Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009;33:14-22. [PMID: 18949513 DOI: 10.1007/s00268-008-9770-y]

Operative Treatment of Flail Chest Injuries Does Not Reduce Pain or In-Hospital Opioid Requirements: Results from a Multicenter Randomized Controlled Trial

BACKGROUND

A previous randomized controlled trial (RCT) evaluating operative versus nonoperative treatment of acute flail chest injuries revealed more ventilator-free days in operatively treated patients who had been ventilated at the time of randomization. It has been suggested that surgery for these injuries may also improve a patient's pain and function. Our goal was to perform a secondary analysis of the previous RCT to evaluate pain and postinjury opioid requirements in patients with operatively and nonoperatively treated unstable chest wall injuries.

METHODS

We analyzed data from a previous multicenter RCT that had been conducted from 2011 to 2019. Patients who had sustained acute, unstable chest wall injuries were randomized to operative or nonoperative treatment. In-hospital pain medication logs were evaluated, and daily morphine milligram equivalents (MMEs) were calculated. The patients' symptoms were also assessed, including generalized pain, chest wall pain, chest wall tightness, and shortness of breath. Additionally, patients completed the 36-Item Short Form Health Survey (SF-36), and they were followed for 1 year postinjury.

RESULTS

In the original trial, 207 patients were analyzed: 99 patients received nonoperative treatment, and 108 received operative treatment. There were no significant differences in pain medication usage between the 2 groups at any of the examined time points (p = 0.477). There were no significant differences in generalized pain, chest wall pain, chest wall tightness, or shortness of breath at any time postinjury in the 2 groups. There were also no significant differences in the SF-36 scores.

CONCLUSIONS

This secondary analysis of a previous RCT suggested that operative treatment of patients with flail chest injuries does not reduce in-hospital daily opioid requirements. There were also no reductions in generalized pain, chest wall pain, chest wall tightness, or shortness of breath with operative treatment. The SF-36 scores were similar for both groups. Further work is needed to identify those patients most likely to benefit from operative treatment of flail chest injuries.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

To fix or let them flail: the who, what and when of rib fixation

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.

Risk factors associated with medium- to long-term outcome and health-related quality of life of patients with conservatively treated rib fractures

Patients with rib fractures often suffer from prolonged pain and dyspnea. The purpose of this study was to evaluate the mid- and long-term outcomes and major predisposing risk factors for clinical limitations such as pain or reduced lung capacity in patients with conservatively managed rib fractures to provide a basis for optimizing current therapy. Patients who underwent conservative management of rib fractures between 2014 and 2018 at a level I trauma center were retrospectively reviewed. Inclusion criteria were Injury Severity Score (ISS) ≤ 16 points and a minimum follow-up of 3 years. Outcome parameters were the SF-36 physical and mental component summary score (PCS and MCS, respectively) as well as current pain and respiratory problems. Risk factors evaluated included age, body mass index (BMI), in-hospital days, number of rib fractures, fracture dislocation and serial rib fracture. PCS was comparable to the normal population. The correlation between age and PCS was significant, p = .002. BMI correlated significantly with PCS, p < .001, current pain, p = .034 and respiratory problems, p = .029. No significant correlations were observed for the number of rib fractures and in-hospital days. Fracture dislocation and serial rib fracture showed no effect on PCS, p = .134 and p = .914, respectively, and current pain, p = .916 and p = .357, respectively. In the medium- to long-term, conservative treatment of simple rib fractures or serial rib fractures showed good results, but was negatively affected by a high patient age or BMI.

The distribution of lateral rib fractures: a validation and further development of the AO/OTA classification system in patients with fractures at the rib shaft

INTRODUCTION

Rib fractures are prevalent and clinically significant injuries, often associated with thoracic trauma. Despite their frequency, the precise distribution and characteristics of rib shaft fractures remain underexplored. This study investigates the distribution, location, and classification of lateral rib fractures using the AO/OTA classification, focusing on fracture patterns and the relationship to neighbored ribs.

METHODS

The study retrospectively analyzed 116 patients with 617 isolated rib fractures treated at a Level 1 trauma center over seven years. Using CT scans, fractures between the tubercle and osteochondral junction of the rib shaft were examined. Fracture type, dislocation, and location were categorized according to AO standards. The 116 patients underwent detailed statistical analysis to identify distribution patterns and correlations between fracture characteristics.

RESULTS

The fractures predominantly occurred between the fifth and seventh ribs, with a focus in the anterolateral to lateral region (40°-69°). Type A fractures were more anteriorly located, while type B fractures and dislocations shifted posteriorly. A regression analysis confirmed the significance of fracture type and dislocation in determining fracture position. Moreover, fractures showed clustering patterns, with adjacent ribs more likely to be injured. A caudal shift in fracture density and localization from the cranial to the caudal thorax was also observed.

DISCUSSION AND CONCLUSION

The findings validate the AO/OTA classification for rib fractures, highlighting the need for refined subsegmental divisions within the rib shaft for more precise clinical application. The study underscores the relationship between fracture location, type, and associated injuries, advocating for multicenter studies and a comprehensive classification system for thoracic trauma. This could enhance our understanding of injury patterns and inform treatment strategies.

Clinical outcome analysis for surgical fixation versus conservative treatment on rib fractures: a systematic evaluation and meta-analysis

BACKGROUND

The efficacy of surgical intervention for traumatic rib fractures in improving clinical outcomes remains a subject of considerable debate. Over the past decade, the adoption of surgical stabilization for rib fractures (SSRF) has increased substantially. This study presents a systematic review and meta-analysis of the literature published over the past 20 years, with the objective of comparing the clinical outcomes of adult patients with multiple traumatic rib fractures who underwent SSRF, relative to those treated conservatively.

METHODS

We searched six online databases (PubMed, Web of Science, Embase, Cochrane Library, and the Sino-American Clinical Trials Database) for literature published between June 2004 and June 2024. The Cochrane Collaboration Risk of Bias 2 (RoB 2) and the Newcastle-Ottawa Scale (NOS) tool were employed to assess methodological quality, and relative risks (RR) with 95% confidence intervals (CI) were calculated to evaluate the outcome measures. The primary outcome was all-cause mortality, while the secondary outcomes included hospital length of stay (HLOS), ICU length of stay (ILOS), duration of mechanical ventilation (DMV), and the incidence of pneumonia. Subgroup analyses were performed to assess the effects of fracture type, age, timing of surgical fixation, and study design on treatment outcomes.

RESULTS

A total of 47 studies involving 1,078,795 patients were included, consisting of three randomized controlled trials and 44 case-control studies. The results demonstrated that patients who underwent SSRF experienced better outcomes than those receiving conservative treatment in terms of all-cause mortality. However, SSRF was not superior to conservative treatment regarding HLOS, ILOS, or health care costs. Subgroup analyses revealed that the SSRF group had a lower incidence of pneumonia and shorter DMV in patients with flail chest, and patients older than 60 years may also benefit from SSRF, Furthermore, those who underwent SSRF within 72 h had shorter HLOS and DMV compared to those treated conservatively.

CONCLUSION

SSRF reduces mortality in patients with multiple rib fractures compared to conservative management, particularly in those with flail chest and in patients over 60 years of age. It also offers benefits in terms of pneumonia incidence and DMV for patients with flail chest. Early SSRF may significantly reduce HLOS and DMV. However, careful screening of appropriate candidates is crucial to maximize the benefits of SSRF.

An early analysis of polyetheretherketone (PEEK) plates for the surgical stabilization of rib fractures: A pilot study

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is a viable treatment option for rib fracture patients. Polyetheretherketone (PEEK) plates have become available for SSRF. The objective of this pilot study was to examine the use of PEEK plates for SSRF.

METHODS

A prospective, observational, multi-center study of patients undergoing SSRF with PEEK plates from 4/23 through 2/24. Standard indications for SSRF were followed and the decision to use PEEK plates was left to the discretion of the treating surgeon. Basic demographics were obtained. Outcomes included the number of rib fractures stabilized with PEEK plates, complications related to SSRF, and 6-month follow-up with chest computed tomography (CT) to assess healing of PEEK repaired fracture sites, identified as complete or incomplete union. Patients also answered a five-question quality-of-life survey regarding mobility, self-care, usual activities, chest pain/discomfort, and anxiety/depression. Answers were scaled 1 to 5 (1=worse condition possible; 5=best possible condition). Patients rated their health on a scale of 0 to 100 (100=closet to their health preinjury). All data was reported as descriptive.

RESULTS

Forty-six patients were included. Average age was 57(±16) years; 82.6 % were male. Median ISS was 18 (IQR 14,29) and median chest-AIS was 4 (IQR 3,4). 219 rib fractures were stabilized with PEEK plates. Sixteen (34.8 %) had a combination (PEEK + titanium) procedure. Three patients had a complication: one required a second surgery for additional SSRF, and two patients were readmitted. Twenty-seven patients were surveyed at 6 months, and 19 agreed to CT scan. Eighty PEEK repaired rib fractures were assessed for healing. 80 % of fractures had complete union and no hardware failure. Quality-of-life survey averaged >4.5/category and mean overall health was 89.

CONCLUSION

PEEK plates for SSRF are safe and effective, allowing for adequate rib fracture healing and are associated with positive patient reported outcomes.

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

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.

Therapeutic efficacy of platelet-rich plasma in the management of rib fractures

BACKGROUND

This study aimed to investigate the therapeutic efficacy of platelet-rich plasma (PRP) therapy in patients with rib fractures.

METHODS

This study retrospectively collected data from patients with acute rib fractures at Ming-Sheng General Hospital from 2020 to 2022 and excluded those who underwent surgical intervention or with severe extrathoracic injuries. PRP was extracted using the patient's blood and injected via ultrasound guidance near the fracture site. Patients self-assessed pain levels and medication usage at 0, 1, 2, 4, and 8 weeks. Pulmonary function tests were conducted at 4 weeks.

RESULTS

This study included 255 patients, with 160 and 95 patients in the conservative (only pain medications administered) and PRP groups (PRP and analgesics administered), respectively. The PRP group reported lower pain levels than the conservative group at 2 and 4 weeks. No substantial differences in medication usage were observed between the groups. The PRP group demonstrated lower pain levels and medication usage than the conservative group in severe rib fractures (≥3 ribs) and better lung function improvement at 4 weeks. After propensity score matching, the PRP group still had a better treatment outcome in pain control and lung function recovery.

CONCLUSION

PRP demonstrated considerable therapeutic efficacy in patients with severe rib fractures, resulting in reduced pain, decreased medication usage, and improved lung function but with no substantial benefits in patients with mild rib fractures.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Fixation devices made of poly-L-lactide composite for rib reconstruction after thoracotomy

GRAND FIX mesh-type plates and pins (Gunze, Kyoto, Japan) are thin, bioabsorbable fixation devices made of poly-L-lactide (PLLA) composite. These devices are new, and how best to use them in clinical practice remains to be determined. Thus, we describe our approach to rib fixation after thoracotomy in an aortic surgery using GRAND FIX mesh-type plates and pins. The advantage of our approach is that it is easy to perform, but careful attention should be paid to fix the ribs appropriately.

Comparative Analysis of Intravenous Opioids Versus Thoracic Epidural Anesthesia in Fractured Rib Pain Management: A Systematic Review and Meta-Analysis

Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic epidural analgesia (TEA) being utilized. While epidural analgesia is often preferred for fractured rib pain, existing data encompasses both lumbar and thoracic approaches. This review aimed to compare TEA and IV opioids for persistent rib fracture pain. A comprehensive search across five databases yielded 987 articles, of which seven met the eligibility criteria. Outcomes were categorized into primary (pain reduction) and secondary (mortality, hospital/ICU stays, analgesia-related complications) endpoints. Analyzed with Review Manager (RevMan) Version 5.4.1 (2020; The Cochrane Collaboration, London, United Kingdom), the pooled data from two sources showed TEA significantly more effective in reducing pain than IV opioids (standardized mean difference (SMD): 2.23; 95%CI: 1.65-2.82; p < 0.00001). Similarly, TEA was associated with shorter ICU stays (SMD: 0.73; 95%CI: 0.33-1.13; p = 0.0004), while hospitalization duration showed no substantial difference (SMD: 0.82; 95%CI: -0.34-1.98). Mortality rates also did not significantly differ between TEA and IV opioids (risk ratio (RR): 1.20; 95%CI: 0.36-4.01; p = 0.77). Subgroup analysis revealed fewer pneumonia cases with TEA (RR: 2.06; 95%CI: 1.07-3.96; P = 0.03), with no notable disparities in other complications. While TEA's superiority in pain relief for rib fractures suggests it is the preferred analgesic, the recommendation's strength is tempered by the low methodological quality of supporting articles.

Use of robotic C-arm cone-beam computed tomography in surgical stabilization of rib fractures

INTRODUCTION

The effectiveness of using intraoperative robotic C-arm cone-beam computerized tomography (CT) to locate rib fractures during surgery was compared to using pre-operative CT.

METHODS

Patients diagnosed with multiple rib fracture and treated surgically in the hospital between January 2019 and September 2020 were included. The study included two groups of patients. One group had their rib fractures identified using pre-operative CT, while the other group had their fractures localized using intraoperative cone-beam CT during surgery. The operative time, blood loss, number of incisions, length of incision, duration of chest drains, visual analogue scale (VAS) score, and duration of post-operation stays were measured.

RESULTS

A total of 12 patients received intraoperative cone-beam CT, while the remaining 18 patients only received pre-operative CT. Statistical analysis showed that the group treated with cone-beam CT had lower blood loss (p = 0.012), shorter incisions (p = 0.005), and better post-operation VAS scores (p = 0.027). There were also non-significant trends towards fewer incisions, shorter operation times, and shorter duration of chest drains in the group treated with cone-beam CT.

CONCLUSIONS

Intraoperative localization of rib fracture sites with cone-beam CT is an effective method for rib fracture stabilization.

Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis

Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.

Comparison between non-surgical and surgical management of rib fractures in major trauma patients without brain injuries

BACKGROUND

This study aimed to evaluate the different outcomes between the non-surgical and surgical groups in patients with major trauma without brain injuries.

METHODS

This study prospectively collected data from patients with traumatic rib fractures without brain injuries from June 2017 to November 2019. The primary outcomes were the pain score at admission and discharge and the length of hospital stay. We performed multiple regression analysis to compare the outcomes and surgical risk as the severity of chest trauma between both groups.

RESULTS

Fifty-three patients were enrolled. There was no statistically significant difference in baseline characteristics between both groups. However, the surgical group had more severe chest trauma than the non-surgical group. After the analysis, the pain score improved significantly in the surgical group. The hospital stay of the surgical group was four days shorter than that of the non-surgical group, and there was severe chest trauma in the surgical group.

CONCLUSIONS

Surgical management of rib fractures can reduce pain and hospital stay in major trauma patients.

Open Reduction and Internal Fixation of a Chronic Precordial Flail Chest Segment: A Case Report

CASE

We report on a 35-year-old man presenting with disabling pain secondary to multiple rib nonunions and a costochondral dislocation 5 months after sustaining a chest wall crush injury. He underwent surgical reconstruction of the chest and was followed for 2 years. Surgical exposure to the heart was necessary during open reduction of the flail segment, followed by costochondral joint fixation with plates and screws. Although he was a workers' compensation patient, he returned to full gainful employment.

CONCLUSION

Open reduction and internal fixation of a symptomatic, chronically displaced, precordial, flail segment can relieve pain and promote return to baseline function.

Identifying predictive factors for mortality in patients with TBI at a neurosurgery department

Traumatic brain injury (TBI) can have severe consequences in most cases. Many therapeutic and neurosurgical strategies have been improved to optimize patient outcomes. However, despite adequate surgery and intensive care, death can still occur during hospitalization. TBI often results in protracted hospital stays in neurosurgery departments, indicating the severity of brain injury. Several factors related to TBI are predictive of longer hospital stays and in-hospital mortality rates. This study aimed to identify predictive factors for intrahospital days of death due to TBI. This was a longitudinal, retrospective, analytical, observational study that included 70 TBI-related deaths admitted to the Neurosurgery Clinic in Cluj-Napoca for a period of four years (January 2017 to December 2021) using a cohort model. We identified some clinical data related to intrahospital death after TBI. The severity of TBI was classified as mild (n=9), moderate(n=13), and severe (n=48) and was associated with significantly fewer hospital days (p=0.009). Patients with associated trauma, such as vertebro-medullary or thoracic trauma, were more likely to die after a few days of hospitalization (p=0.007). Surgery applied in TBI was associated with a higher median number of days until death compared to conservative treatment. A low GCS was an independent predictive factor for early intrahospital mortality in patients with TBI. In conclusion, clinical factors such as the severity of injury, low GCS, and polytrauma are predictive of early intrahospital mortality. Surgery was associated with prolonged hospitalization.

Surgical stabilization of rib fractures in patients with pulmonary comorbidities

INTRODUCTION

Prior studies have shown that the surgical stabilization of rib fractures (SSRF) for patients with multiple rib fractures is associated with improved outcomes by restoring chest wall integrity and decreasing time to return to prior functional status. It is unclear if patients with pulmonary comorbidities (PCM) would benefit from this procedure.

OBJECTIVE

To compare the difference in morbidity and mortality of patients with multiple rib fractures undergoing SSRF who have underlying PCM to those who do not have PCM.

METHODS

We performed a retrospective cohort study of patients with multiple rib fractures using data from the Trauma Quality Improvement Program (January 2015 to December 2018). Patients with penetrating injuries, those who died within the first 24 h, those with substantial head, spine, or abdominopelvic injuries, and those who were pregnant, were excluded. A PCM was defined as chronic lower respiratory disease, active smoking, or morbid obesity. Dichotomous outcomes were adjusted for potential confounders by creating a propensity score for PCM and applying inverse probability weighting. The propensity score accounted for multiple patient-level and hospital level covariates. Continuous outcomes were adjusted for these same covariates using multivariable quantile regression.

RESULTS

Of the 4,084 patients who underwent SSRF, 3048 (75%) were males, the median age was 57 years [IQR 47, 66], and 1504 (37%) had at least one PCM. After adjusting for the propensity score, patients with PCM who underwent SSRF had no significant difference in mortality compared to those without PCM (absolute difference, 0.7% [95% CI -0.2, 1.7]). Similarly, there was no significant difference in time on the ventilator (0.6 days [-0.1, 1.4]). Patients with PCM, however, had a statistically significantly longer hospital LOS (0.8 days [0.3, 1.3]) and ICU LOS (0.6 days [0.1, 1.1]), higher risk of tracheostomy (2.7% [0.1, 4.6]) and higher probability of pulmonary complications (2.7% [1.2, 4.2]), compared to those without PCM.

CONCLUSION

Among patients with multiple rib fractures who undergo SSRF, having a PCM did not result in a clinically important higher probability of dying or experiencing substantial morbidity. This factor should not exclude patients with PCM from receiving SSRF for multiple rib fractures but the small increased risk in morbidity should be discussed with patients prior to SSRF.

Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial

Importance

Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking.

Objective

To compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management.

Design, Setting, and Participants

This was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non-flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021.

Interventions

Patients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment.

Main Outcomes and Measures

The primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy).

Results

A total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, -0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment.

Conclusions and Relevance

The findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated.

Trial Registration

ClinicalTrials.gov Identifier: NCT01367951.

Postoperative submuscular emphysema due to air leakage from the residual screw holes after plate removal in a patient who had undergone surgical stabilization of flail chest

Many studies have reported indications and complications of surgical stabilization of rib fractures. However, data about the postoperative complications after the removal of the plates are still lacking. The author reports a rare complication after plate removal, postoperative submuscular emphysema, due to air leakage from the residual screw hole. A 68-year-old male with a flail chest was successfully treated by surgical rib fixation. A few months later, the patient wanted his implants removed due to chest irritation. The removal operation was completed, and postoperative courses were not unusual. However, a large amount of submuscular emphysema was found in the follow-up period. The patient was successfully managed by applying a submuscular thoracic drainage catheter. Although postoperative subcutaneous emphysema due to residual screw holes after plate removal is rare, we need to pay more attention when selecting the proper length of screws during surgical rib fixation.

The Surgical Timing and Complications of Rib Fixation for Rib Fractures in Geriatric Patients

Rib fractures (RF) are a common injury that cause significant morbidity and mortality, especially in geriatric patients. RF fixation could shorten hospital stay and improve survival. The aim of this retrospective study was to evaluate the clinical impact and proper surgical timing of RF fixation in geriatric patients. We reviewed all the medical data of patients older than 16 years old with RF from the trauma registry database between January 2017 and December 2019 in Chang Gung Memorial Hospital. A total of 1078 patients with RF were enrolled, and 87 patients received RF fixation. The geriatric patients had a higher chest abbreviated injury scale than the non-geriatric group (p = 0.037). Univariate analysis showed that the RF fixation complication rates were significantly related to the injury severity scores (Odds ratio 1.10, 95% CI 1.03–1.20, p = 0.009) but not associated with age (OR 0.99, 95% CI 0.25–3.33, p = 0.988) or the surgical timing (OR 2.94, 95% CI 0.77–12.68, p = 0.122). Multivariate analysis proved that only bilateral RF was an independent risk factor of complications (OR 6.60, 95% CI 1.38–35.54, p = 0.02). RF fixation can be postponed for geriatric patients after they are stabilized and other lethal traumatic injuries are managed as a priority.

The History of Surgical Stabilization of Rib Fractures (SSRF)

Responsible for approximately 35% of all trauma-related deaths in the United States, thoracic trauma is one of the leading causes of death among trauma patients. Furthermore, traumatic rib fractures represent the most frequently encountered injury following thoracic trauma with mortality rates ranging from 8% among the elderly to 13% for patients with a flail chest. This manuscript reviews the history of SSRF as well as the contributions of the pioneering surgeons who championed this treatment. Rib fractures are a marker for severe injury as indicated by a recent National Trauma Data Bank (NTDB) retrospective analysis of 564,798 patients with one or more rib fractures. Approximately half of these patients were found to have multiple injuries with worse outcomes observed in patients with polytrauma and flail chest [1]. In addition, age, male gender, injury severity score (ISS), Glasgow Coma Scale (GCS), preexistent comorbidities, and number of rib fractures are independently associated with significantly higher rates of morbidity and mortality [1, 2]. Recently, studies have demonstrated surgical stabilization of rib fractures (SSRF) improves outcomes for ventilated as well as non-ventilated patients with flail chest, elderly patients, and select patients with multiple rib fractures without a flail injury or non-flail fracture pattern [2-6]. SSRF applies orthopedic principles of reduction and fixation to restore the architecture of the thoracic skeleton and re-establish normal respiratory physiology and minimize pain [7]. There has been a recent increase in prevalence of SSRF operations, however, SSRF is not a new technique, and progress has been anything but mundane or linear [3, 6]. This manuscript reviews the history of SSRF (Figure 1) as well as the contributions of the pioneering surgeons who championed this treatment. This review was conducted utilizing multiple national experts and a thorough literature review of related SSRF was performed. The sources chosen are considered by the authors to be highly influential and include the first publication for each distinctive method of SSRF.

Rib fracture management: A review of surgical stabilization, regional analgesia, and intercostal nerve cryoablation

Rib fractures still remain a common problem in blunt thoracic trauma, often resulting significant acute and/or chronic morbidity and mortality. The management of rib fractures has improved over the past two decades, resulting in overall improved patient outcomes. With advances in surgical stabilization of rib fractures (SSRF), improvements in regional analgesia, and the introduction of intercostal nerve cryoablation, patient outcomes from rib fractures have improved significantly over the past several years. This article explores the indications and technique for SSRF as well as discusses additional therapeutic modalities for rib fractures through regional anesthesia and intercostal nerve cryoablation.

Is it Necessary to Stabilize Every Fracture in Patients with Serial Rib Fractures in Blunt Force Trauma?

Introduction

Management of traumatic rib fractures is subject of controversial discussions. Rib fractures are common, especially after traffic accidents and falls. There is no consensus on whether and how many rib fractures need reconstruction. Not every rib fracture needs to be stabilized, but conservative treatment by internal splinting and analgesia is not effective for all patients. Deformities of the chest wall with reduced thoracic volume and restrictive ventilation disorders must be avoided. Intraoperative assessment of fractures and chest stability plays a central role.

Material and methods

From 07/2016 to 07/2021, a total of 121 chest wall stabilizations were performed (m:f = 2:1, age 65 ± 14.5 a). Indications for surgery were the following criteria: (1) palpatory instability of the chest wall, (2) dislocated fracture endings, (3) concomitant injuries, (4) uncontrollable pain symptoms. In all patients, a computed tomography scan of the thorax was performed before the osteosynthetic treatment to assess dislocation of the fracture endings and possible concomitant injuries of intrathoracic organs.

Results

Video-assisted thoracoscopy was performed in all patients. Hemothorax and concomitant injuries of the lung, diaphragm and mediastinum could be assessed. This was followed by an intraoperative assessment of the rib fractures, in particular penetration of fracture endings and resulting instability and deformity. Relevant fractures could be identified and subsequent incisions for rib osteosynthesis precisely defined. 6.3 (±2.7) rib fractures were detected, but 2.4 (±1.2) ribs treated osteosynthetically. Bilateral rib fractures were present in 26 patients (21.5%). Post-operative bleeding occurred in seven patients (5.8%), a breakage of the osteosynthetic material in two patients (1.7%).

Discussion

Intraoperative assessment of relevant fractures and dislocation is the decisive criterium for osteosynthesis. Thoracoscopy is mandatory for this purpose - also to identify accompanying injuries. Not every fracture has to be approached osteosynthetically. Even with serial rib fractures or multiple fractures in a single rib, the thoracic contour can be restored by stabilizing only relevant fractures. Intraoperative palpation can adequately assess the stability and thus the result of the osteosynthesis. Even after surgical treatment of thoracic trauma, adequate analgesia and respiratory therapy are important to the healing process.

Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma—A Matched-Pairs Analysis of the German Trauma Registry

Purpose

In severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay.

Methods

Data from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS)  ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3–10 days after trauma.

Results

After the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226).

Conclusions

We were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.

Segmentation Performance Comparison Considering Regional Characteristics in Chest X-ray Using Deep Learning

Chest radiography is one of the most widely used diagnostic methods in hospitals, but it is difficult to read clearly because several human organ tissues and bones overlap. Therefore, various image processing and rib segmentation methods have been proposed to focus on the desired target. However, it is challenging to segment ribs elaborately using deep learning because they cannot reflect the characteristics of each region. Identifying which region has specific characteristics vulnerable to deep learning is an essential indicator of developing segmentation methods in medical imaging. Therefore, it is necessary to compare the deep learning performance differences based on regional characteristics. This study compares the differences in deep learning performance based on the rib region to verify whether deep learning reflects the characteristics of each part and to demonstrate why this regional performance difference has occurred. We utilized 195 normal chest X-ray datasets with data augmentation for learning and 5-fold cross-validation. To compare segmentation performance, the rib image was divided vertically and horizontally based on the spine, clavicle, heart, and lower organs, which are characteristic indicators of the baseline chest X-ray. Resultingly, we found that the deep learning model showed a 6-7% difference in the segmentation performance depending on the regional characteristics of the rib. We verified that the performance differences in each region cannot be ignored. This study will enable a more precise segmentation of the ribs and the development of practical deep learning algorithms.

Improved Fixation Stability of a Dedicated Rib Fixation System in Flail Chest: A Retrospective Study

Background and Objectives: Flail chest typically results from major trauma to the thoracic cage and is accompanied by multiple rib fractures. It has been well documented that surgical fixation of rib fractures can decrease both morbidity and mortality rates. This study aimed to evaluate the effectiveness of a dedicated APS Rib Fixation System, which features a pre-contoured design based on anatomical rib data of the Asian population. Materials and Methods: We reviewed 43 consecutive patients, who underwent surgical stabilization for flail chest with the traditional Mini bone plate (n = 20), APS plate (n = 13), or Mini + APS (n = 10). Demographic and injury variables were documented. We used X-ray radiography to determine plate fractures and screw dislocations after surgical fixation. Results: No statistical differences were noted in the demographic or injury variables. APS plates demonstrated fewer cases of plate fractures and screw dislocations than Mini plates (OR = 0.091, p = 0.008). Conclusions: The pre-contoured design of the APS plate demonstrated a superior rib implant failure rate as compared to the traditional Mini bone plate. Our study indicates that the APS plate may serve as an effective surgical tool for the treatment of flail chest.

Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®

Purpose

In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay.

Methods

Data from the TraumaRegister DGU^® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability.

Results

In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h.

Conclusions

In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

Chest Wall Reconstruction for the Treatment of Lung Herniation and Respiratory Failure 1 Month after Emergency Thoracotomy in a Patient with Traumatic Flail Chest

We report a case of delayed chest wall reconstruction after thoracotomy. A 53-year-old female, a victim of a motor vehicle accident, presented with bilateral multiple rib fractures with flail motion and multiple extrathoracic injuries. Whole-body computed tomography revealed multiple fractures of the bilateral ribs, clavicle, and scapula, and bilateral hemopneumothorax with severe lung contusions. Active hemorrhage was also found in the anterior pelvis, which was treated by angioembolization. The patient was transferred to the surgical intensive care unit for follow-up. We planned to perform surgical stabilization of rib fractures (SSRF) because her lung condition did not seem favorable for general anesthesia. Within a few hours, however, massive hemorrhage (presumably due to coagulopathy) drained through the thoracic drainage catheter. We performed an exploratory thoracotomy in the operating room. We initially planned to perform exploratory thoracotomy and “on the way out” SSRF. In the operating room, the hemorrhage was controlled; however, her condition deteriorated and SSRF could not be completed. SSRF was completed after about a month owing to other medical conditions, and the patient was weaned successfully.

Pediatric surgical rib fixation: A collected case series of a rare entity

BACKGROUND

Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data.

METHODS

Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up.

RESULTS

Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months.

CONCLUSION

Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma.

LEVEL OF EVIDENCE

Collected case series, level V.

What is the optimal timing to perform surgical stabilization of rib fractures?

The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.

Abdominal flank bulge following intercostal neurectomy for symptomatic rib fracture nonunion

The gold standard for rib fracture nonunion management remains a matter of debate. Operative treatment of rib fracture nonunion has become increasingly popular. A 69-year-old man was operatively treated with intercostal neurectomy of the left eighth rib to resolve chronic thoracic pain following a rib fracture nonunion. After the intervention, the patient developed a flank bulge which was most likely due to the intercostal neurectomy, causing partial denervation of the abdominal musculature. Although the pain at the nonunion site decreased after the operative intervention, the patient still experienced severe pain during daily activities and reported poor quality of life due to the flank bulge. Physiotherapy and an abdominal belt did not improve this flank bulge. When considering operative neurectomy of the intercostal nerves of ribs 7-12 to resolve chronic pain due to rib fracture nonunion, the treating surgeon should be aware of this debilitating complication.

Epidemiology of combined clavicle and rib fractures: a systematic review

Purpose

The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries.

Methods

A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14^th of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant–Murley score, union and complications.

Results

Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56–60.6% versus 29% in patients without clavicle fractures. Vice versa, 14–18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days).

Conclusion

Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01701-4.

Minimally invasive surgery rib fracture fixation based on location and anatomical landmarks

BACKGROUND

Rib fracture is closely related to thoracic injury with high morbidity and mortality. This study aimed to investigate the clinical effect of Zhang ZhiFei (ZZF) zoning method on the selection of incision and approach in minimally invasive surgery for rib fracture.

METHODS

A total of 110 patients with rib fractures from July 2017 to July 2019 were enrolled in the study. Preoperative computed tomography and three-dimensional reconstruction of ribs was performed. Then, the rib fractures to be surgically fixed were divided into costal cartilage zone, chest zone, lateral costal zone, high posterior costal zone, low posterior costal subscapular zone, and low posterior costal paraspinal zone, which was called ZZF zoning method. Rib fractures in each zone had unique minimally invasive incision approach, and the open reduction and internal fixation of rib fracture was performed under minimally invasive surgery of corresponding small incision.

RESULTS

The average incision length and number of incisions of the 110 patients were 6.2 cm and 1.3, respectively. The average number of internal fixation was 5.3 and the average operation time was 82 min. The postoperative fracture end was well aligned. After 3 months of follow-up, no internal fixation was displaced or detached.

CONCLUSION

Based on the anatomical characteristics of different zones of the chest wall, ZZF zoning method provides a new idea and reference for the selection of incision and approach in minimally invasive internal fixation for rib fracture.

Prosthetic-free ribs stabilization technique in critical complex chest wall traumas: first results and experiences

Background

Surgical stabilization in complex chest wall traumas, especially in case of posterior ribs arch destruction and flail chest, still remains a challenge for thoracic and trauma surgeons. Throughout the years different techniques and materials developed to address the complex anatomy of the ribs and reach an adequate fixation. Our aim is to present a prosthetic-free ribs stabilization technique which is easily reproducible and can achieve an efficient mechanical stabilization of the chest wall.

Methods

This surgical technique can be summarized in three steps: muscle sparing thoracotomy following modified “Shaw-Paulson’s” technique (complete section of the latissimus dorsi muscle along the transverse processes of vertebral spine to rich the serratus muscles plane), prosthetic-free ribs fixation with single stiches (Maxon™ 1) and muscles repositioning.

Results

Between January 2018 and June 2020, we retrospectively evaluated ten consecutive patients (six male and four female) which underwent a chest wall stabilization because of a posterior ribs destruction and flail chest. No chest wall deformities were observed during follow-up with CT-scan after 4, 30 and 90 days and no patient underwent additional early or late stabilization procedures.

Conclusions

In the case of severe thoracic trauma with chest wall destruction and flail chest, modified “Shaw-Paulson approach” and prosthetic-free fixation technique with Maxon thread should be considered as a valuable option allowing an adequate stabilization of the chest with optimal respiratory function.

Attention to detail: A dedicated rib fracture consultation service leads to earlier operation and improved clinical outcomes

BACKGROUND

Surgical stabilization of rib fractures (SSRF) has been correlated with improved outcomes, including decreased length of stay (LOS). We hypothesized that an SSRF consultation service would increase the frequency of SSRF and improve outcomes.

METHODS

A prospective observational study was performed to compare outcomes before and after implementing an SSRF service. Primary outcome was time from admission to surgery; secondary outcomes included LOS, mortality and morphine milligram equivalents (MME) prescribed at discharge.

RESULTS

1865 patients met consultation criteria and 128 patients underwent SSRF. Mortality decreased (6.3% vs. 3%) and patients were prescribed fewer MME at discharge (328 MME vs. 124 MME) following implementation. For the operative cohort, time from admission to surgery decreased by 1.72 days and ICU LOS decreased by 2.6 days.

CONCLUSION

Establishment of an SSRF service provides a mechanism to maximize capture and evaluation of operative candidates, provide earlier intervention, and improve patient outcomes. Additional study to determine which elements and techniques are most beneficial is warranted.

LEVEL OF EVIDENCE

III.

The Effects of Add-On Self-Care Therapy on Epidural Catheter Analgesia and Pain in Patients after Surgical Stabilization of Multiple Rib Fractures

BACKGROUND

Epidural (EPI) catheter analgesia is frequently prescribed as a regional analgesic technique to patients with multiple rib fractures (MRF) following surgical stabilization of rib fractures (SSRF).

AIMS

We aimed to study the effect of add-on self-care therapy on recovery and quality of life (QoL) in patients on EPI analgesia after surgical stabilization of rib fractures (SSRF).

DESIGN/SETTINGS/PARTICIPANTS/SUBJECTS

A total of 267 eligible patients with MRF who received EPI catheter analgesia after SSRF were recruited, and assigned to one of two groups in a random fashion: intervention group received education on self-care therapy, while the control group did not.

METHODS

Pain scores, incentive spirometry (IS) volumes, oxygen saturation (SpO2), respiratory rate, hospital length of stay (LoS) and QoL were evaluated.

RESULTS

Compared with control group, the intervention group showed significantly improved pain scores, IS volume, respiratory rate, and SpO2. Hospital LoS was shorter for the intervention group than the control group. Overall QoL scores in the intervention group were also significantly better than control patients.

CONCLUSIONS

Education on self-care therapy significantly benefited pain management, recovery, and QoL for patients with MRF who received EPI catheter analgesia after SSRF operation.

Assessing the analgesic efficacy of oral epigallocatechin-3-gallate on epidural catheter analgesia in patients after surgical stabilisation of multiple rib fractures: a prospective double-blind, placebo-controlled clinical trial

CONTEXT

Thoracic trauma results in multiple rib fractures (MRF), and surgical stabilisation of rib fractures (SSRF) can relieve fracture pain. Epigallocatechin-3-gallate (EGCG) is reported to exhibit beneficial effects in bone-related metabolic and differentiation processes.

OBJECTIVE

To study the clinical effect of EGCG on regional analgesia for pain relief in MRF patients after SSRF.

MATERIALS AND METHODS

Ninety-seven MRF patients (61 males, 36 females) who were on epidural catheter analgesia after SSRF were recruited. They were randomly divided into: oral EGCG 100 mg (oral grade) twice daily for 10 days and placebo groups. Pain scores, incentive spirometry (IS) volumes, respiratory rate and oxygen saturation (SpO₂) were assessed day 10 after SSRF.

RESULTS

Comparing results from the placebo and EGCG group, in the 10-day intervention course, oral EGCG reduced pain score (8 at base line vs. 4 at end of intervention in EGCG group, p < 0.05; 4 in EGCG group vs. 6 in placebo group at end of intervention, p < 0.05), improved IS volume (713 at base line vs. 1072 at end of intervention in EGCG group, p < 0.05; 1072 in EGCG group vs. 953 in placebo group at end of intervention, p < 0.05) and respiratory rate (24 at base line vs. 15 at end of intervention in EGCG group, p < 0.05; 15 in EGCG group vs. 19 in placebo group at end of intervention, p < 0.05). However, no further enhancing effect on SpO₂ was observed in the EGCG group (0.98 in EGCG group vs. 0.98 in placebo group at end of intervention, p > 0.05).

DISCUSSION AND CONCLUSIONS

Although the study is limited by a relatively small sample size and lack of serum factor analysis, the key results and the study design, for the first time, nevertheless pave the way for trials with larger number of patients to understand the effect of EGCG in MRF patients that are undergoing SSRF.

Operative versus nonoperative treatment of multiple simple rib fractures: A systematic review and meta-analysis

PURPOSE

Surgical rib stabilization in flail chest is proven to be beneficial over nonoperative treatment in terms of rate of pneumonia, Intensive Care (IC) length of stay (ICLOS) and mechanical ventilation days. The aim of this systematic review and meta-analysis was to evaluate the effect of operative versus nonoperative treatment on the occurrence of pneumonia and other relevant clinical outcomes in patients with multiple simple rib fractures.

METHODS

A search was performed in Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. The primary outcome was the occurrence of pneumonia. Secondary outcomes were duration of mechanical ventillation, ICLOS, hospital length of stay (HLOS), mortality, and wound infections. Publication bias was assessed using funnel plots for the outcome measures and random-effect models were used when heterogeneity of data on outcome measures was significant (I2≥40%).

RESULTS

The search resulted in 592 unique records, of which 14 studies on 13 cohorts were included. The 14 studies comprised five prospective and nine retrospective cohort studies with a cumulative total of 4565 patients. Meta-analysis showed a significant decrease of the occurrence of pneumonia (n=2659 patients; risk ratio, RR=0.66; 95% confidential interval [CI] 0.49 to 0.90; p=0.008), mortality (n=4456 patients; RR=0.32; 95% CI 0.19 to 0.54; p<0.001), and HLOS (n=648 patients; mean difference, MD=-5.78 days; 95% CI -10.40 to -1.15; p=0.01) in favor of operative treatment. No effect of operative treatment was found for the duration of mechanical ventilation (n=113 patients; MD=-6.01 days; 95% CI =-19.61 to 7.59; p=0.39), or ICLOS (n=524 patients; MD=-2.93 days; 95% CI -8.65 to 2.80; p=0.32). The postoperative wound infection rate ranged from 0 to 9.4%.

CONCLUSION

Surgical treatment of multiple simple rib fractures may result in a significant reduction of pneumonia, mortality, and hospital length of stay. A reducing effect of treatment on the duration of mechanical ventilation and IC length of stay, was not demonstrated. However, due to nonstandard or absent definitions of outcome measures as well as heterogenous patient groups and the observational design of studies, results must be interpreted with caution and high-quality studies are needed.

Quantifying the expense of deferring surgical stabilization of rib fractures: Operative management of rib fractures is associated with significantly lower charges

INTRODUCTION

Surgical stabilization of rib fractures (SSRF) remains a relatively controversial operation, which is often deferred because of concern about expense. The objective of this study was to determine the charges for SSRF versus medical management during index admission for rib fractures. We hypothesize that SSRF is associated with increased charge as compared with medical management.

METHODS

This is a retrospective chart review of a prospectively maintained database of patients with ≥3 displaced rib fractures admitted to a level 1 trauma center from 2010 to 2019. Patients who underwent SSRF (operative management [OM]) were compared with those managed medically (nonoperative management [NOM]). The total hospital charge between OM and NOM was compared with univariate analysis, followed by backward stepwise regression and mediation analysis.

RESULTS

Overall, 279 patients were included. The majority (75%) were male, the median age was 54 years, and the median Injury Severity Scale score (ISS) was 21. A total of 182 patients underwent OM, whereas 97 underwent NOM. Compared with NOM, OM patients had a lower ISS (18 vs. 22, p = 0.004), less traumatic brain injury (14% vs. 31%, p = 0.0006), shorter length of stay (10 vs. 14 days, p = 0.001), and decreased complications. After controlling for the differences between OM and NOM patients, OM was significantly associated with decreased charges (β = US $35,105, p = 0.01). Four other predictors, with management, explained 30% of the variance in charge (R = 0.30, p < 0.0001): scapular fracture (β = US $471,967, p < 0.0001), ISS per unit increase (β = US $4,139, p < 0.0001), long bone fracture (β = US $52,176, p = 0.01), bilateral rib fractures (β = US $34,392, p = 0.01), and Glasgow Coma Scale per unit decrease (β = US $17,164, p < 0.0001). The difference in charge between NOM and OM management was most strongly, although only partially, mediated by length of stay.

CONCLUSION

Our analysis found that OM, as compared with NOM, was independently associated with decreased hospital charges. These data refute the prevailing notion that SSRF should be withheld because of concerns for increased cost.

LEVEL OF EVIDENCE

Economic, level II.

Comparison of Surgical Stabilization Time in Patients with Flail Chest

BACKGROUND

This study aimed to compare the clinical outcomes of early and late surgical stabilization of rib fractures (SSRFs) in patients with flail chest.

METHODS

A retrospective analysis was performed on patients with flail chest according to surgical stabilization time of rib fractures (early [≤ 72 hours] and late [>72 hours]). Outcome measures included duration of mechanical ventilation, intensive care unit (ICU) stay, hospital stay, and morbidity and mortality rates. A correlation analysis was performed between the time from trauma to stabilization and the clinical outcomes after stabilization.

RESULTS

A total of 70 patients were evaluated (36 and 34 in the early and late groups, respectively). The demographics and indicators of injury severity were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (23.7 vs. 165.6 hours; p = 0.003), ICU stay (6.5 vs. 19.7 days; p = 0.003), hospital stay (9 vs. 22.5 days; p = 0.001), and lower rate of atelectasis (11 vs. 58%; p = 0.01), pneumonia (8.8 vs. 50%; p = 0.001), and empyema (2.8 vs. 20.6%; p = 0.019). According to the correlation analysis, it was found that early surgical stabilization had a positive significant effect on clinical outcomes after stabilization.

CONCLUSION

Early SSRFs in patients with flail chest results in more favorable clinical outcomes. It should be performed as soon as possible in the presence of indication and if feasible.

Rib Fractures and Mortality: Breaking the Causal Relationship

Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor of mortality, but rarely contribute to cause death. We performed a retrospective study (2008–2015) of blunt trauma patients admitted to our urban, Level I trauma center with one or more rib fractures. Medical records were reviewed in detail. Rib fracture deaths were those from any respiratory sequelae or hemorrhage from rib fractures. There were 4413 blunt trauma patients who sustained one or more rib fractures and 295 (6.8%) died. Rib fracture patients who died had a mean Injury Severity Score = 38 and chest Abbreviated Injury Score = 3.4. Rib fractures were the cause of death in only 21 patients (0.5%). After excluding patients who were dead on arrival, patients dying as a result of their rib fractures were found to be older ( P < 0.0001) and had a higher admission respiratory rate ( P = 0.02). Multivariable logistic regression found that age ≥65 was the only variable independently associated with mortality directly related to rib fractures (odds ratio 4.1, 95% confidence interval = 1.3–13.3, P value < .0001). Mortality in patients with rib fractures is uncommon (7%), and mortality directly related to rib fractures is rare (0.5%). Older patients are four times more likely to die as a direct result of rib fractures and may require additional resources to avoid mortality.

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

The floating flail chest: Acute management of an injury combination of the floating shoulder and flail chest

Background/purpose:

The combination of ipsilateral floating shoulder and flail chest is a unique injury pattern that has not been previously described in the literature. We termed the injury pattern floating flail chest (FFC). The purpose of this study was to evaluate the effect of operative treatment of the shoulder girdle component to overall hospital length of stay (LOS).

Methods:

Forty-one patients were enrolled between two level I trauma centers identifying with a combination ipsilateral floating shoulder and flail chest injury, 23 treated with operative stabilization and 18 treated non-operatively. This retrospective cohort study evaluated the overall LOS and intensive care unit (ICU) days.

Results:

The operative group had decreased overall LOS (10.1 vs. 19.8 days, p = 0.02) and decreased ICU days (3.4 vs. 10.3, p = 0.04).

Conclusion:

This study describes a unique injury pattern that combines the floating shoulder and flail chest, FFC. Our study suggests that operative treatment of the shoulder girdle may decrease both overall LOS and ICU days in patients with FFC.