Clinical outcomes of multiple rib fractures: does age matter?

External validation of novel Revised Intensity Battle Score and comparison of static rib fracture scoring systems

BACKGROUND

This study aims to compare and externally validate the previously developed Revised Intensity Battle Score (RIBS) against other proposed scores for predicting poor outcomes after rib fractures.

METHODS

An external validation set was assembled retrospectively, comprising 1,493 adult patients with one or more rib fractures admitted to a Level 1 trauma center between 2019 and 2022. The following rib fracture scores were calculated for each patient: RIBS, Injury Severity Score, Rib Fracture Score, Chest Trauma Score, and Battle score. Each was investigated to assess utility in predicting mortality, intensive care unit upgrade, unplanned intubation and ventilator days. Performance was measured by area under the receiver operating characteristic curve.

RESULTS

Of the 1,493 patients who met inclusion criteria, 239 patients (16%) experienced one of more of the investigated outcomes. Generally, scores performed best at predicting mortality and ventilator days. The RIBS stood out as best predicting "any complication" (AUC = 0.735) and ">7 ventilator days" (AUC = 0.771).

CONCLUSION

The RIBS represents an externally validated triage score in patients with rib fractures and compares favorably to other static scoring systems. Use of this score as a triage tool may allow stratifying patients who may benefit from direct intensive care unit admission, neuraxial anesthesia and aggressive respiratory care. Next steps include prospective investigation of how pairing these interventions with score directed triage impacts outcomes.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Revised Intensity Battle Score (RIBS): Development of a Clinical Score for Predicting Poor Outcomes After Rib Fractures

BACKGROUND

Patients with rib fractures have variable clinical courses and it is difficult to predict which patients will do poorly. Ideally this prediction would happen at the time of admission to facilitate effective triage. One scoring system devised to this end, is the Battle score. This study aims to evaluate the efficacy of the Battle score as triage tool, and to re-tool it for performance in an inpatient trauma setting.

METHODS

A multivariate logistic regression model was trained on patients admitted to a level one trauma center with at least one rib fracture. A composite outcome was used to classify those who had poor outcomes. Eighteen candidate predictors were analyzed in univariate analysis, then the most promising fed into the logistic model until a triage score was built and internally validated by bootstrapping.

RESULTS

Of the 838 patients who met the inclusion criteria, 145 (17.3%) patients had a defined poor outcome. The relevant predictors included in the final scoring system were number of ribs fractured, chest tube, pulmonary contusions, chronic obstructive pulmonary disease, and Glasgow coma score. Age was not found to be predictive. This score was found to have higher fidelity in predicting poor outcomes than the original Battle score (AUROC .858 vs .649.).

DISCUSSION

An easy to calculate clinical scoring system was created to triage patients with rib fractures at the time of admission. Age may be of less importance than previously thought, while injury burden and history of lung disease may play a larger role.

[Bilateral thoracic trauma-"double the trouble"?]

BACKGROUND

Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma.

OBJECTIVE

The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two.

MATERIAL AND METHODS

In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome.

RESULTS

A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors.

CONCLUSION

Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

Risk factors that predict mortality in patients with blunt chest wall trauma: an updated systematic review and meta-analysis

BACKGROUND

Over the last 10 years, research has highlighted emerging potential risk factors for poor outcomes following blunt chest wall trauma. The aim was to update a previous systematic review and meta-analysis of the risk factors for mortality in blunt chest wall trauma patients.

METHODS

A systematic review of English and non-English articles using MEDLINE, Embase and Cochrane Library from January 2010 to March 2022 was completed. Broad search terms and inclusion criteria were used. All observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. Where sufficient data were available, ORs with 95% CIs were calculated using a Mantel-Haenszel method. Heterogeneity was assessed using the I² statistic.

RESULTS

73 studies were identified which were of variable quality (including 29 from original review). Identified risk factors for mortality following blunt chest wall trauma were: age 65 years or more (OR: 2.11; 95% CI 1.85 to 2.41), three or more rib fractures (OR: 1.96; 95% CI 1.69 to 2.26) and presence of pre-existing disease (OR: 2.86; 95% CI 1.34 to 6.09). Other new risk factors identified were: increasing Injury Severity Score, need for mechanical ventilation, extremes of body mass index and smoking status. Meta-analysis was not possible for these variables due to insufficient studies and high levels of heterogeneity.

CONCLUSIONS

The results of this updated review suggest that despite a change in demographics of trauma patients and subsequent emerging evidence over the last 10 years, the main risk factors for mortality in patients sustaining blunt chest wall trauma remained largely unchanged. A number of new risk factors however have been reported that need consideration when updating current risk prediction models used in the ED.

PROSPERO REGISTRATION NUMBER

CRD42021242063. Date registered: 29 March 2021. https://www.crd.york.ac.uk/PROSPERO/%23recordDetails.

Management and outcomes of rib fractures in patients with isolated blunt thoracic trauma: Results of the Aotearoa New Zealand RiBZ study

AIM

Rib fractures are common and associated with significant morbidity and mortality. There is limited literature on patient care and outcomes in Aotearoa New Zealand (AoNZ). The aim of this study is to describe key clinical outcomes and management interventions for patients with rib fractures across AoNZ.

METHODS

A national prospective multicenter observational cohort study was performed. Patients admitted between 1 December 2020 and 28 February 2021 with one or more radiologically proven rib fractures and an Abbreviated Injury Score of the head or abdomen of less than 3 were included. The primary outcomes of interest were the rates of thirty-day pneumonia, re-presentation and mortality. The secondary outcomes of interest were rate of surgical stabilisation of rib fractures (SSRF) and pain management of patients with rib fractures. Binomial logistic regression was performed for the primary outcomes and funnel plots were created of the inter-hospital variation in pneumonia.

RESULTS

Fourteen AoNZ hospitals and 407 patients were included. Mean age was 57.4 (SD 18.7), 28% were female, 15% Māori and 85% non-Māori. The median number of rib fractures was 4. The rate of pneumonia, re-presentation and mortality was 11%, 8% and 2%, respectively. Logistic regression found the odds of pneumonia increased with each additional rib fracture (OR 1.15 95% CI 1.05-1.25) and the odds of re-presentation increased with age (OR 1.028 95% CI 1.005-1.051) and Māori ethnicity (OR 2.754 95% CI 1.077-7.045). The funnel plot of inter-hospital variation in pneumonia rate adjusted for clinically plausible variables found no centre lay outside the 95% confidence interval. SSRF was performed in 2% of patients. 58% of patients had a pain team review and 23% a regional block.

CONCLUSION

This study describes clinical outcomes for patients with isolated rib fractures from multiple hospitals in AoNZ. A moderate pneumonia rate of 11% was found which is likely amendable to reduction with quality improvement initiatives. Consideration should be given to further resource and improve the access to SSRF and regional analgesia given the low utilization found across AoNZ. A higher re-presentation rate in Māori and elderly patients was found which needs further investigation.

Surgical stabilization of serial rib fractures is advantageous in patients with relevant traumatic brain injury

Purpose

To evaluate the clinical benefit of surgical stabilization of rib fractures (SSRF) in polytrauma patients with serial rib fractures.

Methods

Retrospective single-center cohort analysis in trauma patients. Serial rib fracture was defined as three consecutive ribs confirmed by chest computer tomography (CT). Study cohort includes 243 patients that were treated conservatively and 34 patients that underwent SSRF. Demographic patient data, trauma mechanism, injury pattern, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and hospital course were analyzed. Two matched pair analyses stratified for ISS (32 pairs) and GCS (25 pairs) were performed.

Results

The majority of patients was male (74%) and aged 55 ± 20 years. Serial rib fractures were associated with more than 6 broken ribs in average (6.3 ± 3.7). Other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). Visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). Average ISS was 22 ± 7.3. Overall hospital stay was 15.9 and ICU stay 7.4 days. In hospital, mortality was 13%. SSRF did not improve hospital course or postoperative complications in the complete study cohort. However, patients with a significantly reduced GCS (7.6 ± 5.3 vs 11.22 ± 4.8; p = 0.006) benefitted from SSRF. Matched pair analysis stratified for GCS showed shorter ICU stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003).

Conclusion

Patients with serial rib fractures and simultaneous moderate or severe traumatic brain injury benefit from surgical stabilization of rib fractures.

[Thoracic injuries in severely injured children : Association with increased injury severity and a higher number of complications]

BACKGROUND

Severely injured children and adolescents in clinical practice are rare. For adequate treatment of these patients, detailed knowledge of anatomical and physiological peculiarities, as well as abundant injury patterns, are indispensable. Traumatic brain injuries are known to lead to an unfavorable outcome. In addition, thoracic trauma is regarded as prognostically unfavorable.

OBJECTIVES

This study depicts epidemiology and injury patterns of severely injured children and adolescents focusing on peculiarities in the severely injured with associated thoracic injuries.

MATERIALS AND METHODS

A retrospective analysis of underaged patients with suspicion of severe injuries who obtained emergency-room treatment in our level-one trauma center during a four-year time period was performed. The data was collected prospectively using the TraumaRegister® of the German Trauma Society as well as an extended house-internal dataset including data of daily clinical routine. The patients were divided into subgroups with (TT) and without (KT) thoracic trauma based on whether a thoracic injury was present or not. For further analysis, four age groups were established.

RESULTS

In all, 256 patients younger than 18 years were eligible. Of these, 46 patients revealed thoracic injuries. The mean age of patients with thoracic trauma (12.4 ± 4.9 years) was significantly higher than for patients without thoracic trauma (8.0 ± 5.2 years). In both subgroups, most patients were male (TT: 69.9%, KT: 64.8%). Patients with concomitant thoracic trauma showed a significantly higher injury severity score (ISS) than patients without thoracic trauma (ISS: TT: 26.7 ± 15.8 vs. KT: 8.1 ± 6.8 points). Mortality was higher for TT as well (TT: 6.9% vs. KT: 1.9%). For both groups, traffic accidents were the most common cause of injury. Of patients with thoracic injuries, 52.2% developed at least one complication during their hospital stay (KT: 12.9%).

CONCLUSIONS

Thoracic trauma is a relevant factor in children with regard to the severity of total injury and complications. Particular attention should therefore be paid to early diagnosis and treatment.

Safety, complications and clinical outcome after ultrasound-guided paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective observational study

Rib fractures are associated with significant morbidity and mortality. Ultrasound-guided thoracic paravertebral catheter insertion has been described for the management of pain secondary to rib fractures. We conducted a retrospective observational study of all patients with rib fractures who had a paravertebral catheter inserted for analgesia provision over a 4-year period. Data from the Trauma Audit and Research Network were used to compare patients with rib fractures who were managed with paravertebral catheters to those managed with systemic analgesia. A total of 314 consecutive paravertebral catheters were inserted in 290 patients. Five (1.9%) catheters were removed due to ineffective analgesia. Other minor complications occurred in three cases (0.96%). The proportion of rib fracture patients managed with paravertebral catheters increased from 31/200 (15.5%) in the first year of study to 81/168 (48.2%) in the fourth; over this time-period the observed:predicted mortality ratio fell from 1.04 to 0.66. Proportional hazard regression with and without propensity score matching demonstrated a reduction in mortality associated with paravertebral catheter use, but this became statistically non-significant when time-dependent analysis was used. Paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.

Age and sex alone are insufficient to predict human rib structural response to dynamic A-P loading

Thoracic injuries from motor vehicle crashes (MVCs) are common in children and the elderly and are associated with a high rate of mortality for both groups. Rib fractures, in particular, are linked to high mortality rates which increase with the number of fractures sustained. Anthropomorphic test devices (ATDs) and computational models have been developed to improve vehicle safety, however these tools are constructed based on limited physical datasets. To-date, no study has explored variation of rib structural properties across the entire age spectrum with data obtained using the same experimental methodology to allow for comparison. One-hundred eighty-four ribs from 93 post mortem human subjects (PMHS) (70 male, 23 female; ages 4-99) were subjected to dynamic bending tests simulating a frontal impact to the thorax. Structural mechanical properties were calculated and a multi-level statistical model quantified the sample variance as explained by age and sex. Displacement (δ_X), peak force (F_peak), linear structural stiffness (K), energy absorption to fracture (U_tot), and plastic properties including post-yield energy absorption (U_Pl), plastic displacement (δ_Pl), and the ratio of elastic to secant stiffness (K-ratio) all showed negative relationships with age, while only F_peak, K, and U_tot were dependent on sex. Despite these relationships being statistically significant, only 7-39% of variance is explained by age and only 3-17% of variance is explained by sex. This demonstrates that variability in bone properties is more complex than simply chronological age- and sex-dependence and should be explored in the context of biological mechanisms instead.

Clinical Presentation and Time-Based Mortality in Patients With Chest Injuries Associated With Road Traffic Accidents

Background:

Blunt chest trauma (BCT) poses significant morbidity and mortality worldwide.

Objectives:

We investigated the clinical presentation and outcome of BCT related to road traffic accidents (RTA).

Patients and Methods:

A retrospective observational analysis for patients who sustained BCT secondary to RTA in terms of motor vehicle crash (MVC) and pedestrian-motor vehicle accidents (PMVA) who were admitted to the trauma center at Hamad general hospital, Doha, Qatar, between 2008 and 2011.

Results:

Of 5118 traumatic injury cases, 1004 (20%) were found to have BCT secondary to RTA (77% MVC and 23% PMVA). The majority were males (92%), and expatriates (72%). Among MVCs, 84% reported they did not use protective devices. There was a correlation between chest abbreviated injury score (AIS) and injury severity scoring (ISS) (r = 0.35, r² = 0.12, P < 0.001). Regardless of mechanism of injury (MOI), multivariate analysis showed that the head injury associated with chest AIS and ISS was a predictor of mortality in BCT. Overall mortality was 15%, and the highest rate was observed within the first 24 hours post-trauma.

Conclusions:

Blunt chest trauma from RTA represents one-fifth of the total trauma admissions in Qatar, with a high overall mortality. Pedestrians are likely to have more severe injuries and higher fatality rates than MVC victims. Specific injury prevention programs focusing on road safety should be implemented to minimize the incidence of such preventable injuries.

Traumatic injury among females: does gender matter?

BACKGROUND

Trauma remains one of the leading causes of morbidity and mortality worldwide. Generally, the incidence of traumatic injuries is disproportionately high in males. However, trauma in females is underreported.

AIM

To study the epidemiology and outcome of different mechanisms and types of traumatic injuries in women.

METHODS

We conducted a traditional narrative review using PubMed, MEDLINE and EMBASE, searching for English-language publications for gender-specific trauma between January 1993 and January 2013 using key words "trauma", "gender", "female" and "women".

RESULTS

Among 1150 retrieved articles, 71 articles were relevant over 20 years. Although it is an important public health problem, traumatic injuries among females remain under-reported.

CONCLUSION

There is a need for further research and evaluation of the exact burden of traumatic injuries among females together with the implementation of effective community based preventive programs.