATS. In the control group, this study performed the open operative internal fixation for rib fracture with traditional thoracotomy on 31 patients. The surgical-related indexes were retrospectively analyzed. These included the operative time, the intraoperative blood loss, the drainage amount of the chest tube, the placement time of the chest tube, the postoperative hospital stay, the incidence of postoperative complications, the imaging efficacy of rib fixation of rib fractures, and visual analog scale of pain scoring (VAS scoring).

RESULTS

There was no difference in the operative time between the study and control groups (P = 0.806). The intraoperative blood loss, the chest tube drainage amount, the chest tube placement time, the postoperative hospital stay, and the incidence of postoperative complications in the study group were lower than those in the control group (P < 0.05). There was no significant difference in the imaging efficacy of rib fixation of rib fractures between the two groups (P = 0.806). VAS scores in the study group on the seventh postoperative day were significantly reduced compared with the control group (P = 0.026).

CONCLUSION

The internal fixation for rib fractures with single-operation-port complete VATS is a feasible, safe, simple, and minimally invasive surgical procedure to treat multiple rib fractures, which is worthy of clinical application.

Early risk factors for prolonged mechanical ventilation in patients with severe blunt thoracic trauma: A retrospective cohort study

BACKGROUND

A significant proportion of patients with severe chest trauma require mechanical ventilation (MV). Early prediction of the duration of MV may influence clinical decisions. We aimed to determine early risk factors for prolonged MV among adults suffering from severe blunt thoracic trauma.

METHODS

This retrospective, single-center, cohort study included all patients admitted between January 2014 and December 2020 due to severe blunt chest trauma. The primary outcome was prolonged MV, defined as invasive MV lasting more than 14 days. Multivariable logistic regression was performed to identify independent risk factors for prolonged MV.

RESULTS

The final analysis included 378 patients. The median duration of MV was 9.7 (IQR 3.0-18.0) days. 221 (58.5 %) patients required MV for more than 7 days and 143 (37.8 %) for more than 14 days. Male gender (aOR 3.01, 95 % CI 1.63-5.58, p < 0.001), age (aOR 1.40, 95 % CI 1.21-1.63, p < 0.001, for each category above 30 years), presence of severe head trauma (aOR 3.77, 95 % CI 2.23-6.38, p < 0.001), and transfusion of >5 blood units on admission (aOR 2.85, 95 % CI 1.62-5.02, p < 0.001) were independently associated with prolonged MV. The number of fractured ribs and the extent of lung contusions were associated with MV for more than 7 days, but not for 14 days. In the subgroup of 134 patients without concomitant head trauma, age (aOR 1.63, 95 % CI 1.18-2.27, p = 0.004, for each category above 30 years), respiratory comorbidities (aOR 9.70, 95 % CI 1.49-63.01, p = 0.017), worse p/f ratio during the first 24 h (aOR 1.55, 95 % CI 1.15-2.09, p = 0.004), and transfusion of >5 blood units on admission (aOR 5.71 95 % CI 1.84-17.68, p = 0.003) were independently associated with MV for more than 14 days.

CONCLUSIONS

Several predictors have been identified as independently associated with prolonged MV. Patients who meet these criteria are at high risk for prolonged MV and should be considered for interventions that could potentially shorten MV duration and reduce associated complications. Hemodynamically stable, healthy young patients suffering from severe thoracic trauma but no head injury, including those with extensive lung contusions and rib fractures, have a low risk of prolonged MV.

Earthquake-related isolated blunt thoracic trauma patients: A special population study in the emergency department

OBJECTIVE

The objective of this study is to compare patients with severe and mild blunt thoracic trauma, who survived an earthquake and presented to the emergency department (ED), in order to identify factors influencing the severity of trauma in earthquake-related thoracic injuries.

METHODS

This retrospective, cross-sectional, observational comparative study included patients with isolated thoracic injuries due to the February 6th Kahramanmaraş earthquake. The patients were categorized into severe and mild groups based on chest trauma scoring (CTS), and their characteristics were compared.

RESULTS

The study included 53 patients, with 43 (88.1%) classified as having mild thoracic trauma and 10 (18.9%) classified as having severe thoracic trauma. There was no significant difference in the duration of entrapment between the groups (p = 0.824). The incidence of hemothorax, pneumothorax, rib fractures, and pneumomediastinum did not differ significantly between the two groups (p > 0.05). However, severe thoracic trauma was associated with a higher rate of lung contusion compared to the mild group (p = 0.045). The severe group exhibited significantly higher median scores for lung contusion, rib fractures, and total CTS compared to the mild group (p < 0.001). The mortality rate was significantly higher in the severe group (40%, n = 4) compared to the mild group (2.3%, n = 1) (p = 0.003).

CONCLUSION

The duration of entrapment did not significantly affect the severity of thoracic injuries in earthquake-related blunt thoracic trauma. However, lung contusion was found to be a more prominent feature in these injuries compared to other clinical conditions such as hemothorax and pneumothorax. These findings highlight the distinct clinical implications of earthquake-related thoracic trauma and may have implications for management strategies in these cases.

Thoracostomy tube withdrawal during latter phases of expiration or inspiration: a systematic review and meta-analysis

PURPOSE

In patients with thoracic injuries, tube thoracostomy is routinely employed. There is disagreement over which manner of tube withdrawal is best, the latter phases of expiration or inspiration. Considering several earlier investigations' inconsistent findings, their comparative effectiveness is still up for debate. In light of this, we carried out a systematic analysis of studies contrasting the withdrawal of thoracostomy tubes during the latter stages of expiration versus inspiration for traumatic chest injuries. Analyzed outcomes are recurrent pneumothoraces, reinsertion of the thoracostomy tube, and hospital stay.

METHODS

We looked for papers comparing the withdrawal of the thoracostomy tube during the last stages of expiration and inspiration for the management of thoracic injuries on Embase, Pubmed, Cochrane Library and Google Scholar. Review Manager was used to determine mean differences (MD) and risk ratios (RR) using a 95% confidence interval (CI).

RESULTS

The primary outcomes showed no significant difference between the inspiration and expiration groups: recurrent pneumothorax (RR 1.27, 95% CI 0.83-1.93, P 0.28) and thoracostomy tube reinsertion (OR: 1.84, CI 0.50-6.86, P 0.36, I2 5%). However, the duration of hospital stay was significantly lower in patients in whom the thoracostomy tube was removed at the end of inspiration (RR 1.8, 95% CI 1.49-2.11, P < 0.00001, I2 0%). The implications of these findings warrant cautious interpretation, accounting for potential confounding factors and inherent limitations that may shape their significance.

CONCLUSION

The thoracostomy tube can be removed during both the end-expiratory and end-inspiratory stages of respiration with no appreciable difference. Nevertheless, caution should be exercised when ascertaining the implications of these findings, taking into account the potential limitations and confounding variables that may exert influence upon the outcomes.

A patient with a pulmonary hernia and chance fracture of the thoracic vertebra following a fall: A case report and literature review

INTRODUCTION AND IMPORTANCE

Pulmonary hernia is a rare disease caused mostly by chest trauma. Patients often present with non-specific signs and symptoms. Currently, there is no unified approach to treating it. For asymptomatic pulmonary hernias, conservative treatment has been chosen in the past. However, the increasing number of cases has shown that surgery has a more positive effect on some patients with asymptomatic pulmonary hernias.

CASE PRESENTATION

A 63-year-old female patient who accidentally fell from an agricultural vehicle while doing farm work presented with back pain and lower limb paralysis. Her vital signs were stable. A chest computed tomography (CT) scan showed the patient had a pulmonary hernia, thoracic vertebra Chance fracture, rib fractures, and right hydropneumothorax. The patient received an open reduction internal fixation (ORIF) of the thoracic vertebra at the trauma emergency center. The postoperative chest CT scan showed that the pulmonary hernia had reset to the chest cavity. Subsequently, the patient got a pulmonary hernia repair at the thoracic surgery department. The patient was discharged on the 19th day after the injury. Long-term follow-up showed good recovery from the thoracic trauma.

CLINICAL DISCUSSION

The patient had a pulmonary hernia combined with thoracic Chance fracture and other injuries. Surgical repair achieved satisfactory results.

CONCLUSION

We lack guidelines on whether to manage pulmonary hernias surgically. Patients with asymptomatic pulmonary hernias particularly should have their long-term prognoses fully evaluated. Surgery is needed if the patient has high-risk factors and severe intercostal muscle defects.

Aortic arch impingement with Salter Harris II epiphyseal fracture of the medial clavicle: A novel use of video assisted thoracoscopy

Posterior dislocation of the sternoclavicular joint (SCJ), although uncommon, can be life-threatening. Displacement of the clavicular head poses a threat to the vital structures of the mediastinum. We describe the case of a 15-year-old boy with traumatic Salter Harris II medial clavicular fracture with posterior dislocation of the metaphysis resulting in impingement of the aortic arch, left subclavian and common carotid artery, as well as partial obstruction of the brachiocephalic vein. We describe the novel use of video-assisted thoracoscopy to assist with a safe open reduction and fixation of the fracture dislocation. The case highlights the importance of computer tomography imaging for diagnosis of posterior SCJ fracture/dislocations and the early recognition of potential life-threatening complications in the mediastinum.

An impressive case of isolated thoracic impalement

Case

A 61-year-old male construction worker was admitted to our Emergency Department due to being impaled in the chest after fall onto the long pole of his cement mixer. He was promptly scanned through the CT then transferred to theatre where unique technique for intubation was utilised prior to performing a Video Assisted Thoracoscopic Surgery exploration and extraction of the foreign object.

Discussion

Impalement injuries are classified into Types I or II depending on the direction of movement of the human body in relation to the foreign object. There currently is no consensus on the best management of chest wall injuries involving impalements. Our case utilised Video Assisted Thoracoscopic Surgery as the dominant method of intervention together with highly skilled anaesthetic preparation.

Conclusion

The combined expert anaesthetic and surgical approach utilised collectively had a role in ensuring the best possible outcome for the patient.

Xanthoma of rib: a case report and review of the literature

BACKGROUND

Xanthomas are well-circumscribed benign proliferative lesions seen mainly in soft tissues. Usually, they are found in hyperlipidemia and familial hyperlipoproteinemia. Histologically, are characterized by macrophage-like mononuclear cells, multinucleated giant cells and abundant foam cells. The bone involvement, however, is notoriously rare and rib localization is extremely rare.

CASE PRESENTATION

A 55-year-old man performed a chest X-ray and a subsequent chest Computed Tomography scan showing a rib lesion that was surgically removed and a diagnosis of rib xanthoma was made. The patient presented an unknown condition of hyperlipidemia.

CONCLUSION

Rib xanthoma can be discovered accidentally and can be helpful in identifying an unrecognized condition of hyperlipidemia.

Severe non-cardiovascular thoracic trauma: diagnostic clues on computed tomography

OBJECTIVE

About 60% of multiple trauma patients have thoracic trauma, and thoracic trauma results in the death of 10% of these patients. Computed tomography (CT) is the most sensitive and specific imaging modality for the diagnosis of acute disease, and it helps in the management and prognostic evaluation of patients with high-impact trauma. This paper aims to show the practical points that are key for diagnosing severe non-cardiovascular thoracic trauma by CT.

CONCLUSION

Knowing the key features of severe acute thoracic trauma on CT is crucial to avoid diagnostic errors. Radiologists play a fundamental role in the accurate early diagnosis of severe non-cardiovascular thoracic trauma, because the patient's management and outcome will depend largely on the imaging findings.

Aerosolized antibiotics therapy for infected traumatic pulmonary pseudocysts: A case report

Background

Traumatic pulmonary pseudocysts are caused after thoracic trauma. They do not usually require specific therapy when no complications arise, such as infection and bleeding. Complicated pulmonary pseudocysts, however, can be life threatening and require specific treatment. Although treatments of systemic antibiotics and surgery for infected cysts have been reported, to the best of our knowledge, there are no reports on aerosolized antibiotics therapy for infected traumatic pulmonary pseudocysts.

Case presentation

We present the case of a 31-year-old woman who was severely injured and suffered a blunt thoracic trauma in a vehicular accident, and required ventilator management in a previous hospitalization. Seven days later, she developed acute respiratory distress syndrome and was transferred to our department. We were unable to maintain proper oxygenation with ventilator management alone and established venous-venous extracorporeal membrane oxygenation. She then developed persistent bacteremia of Pseudomonas aeruginosa owing to infected traumatic pulmonary pseudocysts. On the 21st day of her hospitalization, the drainage for the enlarged cyst led to minor improvements in her respiratory condition. On the 32nd day of hospitalization, in addition to systemic antibiotics therapy, the aerosolized antibiotics therapy (inhalation of tobramycin (135 mg) every 12 h) was administered for the treatment of resistant infected pseudocysts. Her respiratory condition gradually improved, and the infected pseudocysts shrank. On the 43rd day of hospitalization, she was successfully removed from extracorporeal membrane oxygenation.

Conclusions

Aerosolized antibiotics therapy may be a potential option for patients with infected traumatic pulmonary pseudocysts when conventional therapies are not successful.

Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands

Thoracic injuries are infrequent among children, but still represent one of the leading causes of pediatric mortality. Studies on pediatric chest trauma are dated, and little is known of outcomes in different age categories. This study aims to provide an overview of the incidence, injury patterns, and in-hospital outcomes of children with chest injuries. A nationwide retrospective cohort study was performed on children with chest injuries, using data from the Dutch Trauma Registry. All patients admitted to a Dutch hospital between January 2015 and December 2019, with an abbreviated injury scale score of the thorax between 2 and 6, or at least one rib fracture, were included. Incidence rates of chest injuries were calculated with demographic data from the Dutch Population Register. Injury patterns and in-hospital outcomes were assessed in children in four different age groups. A total of 66,751 children were admitted to a hospital in the Netherlands after a trauma between January 2015 and December 2019, of whom 733 (1.1%) sustained chest injuries accounting for an incidence rate of 4.9 per 100,000 person-years. The median age was 10.9 (interquartile range (IQR) 5.7-14.2) years and 62.6% were male. In a quarter of all children, the mechanisms were not further specified or unknown. Most prevalent injuries were lung contusions (40.5%) and rib fractures (27.6%). The median hospital length of stay was 3 (IQR 2-8) days, with 43.4% being admitted to the intensive care unit. The 30-day mortality rate was 6.8%.

CONCLUSION

Pediatric chest trauma still results in substantial adverse outcomes, such as disability and mortality. Lung contusions may be inflicted without fracturing the ribs. This contrasting injury pattern compared to adults underlines the importance of evaluating children with chest injuries with additional caution.

WHAT IS KNOWN

• Chest injuries are rare among children, but represent one of the leading causes of pediatric mortality. • Children show distinct injury patterns in which pulmonary contusions are more prevalent than rib fractures.

WHAT IS NEW

• The proportion of chest injuries among pediatric trauma patients is currently lower than reported in previous literature, but still leads to substantial adverse outcomes, such as disabilities and death. • The incidence of rib fractures gradually increases with age and in particular around puberty when ossification of the ribs becomes completed. The incidence of rib fractures among infants is remarkably high, which is strongly suggestive for nonaccidental trauma.

Association between three prehospital thoracic decompression techniques by physicians and complications: a retrospective, multicentre study in adults

INTRODUCTION

We sought to compare the complication rates of prehospital needle decompression, finger thoracostomy and three tube thoracostomy systems (Argyle, Frontline kits and endotracheal tubes) and to determine if finger thoracostomy is associated with shorter prehospital scene times compared with tube thoracostomy.

METHODS

In this retrospective cohort study we abstracted data on adult trauma patients transported by three helicopter emergency medical services to five Major Trauma Service hospitals who underwent a prehospital thoracic decompression procedure over a 75-month period. Comparisons of complication rates for needle, finger and tube thoracostomy and between tube techniques were conducted. Multivariate models were constructed to determine the relative risk of complications and length of scene time by decompression technique.

RESULTS

Two hundred and fifty-five patients underwent 383 decompression procedures. Fifty eight patients had one complication, and two patients had two complications. There was a weak association between decompression technique (finger vs tube) and adjusted risk of overall complication (RR 0.58, 95% CI: 0.33-1.03, P = 0.061). Recurrent tension physiology was more frequent in finger compared with tube thoracostomy (13.9 vs 3.2%, P < 0.001). Adjusted prolonged (80th percentile) scene time was not significantly shorter in patients undergoing finger vs tube thoracostomy (56 vs 63 min, P = 0.197), nor was the infection rate lower (2.7 vs 2.1%, P = 0.85).

CONCLUSIONS

There was no clear evidence for benefit associated with finger thoracostomy in reducing overall complication rates, infection rates or scene times, but the rate of recurrent tension physiology was significantly higher. Therefore, tube placement is recommended as soon as practicable after thoracic decompression.

Impact of the implementation of a trauma system on compliance with evidence-based clinical management guidelines in penetrating thoracic trauma

PURPOSE

Since 2014, a trauma system (TS) for the Provence-Alpes-Cote-d'Azur (PACA) region has been set up with protocols based on the European guidelines for the management of bleeding trauma patients. The present study aims to assess compliance with protocols in penetrating thoracic trauma on admission to a level I trauma centre and to determine whether compliance impacts morbidity and mortality.

METHODS

This multicentric pre-post study included all penetrating thoracic trauma patients referred to Marseille area level I centres between January 2009 and December 2019. On the basis of the European guidelines, eight objectively measurable recommendations concerning the in-hospital trauma care for the first 24 h were analysed. Per-patient and per-criterion compliance rates and their impact on morbidity and mortality were evaluated before and after TS implementation.

RESULTS

A total of 426 patients were included. No differences between the two groups (before and after 2014) were reported for demographics or injury severity. The median (interquartile range) per-patient compliance rate increased from 67% [0.50; 0.75] to 75% [0.67; 1.0] (p < 0.01) after implementation of a TS. The 30-day morbidity-mortality was, respectively, of 17% (30/173) and 13% (32/253) (p = 0.18) before and after TS implementation. A low per-patient compliance rate was associated with an increase in the 30-day morbidity-mortality rate (p < 0.01). Severity score-adjusted per-patient compliance rates were associated with decreased 30-day morbidity-mortality (odds ratio [IC 95%] = 0.98 [0.97; 0.99] p = 0.01).

CONCLUSION

Implementation of a TS was associated with better compliance to European recommendations and better outcomes for severe trauma patients. These findings should encourage strict adherence to European trauma protocols to ensure the best patient outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures

BACKGROUND

Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture.

METHODS

All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders.

RESULTS

96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome.

CONCLUSIONS

Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

Thoracic injuries in trauma patients: epidemiology and its influence on mortality

BACKGROUND

Thoracic injuries are common among trauma patients. Studies on trauma patients with thoracic injuries have reported considerable differences in morbidity and mortality, and there is limited research on comparison between trauma patients with and without thoracic injuries, particularly in the Scandinavian population. Thoracic injuries in trauma patients should be identified early and need special attention since the differences in injury patterns among patient population are important as they entail different treatment regimens and influence patient outcomes. The aim of the study was to describe the epidemiology of trauma patients with and without thoracic injuries and its influence on 30-day mortality.

METHODS

Patients were identified through the Karolinska Trauma Register. The Abbreviated Injury Scale (AIS) system was used to find patients with thoracic injuries. Logistic regression analysis was performed to evaluate factors [age, gender, ASA class, GCS (Glasgow Coma Scale), NISS (New Injury Severity Score) and thoracic injury] associated with 30-day mortality.

RESULTS

A total of 2397 patients were included. Of those, 768 patients (32%) had a thoracic injury. The mean (± SD, range) age of all patients (n = 2397) was 46 (20, 18-98) years, and the majority (n = 1709, 71%) of the patients were males. There was a greater proportion of patients with rib fractures among older (≥ 60 years) patients, whereas younger patients had a higher proportion of injuries to the internal thoracic organs. The 30-day mortality was 11% (n = 87) in patients with thoracic injury and 4.3% (n = 71) in patients without. After multivariable adjustment, a thoracic injury was found to be associated with an increased risk of 30-day mortality (OR 1.9, 95% CI 1.3-3.0); as was age ≥ 60 years (OR 3.7, 95% CI 2.3-6.0), ASA class 3-4 (OR 2.3, 95% CI 1.4-3.6), GCS 1-8 (OR 21, 95% CI 13-33) and NISS > 15 (OR 4.2, 2.4-7.3).

CONCLUSION

Thoracic injury was an independent predictor of 30-day mortality after adjustment for relevant key variables. We also found a difference in injury patterns with older patients having a higher proportion of rib fractures, whilst younger patients suffered more internal thoracic organ injuries.

Chest trauma epidemiology and emergency department management in a tertiary teaching hospital in Kigali, Rwanda

Introduction

Chest trauma is a major contributor to injury morbidity and mortality, and understanding trends is a crucial part of addressing this burden in low- and middle-income countries. This study reports the characteristics and emergency department (ED) management of chest trauma patients presenting to Rwanda's national teaching hospital in Kigali.

Methods

This descriptive analysis included a convenience sample of patients presenting to a single tertiary hospital ED with chest trauma from June to December 2017. Demographic data were collected as well as injury mechanism, thoracic and associated injuries, types of imaging obtained, and treatments performed. Chart review was conducted seven days post-admission to follow up on outcomes and additional diagnoses and interventions. Incidences were calculated with Microsoft Excel.

Results

Among the 62 patients included in this study, 74% were male, and mean age was 35 years. Most patients were injured in road traffic crashes (RTCs) (68%). Common chest injuries included lung contusions (79% of cases), rib fractures (44%), and pneumothoraces (37%). Head trauma was a frequent concurrent extra-thoracic injury (61%). Diagnostic imaging primarily included E-FAST ultrasound (92%) and chest x-ray (98%). The most common therapies included painkillers (100%), intravenous fluids (89%), and non-invasive oxygen (63%), while 29% underwent invasive intervention in the form of thoracostomy. The majority of patients were admitted (81%). Pneumonia was the most common complication to occur in the first seven days (32% of admitted patients). Ultimately, 40% of patients were discharged home within seven days of presentation, 50% remained hospitalized, and 5% died.

Conclusion

This study on the epidemiology of chest trauma in Rwanda can guide injury prevention and medical training priorities. Efforts should target prevention in young males and those involved in RTCs. ED physicians in Rwanda need to be prepared to diagnose and treat a variety of chest injuries with invasive and noninvasive means.

Traumatic diaphragmatic rupture: epidemiology, associated injuries, and outcome-an analysis based on the TraumaRegister DGU®

INTRODUCTION

Traumatic diaphragmatic rupture is a rare injury in the severely injured patient and is most commonly caused by blunt mechanisms. However, penetrating mechanisms can also dominate depending on regional and local factors. Traumatic diaphragmatic rupture is difficult to diagnose and can be missed by primary diagnostic procedures in the resuscitation room. Initially not life-threatening, diaphragmatic ruptures can cause severe sequelae in the patient's long-term course if untreated. The objective of this study was to assess the epidemiology, associated injuries, and outcome of traumatic diaphragmatic ruptures based on a multicenter registry-based analysis.

MATERIAL AND METHODS

Data from all patients enrolled in the TraumaRegister DGU® between 2009 and 2018 were retrospectively analyzed. That multicenter database collects data on prehospital, intra-hospital emergency, intensive care therapy, and discharge. Included were all patients with a Maximum Abbreviated Injury Scale (MAIS) score of 3 or above and patients with a MAIS score of 2 who died or were treated in the intensive care unit, for whom standard documentation forms had been completed and who had sustained a diaphragmatic rupture (AIS score of 3 or 4). The data has been analyzed using descriptive statistics and chi-square test or Mann-Whitney U test.

RESULTS

Of the 199,933 patients included in the study population, 687 patients (0.3%) had a diaphragmatic rupture. Of these, 71.9% were male. The mean patient age was 46.1 years. Blunt trauma accounted for 73.5% of the injuries. Primary diagnosis was established in the resuscitation room in 93.1% of the patients. Multislice helical computed tomography (MSCT) was performed in 82.7% of the cases. Rib fractures were detected in 60.7% of the patients with a diaphragmatic injury. Patients with diaphragmatic rupture had a higher mean Injury Severity Score (ISS) than patients without a diaphragmatic injury (32.9 vs. 18.6) and a higher mortality rate (13.2% vs. 9.0%).

CONCLUSIONS

In contrast to the literature, primary diagnostic procedures in the resuscitation room detected relevant diaphragmatic ruptures (AIS ≥ 3) in more than 90% of the patients in our study population. In addition, complex associated serial rib fractures are an important diagnostic indicator.

Outcomes of the resuscitative and emergency thoracotomy at a Dutch level-one trauma center: are there predictive factors for survival?

PURPOSE

To investigate the 30-day survival rate of resuscitative and emergency thoracotomies in trauma patients. Moreover, factors that positively influence 30-day survival rates were investigated.

METHODS

A retrospective study of patients (> 16 years), between 2008 and 2020, who underwent a resuscitative or emergency thoracotomy at a level-one trauma center in the Netherlands was conducted.

RESULTS

Fifty-six patients underwent a resuscitative (n = 45, 80%) or emergency (n = 11, 20%) thoracotomy. The overall 30-day survival rate was 32% (n = 18), which was 23% after blunt trauma and 72% after penetrating trauma, and which was 18% for the resuscitative thoracotomy and 91% for the emergency thoracotomy. The patients who survived had full neurologic recovery. Factors associated with survival were penetrating trauma (p < 0.001), (any) sign of life (SOL) upon presentation to the hospital (p = 0.005), Glasgow Coma Scale (GCS) of 15 (p < 0.001) and a thoracotomy in the operating room (OR) (p = 0.018). Every resuscitative thoracotomy after blunt trauma and pulseless electrical activity (PEA) or asystole in the pre-hospital phase was futile (0 survivors out of 11 patients), of those patients seven (64%) had concomitant severe neuro-trauma.

CONCLUSION

This study found a 30-day survival rate of 32% for resuscitative and emergency thoracotomies, all with good neurological recovery. Factors associated with survival were related to the trauma mechanism, the thoracotomy indication and response to resuscitation prior to thoracotomy (for instance, if resuscitation enables enough time for safe transport to the operating room, survival chances increase). Resuscitative thoracotomies after blunt trauma in combination with loss of SOL before arrival at the emergency room were in all cases futile, interestingly in nearly all cases due to concomitant neuro-trauma.

Distribution of interstitial cells of Cajal in the Esophagus and change in distribution after thoracic trauma

Interstitial cells of Cajal (ICCs) function as pacemaker cells in the gastrointestinal tract. Acute thoracic trauma is a common and lethal cause of death due to physical trauma caused by traffic accidents. This study aimed to explore the distribution of esophageal ICCs and distribution changes observed after acute thoracic trauma. Thirty rabbits were randomly divided into a control group and two study groups. The control group animals underwent an esophagectomy. All animals in the study groups underwent right chest puncture using the Hopkinson bar technique. The study groups were subjected to esophagectomy 24 and 72 h after chest puncture. Distribution, morphology, and density of esophageal ICCs were detected using transmission electron microscopy, toluidine blue staining, and immunohistochemistry. Apoptosis of esophageal ICCs was evaluated using the terminal deoxynucleotidyl transferase (TdT) dUTP Nick-End Labeling assay. Western blotting and reverse transcription polymerase chain reaction were used to detect changes in the SCF/c-kit signaling pathway. Esophageal ICCs distribution and SCF/c-kit signal pathway decreased from the upper part to the lower part in both physiological state and after thoracic trauma. In contrast, death of ICCs increased from the upper part to the lower part, both in physiological and injured state (P < 0.05). After thoracic trauma, increased ICCs and decreased death of ICCs in all parts of the esophagus (P < 0.05) were observed. The observed distribution and changes in esophageal ICCs would have an impact on motility and motility disorders of the esophagus.

Lung failure after polytrauma with concomitant thoracic trauma in the elderly: an analysis from the TraumaRegister DGU®

Background

In developed countries worldwide, the number of older patients is increasing. Pulmonary complications are common in multiple injured patients with chest injuries. We assessed whether geriatric patients develop lung failure following multiple trauma with concomitant thoracic trauma more often than younger patients.

Methods

A retrospective analysis of severely injured patients with concomitant blunt thoracic trauma registered in the TraumaRegister DGU® (TR-DGU) between 2009 and 2018 was performed. Patients were categorized into four age groups: 55–64 y, 65–74 y, 75–84 y, and ≥ 85 y. Adult patients aged 18–54 years served as a reference group. Lung failure was defined as PaO2/FIO2 ≤ 200 mm Hg, if mechanical ventilation was performed.

Results

A total of 43,289 patients were included, of whom 9238 (21.3%) developed lung failure during their clinical stay. The rate of posttraumatic lung failure was seen to increase with age. While lung failure markedly increased the length of hospital stay, duration of mechanical ventilation, and length of ICU stay independent of the patient’s age, differences between younger and older patients with lung failure in regard to these parameters were clinically comparable. In addition, the development of respiratory failure showed a distinct increase in mortality with higher age, from 16.9% (18–54 y) to 67.2% (≥ 85 y).

Conclusion

Development of lung failure in severely injured patients with thoracic trauma markedly increases hospital length of stay, length of ICU stay, and duration of mechanical ventilation in patients, regardless of age. The development of respiratory failure appears to be related to the severity of the chest trauma rather than to increasing patient age. However, the greatest effects of lung failure, particularly in terms of mortality, were observed in the oldest patients.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Iatrogenic rib fractures and the associated risks of mortality

PURPOSE

Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures.

METHODS

Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression.

RESULTS

34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings.

CONCLUSION

IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity.

Azygos vein lacerations, a rare injury from high-impact chest trauma: Two cases and a review of the literature

INTRODUCTION

Thoracic trauma is a significant cause of mortality, being responsible for 25% of trauma deaths. Despite this, azygos vein lacerations are rare, with only 35 published cases. We present two cases of azygos vein laceration over 21 years from 1999 to 2020 at a Level One Trauma Centre in Melbourne, Australia, as well as a review of the literature.

CASE PRESENTATIONS

The first case is a 38-year-old male who fell eight metres from a motorbike jump. He arrived in our emergency department in extremis. The second case is an 81-year-old female driver who presented following a motor vehicle crash. Both patients had massive right haemothorax and haemodynamic instability, so were transferred to the operating theatre for emergency thoracotomies. Both patients survived to hospital discharge.

DISCUSSION

Of the 37 cases of azygos vein injury, including our two, 36 were due to blunt trauma and one from penetrating trauma. Sixteen survived to hospital discharge, producing a 43% mortality rate. Only one of these survivors was managed non-operatively, the remainder underwent emergency thoracotomy and azygos vein ligation. The mortality rate reduced to 31% in those who underwent thoracotomy (n = 29). Presentation was predominantly with shock (83%) and right hemithorax white-out on chest x-ray (81%).

CONCLUSION

Azygos vein injuries are a rare but important cause of thoracic haemorrhage in high-impact blunt trauma. They are often fatal, so management relies on expedient transfer to theatre.

The use of ultrasound in establishing COVID-19 infection as part of a trauma evaluation

Purpose

The use of lung ultrasound for diagnosis of COVID-19 has emerged during the pandemic as a beneficial diagnostic modality due to its rapid availability, bedside use, and lack of radiation. This study aimed to determine if routine ultrasound (US) imaging of the lungs of trauma patients with COVID-19 infections who undergo extended focused assessment with sonography for trauma (EFAST) correlates with computed tomography (CT) imaging and X-ray findings, as previously reported in other populations.

Methods

This was a prospective, observational feasibility study performed at two level 1 trauma centers. US, CT, and X-ray imaging were retrospectively reviewed by a surgical trainee and a board-certified radiologist to determine any correlation of imaging findings in patients with active COVID-19 infection.

Results

There were 53 patients with lung US images from EFAST available for evaluation and COVID-19 testing. The overall COVID-19 positivity rate was 7.5%. COVID-19 infection was accurately identified by one patient on US by the trainee, but there was a 15.1% false-positive rate for infection based on the radiologist examination.

Conclusions

Evaluation of the lung during EFAST cannot be used in the trauma setting to identify patients with active COVID-19 infection or to stratify patients as high or low risk of infection. This is likely due to differences in lung imaging technique and the presence of concomitant thoracic injury.

"Early results after initiation of a rib fixation programme: A propensity score matched analysis"

INTRODUCTION

Chest wall injuries are very common in blunt trauma and development of treatment protocols can significantly improve outcomes. Surgical stabilisation of rib fractures (SSRF) is an adjunct for the most severe chest injuries and can be used as a part of a comprehensive approach to chest injuries care. We hypothesized that implementation of a SSRF programme program would result in improved short-term outcomes.

MATERIALS AND METHODS

The characteristics of the initial group of SSRF patients (Early-SSRF) were used to identify matching factors. Patients prior to SSRF protocol underwent a propensity score match, followed by screening for operative indications and contraindications. After exclusions, a non-operative (Non-Op) cohort was defined (n=36) resulting in an approximately 1:1 match. An overall operative cohort, inclusive of Early-SSRF and all subsequent operative patients, was defined (All- SSRF). A before-and-after analysis using chi-squared, Students T-tests, and Mann-Whitney U-tests were used to assess significance at the level of 0.05.

RESULTS

Early-SSRF (n=22) and All-SSRF (n=45) were compared to Non-Op (n=36). The selection process resulted in well matched groups, and equally well-balanced operative indications between the groups. The Early-SSRF group demonstrated shortened duration of mechanical ventilation and a decreased frequency of being discharged a long-term acute care hospital. The All-SSRF group again demonstrated markedly shorter duration of mechanical ventilation compared to Non-Op (median 6 days vs 16 days, p < 0.01), more decrease discharge to a long-term acute care hospital (9% vs. 36%, p=0.01), and reduced risk for tracheostomy (8.9% vs. 33.3% respectively, p<0.01) CONCLUSION: The introduction of an operative rib fixation to a comprehensive chest wall injury protocol can produce improvements in clinical outcomes that decrease time on the ventilator and tracheostomy rates, and result in more patients being discharged to home. Creation and implementation of a chest wall injury protocol to include SSRF requires a multidisciplinary approach and thoughtful patient selection.

Lung Ultrasound for Pulmonary Contusions

Lung ultrasound (LUS) has high sensitivity for the rapid and reliable diagnosis of pulmonary contusions (PC) in patients who have sustained trauma. LUS diagnosis of PC exceeds that of thoracic radiographs in multiple animal and human studies. The sonographer should understand potential caveats and confounding variables for proper diagnosis of PC with LUS. LUS does not replace conventional radiography or computed tomography, especially in the polytrauma patient. LUS should be used concurrently with other point-of-care ultrasound trauma protocols to rapidly optimize patient assessment before movement to the radiology suite.

Transfixing heart injury by stab wound: Case report

Cardiac impalement is a rare and usually fatal injury. Immediate recognition and surgical intervention are decisive factors for patient survival. This is a reported case of cardiac impalement with left ventricular transfixation, whose prehospital management, surgical treatment and postoperative care were successful.

Epidemiological and clinical characteristics of road traffic crashes related thoracic traumas: analysis of 5095 hospitalized chest injury patients

BACKGROUND

Road traffic crashes related (RTCR) chest traumas remain important global public health challenge. The impact of boosting market of automobile vehicles in China during last decade on thoracic injury needs to be defined. This study aimed to review and analyze the demographic and clinical characteristics of RTCR thoracic injuries in China.

METHODS

Clinical records of patients with thoracic trauma admitted to thoracic surgery department between January 2003 and June 2020 were retrospectively retrieved and reviewed. Patients' profiles and clinical characteristics were comparatively analyzed between road traffic crashes caused injury and other injury mechanisms, and in RTCR chest trauma patients before January 2011 (2003 group), and after January 2011 (2011 group), when is considered as the beginning year of Chinese household vehicle era.

RESULTS

The study included 5095 thoracic trauma patients with mean age of 50.2 years, of whom 79.4% were male. Most of the patients (70.3%, n = 3583) had rib fractures. Associated injuries were present in 52.0% of the patients, of them 78.5% (n = 2080) were extremity fractures. Road traffic crashes accounted for 41.4% (n = 2108) of the injuries, most of them (98.0%) were related to motor vehicles. In comparison with other chest trauma mechanisms, RTCR chest injuries affected females and older males more frequently, with a higher incidence of rib fractures and sternum fractures, and higher injury severity scores (ISS) (all p < 0.05). Surgeries were required in 1495 (70.9%) patients of the RRTCR chest traumas, while the majority of non-RTCR thoracic injuries were managed conservatively or with tube thoracostomy (30.2%, n = 901). RTCR chest traumas caused longer hospital stay (13.0 ± 9.6 days vs. 11.8 ± 7.4 days, p = 0.001), higher ICU usage (30.7% vs. 19.6%, p = 0.001), higher rate of ventilator support (12.9% vs. 7.5%, p = 0.001), and higher mortalities (3.8% vs. 1.6%, p = 0.005) than that of non-RTRA chest injuries. For RTCR patients, when compared with 2003 group, 2011 group had similar patterns in terms of accident category, associated injury and treatment. However, 2011 group had more females (38.5% vs. 18.0%, p = 0.001) and older males (50.6 ± 9.7 vs. 47.9 ± 17.2, p = 0.001), with a higher ISS (18.3 ± 10.2 vs. 17.1 ± 8.9, p = 0.004), and fewer were managed with chest tubes (25.0% vs. 29.2%, p = 0.031). Clinical outcomes were not significantly different between the groups in terms of hospital length of stay, intensive care unit (ICU) usage, ICU length of stay, duration of ventilator hours and mortality. However, the 2011 group had more patients requiring ventilator support (14.4% vs. 10.6%, p = 0.011).

CONCLUSIONS

Road traffic crashes remain to be the major etiology of thoracic injuries in China, which usually affects middle-aged males, causing rib fractures with concomitant injuries frequently occurring to other organ systems. Treatments mainly include tube thoracotomy and surgical procedures. Although the clinical characteristics and outcomes of traffic accident related chest traumas are largely unchanged in spite of the rapid increasing numbers of motor vehicles, variations in the pattern of injuries by gender, age, injury severity and ventilator usage may still provide important information for targeted management.

The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma

BACKGROUND

Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation.

METHODS

Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma.

RESULTS

One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma.

CONCLUSION

We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.

Rib fracture fixation in a patient on veno-venous ECMO for severe blunt thoracic trauma

Thoracic chest wall trauma is a common injury in patients admitted to hospital following injury and is associated with high mortality. British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines recommend consideration of rib fracture fixation in patients with flail chest wall injuries with respiratory compromise or uncontrollable pain. Veno-venous extracorporeal membrane oxygenation (ECMO) can be utilised in patients with severe respiratory dysfunction and we present the case of a patient who underwent rib fracture fixation while receiving ECMO. A 32-year-old male was admitted to our department following a 4.5m fall. He sustained significant thoracic injuries with multiple ribs fractures and a flail segment from the right fourth to ninth ribs. Treatment consisted of bilateral chest drains, ECMO support, tracheostomy and rib fracture fixation to the eighth and ninth ribs. The patient made a rapid recovery following surgery and ECMO support was ceased 2.5 days postoperatively. The case shows that a well-prepared, combined specialty surgical team can safely perform rib fixation for a patient on ECMO.

"Do You Need a Doctor's Note?" Factors Leading to Delayed Return to Work after Blunt Chest Trauma

BACKGROUND

Blunt chest trauma is associated with significant morbidity, but the long-term functional status for these patients is less well-known. Return to work (RTW) is a benchmark for functional recovery in trauma patients, but minimal data exist regarding RTW following blunt chest trauma.

MATERIALS AND METHODS

Patients ≥ 18 y old admitted to a Level 1 trauma center following blunt chest trauma with ≥ 3 rib fractures and length of stay (LOS) ≥ 3 d were included. An electronic survey assessing RTW was administered to patients after discharge. Patients were stratified as having delayed RTW (> 3 mo after discharge) or self-reported worse activities-of-daily-living (ADL) function after injury. Patient demographics, outcomes, and injury characteristics were compared between groups.

RESULTS

Median time to RTW was 3 mo (IQR 2,5). Patients with delayed RTW had higher odds of having more rib fractures than those with RTW ≤ 3 mo (median 10 versus 7; OR:1.24, 95%CI:1.04,1.48) as well as a longer LOS (median 13 versus 7 d; OR:1.15, 95% CI:1.04,1.30). Patients with stable ADL after trauma returned to work earlier than those reporting worse ADL (median 2 versus 3.5 mo, P < 0.01). 23.6% of respondents took longer than 5 mo to return to independent functioning, and 50% of respondents' report limitations in daily activities due to physical health after discharge.

CONCLUSIONS

The significant proportion of patients with poor physical health and functional status suggests ongoing burden of injury after discharge. Patients with longer LOS and greater number of rib fractures may be at highest risk for delayed RTW after injury.

Characteristics of pediatric thoracic trauma: in view of before and after the establishment of a regional trauma center

Purpose

Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of the pediatric thoracic trauma to improve treatment results. In addition, this study examined the changes in pediatric thoracic trauma features and results from the establishment of a level 1 regional trauma center.

Methods

Data of 168 patients’ ≤ 15 years old diagnosed with thoracic trauma between 2008 and 2019 were retrospectively analyzed.

Results

Pedestrian traffic accidents were the most common cause of chest injury. The average injury severity score was 17.1 ± 12.4 and the average pediatric trauma score was 5.6 ± 4.1. Lung contusion was the most common in 134 cases. There were 48 cases of closed thoracostomy. There was one thoracotomy for cardiac laceration, one case for extracorporeal membranous oxygenation, and six cases for embolization. Of all, 25 patients died, providing a mortality rate of 14.9%. In addition, independent risk factors of in-hospital mortality were hemopneumothorax and cardiac contusion. Since 2014, when the level 1 regional trauma center was established, more severely injured thoracic trauma patients came. However, the mortality was similar in the two periods.

Conclusions

Understanding the clinical features of pediatric thoracic trauma patients can help in efficient treatment. In addition, as the severity of pediatric thoracic trauma patients has increased due to the establishment of the regional trauma center, so pediatric trauma center should be organized in regional trauma center to improve the outcomes of pediatric thoracic trauma.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01658-4.

Surgical stabilization of severe flail chest with Judet and Sanchez-Lloret plates. A case report

INTRODUCTION

Flail chest is now usually treated by conservative methods and surgical fixation remains indicated in selected cases. Different techniques can be used for fixation. The aim of this paper is to present a case in which Judet and Sanchez-Loret plates were employed and to discuss the usefulness of this traditional technique.

PRESENTATION OF CASE

A 79-year-old woman was admitted for left thoracic trauma with severe antero-lateral flail chest. She was affected by COPD with chronic respiratory failure, ischemic heart disease, autoimmune thrombocytopenia treated on chronic steroid therapy and severe osteoporosis. CT-scan detected multiple rib fractures, left hemothorax and lung contusions. An initial conservative treatment of flail chest involved compressive bandage and then internal pneumatic stabilization in ICU, but it failed. The patient underwent successful surgical treatment of the flail chest by fixation of the anterior fractures from the second to the eight rib. Judet and Sanchez-Lloret plates were used. A bilateral pneumonia developed during the rehabilitation period and the patient died two months after operation.

DISCUSSION

Judet and Sanchez-Lloret plates represent a traditional technique for fixation of flail chest. This technique is less and less used and progressively replaced by newer materials, especially titanium plates with screws or intramedullary struts. Our patient had multiple comorbidities and a very fragile bones that advised against use of screws or intramedullary struts.

CONCLUSION

Judet and Sanchez-Lloret plates can be still considered a useful tool for the fixation of flail chest in cases of thin and fragile bones.

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

Isolated open bronchus fracture after open die forging

We present a case of an isolated open bronchus rupture following blunt thoracic trauma. Tracheobronchial injuries (TBI) following blunt chest trauma are a rare but possibly life-threatening condition. Though typically associated with additional injuries, high-energy blunt trauma led to perforating chest wound alone. A bronchial injury has not been seen neither in preoperative CT scan nor intraoperatively. This underlines the strong need for bronchoscopy in chest trauma as the only definitive diagnostic in bronchial lesions.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of Delayed Intrapleural Alteplase Instillation for Infected Residual Traumatic Hemothorax. Case Report

In thoracic trauma, many cases may present with hemothorax, and, of those, a portion can complicate in empyema. These cases can reveal themselves to be of difficult management, particularly in peripheral hospitals with complicated access to thoracic surgery. Intrapleural fibrinolytic instillation can be of use and has been widely reported, mostly in the case of empyema. In the literature, the use of fibrinolytics in hemothorax mostly pertained to the older fibrinolytics, such as streptokinase and urokinase. Recent studies describe the use of alteplase in these patients but mostly in the first days after the trauma, when it becomes clear that the first chest tube is not being effective. We report a case of residual traumatic hemothorax that could not be evacuated after multiple chest tubes placements and was finally cleared after instillation of alteplase late in the course of the disease.

Analysis of the therapeutic effect and prognosis in 86 cases of rib fractures and atelectasis

Background

The aim of the present study was to explore the therapeutic effect and prognosis in patients with rib fractures and atelectasis after thoracic trauma in order to provide a basis for clinical decision-making in primary hospitals.

Methods

A retrospective study was conducted on 86 patients admitted to our hospital between January 2016 and May 2020 with rib fractures and atelectasis after thoracic trauma. On the basis of the chest computed tomography scans taken at the time of discharge, the patients were divided into two groups: the reexpansion group and the non-reexpansion group. The two groups were compared with respect to the changes observed in the patients’ levels of blood oxygen saturation (SpO2) and pulmonary function, the presence of secondary pulmonary or thoracic infection, the time of chest tube drainage, the length of hospitalization, the cost of hospitalization, and the patients’ level of satisfaction with their quality of life 3 months after discharge.

Results

In the reexpansion group, there were significant differences in the levels of SpO2 and pulmonary function measured before and after pulmonary reexpansion (P < 0.05). Compared with the non-reexpansion group, the patients in the reexpansion group had a lower incidence of secondary pulmonary and thoracic infection and a higher level of satisfaction with their quality of life after discharge; these differences were statistically significant (P < 0.05). There was no statistical significance between the two groups with respect to the time of chest tube drainage or the length of hospitalization (P > 0.05). However, the cost of hospitalization was significantly higher in the reexpansion group than in the non-reexpansion group (P < 0.05).

Conclusions

The patients in the pulmonary reexpansion group had a lower incidence of complications and a better prognosis than the patients in the non-reexpansion group.

Major penetrating thoracic trauma - The importance of collaboration between different specialties

Introduction

Penetrating thoracic trauma presents a rare and serious condition with great diversity in impalement mechanisms and following injuries, resulting in a high mortality. This case reports successful management of a severe thoracic trauma and need for collaboration between surgical specialties.

Presentation of case

An 18-year-old, otherwise healthy, Caucasian female had penetration of the chest with a wooden post due to a solo car accident and was admitted to a Level 1 trauma center at a university hospital. Trauma computed tomography scan showed costa fractures and fracture of the left clavicular bone. Damage to the subclavian artery, the brachial plexus and pulmonary artery were suspected. Extracorporeal circulation was on standby at surgery. However, removal of the foreign object did not result in any major bleeding. The patient was discharged from hospital on the 19th day after surgery. Fifteen months after the trauma, surgery was performed to remove the first two costae on the left side, as a disfiguring prominence on the neck was the patients' only complaint.

Discussion

Initial management of the patient should follow ATLS® principles with stabilization of airways, breathing and circulation. Multidisciplinary approach resulted in reconstruction of vessels, debridement and wound closure. The importance of follow-up after trauma and surgery are underlined by the current case, as the patient required additional surgery at follow up.

Conclusion

Multidisciplinary approach to the current penetrating trauma resulted in rapid assessment of injuries and management with excellent outcome.

Is a chest radiograph after thoracostomy tube removal necessary? A cost-effective analysis

BACKGROUND

Following placement of tube thoracostomy (TT) for evacuation of traumatic hemopneumothorax (HPTX), controversy persists over the need for routine post-TT removal chest radiograph (CXR). Current research demonstrates routine CXR may offer no advantage over clinical observation alone while simultaneously increasing hospital resource utilization. As such, we hypothesized that in resolved traumatic HPTXs routine post-TT removal CXR to assess recurrent PTX compared to clinical observation is not cost-effective.

METHODS

We performed a decision-analytic model to evaluate the cost-effectiveness of routine CXR compared to clinical observation following TT removal. Our base case was a patient that sustained thoracic trauma with radiographic and clinical resolution of HPTX following TT evacuation. Cost, utility and probability estimates were generated from published literature, with costs represented in 2019 US dollars and utilities in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Decision-analytic model identified that clinical observation after TT removal was the dominant strategy with increased benefit at less cost, when compared to routine CXR, with a net cost of $194.92, QALYs of 0.44. In comparison, routine CXR demonstrated an increase of $821.42 in cost with 0.43 QALYs. On probabilistic sensitivity analysis the clinical observation strategy was found cost-effective in 99.5% of 10,000 iterations.

CONCLUSION

In trauma patients with clinical and radiographic evidence of a resolved HPTX, the adoption of clinical observation in lieu of post-TT removal CXR is cost-effective. Routine CXR following TT removal accrues more cost without additional benefit. The practice of routinely obtaining a CXR following TT removal should be scrutinized.

Occult manubriosternal dislocation-role of manubrio-vertebral column

Traumatic manubriosternal joint dislocation in blunt thoracic trauma is of rare occurrence with only few case reports in the literature. We present a rare case of occult manubriosternal dislocation that was evident only after cervico-dorsal spine fracture correction. Thirty-one-year-old gentleman sustained multiple fractures of C6, C7, and D1 vertebral bodies; bilateral transverse process of C7, D1,and D3; left transverse process of D12; right transverse process of D4; and right clavicle fracture along with bilateral multiple rib fractures after fall from bike at high velocity. The patient was awake, alert, and moving all 4 limbs. The patient underwent right chest drain insertion in high dependency unit. His displaced cervico-thoracic spine was fixed with plate and intrapedicular screws. It was after fixation of spine that type II manubriosternal dislocation was clinically appreciated. He underwent fixation of manubriosternal joint using simple steel wires. Post-operatively he remained pain-free with stable manubriosternal joint. Role of manubrio-vertebral column in such a scenario is discussed.

Thoracic trauma and mortality in geriatric Turkish population: 6-month follow-up study

AIM

The aim of this study was to evaluate survival rates in elderly individuals who have undergone thoracic trauma and to investigate the risk of mortality for 6 months.

METHOD

In this study, the mortality rate was evaluated in 400 thorax trauma cases referred to thoracic surgery, between 65 and 101 years of age. Six-month survival rates in discharged cases of thoracic trauma were examined by using Turkey's Health Ministry Death Notification System.

RESULTS

It was found that thoracic traumas evaluated in the study were due to 314 (78.5%) falls and 51 (12.8%) exterior vehicle traffic accident. It was found that the presence of hemopneumothorax (OR 5.82; 95% CI 1.31-25.98; p = 0.021), and the presence of multiple trauma (OR 16.49; 95% CI 3.13-86.91; p = 0.001) had statistically significant effects on the mortality risk from the moment of the event to the emergency treatment period. In addition, it was found that age (OR 1.06; 95% CI 1.01-1.11; p = 0.011), male gender (OR 2.55; 95% CI 1.15-5.68; p = 0.022), and the presence of comorbidities (OR 3.07; 95% CI 1.29-7.31; p = 0.011) statistically significantly increased mortality during the six months after trauma.

CONCLUSION

It should be kept in mind that the presence of multiple trauma and the presence of hemopneumothorax increase the risk of death in elderly thoracic trauma cases consulted for thoracic surgery.

Differences in clinical characteristics and outcomes for blunt versus penetrating traumatic pulmonary pseudocysts

INTRODUCTION

Traumatic pulmonary pseudocysts (TPPs) are under-reported in blunt trauma and rarely reported in penetrating trauma. Little is known about the impact of injury mechanism on the pathophysiology or the risk factors that predispose to worse patient outcomes. We hypothesized that blunt and penetrating TPPs have different clinical characteristics and outcomes.

METHODS

Computed tomography imaging was evaluated for patients presenting at a level 1 trauma center with confirmed TPP from 2011 to 2018. Diameter was determined by largest dimension of the dominant TPP. Clinical variables and TPP features were compared for blunt versus penetrating trauma by using comparative statistics and multivariable analysis.e RESULTS: A total of 101 TPP patients were identified (blunt = 64; penetrating = 37). In penetrating TPP, rates of concomitant pulmonary laceration, hemothorax, and pneumothorax, were, respectively, 4.5, 3.1, and 1.4 times higher than for blunt TPP. Concomitant rib fracture was twice as common in blunt TPP as in penetrating TPP (69% versus 32%). For penetrating injury, the risk of complications related to TPP was increased (aOR = 5.3), specifically persistent/recurrent pneumothorax (aOR = 10.4). All deaths resulted from pulmonary hemorrhage (blunt = 3, penetrating = 2). Regardless of mechanism, air-fluid level and hemoptysis correlated with death (p < 0.02) and all patients with hemoptysis required pulmonary intervention (p = 0.0001).

CONCLUSION

Penetrating TPPs demonstrate a unique pattern of concurrent lung injury and increased complication risk. Importantly, severe hemoptysis and air-fluid level may indicate risk of impending morbidity and mortality regardless of injury mechanism and should serve as an early warning sign for the trauma physician.

Long-term quality of life and functional outcome after rib fracture fixation

PURPOSE

The primary aim of this study was to assess the long-term quality of life and functional outcome after rib fracture fixation for patients with multiple rib fractures or flail chest. Secondarily, this study sought to identify risk factors associated with the quality of life.

METHODS

A retrospective cohort study with a follow-up by questionnaire was performed at a level-1 trauma center in Switzerland. All adult patients with three or more rib fractures treated with rib fixation between 2010 and 2018 were eligible for inclusion. All outcomes were independently assessed for patients with multiple rib fractures and patients with a flail chest. The outcome measures were quality of life, level of dyspnea, return to work, implant irritation, and implant removal after a minimum of 12 months of follow-up. Quality of life was assessed using the EuroQol five-dimensional five-level questionnaire (EQ-5D-5L) and level of dyspnea was determined with the modified Medical Research Council dyspnea (mMRC) scale.

RESULTS

The survey was completed by 74 out of 102 patients (73%) at a median follow-up of 26 months (IQR 15-37). The median EQ-5D utility index score was 0.91 (0.89-1.0), which was equivalent to the reference population (0.902, p = 0.523). The vast majority of patients experienced 'no problems' or 'slight problems' in any of the EQ-5D-5L dimensions. The complication rate associated with rib fracture fixation was low, implant-related irritation was the most common long-term sequela and occurred in 31% of patients. In multivariable regression analyses, total length of stay on the intensive care unit (ICU-LOS) was independently associated with a worse quality of life.

CONCLUSIONS

Patients who underwent rib fracture fixation for multiple rib fractures or flail chest after severe chest trauma experienced a good quality of life at least 1 year after surgery. A longer ICU-LOS was independently associated with impaired quality of life. In addition, there were no significant differences in the long-term quality of life and functional outcome between patients with multiple rib fractures and a flail chest. Implant-related irritation was the most important long-term sequela and occurred in one-third of patients.

Analysis of risk factors in thoracic trauma patients with a comparison of a modern trauma centre: a mono-centre study

Abstract

Objectives

Thoracic trauma (TT) is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. Its management is still a very challenging task. The purpose of this study was to analyse the risk factors affecting the outcome in a high-volume trauma centre and the efficacy of a specialised trauma team in level 1 trauma centres.

Patients and methods

Between January 2003 and December 2012, data of all patients admitted to the accident and emergency (A&E) department were prospectively collected at the German Trauma Registry (GTR) and thereafter retrospectively analysed.

Patients with chest trauma, an Injury Severity Score (ISS) ≥ 18 and an Abbreviated Injury Scale (AIS) > 2 in more than one body region were included. Patients were divided into two groups: group I included patients presenting with thoracic trauma between January 2003 and December 2007. The results of this group were compared with the results of another group (group II) in a later 5-year period (Jan. 2008–Dec. 2012). Univariate and multivariate analyses were performed, and differences with p < 0.05 were considered statistically significant.

Results

There were 630 patients (56%) with thoracic trauma. A total of 540 patients (48%) had associated extrathoracic injuries. Group I consisted of 285 patients (197 male, mean age 46 years). Group II consisted of 345 patients (251 male, mean age 49 years). Overall 90-day mortality was 17% (n = 48) in group I vs. 9% (n = 31) in group II (p = 0.024). Complication rates were higher in group I (p = 0.019). Higher Injury Severity Scores (ISSs) and higher Abbreviated Injury Acale (AIS) scores in the thoracic region yielded a higher rate of mortality (p < 0.0001). Young patients (< 40 years) were frequently exposed to severe thoracic injury but showed lower mortality rates (p = 0.014). Patients with severe lung contusions (n = 94) (15%) had higher morbidity and mortality (p < 0.001). Twenty-three (8%) patients underwent emergency thoracotomy in group I vs. 14 patients (4%) in group II (p = 0.041). Organ replacement procedures were needed in 18% of patients in group I vs. 31% of patients in group II (p = 0.038).

Conclusions

The presence of severe lung contusion, a higher ISS and AIS_thoracic score and advanced age are independent risk factors that are directly related to a higher mortality rate. Management of blunt chest trauma with corrective chest tube insertion, optimal pain control and chest physiotherapy results in good outcomes in the majority of patients. Optimal management with better survival rates is achievable in specialised centres with multidisciplinary teamwork and the presence of thoracic surgical experience.

The tenets of intrathoracic packing during damage control thoracic surgery for trauma patients: a systematic review

PURPOSE

Although Damage Control Thoracic Surgery (DCTS) has become a provocative alternative to treat patients with chest injuries who are critically ill and physiologically depleted, the management approaches of chest-packing and the measurement of clinically relevant outcomes are not well established. In this paper, we systematically reviewed the available knowledge and evidence about intra-thoracic packing during DCTS for trauma patients. We furthermore inform on the management approaches, surgical strategies, and mortality associated with this intervention.

METHODS

We identified articles in MEDLINE and SCOPUS. We reviewed all studies that included trauma patients with chest injuries and managed with intrathoracic packing during DCTS. Studies were eligible if the use of intrathoracic packing in trauma populations was reported.

RESULTS

We identified 14 studies with a total of 211 patients. Overall, intrathoracic packing was used in 131 trauma patients. Packing was most commonly used to arrest persistent coagulopathic bleeding or oozing either from raw surfaces or repaired structures and in conjunction with other operative techniques. Pneumonectomy was a deadly intervention; however, one study reported survivors when pneumonectomy was deferred.

CONCLUSION

Packing is a feasible, reliable and potentially effective complementary method for hemorrhage control. Therefore, we recommend that packing can be used liberally as a complement to rapid lung-sparing techniques.

Possible advantages of early stabilization of spinal fractures in multiply injured patients with leading thoracic trauma - analysis based on the TraumaRegister DGU®

Background

Major trauma often comprises fractures of the thoracolumbar spine and these are often accompanied by relevant thoracic trauma. Major complications can be ascribed to substantial simultaneous trauma to the chest and concomitant immobilization due to spinal instability, pain or neurological dysfunction, impairing the respiratory system individually and together. Thus, we proposed that an early stabilization of thoracolumbar spine fractures will result in significant benefits regarding respiratory organ function, multiple organ failure and length of ICU / hospital stay.

Methods

Patients documented in the TraumaRegister DGU®, aged ≥16 years, ISS ≥ 16, AIS_Thorax ≥ 3 with a concomitant thoracic and / or lumbar spine injury severity (AIS_Spine) ≥ 3 were analyzed. Penetrating injuries and severe injuries to head, abdomen or extremities (AIS ≥ 3) led to patient exclusion. Groups with fractures of the lumbar (LS) or thoracic spine (TS) were formed according to the severity of spinal trauma (AIS_spine): AIS_LS = 3, AIS_LS = 4–5, AIS_TS = 3 and AIS_TS = 4–5, respectively.

Results

1740 patients remained for analysis, with 1338 (76.9%) undergoing spinal surgery within their hospital stay. 976 (72.9%) had spine surgery within the first 72 h, 362 (27.1%) later on. Patients with injuries to the thoracic spine (AIS_TS = 3) or lumbar spine (AIS_LS = 3) significantly benefit from early surgical intervention concerning ventilation time (AIS_LS = 3 only), ARDS, multiple organ failure, sepsis rate (AIS_TS = 3 only), length of stay in the intensive care unit and length of hospital stay. In multiple injured patients with at least severe thoracic spine trauma (AIS_TS ≥ 4) early surgery showed a significantly shorter ventilation time, decreased sepsis rate as well as shorter time spend in the ICU and in hospital.

Conclusions

Multiply injured patients with at least serious thoracic trauma (AIS_Thorax ≥ 3) and accompanying spine trauma can significantly benefit from early spine stabilization within the first 72 h after hospital admission. Based on the presented data, primary spine surgery within 72 h for fracture stabilization in multiply injured patients with leading thoracic trauma, especially in patients suffering from fractures of the thoracic spine, seems to be beneficial.