Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment

Incidence of adult rib fracture injuries and changing hospitalization practice patterns: a 10-year analysis

PURPOSE

Rib fractures are common after blunt thoracic trauma and can be associated with significant morbidity and mortality. We investigated trends of rib fracture injuries among adults presenting to United States (US) emergency departments, factors related to increased likelihood of hospitalization, and hospitalization practice patterns.

METHODS

We queried the National Electronic Injury Surveillance System database between 2012 and 2021 for all patients 18 years of age and older with rib fractures. These data were extrapolated to provide national estimates. Regression analysis was performed to identify trends for injury and risk factors for hospitalization.

RESULTS

We identified 32,233 adult patients with rib fractures; this extrapolated to a national estimate of 1,430,270 patients with rib fractures during the 10-year period. Between 2012 and 2021, there was a 52% increase in the incidence rate per 100,000 persons (R2 = 0.94, p < 0.001). Males accounted for 58% of patients with rib fractures, and 50% of patients were 65 years or older. Hospitalization was required in 38% of patients, and the hospitalization rate increased by 96% during the study period (R2 = 0.96, p < 0.001). When comparing hospitals of different sizes, a 20% greater increase in the odds of hospitalization over time was identified among patients presenting to "larger" hospitals compared to "smaller" hospitals.

CONCLUSION

The incidence of rib fractures and the associated hospitalization rates are both increasing nationally, with half of cases occurring in patients aged 65 years or older. Our findings emphasize the urgent need to implement evidence-based preventive measures and current management guidelines when managing the increasing caseload of rib fracture injuries.

Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-Analysis

BACKGROUND

Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse.

METHODS

A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality.

RESULTS

Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation.

CONCLUSIONS

Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.

Biomechanical investigation of different surgical strategies for the treatment of rib fractures using a three-dimensional human respiratory model

Rib fracture is a common injury and can result in pain during respiration. Conservative treatment of rib fracture is applied via mechanical ventilation. However, ventilator-associated complications frequently occur. Surgical fixation is another approach to treat rib fractures. Unfortunately, this surgical treatment is still not completely defined. Past studies have evaluated the biomechanics of the rib cage during respiration using a finite element method, but only intact conditions were modelled. Thus, the purpose of this study was to develop a realistic numerical model of the human rib cage and to analyse the biomechanical performance of intact, injured and treated rib cages. Three-dimensional finite element models of the human rib cage were developed. Respiratory movement of the human rib cage was simulated to evaluate the strengths and limitations of different scenarios. The results show that a realistic human respiratory movement can be simulated and the predicted results were closely related to previous study (correlation coefficient>0.92). Fixation of two fractured ribs significantly decreased the fixation index (191%) compared to the injured model. This fixation may provide adequate fixation stability as well as reveal lower bone stress and implant stress compared with the fixation of three or more fractured ribs.

Surgical versus conservative therapy for multiple rib fractures: a retrospective analysis

Background

In this study, we aimed to evaluate the clinical effects of multiple rib fracture treatments using a rib plate fixator.

Methods

From June 2014 to December 2016, 110 cases of patients with multiple rib fractures were collected for our study from the 105th Hospital of PLA; 59 patients were treated by surgery, and 51 patients received conservative treatment. We compared surgical rib plate fixation with conservative treatment for patients with multiple rib fractures.

Results

The hospital stay for the surgical group was 13.12±4.21 days, whereas for the conservative group, it was 18.57±5.39 days (P<0.001). The duration of the thoracic intensive care unit (ICU) stay was 4.02±1.41 days in the surgical group and 5.06±1.80 days in the conservative group (P=0.001). The indwelling thoracic drainage tube time was 5.85±1.52 days in the surgical group and 8.26±1.96 days in the conservative group (P<0.001). The index of partial pressure of arterial oxygen (PaO₂) was 91.05±10.88 mmHg 24 h after surgery whereas 86.49±11.69 mmHg 24 h after conservative treatment (P=0.036). The index of partial pressure of carbon dioxide (PaCO₂) was 37.80±2.86 mmHg 24 h after surgery and it was 39.08±2.46 mmHg 24 h after conservative treatment. The hospitalization cost was 6,206.44±371.42 USD for the surgical group and 4,544.61±524.79 USD for the conservative group (P<0.001). The number of rib displacement cases after treatment was 1 case in the surgical group and 2 cases in the conservative group (P=0.475). Atelectasis occurred in 10 cases in the surgical group and in 17 cases in the conservative group (P=0.046). Delayed hemopneumothorax occurred in 7 cases in the surgical group and in 16 cases in the conservative group (P=0.012).

Conclusions

Surgical treatment is a safe and effective therapy for multiple rib fractures. Our data suggested that surgical treatment can significantly shorten the patients' pain-endurance time, hospitalization time, and can reduce complication incidence. Severe rib fracture patients might benefit from surgical fixation.

Addition of Video-Assisted Thoracoscopic Surgery to the Treatment of Flail Chest

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is increasingly used in chest trauma for diagnostic and therapeutic purposes. In this report we describe our single-institutional experience with VATS in the surgical treatment of patients with flail chest after high-energy trauma.

METHODS

From January 2013 to July 2014, 15 patients with flail chest after high-energy trauma were treated in our hospital. The Injury Severity Score (ISS) ranged from 16 to 44. Rib fixation was performed with precontoured plates or intramedullary splints. In all, patients we additionally used VATS to explore the thoracic cavity and evacuate any hemothorax.

RESULTS

In 10 patients a prominent hemothorax was present, which needed evacuation. The median operative time was 120 minutes (range, 60 to 180 minutes), with a median blood loss of 150 mL (range, <100 to 400 mL). The mean stay in the intensive care unit was 5.27 days (SD 6.79). Ten patients were extubated directly after operation in the operating room. The other 5 patients were extubated after 1 to 13 days. The mean duration of mechanical ventilation was 2 days (SD 4.17). No patient required a tracheostomy. Three patients had minor postoperative adverse events. All patients were discharged after 6 to 44 days (mean, 11.9 hospitalization days) (SD 9.57).

CONCLUSIONS

We believe VATS is effective and safe and can be of additional value by providing the possibility to adjust the planned incision for rib fixation and decrease the area of muscle destruction. Additional pulmonary or mediastinal pathologic conditions can be identified and complete evacuation of hemothorax can be achieved simultaneously.

Evaluation of efficacy and indications of surgical fixation for multiple rib fractures: a propensity-score matched analysis

PURPOSE

The purpose of this study was to assess the effects of recent surgical rib fixation and establish its indications not only for flail chest but also for multiple rib fractures.

METHODS

Between 2007 and 2015, 187 patients were diagnosed as having multiple rib fractures in our institution. After the propensity score matching was performed, ten patients who had performed surgical rib fixation and ten patients who had treated with non-operative management were included. Categorical variables were analyzed with Fischer's exact test and non-parametric numerical data were compared using the Mann-Whitney U test. Wilcoxon signed-rank test was performed for comparison of pre- and postoperative variables. All statistical data are presented as median (25-75 % interquartile range [IQR]) or number.

RESULTS

The surgically treated patients extubated significantly earlier than non-operative management patients (5.5 [1-8] vs 9 [7-12] days: p = 0.019). The duration of continuous intravenous narcotic agents infusion days (4.5 [3-6] vs 12 [9-14] days: p = 0.002) and the duration of intensive care unit stay (6.5 [3-9] vs 12 [8-14] days: p = 0.008) were also significantly shorter in surgically treated patients. Under the same ventilating conditions, the postoperative values of tidal volume and respiratory rate improved significantly compared to those values measured just before the surgery. The incidence of pneumonia as a complication was significantly higher in non-operative management group (p = 0.05).

CONCLUSIONS

From the viewpoints of early respiratory stabilization and intensive care unit disposition without any complications, surgical rib fixation is a sufficiently acceptable procedure not only for flail chest but also for repair of severe multiple rib fractures.

Innovation and new trends in critical trauma disease

The management of critical trauma disease (CTD) has always trends the trends in military war experiences. These conflicts have historically revolutionized clinical concepts, clinical practice guidelines and medical devices, and have marked future lines of research and aspects of training and learning in severe trauma care. Moreover, in the civil setting, the development of intensive care, technological advances and the testing of our healthcare systems in the management of multiple victims, hasve also led to a need for innovation in our trauma care systems.

Surgical Management of Rib Fractures: Strategies and Literature Review

Background and Aims:

Rib fractures can cause significant problems in trauma patients, often resulting in pain and difficulty with respiration. To prevent pulmonary complications and decrease the morbidity and mortality rates of patients with rib fractures, currently there is a trend to provide surgical management of patients with flail chest. However, the indications for rib fracture fixation require further specification.

Material and Methods:

Past and current strategies are described according to a review of the medical literature. A systematic review was performed including current indications for rib fracture fixation. MEDLINE (2000–2013) was searched, as well as Embase (2000–2013) and Cochrane Databases, using the keywords rib, fracture, fixation, plate, repair, and surgery.

Results:

Three retrospective studies were found that described different techniques for rib fracture fixation. The results demonstrated a reduced number of ventilation days, decreased long-term morbidity and pain, and satisfactory rehabilitation after surgical treatment. In addition to flail chest, age, Injury Severity Score, and the number of rib fractures were important predictive factors for morbidity and mortality.

Conclusion:

Surgical rib fracture fixation might be indicated in a broader range of cases than is currently performed. Prospective randomized trials are needed for further confirmation.