S G Campbell, M A Dingle
Rib fractures following minor trauma in older patients: a not-so-benign injury.
CJEM. 2000 Jan;2(1):32-4.
Abstract/Text
Two older adults presented to the emergency department with rib fractures following minor trauma. Both were discharged on oral analgesics and died within 2 days. Rib fractures more often lead to adverse outcomes in older adults. Emergency physicians should consider admitting any such patient who presents with two or more rib fractures.
David H Livingston, Benjamin Shogan, Preeti John, Robert F Lavery
CT diagnosis of Rib fractures and the prediction of acute respiratory failure.
J Trauma. 2008 Apr;64(4):905-11. doi: 10.1097/TA.0b013e3181668ad7.
Abstract/Text
BACKGROUND: The number of rib fractures has been reported to correlate with mortality after blunt chest trauma. These reports, however, predate routine truncal helical computed tomographic (CT) scanning and their conclusions are based on data derived from plain chest radiographs (CXR). CT scan provides better anatomic definition of chest injuries than plain CXR, and we hypothesized CT evaluation of rib fracture number and patterns would provide a better prediction of respiratory failure and mortality after chest injury than the data derived from the initial CXR.
METHODS: The charts on all patients of 16 years or older with one or more rib fractures after blunt trauma admitted from January 2003 through December 2005 were reviewed. Both the initial CXR and the helical CT scans were systematically re-read for the number and location of rib fractures and presence of pulmonary contusions. Anatomic fracture location (anterior, posterior, lateral) was determined using a standardized template. Outcomes data included pneumonia, respiratory failure (>/=3 ventilator days), need for trachestomy, and mortality. Logistic regression was performed to identify factors that predicted pulmonary morbidity.
RESULTS: Three hundred and eighty eight patients had >/=1 rib fracture. The mean (+/-standard deviation) age was 44 +/- 18. injury severity score was 21 +/- 11. Mortality was 6% (22 of 388). Sixty-three (16%) patients developed respiratory failure. The mean number of rib fractures per patient was four (range, 1-23); 21% of patients had one rib fracture and 17% had six or more fractures. 208 (54%) of the initial CXRs were read as having no rib fractures. The mean number of rib fractures per patient in this group was 3.1 (CI95 2.9-3.2). In 43% (179 of 388) of patients, the CT radiology report incorrectly identified the number and location of the fractured ribs. Of these reports, 72% (129 of 179) differed from the prospective review by more than one fracture. The number of fractures was higher in patients who died (7 +/- 5 vs. 4 +/- 3; p = 0.02) and in those developing respiratory failure (6 +/- 4 vs. 3 +/- 3; p = 0.02). Any rib fracture or pulmonary contusion visible on the initial plain CXR significantly increased the incidence of pulmonary morbidity or mortality. CT determination of fracture location had no effect on respiratory failure, pneumonia, or mortality when fractures were confined to one anatomic location. The presence of rib fracture in more than anatomic region doubled the incidence of respiratory failure (24% vs. 12%; p = 0.002) but had no effect on mortality. Logistic regression identified only injury severity score and presence of a parenchymal injury on plain CXR as independent predictors of subsequent respiratory failure.
CONCLUSIONS: Rib fracture mortality was lower than that in the previously published studies and is likely reflect the increased sensitivity of CT scan in diagnosing rib fractures. Screening CXRs miss rib fractures more than 50% of the time. Radiology reports are often not sufficiently descriptive or are incomplete with respect to the number and location fracture and reliance on these data will lead to erroneous conclusions. Using CT scanning, only the finding of rib fractures in multiple locations was associated with increased incidence of respiratory failure. In contrast, the presence of any parenchymal injury or visible rib fracture on the screening CXR significantly increases the risk for subsequent pulmonary morbidity (odds ratio, 3.8; CI95, 2.2-6.6). Although truncal CT scanning markedly improved the diagnosis and delineation of rib fractures, the screening CXR was a better predictor of subsequent pulmonary morbidity and mortality.
高橋周: 運動器超音波の新時代が到来．メディックス50巻 Page32-36, 2009.
堀尾重治：骨・関節X線写真の撮りかたと見かた（第8版）. 医学書院. 2010.
村井聰(信原病院), 信原克哉, 孫常太：肋骨骨折の診断への新しいアプローチ．骨折 1997；19（2）：589-592.
Sule Karadayi, Aydin Nadir, Ekber Sahin, Burcin Celik, Sulhattin Arslan, Melih Kaptanoglu
An analysis of 214 cases of rib fractures.
Clinics (Sao Paulo). 2011;66(3):449-51.
Abstract/Text
INTRODUCTION: Rib fractures are the most common type of injury associated with trauma to the thorax. In this study, we investigated whether morbidity and mortality rates increased in correlation with the number of fractured ribs.
MATERIALS AND METHODS: Data from 214 patients with rib fractures who applied or were referred to our clinic between January 2007 and December 2008 were retrospectively evaluated. The patients were allocated into three groups according to the number of fractures: 1) patients with an isolated rib fracture (RF1) (n = 50, 23.4%), 2) patients with two rib fractures (RF2) (n = 53, 24.8%), and 3) patients with more than two rib fractures (RF3) (n = 111, 51.9%). The patients were evaluated and compared according to the number of rib fractures, mean age, associated chest injuries (hemothorax, pneumothorax, and/or pulmonary contusion), and co-existing injuries to other systems.
FINDINGS: The mean age of the patients was 51.5 years. The distribution of associated chest injuries was 30% in group RF1, 24.6% in group RF2, and 75.6% in group RF3 (p<0.05). Co-existing injuries to other systems were 24% in group RF1, 23.2% in group RF2, and 52.6% in group RF3 (p<0.05). Two patients (4%) in group RF1, 2 patients (3.8%) in group RF2, and 5 patients (4.5%) in group RF3 (total n = 9; 4.2%) died.
CONCLUSION: Patients with any number of rib fractures should be carefully screened for co-existing injuries in other body systems and hospitalized to receive proper treatment.
Mehmet Sirmali, Hasan Türüt, Salih Topçu, Erkmen Gülhan, Ulkü Yazici, Sadi Kaya, Irfan Taştepe
A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management.
Eur J Cardiothorac Surg. 2003 Jul;24(1):133-8.
Abstract/Text
OBJECTIVE: A rib fracture secondary to blunt thoracic trauma is an important indicator of the severity of the trauma. In the present study we explored the morbidity and mortality rates and the management following rib fractures.
METHODS: Between May 1999 and May 2001, 1417 cases who presented to our clinic for thoracic trauma were reviewed retrospectively. Five hundred and forty-eight (38.7%) of the cases had rib fracture. There were 331 males and 217 females, with an overall mean age of 43 years (range: 5-78 years). These patients were allocated into groups according to their ages, the number of fractured ribs and status, i.e. whether they were stable or unstable (flail chest).
RESULTS: The etiology of the trauma included road traffic accidents in 330 cases, falls in 122, assault in 54, and industrial accidents in 42 cases. Pulmonary complications such as pneumothorax (37.2%), hemothorax (26.8%), hemo-pneumothorax (15.3%), pulmonary contusion (17.2%), flail chest (5.8%) and isolated subcutaneous emphysema (2.2%) were noted. 40.1% of the cases with rib fracture were treated in intensive care units. The mean duration of their stay in the intensive care unit was 11.8+/-6.2 days. 42.8% of the cases were treated in the wards whereby their mean duration of hospital stay was 4.5+/-3.4 days, while 17.1% of the cases were followed up in the outpatient clinic. Twenty-seven patients required surgery. Mortality rate was calculated as 5.7% (n=31).
CONCLUSIONS: Rib fractures can be interpreted as signs of significant trauma. The greater the number of fractured ribs, the higher the mortality and morbidity rates. Patients with isolated rib fractures should be hospitalized if the number of fractured ribs is three or more. We also advocate that elderly patients with six or more fractured ribs should be treated in intensive care units due to high morbidity and mortality.
R M Shorr, A Rodriguez, M C Indeck, M D Crittenden, S Hartunian, R A Cowley
Blunt chest trauma in the elderly.
J Trauma. 1989 Feb;29(2):234-7.
Abstract/Text
Significant differences were identified between a group of elderly patients (65 years and older) and a nonelderly group both with blunt thoracic trauma. There was a lower incidence of elderly patients presenting in shock; however, cardiopulmonary arrest at arrival was more frequent in this group. Although the types of complications were similar in both populations, the morbidity and mortality rates were higher in the elderly. A high index of suspicion must be generated for an elderly patient who has sustained blunt chest trauma. An aggressive diagnostic and therapeutic approach may lead to a decrease in the high morbidity and mortality rates in the elderly.
Yoav Barnea, Hanoch Kashtan, Yehuda Skornick, Nahum Werbin
Isolated rib fractures in elderly patients: mortality and morbidity.
Can J Surg. 2002 Feb;45(1):43-6.
Abstract/Text
OBJECTIVES: To describe the management, morbidity and mortality seen with isolated rib fractures in elderly patients and assess the need for hospitalization.
DESIGN: A case series.
SETTING: A tertiary care centre in Tel Aviv.
METHODS: Hospital records of 77 elderly patients (age 65 yr and older) admitted with isolated rib fractures were reviewed over a 9-year period.
MAIN OUTCOME MEASURES: Demographic, medical and hospitalization data, blood hemoglobin and oxygen saturation levels.
RESULTS: The number of fractured ribs was found to correlate with the morbidity (p = 0.027) and mortality (p = 0.006). There were no significant differences in these rates with respect to comorbidity except for diabetes (higher morbidity) and congestive heart failure (higher mortality). Twenty-eight patients (36%) had pulmonary complications and 1 had cardiac complications. Pulmonary complications were fatal in 6 patients (7.8%). Multivariate analysis of the factors related to morbidity demonstrated that only oxygen saturation (p = 0.0009) and diabetes (p = 0.03) correlated significantly.
CONCLUSIONS: In spite of significant morbidity and mortality in elderly patients with isolated rib fractures, prediction of the prognosis for these patients is presently not possible. Admission for observation and treatment is therefore justified and beneficial.
Elsayed M Elmistekawy, Abd Almohsen M Hammad
Isolated rib fractures in geriatric patients.
Ann Thorac Med. 2007 Oct;2(4):166-8. doi: 10.4103/1817-1737.36552.
Abstract/Text
INTRODUCTION: The goal of this study was to investigate the short-term outcomes in patients older than 60 years with isolated rib fractures and admitted to emergency hospital.
MATERIALS AND METHODS: This study included patients who were 60 years old or more and sustained blunt chest injury and had isolated rib fractures. The following data were obtained from the medical records: age, gender, number of fracture ribs, side of fracture ribs, mechanism and nature of injury, preexisting medical conditions, complications, admission to intensive care unit (ICU), need for mechanical ventilation, length of ICU and hospital stay and mortality.
RESULTS: For the study, 39 patients who were 60 years old or more and admitted to the hospital because of isolated rib fractures were enrolled. There were 28 males (71.7%) and 11 females (28.3%) with mean age of (66.84 +/- 4.7) years. No correlation was found between comorbidities and hospital outcomes except in those who were diabetic (P-value = 0.005) and those with chronic lung disease (P-value = 0.006). Pulmonary complications were the most frequent complications encountered in those patients. Pulmonary complications were: lung contusion in 8 patients (20.5%) and pulmonary infection in 6 patients (15.8%).
CONCLUSION: Elderly patients sustaining blunt chest trauma had significant morbidity and potential for mortality.
Blaine A Winters
Older adults with traumatic rib fractures: an evidence-based approach to their care.
J Trauma Nurs. 2009 Apr-Jun;16(2):93-7. doi: 10.1097/JTN.0b013e3181ac9201.
Abstract/Text
It is expected that over the next decade the population of older adults in the United States will increase dramatically. As the older adult population increases, the number of older adults involved in traumatic accidents is also expected to climb. The older population is at an increased risk for complications and poor outcomes following trauma. Practitioners caring for these older adults will need to use evidence-based practice guidelines in an attempt to improve outcomes. This article provides a clinical guideline for the assessment and management of pain in older adults with traumatic rib fractures, and an approach for pain assessment, which includes the use of the numeric rating scale as well as incentive spirometry. The modalities used for pain management include epidural analgesia, paravertebral analgesia, patient controlled analgesia, and the use of oral opioids.
Nichole K Ingalls, Zachary A Horton, Matthew Bettendorf, Ira Frye, Carlos Rodriguez
Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures.
J Am Coll Surg. 2010 Feb;210(2):205-9. doi: 10.1016/j.jamcollsurg.2009.10.020. Epub 2009 Dec 24.
Abstract/Text
BACKGROUND: The lidocaine patch 5% was developed to treat postherpetic neuralgia. Anecdotal experience at our institution suggests the lidocaine patch 5% decreases narcotic usage in patients with traumatic rib fractures. This trial was developed to define the patch's efficacy.
STUDY DESIGN: Patients with rib fractures admitted to the trauma service at our Level I trauma center were enrolled and randomized in a 1 to 1 double-blind manner to receive a lidocaine patch 5% or placebo patch. Fifty-eight patients who met the inclusion criteria were enrolled from January 2007 to August 2008. Demographic and clinical information were recorded. The primary outcomes variable was total narcotic use, analyzed using the 1-tailed Mann-Whitney test. The secondary outcomes variables included non-narcotic pain medication, average pain score, pulmonary complications, and length of stay. Significance was defined based on a 1-sided test for the primary outcome and 2-sided tests for other comparisons, at p < 0.05.
RESULTS: Thirty-three patients received the lidocaine patch 5% and 25 received the placebo patch. There were no significant differences in age, number of rib fractures, gender, trauma mechanism, preinjury lung disease, smoking history, percent of current smokers, and need for placement of chest tube between the lidocaine patch 5% and placebo groups. There was no difference between the lidocaine patch 5% and placebo groups, respectively, with regard to total IV narcotic usage: median, 0.23 units versus 0.26 units; total oral narcotics: median, 4 units versus 7 units; pain score: 5.6 +/- 0.4 versus 6.0 +/- 0.3 (mean +/- SEM); length of stay: 7.8 +/- 1.1 versus 6.2 +/- 0.7; or percentage of patients with pulmonary complications: 72.7% versus 72.0%.
CONCLUSIONS: The lidocaine patch 5% does not significantly improve pain control in polytrauma patients with traumatic rib fractures.
Peter L Althausen, Steven Shannon, Chad Watts, Kenneth Thomas, Martin A Bain, Daniel Coll, Timothy J O'mara, Timothy J Bray
Early surgical stabilization of flail chest with locked plate fixation.
J Orthop Trauma. 2011 Nov;25(11):641-7. doi: 10.1097/BOT.0b013e318234d479.
Abstract/Text
OBJECTIVES: To compare the results of surgical stabilization with locked plating to nonoperative care of flail chest injuries.
DESIGN: Retrospective case-control study.
SETTING: Level II trauma center.
PATIENTS/PARTICIPANTS: From January 2005 to January 2010, 22 patients with flail chest treated with locked plate fixation were compared with a matched cohort of 28 nonoperatively managed patients at our institution.
INTERVENTION: Open reduction internal fixation of rib fractures with 2.7-mm locking reconstruction plates.
MAIN OUTCOME MEASUREMENTS: Demographic data, such as age, sex, injury severity score, number of fractures, and lung contusion severity, were recorded. Intensive care unit data concerning length of stay (LOS), tracheostomy, and ventilator days were noted. Operative data, such as time to OR, operative time, and estimated blood loss, were recorded. Hospital data, including total hospital LOS, need for reintubation, and home oxygen requirements, were documented.
RESULTS: Average follow-up period of operatively managed patients was 17.84 ± 4.51 months, with a range of 13-22 months. No case of hardware failure, hardware prominence, wound infection, or nonunion was reported. Operatively treated patients had shorter intensive care unit stays (7.59 vs. 9.68 days, P = 0.018), decreased ventilator requirements (4.14 vs. 9.68 days, P = 0.007), shorter hospital LOS (11.9 vs. 19.0 days, P = 0.006), fewer tracheostomies (4.55% vs. 39.29%, P = 0.042), less pneumonia (4.55% vs. 25%, P = 0.047), less need for reintubation (4.55% vs. 17.86%, P = 0.34), and decreased home oxygen requirements (4.55% vs. 17.86%, P = 0.034).
CONCLUSIONS: This study demonstrates the potential benefits of surgical stabilization of flail chest with locked plate fixation. When compared with case-matched controls, operatively managed patients demonstrated improved clinical outcomes. Locked plate fixation seems to be safe as no complications associated with hardware failure, plate prominence, wound infection, or nonunion were noted.
Hideharu Tanaka, Tetsuo Yukioka, Yoshihiro Yamaguti, Syoichiro Shimizu, Hideaki Goto, Hiroharu Matsuda, Syuji Shimazaki
Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients.
J Trauma. 2002 Apr;52(4):727-32; discussion 732. doi: 10.1097/00005373-200204000-00020.
Abstract/Text
BACKGROUND: We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support.
METHODS: Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups.
RESULTS: Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and Pao2/Fio2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19).
CONCLUSION: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.
Gaurav Khandelwal, R K Mathur, Sumit Shukla, Ankur Maheshwari
A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture.
Int J Surg. 2011;9(6):478-81. doi: 10.1016/j.ijsu.2011.06.003. Epub 2011 Jul 5.
Abstract/Text
OBJECTIVE: To compare the intensity of pain and duration of return to normal activity in patients with rib fractures treated with surgical stabilization with plating versus conventional treatment modalities.
PATIENTS AND METHODS: This study was conducted over a 12 month period. Patients with rib fractures were assessed by numerical pain scale. Patients having pain scale less than 5 were excluded from study. Patients having pain scale of 5 or more than 5 were treated with conventional treatment for next 10 days. On 11th day patients were again assessed by numerical pain scale and patients having score less than 5 were excluded from study. Patients having pain scale of 5, 6, and 7 were treated with conventional treatment and patients having pain scale of 8, 9, and 10 were selected for operative management. Operative and control group were compared on basis of intensity of pain and duration of return to normal activity. Follow up was done on 5, 15, and 30 post operative day.
RESULTS: There was less pain in operative group as compared to control group. Mean rib fracture pain in operative group was 9.15, 2.31, 1.12 as compared to 6.25, 5.96, 4.50 in control group on 5, 15 and 30 post operative days. Also there was early return to normal activity in operative group.
CONCLUSION: Surgical stabilization of rib fracture, an underutilized intervention is better than conventional conservative management in terms of both, decrease in intensity of pain and early return to normal activity.
Copyright © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Elie Girsowicz, Pierre-Emmanuel Falcoz, Nicola Santelmo, Gilbert Massard
Does surgical stabilization improve outcomes in patients with isolated multiple distracted and painful non-flail rib fractures?
Interact Cardiovasc Thorac Surg. 2012 Mar;14(3):312-5. doi: 10.1093/icvts/ivr028. Epub 2011 Dec 21.
Abstract/Text
A best evidence topic was constructed according to a structured protocol. The question addressed was whether surgical stabilization is effective in improving the outcomes of patients with isolated multiple distracted and painful non-flail rib fractures. Of the 356 papers found using a report search, nine presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that, on the whole, the nine retrieved studies clearly support the use of surgical stabilization in the management of isolated multiple non-flail and painful rib fractures for improving patient outcomes. The interest and benefit was shown not only in terms of pain (McGill pain questionnaire) and respiratory function (forced vital capacity, forced expiratory volume in 1 s and carbon monoxide diffusing capacity), but also in improved quality of life (RAND 36-Item Health Survey) and reduced socio-professional disability. Indeed, most of the authors justified surgical management based on the fact that the results of surgical stabilization showed improvement in short- and long-term patient outcomes, with fast reduction in pain and disability, as well as lower average wait before recommencing normal activities. Hence, the current evidence shows surgical stabilization to be safe and effective in alleviating post-operative pain and in improving patient recovery, thus enhancing the outcome after isolated multiple rib fractures. However, given the little published evidence, prospective trials are necessary to confirm these encouraging results.
Alexander Simmonds, Julia Smolen, Mathew Ciurash, Kyle Alexander, Yahya Alwatari, Luke Wolfe, James F Whelan, Jonathan Bennett, Stefan W Leichtle, Michel B Aboutanos, Edgar B Rodas
Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review.
J Trauma Acute Care Surg. 2023 Apr 1;94(4):532-537. doi: 10.1097/TA.0000000000003809.
Abstract/Text
BACKGROUND: Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days).
METHODS: Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0.
RESULTS: For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia.
CONCLUSION: In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia.
LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Copyright © 2023 American Association for the Surgery of Trauma.
Niloofar Dehghan, Aaron Nauth, Emil Schemitsch, Milena Vicente, Richard Jenkinson, Hans Kreder, Michael McKee, Canadian Orthopaedic Trauma Society and the Unstable Chest Wall RCT Study Investigators
Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial.
JAMA Surg. 2022 Nov 1;157(11):983-990. doi: 10.1001/jamasurg.2022.4299.
Abstract/Text
IMPORTANCE: Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking.
OBJECTIVE: To compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management.
DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non-flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021.
INTERVENTIONS: Patients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment.
MAIN OUTCOMES AND MEASURES: The primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy).
RESULTS: A total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, -0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment.
CONCLUSIONS AND RELEVANCE: The findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01367951.
Michael Tichenor, Laura B Reparaz, Christopher Watson, Jeremy Reeves, Phillip Prest, Michael Fitzgerald, Neema Patel, Xiyan Tan, Jacob Hessey
Intrathoracic plates versus extrathoracic plates: a comparison of postoperative pain in surgical stabilization of rib fracture technique.
Trauma Surg Acute Care Open. 2023;8(1):e001201. doi: 10.1136/tsaco-2023-001201. Epub 2023 Nov 3.
Abstract/Text
BACKGROUND: Surgical stabilization of rib fractures (SSRF) has been shown to improve outcomes, yet there is an absence of studies comparing SSRF techniques. An intrathoracic system that minimizes incision length has recently been developed and adopted by multiple institutions. We hypothesized that SSRF with an intrathoracic system plus intercostal nerve cryoneurolysis (IC) leads to improved pain control compared with an extrathoracic system plus IC.
METHODS: A single-center, retrospective chart review was performed comparing intrathoracic SSRF versus extrathoracic SSRF, and included patients undergoing SSRF from 2015 to 2021 at a level 1 trauma center. Patients who did not undergo intercostal nerve cryoablation were excluded. The primary outcome was opioid consumption based on morphine milligram equivalent (MME) consumption. We collected Rib score, Blunt Pulmonary Contusion 18 Score, number of rib fractures, number of ribs plated, and Injury Severity Score (ISS) to compare baseline characteristics of each group.
RESULTS: A total of 112 patients were evaluated for study inclusion. Thirty-one patients were excluded due to missing outcomes data and/or lack of cryoablation. There was no difference in ISS or Rib Score between the intrathoracic (n=33) and extrathoracic (n=48) groups. At 7-day follow-up, the median MME requirement was significantly lower in the intrathoracic group (21.25) versus the extrathoracic group (46.20) (p=0.02).
CONCLUSION: Intrathoracic SSRF was associated with a lower postoperative MME consumption compared with extrathoracic SSRF. These data support the use of intrathoracic SSRF to improve pain control compared to extrathoracic SSRF.
LEVEL OF EVIDENCE: III.
© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
S L Beal, M R Oreskovich
Long-term disability associated with flail chest injury.
Am J Surg. 1985 Sep;150(3):324-6.
Abstract/Text
Twenty-two trauma victims who had sustained flail chest as their only significant injury were evaluated to determine the final outcome. Fourteen patients (63.9 percent) were found to have long-term sequelae. The most common long-term problems after flail chest injury were persistent chest wall pain, chest wall deformity, and dyspnea on exertion. Five patients (22 percent) remained disabled in varying degrees.
J Landercasper, T H Cogbill, L A Lindesmith
Long-term disability after flail chest injury.
J Trauma. 1984 May;24(5):410-4.
Abstract/Text
A review of 62 consecutive patients who sustained flail chest after trauma from 1971 to 1982 was conducted to document the late effects of this injury. The mechanism of injury was motor vehicle accident in 44 (71%), fall in nine (14.5%), and farming accident in nine (14.5%). Patients ranged in age from 7 to 87 years. Twenty-four (39%) patients arrived in shock and 54 (87%) had major extra-thoracic associated injuries. Thirty-seven (60%) patients were managed by intubation and mechanical ventilation and 25 (40%) by chest physiotherapy. Pulmonary complications developed in 60% of the total group. Eight patients (12.9%) died during the initial hospitalization. Five patients died 1 month to 9 years after discharge, and 17 were eventually lost to followup. Six-month to 12-year followup (mean, 5 years) was re-established for 32 patients. Twenty-one of these returned for comprehensive testing including physical examination, chest roentgenograms, spirometry, flow volume curves, diffusion testing, and calculation of dyspnea index. Of 32 patients questioned, only 12 had returned to full-time employment. Eight (25%) still had subjective chest tightness, 15 (49%) complained of thoracic cage pain, and 12 (38%) had experienced moderate or severe change in their overall level of activity. Using the British Medical Research Gradation for Dyspnea, three (9%) patients had moderate and six (19%) severe shortness of breath. Objective dyspnea index calculated from VEBTPS /MVV revealed mild dyspnea in 50% and moderate dyspnea in 20%. Formal carbon monoxide diffusion testing was normal in 90% of patients and revealed mild decrease in 10%.(ABSTRACT TRUNCATED AT 250 WORDS)
日本救急医学会監修:標準救急医学 第5版. 医学書院. 2014.
