Intelligent detection and grading diagnosis of fresh rib fractures based on deep learning

BACKGROUND

Accurate detection and grading of fresh rib fractures are crucial for patient management but remain challenging due to the complexity of rib structures on CT images.

METHODS

Chest CT images from 383 patients with rib fractures were retrospectively analyzed. The dataset was divided into a training set (n = 306) and an internal testing set (n = 77). An external testing set of 50 patients from the public RibFrac dataset was included. Fractures were classified into severe and non-severe categories. A modified YOLO-based deep learning model was developed for detection and grading. Performance was compared with thoracic surgeons using precision, recall, mAP50, and F1 score.

RESULTS

The deep learning model showed excellent performance in diagnosing fresh rib fractures. For all fractures types in internal test set, the precision, recall, mAP50, and F1 score were 0.963, 0.934, 0.972, and 0.948, respectively. The model outperformed thoracic surgeons of varying experience levels (all p < 0.01).

CONCLUSION

The proposed deep learning model can automatically detect and grade fresh rib fractures with accuracy comparable to that of physicians. This model helps improve diagnostic accuracy, reduce physician workload, save medical resources, and strengthen health care in resource-limited areas.

CLINICAL TRIAL NUMBER

Not applicable.

A risk prediction model for venous thromboembolism in hospitalized patients with thoracic trauma: a machine learning, national multicenter retrospective study

BACKGROUND

Early treatment and prevention are the keys to reducing the mortality of VTE in patients with thoracic trauma. This study aimed to develop and validate an automatic prediction model based on machine learning for VTE risk screening in patients with thoracic trauma.

METHODS

In this national multicenter retrospective study, the clinical data of chest trauma patients hospitalized in 33 hospitals in China from October 2020 to September 2021 were collected for model training and testing. The data of patients with thoracic trauma at Shanghai Sixth People's Hospital from October 2021 to September 2022 were included for further verification. The performance of the model was measured mainly by the area under the receiver operating characteristic curve (AUROC) and the mean accuracy (mAP), and the sensitivity, specificity, positive predictive value, and negative predictive value were also measured.

RESULTS

A total of 3116 patients were included in the training and validation of the model. External validation was performed in 408 patients. The random forest (RF) model was selected as the final model, with an AUROC of 0·879 (95% CI 0·856-0·902) in the test dataset. In the external validation, the AUROC was 0.83 (95% CI 0.794-0.866), the specificity was 0.756 (95% CI 0.713-0.799), the sensitivity was 0.821 (95% CI 0.692-0.923), the negative predictive value was 0.976 (95% CI 0.958-0.993), and the positive likelihood ratio was 3.364.

CONCLUSIONS

This model can be used to quickly screen for the risk of VTE in patients with thoracic trauma. More than 90% of unnecessary VTE tests can be avoided, which can help clinicians target interventions to high-risk groups and ensure resource optimization. Although further validation and improvement are needed, this study has considerable clinical value.

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.

Analysis of risk factors for poor healing and long-duration pain in conservative treatment of rib fractures

Rib fractures are a common injury following blunt chest trauma, accounting for approximately 10% of all traumatic injuries and up to 50% of blunt chest trauma cases. These fractures are associated with a high risk of complications, such as pneumothorax, hemothorax, and pulmonary infections, and can significantly impact respiratory function. This study analyzes the risk factors for poor healing and long-duration pain in the conservative treatment of rib fractures, providing a reference for clinicians in choosing conservative treatment and formulating treatment plans. A retrospective analysis was conducted on 342 patients who underwent conservative treatment for rib fractures from January 2023 to May 2024. Baseline data, clinical data, and follow-up data were collected. Comparisons were made between the poor healing group and the good healing group, as well as between the long-duration pain group and the short-duration pain group in the conservative treatment of rib fractures. Univariate and multivariate logistic regression analyses were performed to identify risk factors for poor healing and long-duration pain. In patients undergoing conservative treatment for rib fractures, the average duration of pain was 12.18 ± 10.78 days, with an incidence of pulmonary complications of 59.06% (202/342) and poor healing rate of 6.43% (22/342). Significant differences were observed between the good and poor healing groups in terms of age (P = .018), presence of coronary heart disease (CHD, P = .023), chronic obstructive pulmonary disease (COPD, P < .001), blood calcium (P = .007), and alkaline phosphatase (P < .001). Similarly, significant differences were found between the long-duration and short-duration pain groups in age (P = .039), presence of diabetes (P < .001), CHD (P < .001), COPD (P < .001), and alkaline phosphatase (P < .001). Multivariate analysis identified COPD (P = .015), blood calcium (P = .013), and alkaline phosphatase (P = .006) as independent risk factors for poor healing, while diabetes (P = .001), CHD (P = .014), and alkaline phosphatase (P < .001) were independent risk factors for prolonged pain duration. COPD, blood calcium, and alkaline phosphatase are independent risk factors for poor healing in conservative treatment of rib fractures. Diabetes, CHD, and alkaline phosphatase are independent risk factors for long-duration pain in conservative treatment of rib fractures.

Rib fracture characteristics increasing the risk of hemothorax: a multicenter study

The precise assessment of hemothorax risk resulting from a rib fracture is not feasible. CT images, patient characteristics, and clinical experience are utilized in daily practice to assess risk intuitively. This study aimed to identify specific markers on CT images that can predict the risk of hemothorax. The study was retrospectively conducted between May 2021 and December 2023 at three different centers. Patients diagnosed with hemothorax at the initial assessment or during follow-up were identified among those being followed for rib fractures. An investigation was carried out to examine the relationship between the number of rib fractures, displacement status, and the location of the fracture on the rib arch with the risk of hemothorax. Of the 273 patients included in the study, 201 (73.6%) were male. The mean age was 53.9 ± 17.27 (19-93) years. Lateral (p = 0.029) and posterior (p < 0.001) location of the fracture and displacement of at least one fracture (p = 0.003) were associated with an increased risk. There was a significant correlation between the number of rib fractures and the risk of hemothorax (p < 0.001). The optimal cut-off for the number of rib fractures associated with a high risk of hemothorax was determined to be 4. Anatomical characteristics of a rib fracture can be useful to assess the risk of hemothorax practically in patients with thoracic trauma especially in emergency rooms. Patients with four or more rib fractures, at least one displaced rib fracture, and lateral and posterior rib fractures should be followed more carefully for hemothorax.

Performance of thoracic ultrasonography compared with chest radiography for the detection of rib fractures using computed tomography as a reference standard

OBJECTIVE

Although there is growing evidence that ultrasonography is superior to X-ray for rib fractures' detection, X-ray is still indicated as the most appropriate method. This has partially been attributed to a lack of studies using an appropriate reference modality. We aimed to compare the diagnostic accuracy of ultrasonography and X-ray in the detection of rib fractures, considering CT as the reference standard.

MATERIALS AND METHODS

Within a 2.5-year period, all consecutive patients with clinically suspected rib fracture(s) following blunt chest trauma and available posteroanterior/anteroposterior X-ray and thoracic CT were prospectively studied and planned to undergo thoracic ultrasonography, by a single operator. All imaging examinations were evaluated for cortical rib fracture(s), and their location was recorded. The cartilaginous rib portions were not assessed. CTs and X-rays were evaluated retrospectively. Concomitant thoracic/extra-thoracic injuries were assessed on CT. Comparisons were performed with the Mann-Whitney U test and Fisher's exact test.

RESULTS

Fifty-nine patients (32 males, 27 females; mean age, 53.1 ± 16.6 years) were included. CT, ultrasonography, and X-ray (40 posteroanterior/19 anteroposterior views) diagnosed 136/122/42 rib fractures in 56/54/27 patients, respectively. Ultrasonography and X-ray had sensitivity of 100%/40% and specificity of 89.7%/30.9% for rib fractures' detection. Ultrasound accuracy was 94.9% compared to 35.4% for X-rays (P < .001) in detecting individual rib fractures. Most fractures involved the 4th-9th ribs. Upper rib fractures were most commonly overlooked on ultrasonography. Thoracic cage/spine fractures and haemothorax represented the most common concomitant injuries.

CONCLUSION

Ultrasonography appeared to be superior to X-ray for the detection of rib fractures with regard to a reference CT.

Holistic shape variation of the rib cage in an adult population

Traumatic injuries to the thorax are a common occurrence, and given the disparity in outcomes, injury risk is non-uniformly distributed within the population. Rib cage geometry, in conjunction with well-established biomechanical characteristics, is thought to influence injury tolerance, but quantifiable descriptions of adult rib cage shape as a whole are lacking. Here, we develop an automated pipeline to extract whole rib cage measurements from a large population and produce distributions of these measurements to assess variability in rib cage shape. Ten measurements of whole rib cage shape were collected from 1,719 individuals aged 25-45 years old including angular, linear, areal, and volumetric measures. The resulting pipeline produced measurements with a mean percent difference to manually collected measurements of 1.7% ± 1.6%, and the whole process takes 30 s per scan. Each measurement followed a normal distribution with a maximum absolute skew value of 0.43 and a maximum absolute excess kurtosis value of 0.6. Significant differences were found between the sexes (p < 0.001) in all except angular measures. Multivariate regression revealed that demographic predictors explain 29%-68% of the variance in the data. The angular measurements had the three lowest R2 values and were also the only three to have little correlation with subject stature. Unlike other measures, rib cage height had a negative correlation with BMI. Stature was the dominant demographic factor in predicting rib cage height, coronal area, sagittal area, and volume. Subject weight was the dominant demographic factor for rib cage width, depth, axial area, and angular measurements. Age was minimally important in this cohort of adults from a narrow age range. Individuals of similar height and weight had average rib cage measurements near the regression predictions, but the range of values across all subjects encompassed a large portion of their respective distributions. Our findings characterize the variability in adult rib cage geometry, including the variation within narrow demographic criteria. In future work, these can be integrated into computer aided engineering workflows to assess the influence of whole rib cage shape on the biomechanics of the adult human thorax.

[Diagnosis of Rib Fracture Using Artificial Intelligence on Chest CT Images of Patients with Chest Trauma]

Purpose

To determine the pros and cons of an artificial intelligence (AI) model developed to diagnose acute rib fractures in chest CT images of patients with chest trauma.

Materials and Methods

A total of 1209 chest CT images (acute rib fracture [n = 1159], normal [n = 50]) were selected among patients with chest trauma. Among 1159 acute rib fracture CT images, 9 were randomly selected for AI model training. 150 acute rib fracture CT images and 50 normal ones were tested, and the remaining 1000 acute rib fracture CT images was internally verified. We investigated the diagnostic accuracy and errors of AI model for the presence and location of acute rib fractures.

Results

Sensitivity, specificity, positive and negative predictive values, and accuracy for diagnosing acute rib fractures in chest CT images were 93.3%, 94%, 97.9%, 82.5%, and 95.6% respectively. However, the accuracy of the location of acute rib fractures was low at 76% (760/1000). The cause of error in the diagnosis of acute rib fracture seemed to be a result of considering the scapula or clavicle that were in the same position (66%) or some ribs that were not recognized (34%).

Conclusion

The AI model for diagnosing acute rib fractures showed high accuracy in detecting the presence of acute rib fractures, but diagnosis of the exact location of rib fractures was limited.

Development and Validation of an Artificial Intelligence Model for Detecting Rib Fractures on Chest Radiographs

Background: Chest radiography is the standard method for detecting rib fractures. Our study aims to develop an artificial intelligence (AI) model that, with only a relatively small amount of training data, can identify rib fractures on chest radiographs and accurately mark their precise locations, thereby achieving a diagnostic accuracy comparable to that of medical professionals. Methods: For this retrospective study, we developed an AI model using 540 chest radiographs (270 normal and 270 with rib fractures) labeled for use with Detectron2 which incorporates a faster region-based convolutional neural network (R-CNN) enhanced with a feature pyramid network (FPN). The model's ability to classify radiographs and detect rib fractures was assessed. Furthermore, we compared the model's performance to that of 12 physicians, including six board-certified anesthesiologists and six residents, through an observer performance test. Results: Regarding the radiographic classification performance of the AI model, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were 0.87, 0.83, and 0.89, respectively. In terms of rib fracture detection performance, the sensitivity, false-positive rate, and free-response receiver operating characteristic (JAFROC) figure of merit (FOM) were 0.62, 0.3, and 0.76, respectively. The AI model showed no statistically significant difference in the observer performance test compared to 11 of 12 and 10 of 12 physicians, respectively. Conclusions: We developed an AI model trained on a limited dataset that demonstrated a rib fracture classification and detection performance comparable to that of an experienced physician.

Feasibility of rib fracture detection in low-dose computed tomography images with a large, multicenter datasets-based model

Purpose

To evaluate the feasibility of rib fracture detection in low-dose computed tomography (CT) images with a RetinaNet-based approach and to evaluate the potential of lowdose CT for rib fracture detection compared with regular-dose CT images.

Materials and methods

The RetinaNet-based deep learning model was trained using 7300 scans with 50,410 rib fractures that were used as internal training datasets from four multicenter. The external test datasets consisted of both regular-dose and low-dose chest-abdomen CT images of rib fractures; the MICCAI 2020 RibFrac Challenge Dataset was used as the public dataset. Radiologists' interpretations were used as reference standards. The performance of the model in rib fracture detection was compared with the radiologists' interpretation.

Results

In total, 728 traumatic rib fractures of 100 patients [60 men (60 %); mean age, 53.45 ± 11.19 (standard deviation (SD)); range, 18-77 years] were assessed in the external datasets. In these patients, the regular-dose group had a mean CT dose index volume (CTDIvol) of 7.18 mGy (SD: 2.22) and a mean dose length product (DLP) of 305.38 mGy cm (SD: 95.31); the low-dose group had a mean CTDIvol of 2.79 mGy (SD: 1.11) and a mean DLP of 131.52 mGy cm (SD: 55.58). The sensitivity of the RetinaNet-based model and that of the radiologists was 0.859 and 0.721 in the low-dose CT images and 0.886 and 0.794 in the regular-dose CT images, respectively.

Conclusions

These findings indicate that the RetinaNet-based model can detect rib fractures in low-dose CT images with a robust performance, indicating its feasibility in assisting radiologists with rib fracture diagnosis.

Deep Omni-Supervised Learning for Rib Fracture Detection From Chest Radiology Images

Deep learning (DL)-based rib fracture detection has shown promise of playing an important role in preventing mortality and improving patient outcome. Normally, developing DL-based object detection models requires a huge amount of bounding box annotation. However, annotating medical data is time-consuming and expertise-demanding, making obtaining a large amount of fine-grained annotations extremely infeasible. This poses a pressing need for developing label-efficient detection models to alleviate radiologists' labeling burden. To tackle this challenge, the literature on object detection has witnessed an increase of weakly-supervised and semi-supervised approaches, yet still lacks a unified framework that leverages various forms of fully-labeled, weakly-labeled, and unlabeled data. In this paper, we present a novel omni-supervised object detection network, ORF-Netv2, to leverage as much available supervision as possible. Specifically, a multi-branch omni-supervised detection head is introduced with each branch trained with a specific type of supervision. A co-training-based dynamic label assignment strategy is then proposed to enable flexible and robust learning from the weakly-labeled and unlabeled data. Extensive evaluation was conducted for the proposed framework with three rib fracture datasets on both chest CT and X-ray. By leveraging all forms of supervision, ORF-Netv2 achieves mAPs of 34.7, 44.7, and 19.4 on the three datasets, respectively, surpassing the baseline detector which uses only box annotations by mAP gains of 3.8, 4.8, and 5.0, respectively. Furthermore, ORF-Netv2 consistently outperforms other competitive label-efficient methods over various scenarios, showing a promising framework for label-efficient fracture detection. The code is available at: https://github.com/zhizhongchai/ORF-Net.

Development and evaluation of a deep learning-based model for simultaneous detection and localization of rib and clavicle fractures in trauma patients' chest radiographs

Purpose

To develop a rib and clavicle fracture detection model for chest radiographs in trauma patients using a deep learning (DL) algorithm.

Materials and methods

We retrospectively collected 56 145 chest X-rays (CXRs) from trauma patients in a trauma center between August 2008 and December 2016. A rib/clavicle fracture detection DL algorithm was trained using this data set with 991 (1.8%) images labeled by experts with fracture site locations. The algorithm was tested on independently collected 300 CXRs in 2017. An external test set was also collected from hospitalized trauma patients in a regional hospital for evaluation. The receiver operating characteristic curve with area under the curve (AUC), accuracy, sensitivity, specificity, precision, and negative predictive value of the model on each test set was evaluated. The prediction probability on the images was visualized as heatmaps.

Results

The trained DL model achieved an AUC of 0.912 (95% CI 87.8 to 94.7) on the independent test set. The accuracy, sensitivity, and specificity on the given cut-off value are 83.7, 86.8, and 80.4, respectively. On the external test set, the model had a sensitivity of 88.0 and an accuracy of 72.5. While the model exhibited a slight decrease in accuracy on the external test set, it maintained its sensitivity in detecting fractures.

Conclusion

The algorithm detects rib and clavicle fractures concomitantly in the CXR of trauma patients with high accuracy in locating lesions through heatmap visualization.

The Role of Artificial Intelligence in the Identification and Evaluation of Bone Fractures

Artificial intelligence (AI), particularly deep learning, has made enormous strides in medical imaging analysis. In the field of musculoskeletal radiology, deep-learning models are actively being developed for the identification and evaluation of bone fractures. These methods provide numerous benefits to radiologists such as increased diagnostic accuracy and efficiency while also achieving standalone performances comparable or superior to clinician readers. Various algorithms are already commercially available for integration into clinical workflows, with the potential to improve healthcare delivery and shape the future practice of radiology. In this systematic review, we explore the performance of current AI methods in the identification and evaluation of fractures, particularly those in the ankle, wrist, hip, and ribs. We also discuss current commercially available products for fracture detection and provide an overview of the current limitations of this technology and future directions of the field.

Long-term outcome after surgical management of symptomatic non-union rib fractures

INTRODUCTION

Traumatic chest wall injuries are common however the incidence of non-union rib fractures is unknown. Previous studies have suggested that surgical management of symptomatic non-union rib fractures could be beneficial in selected patients, although many experience persisting pain despite surgery. The aim of this study is to investigate the long-term outcome after surgical management of symptomatic non-union rib fractures.

METHODS

This is a cross-sectional study including adults (≥18 years) managed surgically for symptomatic non-union rib fractures with plate fixation during the period 2010-2020 at Sahlgrenska University Hospital. Patients operated for acute chest wall injury or injury due to cardiopulmonary resuscitation were excluded. Patients answered standardized questionnaires concerning remaining symptoms and satisfaction with surgery, quality of life (QoL, EQ-5D-5 L) and disability (Disability Rating Index, DRI). Lung function, movement of chest wall and thoracic spine, and shoulder function (Boström index) were assessed.

RESULTS

Sixteen patients, 12 men and four women, with mean age 61.6± 11.1 were included in the study. The mechanism of injury was trauma in 10 patients and cough-induced injuries in five patients. Lung disease was significantly more prevalent in cough-induced injuries compared to traumatic injuries, 5 vs 1 (p = 0.008). The mean follow-up time was 3.5 years. Ninety-four percent were satisfied with the surgery and reported that their symptoms had decreased, although 69 % had remaining symptoms, especially pain, from the chest wall. Quality of Life was decreased with EQ-5D-5 L index 0.819 (0.477-0.976) and EQ-VAS 69 (10-100). Disability Rating Index was 31.5 (1.3-76.7) with problems running, lifting heavy objects, and performing heavy work. Predicted lung function was decreased with Forced Vital Capacity (FVC) 86.2 ± 14.2 %, Forced Expiratory Volume in 1 second (FEV1) 79.1 ± 10.7 % and Peak Expiratory Flow (PEF) 89.7 ± 14.5 %. Patients with cough-induced injuries had full shoulder mobility.

CONCLUSIONS

Chest wall surgery for symptomatic non-union rib fractures results in decreased symptoms and patient satisfaction in most cases despite remaining symptoms, reduced lung function, chest wall movement, and QoL and persistent disability.

MRI in suspected chest wall fractures: diagnostic value in work-related chest blunt trauma

OBJECTIVE

To describe and analyze MRI findings in suspected early fractures of the chest (ribs and sternum) and assess if this technique can add value in occupational medicine.

MATERIALS AND METHODS

In this retrospective study, we reviewed 112 consecutive patients with work-related mild closed chest trauma who underwent early thoracic MRI, when there was not a clear fracture on radiograph or when the symptoms were intense and not explained by radiographic findings. MRI was evaluated by two experienced radiologists independently. The number and location of fractures and extraosseous findings were recorded. A multivariate analysis was performed to correlate the fracture characteristics and time to RTW (return-to-work). Interobserver agreement and image quality were assessed.

RESULTS

100 patients (82 men, mean age 46 years, range 22-64 years) were included. MRI revealed thoracic wall injuries in 88%: rib and/or sternal fractures in 86% and muscle contusion in the remaining patients. Most patients had multiple ribs fractured, mostly at the chondrocostal junction (n=38). The interobserver agreement was excellent, with minor discrepancies in the total number of ribs fractured. The mean time to return-to-work was 41 days, with statistically significant correlation with the number of fractures. Time to return-to-work increased in displaced fractures, sternal fractures, extraosseous complications, and with age.

CONCLUSION

Early MRI after work-related chest trauma identifies the source of pain in most patients, mainly radiographically occult rib fractures. In some cases, MRI may also provide prognostic information about return-to-work.

Functionally graded 3D printed plates for rib fracture fixation

BACKGROUND

Design freedom offered by additive manufacturing allows for the implementation of functional gradients - where mechanical stiffness is decreased along the length of the implant. It is unclear if such changes will influence failure mechanisms in the context of rib fracture repair. We hypothesized that our novel functionally graded rib implants would be less stiff than controls and decrease occurrence of secondary fracture at implant ends.

METHODS

Five novel additively manufactured rib implants were tested along with a clinically used Control implant. Fracture reconstructions were modeled with custom synthetic rib bones with a transverse B1 fracture. Ribs were compressed in a cyclic two-point bend test for 360,000 cycles followed by a ramp to failure test. Differences in cyclic stiffness, 3D interfragmentary motions, ramp-to-failure stiffness, maximum load, and work to failure were determined.

FINDINGS

The Control group had lower construct stiffness (0.76 ± 0.28 N/mm), compared to all novel implant designs (means: 1.35-1.61 N/mm, p < 0.05) and rotated significantly more about the bending axis (2.7° ± 1.3°) than the additively manufactured groups (means between 1.2° - 1.6°, p < 0.05). All constructs failed via bone fracture at the most posterior screw hole. Experimental implants were stiffer than Controls, and there were few significant differences between functional gradient groups.

INTERPRETATION

Additively manufactured, functionally graded designs have the potential to change the form and function of trauma implants. Here, the impact of functional gradients was limited because implants had small cross-sectional areas.

Traumatic rib fracture patterns associated with bone mineral density statuses derived from CT images

Background

The impact of decreased bone mineral density (BMD) on traumatic rib fractures remains unknown. We combined computed tomography (CT) and artificial intelligence (AI) to measure BMD and explore its impact on traumatic rib fractures and their patterns.

Methods

The retrospective cohort comprised patients who visited our hospital from 2017-2018; the prospective cohort (control group) was consecutively recruited from the same hospital from February-June 2023. All patients had blunt chest trauma and underwent CT. Volumetric BMD of L1 vertebra was measured by using an AI software. Analyses were done by using BMD categorized as osteoporosis (<80 mg/cm3), osteopenia (80-120 mg/cm3), or normal (>120 mg/cm3). Pearson's χ2, Fisher's exact, or Kruskal-Wallis tests and Bonferroni correction were used for comparisons. Negative binomial, and logistic regression analyses were used to assess the associations and impacts of BMD status. Sensitivity analyses were also performed.

Findings

The retrospective cohort included 2,076 eligible patients, of whom 954 (46%) had normal BMD, 806 (38.8%) had osteopenia, and 316 (15.2%) had osteoporosis. After sex- and age-adjustment, osteoporosis was significantly associated with higher rib fracture rates, and a higher likelihood of fractures in ribs 4-7. Furthermore, both the osteopenia and osteoporosis groups demonstrated a significantly higher number of fractured ribs and fracture sites on ribs, with a higher likelihood of fractures in ribs 1-3, as well as flail chest. The prospective cohort included 205 eligible patients, of whom 92 (44.9%) had normal BMD, 74 (36.1%) had osteopenia, and 39 (19.0%) had osteoporosis. The findings observed within this cohort were in concurrence with those in the retrospective cohort.

Interpretation

Traumatic rib fractures are associated with decreased BMD. CT-AI can help to identify individuals who have decreased BMD and a greater rib fracture rate, along with their fracture patterns.

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.

Delayed hemothorax readmissions after rib fracture in blunt trauma patients

Background

Rib fractures are the most common traumatic injury. Hemothorax is one of the widespread complications associated with a rib fracture and occurs in 10-37 % of all rib fractures. Delayed hemothorax (DHTX) is defined as an accumulation of blood within the pleural cavity. Although there is extensive literature on hemothorax, there is limited literature on rib fractures and DHTX readmissions. The objective of this study was to identify potential risk factors for DHTX readmission and examine descriptive information on readmission.

Methods

Using the 2016-2019 National Readmission Database (NRD), patients that experienced an admission with a blunt traumatic rib fracture were included. It was determined if the patients experienced DHTX by screening for an admission containing an ICD-10 code for hemothorax within 30 days after an admission containing a ICD-10 code for rib fracture. Univariable and multivariable analysis was performed to determine independent risk factors associated with DHTX readmission. Additionally, information on the clinical and financial characteristics of DHTX readmissions were examined.

Results

A total of 242,071 patients were included, of whom 635 experienced DHTX readmission ≤30 days after discharge. Diagnosed with hemothorax on the index admission had the largest odds ratio for DHTX readmission (7.43 [6.14-8.99], P < 0.001). Complications found during DHTX readmission included acute respiratory failure (16.9 %), sepsis (6.9 %), and empyema (4.3 %). Treatment mainly consisted of pleural drainage (62.2 %) and video-assisted thoracoscopic surgery (VATS) evacuation of hemothorax (10.1 %).

Conclusion

Patients admitted for a rib fracture have a low incidence for DHTX readmission within 30 days. However, multivariable analysis has demonstrated some risk and protective factors associated with DHTX readmission. Further studies should focus on exploring these risk factors to screen for potential DHTX readmission and/or protective factors to decrease the change for DHTX readmission.

Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration

PURPOSE

Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic.

METHODS

A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens.

RESULTS

After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures.

CONCLUSIONS

The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

Diagnostic Value of Pulmonary Ultrasound and Arterial Blood Gas Analysis in Acute Patients with Severe Injuries Complicated by Respiratory Failure-A Retrospective Study

Background

To investigate the early application of pulmonary ultrasonography and arterial blood gas analysis in critical patients with severe multiple injuries exacerbated by respiratory failure.

Patients and Methods

The retrospective selection was performed on 81 patients admitted to our critical care unit between January 2020 and January 2021 with severe multiple injuries rendered worse by respiratory failure. Based on the different examination procedures, the patients were categorised into three groups (n=27): group A; diagnosed with pulmonary ultrasonography, group B; diagnosed with arterial blood gas; and group C; diagnosed with both pulmonary ultrasonography and arterial blood gas analyses. Patients were subsequently divided into a survival group (n = 65) and a death group (n = 16). On an annual basis, patients' prognoses were examined in relation to the predictive value of pulmonary ultrasound.

Results

Initial diagnosis, diagnosis, and initial correct treatment times were significantly shorter in groups B and C than group A (P<0.05). In contrast, initial diagnosis time, diagnosis time, and initial correct treatment times were potentially shorter in group C than in group B (P<0.05). Compared to groups B and C, group A had a considerably lower diagnosis rate for the examination methods (P<0.05). The right diaphragm displacement and left diaphragm displacement in the survival group were potentially higher than the LUS score (P < 0.05). In contrast, the survival group's lung ultrasound score (LUS) was considerably lower than the death group's. Statistical analysis showed that the predictive values of right diaphragm displacement, left diaphragm displacement, and mean diaphragm displacement were significant compared with the LUS score. The findings of the receiver operating characteristic curve demonstrated that the right, left, and average diaphragm displacements had high predictive values.

Conclusion

In the early evaluation of patients with severe multiple injuries complicated by respiratory failure, pulmonary ultrasonography combined with arterial blood gas analysis is crucial for the rapid diagnosis and prognosis prediction of patients.

Rib Fracture Management in Older Adults: A Scoping Review

Background

Unique challenges posed by caring for patients of geriatric age, require concurrent management of chronic comorbidities and strategies to avoid or minimize complications related to the injury and/or hospitalization. The presentation in this population of two or more rib fractures is associated higher morbidity and mortality compared to a younger age group. A lack of guidelines regarding the management of multiple rib fractures in the elderly for primary care providers in the community and the complexity of rib fracture management led to reviewing available evidence regarding various approaches to rib fracture management.

Methods

Online databases (PubMed and MEDLINE) were used to identify 57 publications between 2000 and 2022 regarding the management of multiple rib fractures.

Results

The majority of publications were retrospective studies and observational cohort studies (56%). 32% of studies were review articles, meta-analyses, and guidelines. Three articles (5.3%) were randomized control studies. Four articles (7%) cited statistics from a national resource.

Conclusions

The management of rib fractures is predominantly non-surgical, managed with pain control and respiratory rehabilitation. Triaging protocols, available to healthcare providers in outpatient clinics, urgent care centers, and emergency departments, to identify the most vulnerable patients with rib fractures in a timely fashion likely help expedite the level of care they need. A comprehensive treatment team includes not only the primary trauma team (consisting of emergency physicians/trauma surgeons, trauma nurses, and mid-level practitioners) but also incorporates a multidisciplinary team with the early involvement of a geriatrician, physical therapist, anesthesiologist, social worker, and respiratory therapist when required to improve ventilation, breathing and patient comfort.

An automatic fresh rib fracture detection and positioning system using deep learning

OBJECTIVE

To evaluate the performance and robustness of a deep learning-based automatic fresh rib fracture detection and positioning system (FRF-DPS).

METHODS

CT scans of 18,172 participants admitted to eight hospitals from June 2009 to March 2019 were retrospectively collected. Patients were divided into development set (14,241), multicenter internal test set (1612), and external test set (2319). In internal test set, sensitivity, false positives (FPs) and specificity were used to assess fresh rib fracture detection performance at the lesion- and examination-levels. In external test set, the performance of detecting fresh rib fractures by radiologist and FRF-DPS were evaluated at lesion, rib, and examination levels. Additionally, the accuracy of FRF-DPS in rib positioning was investigated by the ground-truth labeling.

RESULTS

In multicenter internal test set, FRF-DPS showed excellent performance at the lesion- (sensitivity: 0.933 [95%CI, 0.916-0.949], FPs: 0.50 [95%CI, 0.397-0.583]) and examination-level. In external test set, the sensitivity and FPs at the lesion-level of FRF-DPS (0.909 [95%CI, 0.883-0.926], p < 0.001; 0.379 [95%CI, 0.303-0.422], p = 0.001) were better than the radiologist (0.789 [95%CI, 0.766-0.807]; 0.496 [95%CI, 0.383-0.571]), so were the rib- and patient-levels. In subgroup analysis of CT parameters, FRF-DPS were robust (0.894-0.927). Finally, FRF-DPS(0.997 [95%CI, 0.992-1.000], p < 0.001) is more accurate than radiologist (0.981 [95%CI, 0.969-0.996]) in rib positioning and takes 20 times less time.

CONCLUSION

FRF-DPS achieved high detection rate of fresh rib fractures with low FP values, and precise positioning of ribs, thus can be used in clinical practice to improve the detection rate and work efficiency.

ADVANCES IN KNOWLEDGE

We developed the FRF-DPS system which can detect fresh rib fractures and rib position, and evaluated by a large amount of multicenter data.

Helping to shine light on the Dark Ages: Applying the bioarchaeology of care approach to remains from the early Anglo-Saxon cemetery at Worthy Park

OBJECTIVE

To test the hypothesis that a bioarchaeological focus on health-related care provision can contribute to the currently limited understanding of social practice in Early Anglo-Saxon England (mid5th-early7th centuries AD).

MATERIALS

Published descriptions of pathology in 69 adult remains from the Early Anglo-Saxon cemetery of Worthy Park, southern England.

METHODS

Three case studies (one examining likely need for care at an individual level and two at a population level) were undertaken using the bioarchaeology of care approach.

RESULTS

Analyses indicate likely care provision ('direct support' and/or 'accommodation of difference') to Worthy Park individuals experiencing temporary or permanent disability. Interpretation suggests community interdependence, cooperation, flexibility and tolerance of difference, as well as cultural and socioeconomic mechanisms for managing physical and social challenges of ageing.

CONCLUSIONS

This study provides proof of concept that bioarchaeology of care analysis can offer new insights into social practice in this period.

SIGNIFICANCE

This study demonstrates that a bioarchaeological focus on caregiving behaviours in an Early Anglo-Saxon community extends modern thinking about social relations in post-Roman Britain, offering a model for future investigations into social practice in this, and potentially other, periods. More generally, it illustrates the richness of results achievable when combining bioarchaeological and historical research.

LIMITATIONS

Reliance on secondary sources limited detail (and potentially accuracy) of interpretation possible.

SUGGESTIONS FOR FURTHER RESEARCH

This study's approach should be further tested and refined, either through application to different Anglo-Saxon (or other historic) populations or in a more thorough analysis of the Worthy Park sample itself.

Severe non-cardiovascular thoracic trauma: diagnostic clues on computed tomography

OBJECTIVE

About 60% of multiple trauma patients have thoracic trauma, and thoracic trauma results in the death of 10% of these patients. Computed tomography (CT) is the most sensitive and specific imaging modality for the diagnosis of acute disease, and it helps in the management and prognostic evaluation of patients with high-impact trauma. This paper aims to show the practical points that are key for diagnosing severe non-cardiovascular thoracic trauma by CT.

CONCLUSION

Knowing the key features of severe acute thoracic trauma on CT is crucial to avoid diagnostic errors. Radiologists play a fundamental role in the accurate early diagnosis of severe non-cardiovascular thoracic trauma, because the patient's management and outcome will depend largely on the imaging findings.

The value of deep learning-based computer aided diagnostic system in improving diagnostic performance of rib fractures in acute blunt trauma

BACKGROUND

To evaluate the value of a deep learning-based computer-aided diagnostic system (DL-CAD) in improving the diagnostic performance of acute rib fractures in patients with chest trauma.

MATERIALS AND METHODS

CT images of 214 patients with acute blunt chest trauma were retrospectively analyzed by two interns and two attending radiologists independently firstly and then with the assistance of a DL-CAD one month later, in a blinded and randomized manner. The consensusdiagnosis of fib fracture by another two senior thoracic radiologists was regarded as reference standard. The rib fracture diagnostic sensitivity, specificity, positive predictive value, diagnostic confidence and mean reading time with and without DL-CAD were calculated and compared.

RESULTS

There were 680 rib fracture lesions confirmed as reference standard among all patients. The diagnostic sensitivity and positive predictive value of interns weresignificantly improved from (68.82%, 84.50%) to (91.76%, 93.17%) with the assistance of DL-CAD, respectively. Diagnostic sensitivity and positive predictive value of attendings aided by DL-CAD (94.56%, 95.67%) or not aided (86.47%, 93.83%), respectively. In addition, when radiologists were assisted by DL-CAD, the mean reading time was significantly reduced, and diagnostic confidence was significantly enhanced.

CONCLUSIONS

DL-CAD improves the diagnostic performance of acute rib fracture in chest trauma patients, which increases the diagnostic confidence, sensitivity, and positive predictive value for radiologists. DL-CAD can advance the diagnostic consistency of radiologists with different experiences.

Prospective single-center paradigm shift of surgical stabilization of rib fractures with decreased length of stay and operative time with an intrathoracic approach

INTRODUCTION

Intrathoracic surgical stabilization of rib fractures allows for a novel approach to rib fracture repair. This approach can help minimize muscle disruption, which may improve patient recovery compared with traditional extrathoracic plating. We hypothesized patients undergoing intrathoracic plating (ITP) to have a shorter length of stay (LOS) and intensive care unit (ICU) LOS compared with extrathoracic plating (ETP).

METHODS

A prospective observational paradigm shift study was performed from November 2017 until September 2021. Patients 18 and older who underwent surgical stabilization of rib fractures were included. Patients with ahead Abbreviated Injury Scale score ≥3 were excluded. Patients undergoing ETP (July 2017 to October 2019) were compared with ITP (November 2019 to September 2021) with Pearson χ 2 tests and Mann-Whitney U tests, with the primary outcome being LOS and ICU LOS.

RESULTS

Ninety-six patients were included, 59 (61%) underwent ETP and 37 (38%) underwent ITP. The most common mechanism of injury was motor vehicle collision (29%) followed by falls (23%). There were no differences between groups in age, comorbidities, insurance, discharge disposition and injury severity score (18 vs. 19, p = 0.89). Intrathoracic plating had a shorter LOS (10 days vs. 8 days, p = 0.04) when compared with ETP but no difference in ICU LOS (4 days vs. 3 days, p = 0.12) and ventilator days. Extrathoracic plating patients more commonly received epidural anesthesia (56% vs. 24%, p < 0.001) and intercostal nerve block (56% vs. 29%, p = 0.01) compared with ITP. However, there was no difference in median morphine equivalents between cohorts. Operative time was shorter for ITP with ETP (279 minutes vs. 188 minutes, p < 0.001) after adjusting for numbers of ribs fixed.

CONCLUSION

In this single-center study, patients who underwent ITP had a decreased LOS and operative time in comparison to ETP in patients with similar injury severity. Future prospective multicenter research is needed to confirm these findings and may lead to further adoption of this minimally invasive technique.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Rib Fracture Map in High-Energy Injuries

OBJECTIVES

To use a novel rib unfurling technology to investigate the locations of multiple rib fractures occurring from high-energy trauma to discern if there are reproducible rib fracture patterns.

METHODS

Patients between the ages of 18 and 48 years presenting to a Level 1 academic trauma center with ≥2 rib fractures after a high-energy mechanism of injury between 2017 and 2019 were identified. Curved planar reformatting of CT scans was used to create two-dimensional unfurled rib images by flattening out the view of the ribs from a CT scan. Rib fractures were placed on a template map using a standardized measurement method, and subsequent frequency and heat maps were created.

RESULTS

Among 100 consecutive patients, 534 fractures on 454 ribs were identified. The most common high-energy mechanism of injury was motor vehicle accidents (41%). Flail chest occurred in 8% of patients. The mean number of ribs fractured per patient was 4.54 ± 3.14 and included a mean of 5.34 ± 4.38 total fractures. Among all fractures, 50.9% were located on ribs 4 through 7. The most common fracture location was located in the lateral or anterolateral zone of the rib cage.

CONCLUSIONS

Patients with multiple rib fractures from high-energy trauma have rib fractures with locations of common occurrence. An understanding of location and frequency of rib fractures can help inform surgical approaches, prognosis, indications, classifications, and implant design in the management of a complex population of patients with chest wall injury after trauma.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Characteristics of rib fracture patients who require chest computed tomography in the emergency department

BACKGROUND

The disadvantages and complications of computed tomography (CT) can be minimized if CT is performed in rib fracture patients with high probability of intra-thoracic and intra-abdominal injuries and CT is omitted in rib fracture patients with low probability of intra-thoracic and intra-abdominal injuries. This study aimed to evaluate the factors that can identify patients with rib fractures with intra-thoracic and intra-abdominal injuries in the emergency department among patients with rib fracture.

METHODS

This retrospective observational study included adult patients (age ≥ 18 years) diagnosed with rib fracture on chest radiography prior to chest CT due to blunt chest trauma in the emergency department who underwent chest CT from January 2016 to February 2021. The primary outcomes were intra-thoracic and intra-abdominal injuries that could be identified on a chest CT. Multivariate logistic regression analysis was performed.

RESULTS

Among the characteristics of rib fractures, the number of rib fractures was greater (5.0 [3.0-7.0] vs. 2.0 [1.0-3.0], p < 0.001), bilateral rib fractures were frequent (56 [20.1%] vs. 12 [9.8%], p = 0.018), and lateral and posterior rib fracture was more frequent (lateral rib fracture: 160 [57.3%] vs. 25 [20.5%], p < 0.001; posterior rib fracture: 129 [46.2%] vs. 21 [17.2%], p < 0.001), and displacement was more frequent (99 [35.5%] vs. 6 [6.6%], p < 0.001) in the group with intra-thoracic and intra-abdominal injuries than in the group with no injury. The number of rib fractures (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.16-1.78; p = 0.001), lateral rib fracture (aOR, 2.80; 95% CI, 1.32-5.95; p = 0.008), and posterior rib fracture (aOR, 3.18; 95% CI, 1.45-6.94; p = 0.004) were independently associated with intra-thoracic and intra-abdominal injuries. The optimal cut-off for the number of rib fractures on the outcome was three. The number of rib fractures ≥ 3 (aOR, 3.01; 95% CI, 1.35-6.71; p = 0.007) was independently associated with intra-thoracic and intra-abdominal injuries.

CONCLUSION

In patients with rib fractures due to blunt trauma, those with lateral or posterior rib fractures, those with ≥ 3 rib fractures, and those requiring O₂ supplementation require chest CT to identify significant intra-thoracic and intra-abdominal injuries in the emergency department.

Discrimination between falls and blows from the localization and the number of fractures on computed tomography scans of the skull and the trunk

The distinction between falls and blows is a common and difficult task in forensic sciences. One of the most often used criteria to address this issue is the hat brim line (HBL) rule, which states that fall-related injuries do not lie above the HBL. Some studies, however, have found that the use of HBL rule is not so relevant. This study assesses the aetiologies, the number of fractures, and their location on the skull and the trunk in a sample of 400 individuals aged 20-49 years, which were CT scanned after traumas. This may facilitate the interpretation of such injuries in skeletonized or heavily decomposed bodies in which soft tissues are no longer available. Our aim is to improve the distinction rate between falls and blows by combining several criteria and assessing their predictability. Skeletal lesions were analysed using retrospective CT scans. Cases selected comprise 235 falls and 165 blows. We registered the presence and the number of fractures in 14 skeletal anatomical regions related to the two different aetiologies. We showed that the HBL rule should be used with caution, but there is nevertheless a possibility of discussing the aetiology of blunt fractures. Possibly, parameters like the anatomical location and the number of fractures by region can be used to distinguish falls and blows.

Biomechanical characteristics of rib fracture fixation systems

BACKGROUND

The primary aim of this study was to determine and compare the biomechanical properties of a fractured or intact rib after implant fixation on an embalmed thorax.

METHODS

Five systems were fixated on the bilateral fractured or intact (randomly allocated) 6th to 10th rib of five post-mortem embalmed human specimens. Each rib underwent a four-point bending test to determine the bending structural stiffness (Newton per m²), load to failure (Newton), failure mode, and the relative difference in bending structural stiffness and load to failure as compared to a non-fixated intact rib.

FINDINGS

As compared to a non-fixated intact rib, the relative difference in stiffness of a fixated intact rib ranged from -0.14 (standard deviation [SD], 0.10) to 0.53 (SD 0.35) and for a fixated fractured rib from -0.88 (SD 0.08) to 0.17 (SD 0.50). The most common failure mode was a new fracture at the most anterior drill hole for the plate and screw systems and a new fracture within the anterior portion of the implant for the clamping systems.

INTERPRETATION

The current fixation systems differ in their design, mode of action, and biomechanical properties. Differences in biomechanical properties such as stiffness and load to failure especially apply to fractured ribs. Insight in the differences between the systems might guide more specific implant selection and increase the surgeon's awareness for localizing hardware complaints or failure.

Convolutional neural network for detecting rib fractures on chest radiographs: a feasibility study

BACKGROUND

Chest radiography is the standard investigation for identifying rib fractures. The application of artificial intelligence (AI) for detecting rib fractures on chest radiographs is limited by image quality control and multilesion screening. To our knowledge, few studies have developed and verified the performance of an AI model for detecting rib fractures by using multi-center radiographs. And existing studies using chest radiographs for multiple rib fracture detection have used more complex and slower detection algorithms, so we aimed to create a multiple rib fracture detection model by using a convolutional neural network (CNN), based on multi-center and quality-normalised chest radiographs.

METHODS

A total of 1080 radiographs with rib fractures were obtained and randomly divided into the training set (918 radiographs, 85%) and the testing set (162 radiographs, 15%). An object detection CNN, You Only Look Once v3 (YOLOv3), was adopted to build the detection model. Receiver operating characteristic (ROC) and free-response ROC (FROC) were used to evaluate the model's performance. A joint testing group of 162 radiographs with rib fractures and 233 radiographs without rib fractures was used as the internal testing set. Furthermore, an additional 201 radiographs, 121 with rib fractures and 80 without rib fractures, were independently validated to compare the CNN model performance with the diagnostic efficiency of radiologists.

RESULTS

The sensitivity of the model in the training and testing sets was 92.0% and 91.1%, respectively, and the precision was 68.0% and 81.6%, respectively. FROC in the testing set showed that the sensitivity for whole-lesion detection reached 91.3% when the false-positive of each case was 0.56. In the joint testing group, the case-level accuracy, sensitivity, specificity, and area under the curve were 85.1%, 93.2%, 79.4%, and 0.92, respectively. At the fracture level and the case level in the independent validation set, the accuracy and sensitivity of the CNN model were always higher or close to radiologists' readings.

CONCLUSIONS

The CNN model, based on YOLOv3, was sensitive for detecting rib fractures on chest radiographs and showed great potential in the preliminary screening of rib fractures, which indicated that CNN can help reduce missed diagnoses and relieve radiologists' workload. In this study, we developed and verified the performance of a novel CNN model for rib fracture detection by using radiography.

Blows or Falls? Distinction by Random Forest Classification

In this study, we propose a classification method between falls and blows using random forests. In total, 400 anonymized patients presenting with fractures from falls or blows aged between 20 and 49 years old were used. There were 549 types of fractures for 57 bones and 12 anatomical regions observed. We first tested various models according to the sensibility of random forest parameters and their effects on model accuracies. The best model was based on the binary coding of 12 anatomical regions or 28 bones with or without baseline (age and sex). Our method achieved the highest accuracy rate of 83% in the distinction between falls and blows. Our findings pave the way for applications to help forensic experts and archaeologists.

Near-maximum rib dose is the most relevant risk factor for ipsilateral spontaneous rib fracture: a dosimetric analysis of breast cancer patients after radiotherapy

PURPOSE

Spontaneous rib fracture (SRF) is a common late complication in treated breast cancer patients. This study evaluated the incidence and risk factors of ipsilateral SRF after radiotherapy (RT) in breast cancer patients. In addition, we identified dosimetric parameters that were significantly associated with ipsilateral SRF.

METHODS

We retrospectively reviewed 2204 patients with breast cancer who underwent RT between 2014 and 2016, and were followed up with bone scans. We evaluated clinical risk factors for ipsilateral SRF. Dose-volume histogram analysis was also performed for patients (n = 538) whose dosimetric data were available. All ipsilateral ribs were manually delineated, and dosimetric parameters of the ribs were converted into the equivalent dose in 2 Gy fractions (EQD2).

RESULTS

Most of the patients with SRF (87.3%) were asymptomatic, and the remaining symptomatic patients complained of mild tenderness or chest wall discomfort; these symptoms all resolved within 6 months without any treatment. Ipsilateral SRF occurred in 14.5% of patients 3 years after RT. The median time to develop ipsilateral SRF was 15 months. In dosimetric analysis, near-maximum rib dose (D2cc) best predicted ipsilateral SRF. The cut-off value of D2cc was EQD2 52 Gy, as determined by receiver operating characteristic analysis. In multivariate analysis including dosimetric variables, D2cc EQD2 ≥ 52 Gy was the only significant risk factor for ipsilateral SRF.

CONCLUSION

Our data demonstrated that near-maximum rib dose was the best dosimetric parameter to predict ipsilateral SRF in RT-treated breast cancer patients. In addition, our results suggest that patients who received RT with exceeding rib dose cut-off value and had ipsilateral SRF on bone scan be recommended routine follow-up without additional imaging tests.

Imaging patterns of thoracic injuries in survivors of intimate partner violence (IPV)

PURPOSE

To recognize the imaging patterns of thoracic injuries in survivors of intimate partner violence (IPV).

MATERIALS AND METHODS

A retrospective radiological review of 688 patients self-reporting IPV to our institution's violence intervention and prevention program between January 2013 and June 2018 identified 30 patients with 89 thoracic injuries. Imaging and demographic data were collected.

RESULTS

Thirty survivors with 89 injuries to the thorax were identified with a median age of 43.5 years (21-65 years). IPV was reported or disclosed as the direct cause of injury in 50% (15/30) of survivors, including all nine patients who sustained penetrating injuries. The most common injury type was fracture (72%, 64/89) with 52 rib, 3 sternal, 2 clavicular, and 7 vertebral fractures. There were 3 acromioclavicular dislocations. Among rib fractures, right lower anterior rib fractures (9-12 ribs) were the most common(30%, 16/52). There were 10 superficial soft tissue injuries. There were 12 deep tissue injuries which included 2 lung contusions, 2 pneumomediastinum, 7 pneumothoraces, 1 hemothorax. One third of patients had concomitant injuries of other organ systems, most commonly to the head and face, followed by extremities and one third of patients had metachronous injuries.

CONCLUSION

Acute rib fractures with concomitant injuries to the head, neck, face, and extremities with an unclear mechanism of injury should prompt the radiologist to discuss the possibility of IPV with the ordering physician.

ADVANCES IN KNOWLEDGE

Recognizing common injuries to the thorax will prompt the radiologists to suspect IPV and discuss it with the clinicians.

Improving diagnostic performance of rib fractures for the night shift in radiology department using a computer-aided diagnosis system based on deep learning: A clinical retrospective study

OBJECTIVE

To investigate the application value of a computer-aided diagnosis (CAD) system based on deep learning (DL) of rib fractures for night shifts in radiology department.

METHODS

Chest computed tomography (CT) images and structured reports were retrospectively selected from the picture archiving and communication system (PACS) for 2,332 blunt chest trauma patients. In all CT imaging examinations, two on-duty radiologists (radiologists I and II) completed reports using three different reading patterns namely, P1 = independent reading during the day shift; P2 = independent reading during the night shift; and P3 = reading with the aid of a CAD system as the concurrent reader during the night shift. The locations and types of rib fractures were documented for each reading. In this study, the reference standard for rib fractures was established by an expert group. Sensitivity and false positives per scan (FPS) were counted and compared among P1, P2, and P3.

RESULTS

The reference standard verified 6,443 rib fractures in the 2,332 patients. The sensitivity of both radiologists decreased significantly in P2 compared to that in P1 (both p <  0.017). The sensitivities of both radiologists showed no statistical difference between P3 and P1 (both p >  0.017). Radiologist I's FPS increased significantly in P2 compared to P1 (p <  0.017). The FPS of radiologist I showed no statistically significant difference between P3 and P1 (p >  0.017). The FPS of Radiologist II showed no statistical difference among all three reading patterns (p >  0.05).

CONCLUSIONS

DL-based CAD systems can be integrated into the workflow of radiology departments during the night shift to improve the diagnostic performance of CT rib fractures.

Radiomics-Based Machine Learning for Predicting the Injury Time of Rib Fractures in Gemstone Spectral Imaging Scans

This retrospective study aimed to predict the injury time of rib fractures in distinguishing fresh (30 days) or old (90 days) rib fractures. We enrolled 111 patients with chest trauma who had been scanned for rib fractures at our hospital between January 2018 and December 2018 using gemstone spectral imaging (GSI). The volume of interest of each broken end of the rib fractures was segmented using calcium-based material decomposition images derived from the GSI scans. The training and testing sets were randomly assigned in a 7:3 ratio. All cases were divided into groups distinguishing the injury time at 30 and 90 days. We constructed radiomics-based models to predict the injury time of rib fractures. The model performance was assessed by the area under the curve (AUC) obtained by the receiver operating characteristic analysis. We included 54 patients with 259 rib fracture segmentations (34 men; mean age, 52 years ± 12.02; and range, 19-72 years). Nine features were excluded by the least absolute shrinkage and selection operator logistic regression to build the radiomics signature. For distinguishing the injury time at 30 days, the Support Vector Machine (SVM) model and human-model collaboration resulted in an accuracy and AUC of 0.85 and 0.871 and 0.91 and 0.912, respectively, and 0.81 and 0.804 and 0.83 and 0.85, respectively, at 90 days in the testing set. The radiomics-based model displayed good accuracy in differentiating between the injury time of rib fractures at 30 and 90 days, and the human-model collaboration generated more accurate outcomes, which may help to add value to clinical practice and distinguish artificial injury in forensic medicine.

Rib cortical bone thickness variation in adults by age and sex

Rib fractures are a common and serious outcome of blunt thoracic trauma and their likelihood is greater in older individuals. Osteoporotic bone loss is a well-documented aging phenomenon with sex-specific characteristics, but within rib bones, neither baseline maps of regional thickness nor the rates of bone thinning with age have been quantified across whole ribs. This study presents such data from 4014 ribs of 240 adult subjects aged 20-90. A validated cortical bone mapping technique was applied to clinical computed tomography scans to obtain local rib cortical bone thickness measurements over the surfaces of ribs 2 through 11. Regression models to age and sex gave rates of cortex thinning in local zones and aggregated across whole ribs. The statistical parametric mapping provided these relationships regionally as a function of rib surface location. All models showed significant reductions in bone thickness with age (p < 0.01). Average whole-rib thinning occurred at between 0.011 to 0.032 mm/decade (males) and 0.035 to 0.043 mm/decade (females), with sex and age accounting for up to 37% of population variability (R2 ). Rates of thinning differed regionally and by rib, with the highest bone loss of up to 0.074 mm/decade occurring in mid-rib cutaneous and superior regions of ribs 2-6. Rates were consistently higher in females than males (significantly so across whole ribs but not all local regions) and were more pronounced in cutaneous, superior, and inferior rib aspects (average 0.025 mm/decade difference in ribs 4-8) compared to pleural aspects which had the thickest cortices but saw only minor differences in thinning rates by sex (0.045 mm/decade for females and 0.040 mm/decade for males). Regional analysis showed male and female bone thickness differences that were not statistically significant at 20 years of age (p > 0.05 across practically all regions) but subsequent cortex thinning meant that substantial pleural and cutaneous regions were thinner (p < 0.05) in females than males by 55 years of age. The techniques and results from this study can be applied to assess rib bone content loss in clinical settings across wide populations. Additionally, average cortex thickness results can be mapped directly to finite element models of the thorax, and regression results are used to modify such models to represent the ribs of men and women across their full adult lifespan.

Thoracic trauma: Clinical and paleopathological perspectives

OBJECTIVES

Although trauma is one of the most significant areas of study in paleopathology, most studies focus on fractures of single anatomical elements. Paleopathological research on regional trauma, such as of the thorax, is rare. This paper explores the causes, complications, and consequences of adult thoracic trauma using clinical data in order to inform paleopathological research.

MATERIALS AND METHODS

Trends in paleopathological thoracic trauma literature were assessed by evaluating publications from Bioarchaeology International, International Journal of Osteoarchaeology, International Journal of Paleopathology, and American Journal of Biological Anthropology. Clinical publications on thoracic trauma throughout time were also assessed through a PubMed search, and modern prevalence data was found through trauma databases such as the National Trauma Databank.

RESULTS

Consideration of thoracic trauma involving concomitant injuries is a recent trend in clinical literature and patient care, but paleopathological research on thoracic trauma has been limited. Since thoracic fractures tend to occur in conjunction with other injuries, assessing them together is critical to the interpretation of trauma in the past.

CONCLUSIONS

Clinical research into thoracic fractures and concomitant injuries provides valuable data for paleopathological research. Evaluating the likelihood and consequences of concomitant injury in skeletal remains provides a more robust understanding of trauma in the past and its impact on past lifeways.

SIGNIFICANCE

This paper provides a review of current clinical and paleopathological literature on thoracic trauma and demonstrates the importance of moving beyond the analysis of fractures or trauma of single anatomical elements.

LIMITATIONS

Thoracic bones are often taphonomically altered and differentially preserved leading to difficulty in identifying and interpreting fractures.

SUGGESTIONS FOR FURTHER RESEARCH

Practical application of the data presented here to archaeological samples will help to advance paleopathological understandings of thoracic trauma.

Blunt chest wall trauma: Rib fractures and associated injuries

ABSTRACT

Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.

The clinical characteristics and surgical treatment for delayed blunt thoracic aortic injury-a case series

BACKGROUND

Delayed thoracic aortic injury (DTAI) induced by left closed rib fractures (RFs) is a clinically rare blunt injury to the thoracic aorta with an insidious onset. DTAI is very prone to missed diagnosis due to the unreliability of using the initial post-injury computed tomography (CT) scan to explicitly detect any signs of an aortic injury, potentially leading to a fatal hemorrhage. Timely diagnosis and treatment are therefore key to preventing such deadly complications. With that said, not all cases of left RFs lead to delayed aortic injuries, so how can surgeons tell which cases are to be culled and focused on? Also, what kinds of treatment should be administered upon detection?

METHODS

A retrospective analysis was performed on the clinical data of DTAI cases induced by left closed RF that were admitted to our Hospital from June 2015 through June 2020. Injuries to the aortic tunica adventitia or the elastic layer were intraoperatively confirmed. CT scan findings, locations and numbers of RFs, as well as the choices of surgical procedure were reviewed postoperatively. In addition, a literature review was conducted to analyze characteristics shared by similar cases.

RESULTS

This study included 7 patients treated by our hospital and 8 reported in the literature. The broken ends of RFs causing aortic wall injury (including the tunica adventitia) were all found in the medial to the lateral erector spinae. All patients in our hospital received internal fixation for RFs and thoracoscopic removal of free bone fragments (if any). Concomitant injuries were managed either by simultaneous or staged surgery.

CONCLUSIONS

For multiple left RFs with the broken ends located in the inside of the lateral erector spinae, the number of fractured ribs ≥4 and a smaller number of fractured ribs with multiple fractures in a single rib are important factors for DTAI. Active surgical intervention is recommended for patients with these important factors. The specific intervention is tailored to each patient's particular needs to eliminate the risk of developing life-threatening thoracic aortic injury (TAI) and rupture.

The Association Between the Duration of Chest Compression and Thoracic Injuries in Patients With Non-Traumatic Out-of-Hospital Cardiac Arrest

BACKGROUND

Current guidelines emphasize the indispensability of high-quality chest compression for improving survival in patients who experience out-of-hospital cardiac arrest (OHCA). However, chest compression can cause thoracic injuries that may contribute to poor prognosis; therefore, the purpose of this study is to identify the predictors of thoracic injuries and evaluate the association between thoracic injuries and prognosis.

METHODS AND RESULTS

Between June 2017 to July 2019, Utstein-style data on 384 consecutive adult patients who experienced non-traumatic OHCA and who were transferred to our hospital (Aso Iizuka Hospital) were collected. Each patient underwent a full-body computed tomography scan. Two-hundred and thirty-four patients (76%) had thoracic injuries (Group-T). The duration of chest compression was significantly longer in Group-T than in patients without thoracic injuries (Group-N; 43 vs. 32 min, respectively, P<0.001). Multivariate analysis revealed that older age and longer chest compression duration were predictors of thoracic injuries (odds ratios 1.03 and 1.07, respectively, P≤0.005). Among patients who achieved return of spontaneous circulation, Kaplan-Meier curves showed a significantly higher cumulative survival rate in Group-N than in Group-T at the 30-day follow up (log-rank test P=0.009).

CONCLUSIONS

Older age and longer chest compression duration were independent predictors of thoracic injuries due to chest compression in patients who experienced non-traumatic OHCA. Moreover, the presence of thoracic injuries was associated with worse short-term prognosis.

Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period

Purpose

Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia.

Methods

This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics).

Results

Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08–7.82, p < 0.001).

Conclusions

Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.

A case of hemorrhagic shock due to intercostal artery injury that occurred during initial trauma care with multiple displaced rib fractures and traumatic head injury

Rib fractures can cause injury to some organs. We herein report a case of hemorrhagic shock due to intercostal artery injury that occurred during initial trauma care (ITC) treated by resuscitative thoracotomy (RT) and transcatheter arterial embolization (TAE) with multiple displaced rib fractures (RFs) and traumatic head injury (THI). A man in his 50s who was injured in a traffic accident was transferred to our institution by helicopter for emergency medical treatment. He underwent left thoracic drainage on site. On admission, he was diagnosed with multiple RF, THI, pelvic fracture and right humerus fracture. His D-dimer and fibrin degradation products (FDP) level were extremely elevated. However, contrast enhance CT (CECT) revealed no extravasation. At 2 h after arrival, massive hemorrhaging from his thoracic tube suddenly occurred and his blood pressure decreased to approximately 40s mmHg. CECT performed after volume resuscitation and massive transfusion revealed extravasation from the intercostal artery. Because his blood pressure could not be maintained by massive transfusion, we performed RT and TAE followed by RT. He then received intensive care and several surgical procedures were performed, including craniotomy for removal of hematoma, rib fixation and humerus fixation. He was transferred to another hospital for rehabilitation on day 63, with a GCS of 15. Hemorrhagic shock due to intercostal artery injury may occur at any time from arrival in cases with displaced RF, especially when complicated by THI.

Press tack needle stimulation for blunt chest trauma: a randomized double-blind control trial

OBJECTIVES

Blunt chest trauma is often associated with severe pain, reduced lung function and decreased sleep quality. This study aims to investigate the immediate and long-term effect of acupuncture on these factors using a randomized control double-blind design.

METHODS

A total of 72 patients were randomized into 2 groups: treatment group (press tack acupuncture) and control group (press tack placebo). The face rating scale, numerical rating scale (NRS), portable incentive spirometer and Verran Snyder-Halpern sleep scale were measured at baseline, immediately after the intervention, and at the 4th day, with 2-weeks and 3-months follow-ups.

RESULTS

There were no significant changes between the groups at the baseline measurements, with the exception of hypertension comorbidity. Immediately after the intervention and on the 4th day follow-up, the patients in the treatment group showed a significantly lower face rating scale when compared to the control (P < 0.05). There were no significant changes in any of the other measurements between the groups (P > 0.05). Subgroup analysis revealed that the NRS for turn over on the 4th day was reduced significantly in the treatment group of patients without lung contusion (P < 0.05). For patients without pleural drainage, cough NRS in the treatment group was significantly reduced in the 2-week follow-up (P < 0.05).

CONCLUSIONS

This study showed that press tack acupuncture effects on pain reduction were inconclusive. However, future studies on the effect of acupuncture on blunt chest trauma patients are needed.

CLINICAL TRIAL REGISTRATION

clinicaltirl.gov: NCT04318496.

Deep learning-based framework for segmentation of multiclass rib fractures in CT utilizing a multi-angle projection network

PURPOSE

Clinical rib fracture diagnosis via computed tomography (CT) screening has attracted much attention in recent years. However, automated and accurate segmentation solutions remain a challenging task due to the large sets of 3D CT data to deal with. Down-sampling is often required to face computer constraints, but the performance of the segmentation may decrease in this case.

METHODS

A new multi-angle projection network (MAPNet) method is proposed for accurately segmenting rib fractures by means of a deep learning approach. The proposed method incorporates multi-angle projection images to complementarily and comprehensively extract the rib characteristics using a rib extraction (RE) module and the fracture features using a fracture segmentation (FS) module. A multi-angle projection fusion (MPF) module is designed for fusing multi-angle spatial features. RESULTS: It is shown that MAPNet can capture more detailed rib fracture features than some commonly used segmentation networks. Our method achieves a better performance in accuracy (88.06 ± 6.97%), sensitivity (89.26 ± 5.69%), specificity (87.58% ± 7.66%) and in terms of classical criteria like dice (85.41 ± 3.35%), intersection over union (IoU, 80.37 ± 4.63%), and Hausdorff distance (HD, 4.34 ± 3.1).

CONCLUSION

We propose a rib fracture segmentation technique to deal with the problem of automatic fracture diagnosis. The proposed method avoids the down-sampling of 3D CT data through a projection technique. Experimental results show that it has excellent potential for clinical applications.