1
|
Simpson JT, Camarena A, Georgoff P, Fernandez-Moure J. To fix or let them flail: the who, what and when of rib fixation. Trauma Surg Acute Care Open 2025; 10:e001801. [PMID: 40400729 PMCID: PMC12094122 DOI: 10.1136/tsaco-2025-001801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2025] [Accepted: 03/30/2025] [Indexed: 05/23/2025] Open
Abstract
Rib fractures occur in 10% of traumatic injuries and are a common source of morbidity and mortality. Mortality rates for rib fractures remain alarmingly high. Despite increasing literature in support of surgical stabilization of rib fracture (SSRF), acceptance and incorporation of SSRF as the standard of care has not occurred across trauma centers. This expert review highlights the 'who, what and when' of SSRF and argues for SSRF as the gold standard for the restoration of form and function following chest wall injury.
Collapse
Affiliation(s)
- John T Simpson
- General Surgery, Duke University, Durham, North Carolina, USA
| | - Adrian Camarena
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | | | | |
Collapse
|
2
|
Ferre AC, Centeno AC, Vanderploeg DG, Pieracci FM. When to pursue acute rib fracture fixation. Curr Opin Crit Care 2025:00075198-990000000-00257. [PMID: 40079510 DOI: 10.1097/mcc.0000000000001266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2025]
Abstract
PURPOSE OF REVIEW This review will explore acute rib fracture management focusing on indications and timing for acute surgical stabilization of rib fractures (SSRF). RECENT FINDINGS SSRF is a well tolerated and effective approach for a variety of rib fracture patterns and is most commonly used to correct either clinical flail chest or multiple displaced fractures. Objective tools that assess for deranged pulmonary dynamics may identify patients with other fracture patterns who will also benefit from SSRF. Multimodal analgesia approaches are essential regardless of whether SSRF is pursued; intractable pain may also prompt SSRF. Hemodynamic instability precludes acute SSRF. Otherwise, SSRF should occur within 72 h of injury. Preoperative planning includes thoracic computed tomography scanning, and a preanesthetic evaluation, especially in the geriatric patient based on the presence of comorbidities. Preoperative coordination with other services that also need to address acute injuries helps condense anesthesia exposures. Acute SSRF reduces pain and in particular pulmonary complications in those with acute rib fractures. SUMMARY SSRF is a well tolerated and effectively acutely deployed operative technique to address specific rib fracture injury patterns. It is ideally embraced as a structured program to facilitate collaboration, coordination, and program performance evaluation.
Collapse
|
3
|
Kobes T, van Baal MCPM, Heng M. Does the treatment modality affect nosocomial pneumonia and other in-hospital outcomes in patients with combined injuries to the ribs and clavicle? A propensity score weighted analysis of a retrospective cohort. Arch Orthop Trauma Surg 2024; 145:81. [PMID: 39708166 DOI: 10.1007/s00402-024-05661-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 10/17/2024] [Indexed: 12/23/2024]
Abstract
OBJECTIVE What is the effect of surgical or conservative treatment on the in-hospital outcomes of patients with combined fractures of the clavicle and ribs? DESIGN Retrospective cohort study. SETTING Two level-1 trauma centers and academic teaching hospitals in Boston, Massachusetts. PATIENTS All adult patients with a clavicle fracture and ≥3 rib fractures admitted from 2016 to 2021. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Nosocomial pneumonia, hospital length-of-stay (HLOS), ICU length-of-stay (ILOS), days on mechanical ventilation (DMV). RESULTS 252 patients were included (212 conservative, 40 surgical; median age 62 years, 67% male). The median ISS and GCS scores were 17 and 15, respectively. Thirty-seven patients developed nosocomial pneumonia. For clavicle fixation (n = 26), the OR for pneumonia was 0.3 (95% CI 0.0-2.2), ILOS had a ß-coefficient of -2.6 (95% CI -5.9-0.8), and DMV a ß-coefficient of -3.6 (95% CI -12.0-4.8). For rib plating (n = 10), the OR for pneumonia was 1.4 (95% CI 0.2-8.6), HLOS had a ß-coefficient of 4.9 (95% CI -1.6-11.5), and ILOS a ß-coefficient of 4.1 (95% CI -0.4-8.6). For both surgeries (n = 4), the CIs were wide. CONCLUSION Clavicle fixation in patients with combined injuries of the clavicle and ribs did not improve nor worsen in-hospital outcomes; the orthopedic surgeon should make a patient-tailored treatment decision. Rib plating did not improve in-hospital outcomes in non-flail patients with a concomitant clavicle fracture. Guidelines on non-flail rib plating could profit from these findings in combination with previous and additional research. LEVEL OF EVIDENCE Level III, Therapeutic Study.
Collapse
Affiliation(s)
- Tim Kobes
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02115, USA.
- Department of Trauma Surgery, University Medical Center Utrecht, PO Box 85500, Utrecht, GA, 3508, The Netherlands.
| | - Mark C P M van Baal
- Department of Trauma Surgery, University Medical Center Utrecht, PO Box 85500, Utrecht, GA, 3508, The Netherlands
| | - Marilyn Heng
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, NW 14th Street, Miami, FL, 33136, USA
- Orthopedic Trauma Service, Jackson Memorial Hospital Ryder Trauma Center, NW 14th Street, Miami, FL, 33136, USA
| |
Collapse
|
4
|
Bauman ZM, Khan H, Phillips J, Wells A, Evans CH, Liu JL, Kamien A, Cemaj S, Sheppard O, Lamb G, Veatch J, Nguyen J, Matos M, Cantrell E. Comparison of patients who meet criteria for surgical stabilization of rib fractures versus those who actually get rib fixation: A single center review. Injury 2024; 55:111930. [PMID: 39383613 DOI: 10.1016/j.injury.2024.111930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 09/24/2024] [Accepted: 09/25/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) has shown benefits for rib fracture patients. However, the incidence of SSRF performed remains low. We compare our institution's rib fracture patients meeting criteria for SSRF versus those actually receiving the operation, hypothesizing a significant portion are not undergoing SSRF. METHODS A retrospective review of rib fracture patients presenting to our Level 1 trauma center from 1/2016 to 4/2023. Patients were categorized as those who met SSRF inclusion criteria versus those who didn't based on the 2023 Chest Wall Injury Society (CWIS) SSRF Guidelines. Basic demographics were obtained. Patients meeting SSRF criteria were divided into those who received SSRF versus those who didn't. Outcomes of interest included type and frequency of SSRF indications and frequency of absolute/relative contraindications. Descriptive statistics were used. Median test and t-test were used for statistical analysis. Statistical significance was set at p < 0.05. RESULTS A total of 3,432 patients presented with ≥1 rib fracture(s). Of those, 1,573(45.8 %) met SSRF inclusion criteria. These patients were predominantly male, with mean age of 57.4(±18.5) and a similar Injury Severity Score but significantly higher chest-Abbreviated Injury Score of 3 (Interquartile range 3,4)(p = 0.048). Only 458(29.1 %) patients underwent SSRF, leaving 1,115(70.9 %) managed non-operatively, of which 215(19.3 %) were ventilated and "failure to wean from the ventilator" was the most common (81.4 %) indication for SSRF. Of the 900(80.7 %) non-ventilated patients managed non-operatively, 659 (69.9 %) had ≥two indications for SSRF, 382(34.3 %) had zero relative contraindications and 394(35.3 %) had one relative contraindication for SSRF. Lastly, 52.6 % of patients in this cohort had reported "clicking/popping" of their fractures. CONCLUSION Only 29.1 % of patients meeting criteria for SSRF had the operation based on data from our institution. There may be additional opportunity to benefit this cohort of patients meeting SSRF criteria but not undergoing surgery.
Collapse
Affiliation(s)
- Zachary M Bauman
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Hason Khan
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Jakob Phillips
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Alyssa Wells
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Charity H Evans
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - John L Liu
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Andrew Kamien
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Samuel Cemaj
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Olabisi Sheppard
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Gina Lamb
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Jessica Veatch
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Jonathan Nguyen
- Division of Acute Care Surgery, Department of Surgery, Grady Memorial Hospital, Atlanta, GA, 30303, USA.
| | - Mike Matos
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Emily Cantrell
- Division of Trauma, Emergency General Surgery and Critical Care Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
| |
Collapse
|
5
|
Liu G, Zhou L, Li C, Cao J, Zhang Y, Cui S, Liu Y, Xu Y, Zang Y, Yang M, Li Q. Application of Titanium Mesh in the Early Treatment of Flail Chest. Int J Biomater 2024; 2024:8213995. [PMID: 39569041 PMCID: PMC11578650 DOI: 10.1155/2024/8213995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 07/19/2024] [Accepted: 10/12/2024] [Indexed: 11/22/2024] Open
Abstract
Objective: To investigate the effect of the titanium mesh on flail chest and bone healing from clinical and animal experiments. Methods: Clinical experiment: 24 patients with flail chests in our hospital from January 2020 to January 2023 were prospectively selected and divided into control and titanium mesh groups according to different treatment plans and basic data-matching principles, with 12 cases in each group. The control group was treated with conservative external fixation, and the titanium mesh group was treated with titanium mesh fixation. The clinical efficacy index, visual analog scale and blood gas indexes and hemodynamic indexes of the two groups of patients were recorded. Chest CT and pulmonary function and life quality were examined after operation. Animal experiment: The flail chest sheep were treated conservatively with a titanium mesh, and the expression of bone-healing-related proteins was detected. Results: The mechanical ventilation time, drain indwelling time, ICU observation time, and hospital time in the titanium mesh group were significantly shorter than those in the control group (p < 0.05). The PaO2, CVP, FVC, FEV1, MVV, and life quality of the titanium mesh group were significantly better than those of the control group after operation, and the visual analog scale, PaCO2, CI, ELWI, and the proportions of atelectasis, thoracocyllosis, and consolidation tardive after operation were significantly lower than those of the control group (p < 0.05). The expressions of BMP2, IGF-1, VEGF, and PDGFD in the rib tissue of titanium mesh sheep were higher than those of control sheep at 4 weeks after operation (p < 0.05). Conclusion: Titanium mesh is a safe and effective treatment for flail chest, which can improve pain, blood gas, hemodynamic indexes, and pulmonary function and promote fracture healing.
Collapse
Affiliation(s)
- Gaofeng Liu
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
- Xinxiang Medical University, Xinxiang 453003, Henan Province, China
| | - Li Zhou
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Chen Li
- Xinxiang Medical University, Xinxiang 453003, Henan Province, China
| | - Junying Cao
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Yong Zhang
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Sujuan Cui
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Yan Liu
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Yanbin Xu
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Yongjie Zang
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Meiming Yang
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| | - Qingyuan Li
- Department of Cardiothoracic Surgery, The 988th Hospital of PLA Joint Logistics Support, Zhengzhou 450042, Henan Province, China
| |
Collapse
|
6
|
Sermonesi G, Bertelli R, Pieracci FM, Balogh ZJ, Coimbra R, Galante JM, Hecker A, Weber D, Bauman ZM, Kartiko S, Patel B, Whitbeck SS, White TW, Harrell KN, Perrina D, Rampini A, Tian B, Amico F, Beka SG, Bonavina L, Ceresoli M, Cobianchi L, Coccolini F, Cui Y, Dal Mas F, De Simone B, Di Carlo I, Di Saverio S, Dogjani A, Fette A, Fraga GP, Gomes CA, Khan JS, Kirkpatrick AW, Kruger VF, Leppäniemi A, Litvin A, Mingoli A, Navarro DC, Passera E, Pisano M, Podda M, Russo E, Sakakushev B, Santonastaso D, Sartelli M, Shelat VG, Tan E, Wani I, Abu-Zidan FM, Biffl WL, Civil I, Latifi R, Marzi I, Picetti E, Pikoulis M, Agnoletti V, Bravi F, Vallicelli C, Ansaloni L, Moore EE, Catena F. Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper. World J Emerg Surg 2024; 19:33. [PMID: 39425134 PMCID: PMC11487890 DOI: 10.1186/s13017-024-00559-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 08/27/2024] [Indexed: 10/21/2024] Open
Abstract
BACKGROUND Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. METHODS This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. RESULTS A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. CONCLUSION This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.
Collapse
Affiliation(s)
- Giacomo Sermonesi
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Riccardo Bertelli
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Fredric M Pieracci
- Department of Surgery, University of Colorado School of Medicine, Denver, CO, USA
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Zachary M Bauman
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Susan Kartiko
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Bhavik Patel
- Division of Trauma, Gold Coast University Hospital, Southport, QLD, Australia
| | | | | | - Kevin N Harrell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA
| | - Daniele Perrina
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Alessia Rampini
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Brian Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Francesco Amico
- Discipline of Surgery, School of Medicine and Public Health, Newcastle, NSW, Australia
| | - Solomon G Beka
- Ethiopian Air Force Hospital, Bishoftu, Oromia, Ethiopia.
| | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | - Marco Ceresoli
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Lorenzo Cobianchi
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Lodz, Poland
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Francesca Dal Mas
- Collegium Medicum, University of Social Sciences, Lodz, Poland
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
| | - Belinda De Simone
- Department of Minimally Invasive Emergency and General Surgery, Infermi Hospital, Rimini, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche Region, Italy
| | - Agron Dogjani
- Department of General Surgery, University of Medicine of Tirana, Tirana, Albania
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carlos Augusto Gomes
- Faculdade de Medicina, SUPREMA, Hospital Universitario Terezinha de Jesus de Juiz de Fora, Juiz de Fora, MG, Brazil
| | - Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Vitor F Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus
| | - Andrea Mingoli
- Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
| | - David Costa Navarro
- Colorectal Surgery Unit, Trauma Care Committee, Alicante General University Hospital, Alicante, Spain
| | - Eliseo Passera
- Departments of Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Michele Pisano
- Departments of Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Emanuele Russo
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Domenico Santonastaso
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Ingo Marzi
- Department of Trauma Surgery and Orthopedics, University Hospital Goethe University Frankfurt, Frankfurt, Germany
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Manos Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Vanni Agnoletti
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Carlo Vallicelli
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Ernest E Moore
- Department of Surgery, University of Colorado School of Medicine, Denver, CO, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| |
Collapse
|
7
|
Manes TJ, DeGenova DT, Taylor BC, Patel JN. Far Posterior Approach for Rib Fracture Fixation: Surgical Technique and Tips. JBJS Essent Surg Tech 2024; 14:e23.00094. [PMID: 39650795 PMCID: PMC11617350 DOI: 10.2106/jbjs.st.23.00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2024] Open
Abstract
Background The present video article describes the far posterior or paraspinal approach to posterior rib fractures. This approach is utilized to optimize visualization intraoperatively in cases of far-posterior rib fractures. This technique is also muscle-sparing, and muscle-sparing posterolateral, axillary, and anterior approaches have been shown to return up to 95% of periscapular strength by 6 months postoperatively1. Description Like most fractures, the skin incision depends on the fracture position. The vertical incision is made either just medial to a line equidistant between the palpable spinous processes and medial scapular border or directly centered over the fracture line in this region. The incision and superficial dissection must be extended cranially and caudally, approximately 1 or 2 rib levels past the planned levels of instrumentation, in order to allow muscle elevation and soft-tissue retraction. Superficial dissection reveals the trapezius muscle, with its fibers coursing from inferomedial to superolateral caudal to the scapular spine, and generally coursing transversely above this level. The trapezius is split in line with its fibers (or elevated proximally at the caudal-most surface), and the underlying layer will depend on the location of the incision. The rhomboid minor muscle overlies ribs 1 and 2, the rhomboid major muscle overlies ribs 3 to 7, and the latissimus dorsi overlies the remaining rib levels. To avoid muscle transection, the underlying muscle is also split in line with its fibers. Next, the thoracolumbar fascia is encountered and sharply incised, revealing the erector spinae muscles, which comprise the spinalis thoracis, longissimus thoracis, and iliocostalis thoracis muscles. These muscles and their tendons must be sharply elevated from lateral to midline; electrocautery is useful for this because there is a robust blood supply in this region. Medially, while retracting the paraspinal musculature, visualization with this approach can extend to the head and neck of the rib, and even to the spine. Following deep dissection, the fractures are now visualized. During fracture reduction, it is critical to assess reduction of both the costovertebral joint and the costotransverse joint. With fractures closer to the spine, it is recommended to have at least 2 cm between the rib head and tubercle in order to allow 2 plate holes to be positioned on the neck of the rib; if comminution exists and plating onto the transverse process is needed, several screws are required here for stability as well. For appropriate stability if plating onto the spine is not required, a minimum of 3 locking screws on each side of the fracture are recommended. Contouring of the plates to match the curvature of the rib and to allow for proper apposition may be required with posterior rib fractures. Screws must be placed perpendicular to the rib surface. Following operative stabilization of the rib fractures, a layered closure is performed, and a soft dressing is applied. Alternatives Nonoperative alternatives include non-opioid and opioid medications as well as corticosteroid injections for pain control. Supportive mechanical ventilation and physiotherapy breathing exercises can also be implemented as needed. Operative alternatives include open reduction and internal fixation utilizing conventional locking plates and screws. Rationale Rib fractures are often treated nonoperatively when nondisplaced because of the surrounding soft-tissue support2,3. According to Chest Wall Injury Society guidelines, contraindications to surgical fixation of rib fractures include patients requiring ongoing resuscitation; rib fractures involving ribs 1, 2, 11, or 12, which are relative contraindications; severe traumatic brain injury; and acute myocardial infarction. Patient age of <18 years is also a relative contraindication for the operative treatment of rib fractures. The current literature does not recommend surgical fixation in this age group because these fractures typically heal as the patient ages; however, fracture-dislocations may require the use of instrumentation to prevent displacement. Currently, the U.S. Food and Drug Administration does not approve most plating systems for patients <18 years old4. In certain cases, including those with substantial displacement, persistent respiratory distress, pain, or fracture nonunion, stabilization with open reduction and internal fixation may be appropriate5-7. In cases of flail chest injuries, surgery is often indicated6. Flail chest injuries have been noted in the literature to have an incidence of approximately 150 cases per 100,000 injuries and have been shown to carry a mortality rate of up to 33%8,9. Surgical treatment of rib fractures has been shown to be associated with a decreased hospital length of stay and mortality rate in patients with major trauma1. Expected Outcomes Expected outcomes of this procedure include low complication rates, decreased hospital and intensive care unit length of stay, and reduced mechanical ventilation time10,11. However, as with any procedure, there are also risks involved, including iatrogenic lung injury from long screws or an aortic or inferior vena cava injury with aggressive manipulation of displaced fractured fragments, especially on the left side of the body. During open reduction, there is also a risk of injuring the neurovascular bundle. Tanaka et al. demonstrated a significant reduction in the rate of postoperative pneumonia in their operative group (22%) compared with their nonoperative group (90%)12. Schuette et al. demonstrated a 23% rate of postoperative pneumonia, 0% mortality at 1 year, an average of 6.2 days in the intensive care unit, an average total hospital length of stay of 17.3 days, and an average total ventilator time of 4 days in the operative group10. Prins et al. reported a significantly lower incidence of pneumonia in operative (24%) versus nonoperative patients (47.3%; p = 0.033), as well as a significantly lower 30-day mortality rate (0% versus 17.7%; p = 0.018)3. This procedure utilizes a muscle-sparing technique, which has demonstrated successful results in the literature on the use of the posterolateral, axillary, and anterior approaches, returning up to 95% of periscapular strength, compared with the uninjured shoulder, by 6 months postoperatively1. The use of a muscle-sparing technique with the far-posterior approach represents a topic that requires further study in order to compare the results with the successful results previously shown with other approaches. Important Tips The ipsilateral extremity can be prepared into the field to allow its intraoperative manipulation in order to achieve scapulothoracic motion and improved subscapular access.For costovertebral fracture-dislocations, the vertical incision line is made just medial to a line equidistant between the palpable spinous processes and medial scapular border.Lateral decubitus positioning can be utilized to allow for simultaneous access to fractures that extend more laterally and warrant a posterolateral approach; however, it is generally more difficult to access the fracture sites near the spine with this approach.This muscle-sparing technique is recommended to optimize postoperative periscapular strength, as previously demonstrated with other approaches.Incision and superficial dissection must be extended cranially and caudally approximately 1 or 2 rib levels past the planned levels of instrumentation in order to allow muscle elevation and soft-tissue retraction.To avoid muscle transection during surgical dissection, the underlying muscle is split in line with its fibers.During deep dissection, it can be difficult to delineate underlying muscles because these muscles have fibers that do not run in line with the trapezius, and some, like the rhomboid major, run nearly perpendicular to it.Electrocautery is useful while elevating the erector spinae muscles and tendons, as there is a robust blood supply in this region.The erector spinae muscle complex is relatively tight and adherent to the underlying ribs, which may make it difficult to achieve adequate visualization; therefore, at least 3 rib levels must be elevated to access a rib for reduction and instrumentation.Although internal rotation deformities are more common in this region, any external displacement of a fracture can lead to a muscle injury that can be utilized for access.During fracture reduction, it is critical to assess reduction of both the costovertebral joint and the costotransverse joint.Special attention must be given to contouring the implants because there are not any commercially available precontoured implants for this region at this time, and plating onto the spine remains an off-label use of any currently available implant.For the more challenging fracture patterns, the use of a right-angled power drill and screwdriver is recommended.Generally, the incision is utilized as previously described to provide access as far medial as the transverse process if needed. However, in cases in which this approach does not allow proper visualization with rib fracture-dislocations involving the posterior ribs or spine, a midline spinal incision can be utilized while working in combination with a spine surgeon.With fractures closer to the spine, it is recommended to have at least 2 cm between the rib head and tubercle in order to allow 2 plate holes to be positioned on the neck of the rib.If comminution exists and plating onto the transverse process is needed, several screws are required for stability.When measuring the length of screws to be placed in the transverse process, preoperative CT scans can be utilized. Acronyms and Abbreviations CT = computed tomographyCWIS = Chest Wall Injury SocietyIVC = inferior vena cava.
Collapse
Affiliation(s)
- Taylor J. Manes
- Department of Orthopedics, OhioHealth Health System, Columbus, Ohio
| | | | - Benjamin C. Taylor
- OhioHealth Orthopedic Trauma and Reconstructive Surgery, Grant Medical Center, Columbus, Ohio
| | - Jignesh N. Patel
- Department of Orthopedics, OhioHealth Health System, Columbus, Ohio
| |
Collapse
|
8
|
Al Tannir AH, Pokrzywa CJ, Dodgion C, Boyle KA, Eddine SBZ, Biesboer EA, Milia DJ, de Moya MA, Carver TW. Physiologic parameters and radiologic findings can predict pulmonary complications and guide management in traumatic rib fractures. Injury 2024; 55:111508. [PMID: 38521636 DOI: 10.1016/j.injury.2024.111508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/17/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Traumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures. METHODS This is a single-center retrospective review (2015-2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC. RESULTS A total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS. CONCLUSION VC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study.
Collapse
Affiliation(s)
- Abdul Hafiz Al Tannir
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Courtney J Pokrzywa
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christopher Dodgion
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Kelly A Boyle
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Savo Bou Zein Eddine
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Elise A Biesboer
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - David J Milia
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Marc A de Moya
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Thomas W Carver
- Department of Surgery, Division of Trauma & Critical Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| |
Collapse
|
9
|
Meyer CH, Aworanti E, Santos A, Castater C, Bauman ZM, Archer-Arroyo K, Sola R, Grant A, Smith RN, Sciarretta JD, Nguyen JH. Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience. Am Surg 2024; 90:695-702. [PMID: 37853722 PMCID: PMC10922850 DOI: 10.1177/00031348231209530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
INTRODUCTION The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries. METHODS A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series. RESULTS 6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge. CONCLUSIONS This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.
Collapse
Affiliation(s)
- Courtney H. Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Adora Santos
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Christine Castater
- Grady Health System, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Krystal Archer-Arroyo
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | | | | | - Randi N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jason D. Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Jonathan H. Nguyen
- Grady Health System, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| |
Collapse
|
10
|
Bethlahmy JM, Hanst BA, Giafaglione SM, Elia JM. Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review. J Clin Anesth 2023; 91:111275. [PMID: 37797395 DOI: 10.1016/j.jclinane.2023.111275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/12/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.
Collapse
Affiliation(s)
- Jessica M Bethlahmy
- UC Irvine School of Medicine, 1001 Health Sciences Road Irvine, CA 92617, USA
| | - Brian A Hanst
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Sarah M Giafaglione
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA
| | - Jennifer M Elia
- UC Irvine Department of Anesthesiology & Perioperative Care, 101 The City Drive South 52-225C, Orange, CA 92868, USA.
| |
Collapse
|
11
|
Lagazzi E, Argandykov D, de Roulet A, Proaño-Zamudio JA, Romijn ASC, Abiad M, Rafaqat W, Velmahos GC, Hwabejire JO, Paranjape CN. Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis. J Trauma Acute Care Surg 2023; 95:846-854. [PMID: 37822127 DOI: 10.1097/ta.0000000000004100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI. METHODS We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017-2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours). RESULTS Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (β) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001-0.023), longer hospital LOS (β = 0.053; p < 0.001; 95% CI, 0.042-0.064), prolonged ICU LOS (β = 0.032; p < 0.001; 95% CI, 0.025-0.038), and more ventilator days (β = 0.026, p < 0.001; 95% CI, 0.020-0.032). CONCLUSION In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
Affiliation(s)
- Emanuele Lagazzi
- From the Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery (E.L., D.A., A.d.R., J.A.P.-Z., M.A., W.R., G.C.V., J.O.H., C.N.P.), Massachusetts General Hospital, Boston, MA; Department of Surgery (E.L.), Humanitas Research Hospital, Rozzano MI, Italy; and Division of Trauma & Emergency Surgery, Department of Surgery (A.-S.C.R.), Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Tarrant S, Poon J, Sanders D, Buckley R. Is rib plating for a significant chest injury worthwhile? Injury 2023; 54:111000. [PMID: 37597468 DOI: 10.1016/j.injury.2023.111000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
- Seth Tarrant
- Dept. of Traumatology, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Center 2310, Newcastle, NSW, Australia
| | - Jeff Poon
- London Health Science Center, Victoria Hospital Room E1-326, 800 Commissioners Rd E. London, N6A 5W9 Ontario, Canada
| | - Dave Sanders
- London Health Science Center, Victoria Hospital Room E1-326, 800 Commissioners Rd E. London, N6A 5W9 Ontario, Canada
| | - Richard Buckley
- University of Calgary, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW Calgary T2N 5A1, Alberta, Canada.
| |
Collapse
|
13
|
Lagazzi E, de Roulet A, Proaño-Zamudio JA, Argandykov D, Romijn AS, Abiad M, Rafaqat W, Hwabejire JO, Velmahos GC, Paranjape C. Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis. J Trauma Acute Care Surg 2023; 94:823-830. [PMID: 37079864 DOI: 10.1097/ta.0000000000003954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
|
14
|
Choi J, Badrinathan A, Shine R, Benz C, Toia A, Crown T, Whitbeck SA, Kryskow M, White T, Kirsch J. Challenges in closing the gap between evidence and practice: International survey of institutional surgical stabilization of rib fractures guidelines. J Trauma Acute Care Surg 2023; 94:562-566. [PMID: 36149855 DOI: 10.1097/ta.0000000000003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) has gained increasing interest over the past decade, yet few candidates who could benefit from SSRF undergo operative management. We conducted an international survey of institutional SSRF guidelines comparing congruence between practice and contemporary evidence. We hypothesized that few guidelines reflect comprehensive evidence to facilitate standardized patient selection, operation, and postoperative management. METHODS A request for institutional rib fracture guidelines was distributed from the Chest Wall Injury Society. Surgical stabilization of rib fractures-specific guideline contents were extracted using a priori-designed extraction sheets and compared against 28 SSRF evidence-based recommendations outlined by a panel of 14 international experts. Fisher's exact test compared the proportion of strong and weak evidence-based recommendations specified within a majority of institutional guidelines to evaluate whether strength of evidence is associated with implementation. RESULTS A total of 36 institutions from 3 countries submitted institutional rib fracture management guidelines, among which 30 had SSRF-specific guidance. Twenty-eight guidelines (93%) listed at least one injury pattern criteria as an indication for SSRF, while 22 (73%) listed pain and 21 (70%) listed impaired respiratory function as other indications. Quantitative pain and respiratory function impairment thresholds that warrant SSRF varied across institutions. Few guidelines specified nonacute indications for SSRF or perioperative considerations. Seven guidelines (23%) detailed postoperative management but recommended timing and interval for follow-up varied. Overall, only 3 of the 28 evidence-based SSRF recommendations were specified within a majority of institutional practice guidelines. There was no statistically significant association ( p = 0.99) between the strength of recommendation and implementation within institutional guidelines. CONCLUSION Institutional SSRF guidelines do not reflect the totality of evidence available in contemporary literature. Guidelines are especially important for emerging interventions to ensure standardized care delivery and minimize low-value care. Consensus effort is needed to facilitate adoption and dissemination of evidence-based SSRF practices. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
Affiliation(s)
- Jeff Choi
- From the Department of Surgery (J.C.), Stanford University, Stanford, California; Department of Surgery (A.B.), The Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Surgery (R.S.), The University of Texas Rio Grande Valley, Edinburg, Texas; Department of Cardiovascular and Thoracic Surgery (C.B.), The University of Texas Medical Branch at Galveston, Galveston, Texas; Department of Surgery (T.C.), Menorah Medical Center, Overland Park, KS; Department of Surgery (A.T., M.K.), Berkshire Health Systems, Pittsfield, Massachusetts; Chest Wall Injury Society (S.A.W.), Salt Lake City, Utah; Department of Surgery (T.W.), Intermountain Healthcare, Salt Lake City, Utah; and Department of Surgery (J.K.), Westchester Medical Center, Valhalla, New York
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Abidali M, Bauer F, Faliks B, Najafi K. Chest wall stabilization in a patient with severe TBI: A case report. Int J Surg Case Rep 2023; 105:108095. [PMID: 37023689 PMCID: PMC10106488 DOI: 10.1016/j.ijscr.2023.108095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Flail chest is a serious complication that may arise secondary to thoracic trauma and is associated with increased morbidity and mortality. In a flail chest, paradoxical chest movement decreases the functional residual capacity, leading to hypoxia, hypercapnia, and atelectasis. Adequate ventilation, fluid and pain management have classically been the cornerstones to flail chest treatment, with operative fixation being utilized in specific cases. Traumatic brain injury (TBI) has historically been believed to be an absolute contraindication for surgical fixation of rib fractures (SSRF); however, emerging studies have shown a favorable prognosis in select patients who underwent SSRF with severe TBI (Glasgow Coma Scale ≤8). CASE PRESENTATION A 66-year-old male was brought into the Emergency Department by EMS following a traumatic injury that resulted in multiple rib fractures, spinal fractures, and traumatic brain injury. On hospital day 3, the patient underwent SSRF to repair bilateral flail chest. SSRF stabilized cardiopulmonary physiology, improving this patient's hospital course and avoiding the need for a tracheostomy. Herein, we report the successful use of SSRF in a flail chest patient with severe TBI that improved outcomes without evidence of secondary brain injury. CLINICAL DISCUSSION TBI is a severe condition that often presents with other injuries. Chest wall injuries (CWI) with concurrent TBI remain a significant challenge for clinicians as one set of injuries may exacerbate the other [10]. Through respiratory physiology and predisposition to pneumonia, CWI may lead to prolonged cerebral hypoxia resulting in secondary brain injury-worsening severe TBI. SSRF improves outcomes in polytrauma patients exhibiting CWI with TBI. CONCLUSION Surgical management of rib fractures has an essential role in select patients with severe TBI. Further research is warranted to improve our understanding of the complex interplay between the physiology of respiratory mechanics and the neurologic system in the trauma population suffering from TBI.
Collapse
|