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Van Wijck SFM, Van Diepen MR, Prins JTH, Verhofstad MHJ, Wijffels MME, Van Lieshout EMM. Radiographic rib fracture nonunion and association with fracture classification in adults with multiple rib fractures without flail segment: A multicenter prospective cohort study. Injury 2024; 55:111335. [PMID: 38290909 DOI: 10.1016/j.injury.2024.111335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 01/01/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Rib fracture nonunion is a probable cause of chronic pain following chest trauma, although its prevalence remains unknown. The aims of this study were to determine rib fracture nonunion prevalence following nonoperative management and to determine if presence of nonunion was associated with the number of rib fractures, or the rib fracture classification of anatomical location, type, and displacement. METHODS This multicenter prospective cohort study included trauma patients with three or more fractured ribs but without a flail segment, who participated in the nonoperative management group of the FixCon trial between January 2019 and June 2022. The number and classification of rib fractures were assessed on trauma chest CT. Chest CTs conducted six months post-trauma were evaluated for the presence of nonunion. Radiological characteristics of nonunions were compared with normally healed rib fractures using the Mann-Whitney U, χ2 test, and Fisher's exact test as appropriate. A generalized linear model adjusted for multiple observations per patient when assessing the associations between nonunion and fracture characteristics. RESULTS A total of 68 patients were included with 561 post-traumatic fractures in 429 ribs. Chest CT after six months revealed nonunions in 67 (12 %) rib fractures in 29 (43 %) patients with a median of 2 (P25-P75 1-3) nonunions per patient. Nonunion was most commonly observed in ribs seven to 10 (20-23 %, p < 0.001, adjusted p = 0.006). Nonunion occurred in 14 (5 %) undisplaced, 22 (19 %) offset, and 20 (23 %) displaced rib fractures (p < 0.001). No statistically significant association between rib fracture type and nonunion was found. CONCLUSIONS Forty-three percent of patients with multiple rib fractures had radiographic nonunion six months after trauma. Fractures in ribs seven to 10 and dislocated fractures had an increased risk of rib fracture nonunion.
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Ye JB, Lee JY, Seok J. Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report. J Int Med Res 2024; 52:3000605241244990. [PMID: 38629496 PMCID: PMC11025438 DOI: 10.1177/03000605241244990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024] Open
Abstract
We present the case of a victim of a motor vehicle accident in his late 60s who suffered from severe torso injuries. He initially presented with abdominal and chest pain, and underwent emergency laparotomy for hemoperitoneum. After surgery, the patient developed pneumonia and septicemia, which were responsive to antibiotics. The patient was treated with mechanical ventilation in the intensive care unit for approximately 10 days and experienced a severe weight loss of approximately 30%, but slowly recovered without dyspnea. Notably, on hospital day 24, he experienced sudden respiratory distress and flail motion of the chest wall in a general ward. This late presentation of flail chest was attributed to non-union at rib fracture sites, and was likely exacerbated by malnutrition and osteomyelitis. Surgical stabilization of rib fractures and excision of the infected rib were successfully performed. The findings from this case highlight the complexity of managing delayed onset of flail chest. The findings from this case suggest the importance of vigilance for late emerging complications in patients with trauma, even when initial symptoms are absent.
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Affiliation(s)
- Jin Bong Ye
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, South Korea
| | - Jin Young Lee
- Deparment of Trauma Surgery, Trauma Center, Chungbuk National University Hospital, Cheongju, South Korea
- Department of Trauma Surgery, College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - Junepill Seok
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Cheongju, South Korea
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Chungbuk National University, Cheongju, South Korea
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Meyer CH, Aworanti E, Santos A, Castater C, Bauman ZM, Archer-Arroyo K, Sola R, Grant A, Smith RN, Sciarretta JD, Nguyen JH. Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience. Am Surg 2024; 90:695-702. [PMID: 37853722 PMCID: PMC10922850 DOI: 10.1177/00031348231209530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
INTRODUCTION The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries. METHODS A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series. RESULTS 6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge. CONCLUSIONS This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.
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Affiliation(s)
- Courtney H. Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Adora Santos
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Christine Castater
- Grady Health System, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Krystal Archer-Arroyo
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | | | | | - Randi N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jason D. Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Health System, Atlanta, GA, USA
| | - Jonathan H. Nguyen
- Grady Health System, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
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Spering C, Moerer O, White TW, Lehmann W. [Surgical reconstruction of chest wall instability : Indications, contraindications and timing of surgery]. Unfallchirurgie (Heidelb) 2024; 127:171-179. [PMID: 38214732 DOI: 10.1007/s00113-023-01400-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/13/2024]
Abstract
The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for a surgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including a Cochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for a structured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by a timely surgery within 72 h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.
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Affiliation(s)
- Christopher Spering
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland.
| | - Onnen Moerer
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Thomas W White
- Department of Surgery, Intermountain Medical Center, Murray, UT, USA
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
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Nilsson J, Caragounis EC. Long-term outcome after surgical management of symptomatic non-union rib fractures. Injury 2024; 55:111297. [PMID: 38151437 DOI: 10.1016/j.injury.2023.111297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 12/29/2023]
Abstract
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.
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Affiliation(s)
- Julia Nilsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Per Dubbsgatan 15, SE 413 45 Gothenburg, Sweden
| | - Eva-Corina Caragounis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Per Dubbsgatan 15, SE 413 45 Gothenburg, Sweden.
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Patel DD, Zambetti BR, Magnotti LJ. Timing to Rib Fixation in Patients With Flail Chest. J Surg Res 2024; 294:93-98. [PMID: 37866069 DOI: 10.1016/j.jss.2023.09.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/09/2023] [Accepted: 09/15/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Flail chest (FC) after blunt trauma is associated with significant morbidity and prolonged hospitalizations. The goal of this study was to examine the relationship between timing of rib fixation (ORIF) and pulmonary morbidity and mortality in patients with FC. METHODS FC patients were identified from the Trauma Quality Improvement Program database over 3-year, ending 2019. Demographics, severity of injury and shock, time to ORIF, pulmonary morbidity, and mortality were recorded. Youden's index identified optimal time to ORIF. Patients were compared based on undergoing ORIF versus nonoperative management, then for patients undergoing ORIF based on time from admission to operation, utilizing Youden's index to determine the preferred time for fixation. Multivariable logistic regression determined predictors of pulmonary morbidity and mortality. RESULTS 20,457 patients were identified: 3347 (16.4%) underwent ORIF. The majority were male (73%) with median age and injury severity score of 58 and 22, respectively. Patients undergoing ORIF were clinically similar to those managed nonoperatively but had increased pulmonary morbidity (27.6 versus 15.2%, P < 0.0001) and reduced mortality (2.9 versus 11.7%, P < 0.0001). Multivariable logistic regression identified ORIF as the only modifiable risk factor significantly associated with reduced mortality (odds ratio: 0.26; 95% CI:0.21-0.32, P < 0.0001). Youden's index identified the inflection point for time to ORIF as 4 d postinjury: EARLY (≤4 d) and LATE (>4 d). EARLY fixation was associated with a significant decrease in ventilator days, intensive care unit and hospital length of stay, and pulmonary morbidity. CONCLUSIONS Patients undergoing ORIF for FC experienced increased pulmonary morbidity; however, had an associated reduced mortality benefit compared to the nonoperative cohort. EARLY ORIF was associated with a reduction in pulmonary morbidity, without impacting the mortality benefit found with ORIF. Thus, for patients with FC, ORIF performed within 4 d postinjury may help reduce pulmonary morbidity, length of stay, and mortality.
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Affiliation(s)
- Devanshi D Patel
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Benjamin R Zambetti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Li Z, Zhu W, Zhang B, Zhang Y, Li H, Lv B, Zhen Q, Liu L, Liu L, Wu Y, Li S. A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research. J Cardiothorac Surg 2023; 18:359. [PMID: 38098070 PMCID: PMC10722814 DOI: 10.1186/s13019-023-02445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 11/04/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries. METHODS Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes. RESULTS Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility. CONCLUSIONS The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes.
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Affiliation(s)
- Zhe Li
- Department of Thoracic Surgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang City, Hebei, 050000, China
- Department of Thoracic Surgery, Shijiazhuang People's Hospital, No. 365 Jianhua South Street, Shijiazhuang City, Hebei, 050031, China
| | - Weiwei Zhu
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Bing Zhang
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Yaxiao Zhang
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Huixian Li
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Baolei Lv
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Qiang Zhen
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Lin Liu
- Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Lijun Liu
- Department of Thoracic Surgery, Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Yanxin Wu
- Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Shujun Li
- Department of Thoracic Surgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang City, Hebei, 050000, China.
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Ferreira ROM, Pasqualotto E, Viana P, Schmidt PHS, Andrighetti L, Chavez MP, Flausino F, de Oliveira Filho GR. Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials. Eur J Trauma Emerg Surg 2023; 49:2531-2541. [PMID: 37526708 DOI: 10.1007/s00068-023-02339-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/23/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. METHODS Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. RESULTS Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD - 4.34, 95% CI - 6.98, - 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI - 13.51, 4.84); length of intensive care unit stay (WMD - 4.62, 95% CI - 7.19, - 2.05; p < 0.01; I2 = 78%; GRADE: low; PI - 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD - 5.39, 95% CI - 11.38, - 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI - 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. CONCLUSIONS Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.
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Affiliation(s)
- Rafael Oliva Morgado Ferreira
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil.
| | - Eric Pasqualotto
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
| | - Patrícia Viana
- University of the Extreme South of Santa Catarina, Criciúma, Santa Catarina, Brazil
| | | | - Leonardo Andrighetti
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
| | - Matheus Pedrotti Chavez
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
| | - Felippe Flausino
- Federal University of Santa Catarina, R. João Pio Duarte, 144, Córrego Grande, Florianópolis, SC, 88037-000, Brazil
- Joana de Gusmão Children's Hospital, Florianópolis, Santa Catarina, Brazil
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Hoepelman RJ, Kik CC, Beeres FJP, Zwart DLM, Groenwold RHH, Houwert RM. [Treatment of traumatic rib fractures]. Ned Tijdschr Geneeskd 2023; 167:D7434. [PMID: 37742123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Patients with rib fractures are a heterogenous group of patients who are treated by general practitioners as well as by specialized trauma surgeons. We present three patients with rib fractures with different degrees of thoracic trauma and therefore treatments differ significantly. The cornerstone in the treatment of rib fractures remains attaining adequate analgesia and breathing exercises. The last decade, there has been an increase in the utilization of rib fixation, however, precise indications remain unknown. It has proven effective in patients with flail chest on mechanical ventilation in whom it decrease intensive care and hospital length and reduces mortality. In case of prolonged (> 3 months) pain, dyspnea or a clicking sensation one could think of a nonunion of the rib fracture. Rib fixation can relieve these complaints in about 60% of the patients, however due to a high implant irritation rate and secondary operation to remove the osteosynthesis is common.
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Affiliation(s)
| | | | | | - Dorien L M Zwart
- UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijnsgeneeskunde, Utrecht
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Varre JSV, Hopmann P, Wu JL, Bach JA, Suh KI, Goslin BJ, DeVoe WB. In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience. Injury 2023; 54:110871. [PMID: 37353448 DOI: 10.1016/j.injury.2023.110871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/17/2023] [Accepted: 06/02/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF. METHODS A retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days. RESULTS 50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days. CONCLUSION In this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.
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Affiliation(s)
- Jaya Sai V Varre
- Ohio Health Riverside Methodist Hospital, 3535 Olentangy River Road Columbus, Ohio 43214, USA.
| | - Peter Hopmann
- Ohio Health Riverside Methodist Hospital, 3535 Olentangy River Road Columbus, Ohio 43214, USA
| | - Jin L Wu
- Ohio Health Riverside Methodist Hospital, 3535 Olentangy River Road Columbus, Ohio 43214, USA
| | - John A Bach
- Ohio Health Riverside Methodist Hospital, 3535 Olentangy River Road Columbus, Ohio 43214, USA
| | - Kwang I Suh
- Ohio Health Riverside Methodist Hospital, 3535 Olentangy River Road Columbus, Ohio 43214, USA
| | - Brent J Goslin
- Ohio Health Riverside Methodist Hospital, 3535 Olentangy River Road Columbus, Ohio 43214, USA
| | - William B DeVoe
- Ohio Health Riverside Methodist Hospital, 3535 Olentangy River Road Columbus, Ohio 43214, USA
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Meyer DE, Harvin JA, Vincent L, Motley K, Wandling MW, Puzio TJ, Moore LJ, Cotton BA, Wade CE, Kao LS. Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury. Ann Surg 2023; 278:357-365. [PMID: 37317861 PMCID: PMC10527348 DOI: 10.1097/sla.0000000000005950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To compare the effectiveness of surgical stabilization of rib fractures (SSRFs) to nonoperative management in severe chest wall injury. BACKGROUND SSRF has been shown to improve outcomes in patients with clinical flail chest and respiratory failure. However, the effect of SSRF outcomes in severe chest wall injuries without clinical flail chest is unknown. METHODS Randomized controlled trial comparing SSRF to nonoperative management in severe chest wall injury, defined as: (1) a radiographic flail segment without clinical flail or (2) ≥5 consecutive rib fractures or (3) any rib fracture with bicortical displacement. Randomization was stratified by the unit of admission as a proxy for injury severity. Primary outcome was hospital length of stay (LOS). Secondary outcomes included intensive care unit (ICU) LOS, ventilator days, opioid exposure, mortality, and incidences of pneumonia and tracheostomy. Quality of life at 1, 3, and 6 months was measured using the EQ-5D-5L survey. RESULTS Eighty-four patients were randomized in an intention-to-treat analysis (usual care = 42, SSRF = 42). Baseline characteristics were similar between groups. The numbers of total fractures, displaced fractures, and segmental fractures per patient were also similar, as were the incidences of displaced fractures and radiographic flail segments. Hospital LOS was greater in the SSRF group. ICU LOS and ventilator days were similar. After adjusting for the stratification variable, hospital LOS remained greater in the SSRF group (RR: 1.48, 95% CI: 1.17-1.88). ICU LOS (RR: 1.65, 95% CI: 0.94-2.92) and ventilator days (RR: 1.49, 95% CI: 0.61--3.69) remained similar. Subgroup analysis showed that patients with displaced fractures were more likely to have LOS outcomes similar to their usual care counterparts. At 1 month, SSRF patients had greater impairment in mobility [3 (2-3) vs 2 (1-2), P = 0.012] and self-care [2 (1-2) vs 2 (2-3), P = 0.034] dimensions of the EQ-5D-5L. CONCLUSIONS In severe chest wall injury, even in the absence of clinical flail chest, the majority of patients still reported moderate to extreme pain and impairment of usual physical activity at one month. SSRF increased hospital LOS and did not provide any quality of life benefit for up to 6 months.
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Affiliation(s)
- David E Meyer
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - John A Harvin
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Laura Vincent
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Kandice Motley
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Michael W Wandling
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Thaddeus J Puzio
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Laura J Moore
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Bryan A Cotton
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
| | - Charles E Wade
- The Center for Translational Injury Research, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Lillian S Kao
- Department of Surgery; McGovern Medical School at UTHealth Houston, Houston, TX
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12
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Affiliation(s)
- Silvana F Marasco
- CJOB Cardiothoracic Surgery Unit, The Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia.
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13
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Brahme IS, LaRoque MC, Flagstad IR, Cole PA. Open Reduction and Internal Fixation of a Chronic Precordial Flail Chest Segment: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00037. [PMID: 37561659 DOI: 10.2106/jbjs.cc.22.00714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
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.
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Affiliation(s)
- Indraneel S Brahme
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
| | - Michael C LaRoque
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
| | - Ilexa R Flagstad
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
| | - Peter A Cole
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
- HealthPartners Orthopaedics & Sports Medicine, Bloomington, Minnesota
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14
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Wang Z, Jia Y, Li M. The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial. J Cardiothorac Surg 2023; 18:118. [PMID: 37038166 PMCID: PMC10084648 DOI: 10.1186/s13019-023-02203-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/31/2023] [Indexed: 04/12/2023] Open
Abstract
INTRODUCTION Multiple rib fractures (≥ 3 displaced rib fractures and/or flail chest) are severe chest trauma with high morbidity and mortality. Rib fixation has become the first choice for multiple rib fracture treatment. However, the timing of surgical rib fixation is unclear. MATERIALS AND METHODS The present study explored whether early rib fracture fixation can improve the outcome of multiple rib fractures. The present research included patients who were hospitalized in three Jiangsu hospitals following diagnosis with multiple rib fractures. Patients received early rib fracture fixation (≤ 48 h) or delayed rib fracture fixation (> 48 h) utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures included hospital length of stay, intensive care unit (ICU) stay, mechanical ventilation, inflammatory cytokine levels, infection marker levels, infection, and mortality. RESULTS A total of 403 individuals were classified into two groups, namely, the early group (n = 201) and the delayed group (n = 202). Patients belonging to the two groups had similar baseline clinical data, and there were no statistically significant differences between them. Early rib fracture fixation greatly decreased the length of stay in the ICU (4.63 days vs. 6.72 days, p < 0.001), overall hospital stay (10.15 days vs. 12.43 days, p < 0.001), ventilation days (3.67 days vs. 4.55 days, p < 0.001), and hospitalization cost (6900 USD vs. 7600 USD, p = 0.008). Early rib fracture fixation can decrease inflammatory cytokine levels and infection marker levels, prevent hyperinflammation and improve infection in patients with multiple rib fractures. The timing of rib fracture fixation does not influence the surgical procedure time, operative blood loss, 30-day all-cause mortality, or surgical site infection. CONCLUSION The findings from the present research indicated that early rib fracture fixation (≤ 48 h) is a safe, rational, effective and economical strategy and worth clinical promotion.
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Affiliation(s)
- Zhengwei Wang
- Department of Thoracic Surgery, The 904th Hospital of PLA Joint Logistic Support Force, Xing Yuan North Road 101, Wuxi, 214044, China
| | - Yifei Jia
- Department of Thoracic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, 214044, China
| | - Mi Li
- Department of Thoracic Surgery, The 904th Hospital of PLA Joint Logistic Support Force, Xing Yuan North Road 101, Wuxi, 214044, China.
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15
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Simmonds A, Smolen J, Ciurash M, Alexander K, Alwatari Y, Wolfe L, Whelan JF, Bennett J, Leichtle SW, Aboutanos MB, Rodas EB. Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review. J Trauma Acute Care Surg 2023; 94:532-537. [PMID: 36949054 DOI: 10.1097/ta.0000000000003809] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days). METHODS Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0. RESULTS For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia. CONCLUSION In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Alexander Simmonds
- From the Division of Acute Care Surgery, Department of Surgery (A.S., K.A., Y.A., L.W., J.F.W., J.B., S.W.L., M.B.A., E.B.R.), Virginia Commonwealth University, and Virginia Commonwealth University School of Medicine (J.S., M.C.), Richmond, Virginia
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16
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Thomas CN, Lindquist TJ, Schroder LK, Cole PA. Rib Fracture Map in High-Energy Injuries. J Orthop Trauma 2023; 37:e165-e169. [PMID: 36730005 DOI: 10.1097/bot.0000000000002531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Claire N Thomas
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | | | - Lisa K Schroder
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
| | - Peter A Cole
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN
- HealthPartners Orthopaedics & Sports Medicine, Bloomington, MN
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17
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Wang N, Bachman KC, Linden PA, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest. Am Surg 2023; 89:927-934. [PMID: 34732075 PMCID: PMC9061890 DOI: 10.1177/00031348211047490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. METHODS The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. RESULTS 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005). CONCLUSION Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.
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Affiliation(s)
- Naomi Wang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Matthew L Moorman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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18
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Liao CA, Kuo LW, Huang JF, Fu CY, Chen SA, Tee YS, Hsieh CH, Liao CH, Cheng CT, Young TH, Hsu CP. Timely surgical fixation confers beneficial outcomes in patients' concomitant flail chest with mild-to-moderate traumatic brain injury: a trauma quality improvement project analysis - a cohort study. Int J Surg 2023; 109:729-736. [PMID: 37010189 PMCID: PMC10389630 DOI: 10.1097/js9.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/26/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Traumatic flail chest results in respiratory distress and prolonged hospital stay. Timely surgical fixation of the flail chest reduces respiratory complications, decreases ventilator dependence, and shortens hospital stays. Concomitant head injury is not unusual in these patients and can postpone surgical timing due to the need to monitor the status of intracranial injuries. Reducing pulmonary sequelae also assists in the recovery from traumatic brain injury and improves outcomes. No previous evidence supports that early rib fixation can improve the outcome of patients with concomitant flail chest and traumatic brain injury. RESEARCH QUESTION Can early rib fixation improve the outcome of patients with concomitant flail chest and traumatic brain injury? STUDY DESIGN AND METHODS Adult patients with blunt injuries from the Trauma Quality Improvement Project between 2017 and 2019 were eligible for inclusion. Patients were divided into two treatment groups: operative and nonoperative. Inverse probability treatment weighting was used to identify the predictors of mortality and adverse hospital events. RESULTS Patients in the operative group had a higher intubation rate [odds ratio (OR), 2.336; 95% CI, 1.644-3.318; p <0.001), a longer length of stay (coefficient β , 4.664; SE, 0.789; p <0.001), longer ventilator days (coefficient β , 2.020; SE, 0.528; p <0.001), and lower mortality rate (OR], 0.247; 95% CI, 0.135-0.454; p <0.001). INTERPRETATION Timely rib fixation can improve the mortality rate of patients with flail chest and a concomitant mild-to-moderate head injury.
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Affiliation(s)
- Chien-An Liao
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Ling-Wei Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Szu-An Chen
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Yu-San Tee
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Tai-Horng Young
- Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, Republic of China
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19
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Lin CJ, Yeh YS, Lin YK, Chen CW. K-Rod: An Innovative Method of Personalized Rib Splinting for Expeditious Management of Flail Chest in Acute Care Settings. Medicina (B Aires) 2022; 59:medicina59010076. [PMID: 36676700 PMCID: PMC9865151 DOI: 10.3390/medicina59010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Flail chest is a severe type of multiple rib fracture that can cause ventilation problems and respiratory complications. Historically, flail chest has been mainly managed through pain control and ventilatory support as needed. Operative fixation has recently become popular for the condition, and some studies have revealed its potentially positive effects on the outcomes of patients with flail chest. However, for those for whom surgery is unsuitable, few treatment options, other than simply providing analgesia, are available. Herein, we introduce our innovative method of applying personalized rib splinting for quick management of flail chest, which is easy, tailor-made, and has significant effects on pain reduction.
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Affiliation(s)
- Chia-Jung Lin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yung-Sung Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yen-Ko Lin
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Department of Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung 80708, Taiwan
| | - Chao-Wen Chen
- Division of Trauma and Surgical Critical Care, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Department of Emergency Medicine, Faculty of Medicine, College of Medicine, Kaohsiung 80708, Taiwan
- Correspondence:
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20
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Milson N, Treger I, Vered M, Acker A, Kalichman L. Hospital-Based Rehabilitation of Patients Who Had Undergone an Open Reduction and Internal Fixation of the Ribs Due to a Flail Chest: Case Series. Int J Environ Res Public Health 2022; 19:16026. [PMID: 36498097 PMCID: PMC9739889 DOI: 10.3390/ijerph192316026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 06/17/2023]
Abstract
Flail chest, a severe chest injury, is caused by multiple rib fractures. The open reduction and internal fixation (ORIF) of rib fractures is an effective treatment; however, the patients' subsequent condition remains unsatisfactory in terms of the activities of daily living (ADL) and pain. No research study has, as yet, reported on hospital-based rehabilitation of patients who had undergone an ORIF. Our aim was to evaluate the efficacy of hospital-based rehabilitation of flail chest post-ORIF patients. Physical therapists assessed the pain, functional independence measure (FIM), and the Berg balance test. A total of three females and four males (mean age 59.43 ± 18.88) were hospitalized. A significant reduction in pain was observed (7.00 ± 1.83 upon admission to 4.10 ± 2.05 pre-discharge (Z = -2.07, p = 0.027). A significant improvement in FIM (69.43 ± 14.86 upon admission to 113.57 ± 6.40 pre-discharge, Z = -2.37, p = 0.018), and the Berg balance test (35.23 ± 5.87 upon admission to 49.50 ± 3.40 pre-discharge, Z = -2.37, p = 0.018), was observed. Upon admission, all the patients required moderate to complete ADL assistance. Upon discharge, all were independent for all ADL functions. Patients after flail chest post-ORIF can benefit from hospital-based rehabilitation.
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Affiliation(s)
- Nehama Milson
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Iuly Treger
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
- Department of Medicine, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84101, Israel
| | - Michal Vered
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Asaf Acker
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
- Department of Medicine, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84101, Israel
| | - Leonid Kalichman
- Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
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Azuma Y, Iyoda A. [Chest Wall Injury]. Kyobu Geka 2022; 75:878-882. [PMID: 36155586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
A traumatic chest wall injury is a condition that is often encountered in medical practice, but the underlying pathophysiology varies widely depending on the circumstances of the injury and the patient's background. The chest wall, which protects vital organs and provides respiratory movement, can be a life-threatening emergency when injured, thus it is important to respond promptly and appropriately. Because a penetrating chest wall trauma is often associated with intra-thoracic organ damage, it is important to consider an emergency thoracotomy in cases involving massive hemorrhage or air leakage. The ribs and sternum are primarily injured in patients with blunt wall trauma. Flail chest, which is defined as multiple bifocal fractures of the ribs or multiple rib fractures with a sternal fracture, causes respiratory failure secondary to paradoxical respiration. The main treatment for flail chest is ventilatory care and surgical treatment, although early rib fixation has been reported to improve prognosis in recent years. There are several types of devices to fix the ribs and sternum, but selection criteria have yet to be established.
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Affiliation(s)
- Yoko Azuma
- Department of Thoracic Surgery, Toho University, Tokyo, Japan
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22
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Hori S, Miyahara N, Hiratsuka M. [Fixation of Flail Chest with Bioabsorbable Plate]. Kyobu Geka 2022; 75:602-605. [PMID: 35892299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A 57-year-old man presented to our hospital with multiple rib fractures and pleural effusion caused by a traffic accident. We inserted a chest tube and diagnosed him with hemothorax. We performed damage control surgery with right thoracotomy in the emergency room to confirm the bleeding point. The main sources of bleeding were multiple rib fractures and lung injury. We performed partial lung resection and gauze packing into the thoracic cavity and confirmed the stability of the patient's hemodynamics. The next day, we performed a second-look operation at which we fixed the rib fractures and confirmed hemostasis. When fixing the ribs, we used a bioabsorbable plate instead of a metal plate. It has been reported that bioabsorbable plates are less susceptible to infection than metal plates. After the operation, the patient's respiratory condition stabilized, and no signs of infection were noted. In our experience, rib fixation using absorbent plates is useful in surgery that requires attention to infection.
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Affiliation(s)
- Shinichiro Hori
- Department of Thoracic and Cardiovascular Surgery, Saga University, Saga, Japan
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Sawyer E, Wullschleger M, Muller N, Muller M. Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-Analysis. J Surg Res 2022; 276:221-234. [PMID: 35390577 DOI: 10.1016/j.jss.2022.02.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/13/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse. METHODS A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality. RESULTS Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation. CONCLUSIONS Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.
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Affiliation(s)
- Emily Sawyer
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
| | - Martin Wullschleger
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, Griffith University, Southport, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Nicholas Muller
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Michael Muller
- Trauma Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, Griffith University, Southport, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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DeVoe WB, Abourezk M, Goslin BJ, Saraswat N, Kiel B, Bach JA, Suh KI, Eriksson EA. Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation. J Trauma Acute Care Surg 2022; 92:98-102. [PMID: 34629459 DOI: 10.1097/ta.0000000000003426] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR. METHODS A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able. RESULTS Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home. CONCLUSION Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed. LEVEL OF EVIDENCE Therapeutic, Level V.
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Affiliation(s)
- William B DeVoe
- From the Department of Surgery (W.B.D., M.A., B.J.G., N.S., B.K., J.A.B., K.I.S.), Riverside Methodist Hospital, Columbus, Ohio; and Department of Surgery (E.A.E.), Medical University of South Carolina, Charleston, South Carolina
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Boserup B, Sutherland M, Paloka R, McKenney M, Elkbuli A. The Impact of Seatbelt Use on Trauma Outcomes in Adult Motor Vehicle Collision Patients With Rib Fractures: A National ACS-TQP-PUF Database Analysis. J Surg Res 2021; 270:376-385. [PMID: 34739997 DOI: 10.1016/j.jss.2021.06.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 06/11/2021] [Accepted: 06/21/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Motor vehicle collisions (MVCs) are a leading cause of morbidity and mortality. However, there is limited evidence examining the effects seatbelt use has on MVC-related injuries and outcomes in patients with rib fractures. We aim to assess how seatbelt use affects associated injuries and outcomes in adult MVC patients with ≥2 rib fractures. METHODS This retrospective study utilized the American College of Surgeons (ACS) Trauma Quality Programs (TQP) Participant Use File (PUF) Database. Drivers/passengers who sustained ≥2 rib fractures following an MVC and had an AIS ≤2 for extra-thoracic body regions were analyzed. Patients were then subdivided by presence of flail chest into two cohorts, which were subdivided according to injury severity score (ISS) and seatbelt use. Logistic and linear regression was used to assess the impact of seatbelt use on outcomes. RESULTS Among both low and intermediate ISS classifications, restrained patients in the non-flail chest cohort had decreased incidence of pneumothorax, pulmonary contusion, and liver injury (P < 0.001). After adjusting for confounders, restrained patients (versus unrestrained) had decreased odds of pneumothorax (aOR = 0.91, P = <0.001) and acute respiratory distress syndrome (aOR=0.65, P = 0.02), while having increased odds of splenic laceration (aOR = 1.18, P = 0.003) (intermediate ISS group). Compared to unrestrained patients, restrained non-flail chest patients had a significantly decreased hospital length of stay (LOS) and intensive care unit LOS (P < 0.05). CONCLUSIONS Seatbelt use may be protective against serious injuries in patients with ≥2 rib fractures, resulting in improved outcomes. Education programs should be developed to bolster seatbelt compliance.
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Affiliation(s)
- Brad Boserup
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Rinald Paloka
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida.
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Caragounis EC, Xiao Y, Granhed H. Mechanism of injury, injury patterns and associated injuries in patients operated for chest wall trauma. Eur J Trauma Emerg Surg 2021; 47:929-938. [PMID: 30953111 PMCID: PMC8319693 DOI: 10.1007/s00068-019-01119-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/27/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms of injury (MOI), injury patterns, and associated injuries in patients who undergo surgery for chest wall trauma. METHODS This was a retrospective study of trauma patients with multiple rib fractures and unstable thoracic cage injuries who were managed surgically at Sahlgrenska University Hospital during the period September 2010-September 2017. The MOI, injury severity score (ISS), new injury severity score (NISS), thoracic and associated injuries were recorded. Patients were categorized according to age (years): groups I (15‒44), II (45‒64) and III ( > 64). Unstable thoracic cage injuries were classified as sternal, anterior, lateral and posterior flail chest. RESULTS Two hundred and eleven trauma patients with a mean age (years) of 58.2 ± 15.6, mean ISS 23.6 ± 11.0, and mean NISS 34.1 ± 10.6 were included in the study. Traffic accidents were the most common MOI in Group I (62%) and falls in Group III (59%). The most common flail segments were lateral and posterior. Sternal and anterior flail segments were more common with bilateral injuries and traffic accidents, particularly frontal collisions. Injuries in at least three body regions were also more associated with traffic accidents. Diaphragmatic injury was seen in 18% of patients who underwent thoracotomy. CONCLUSIONS The MOI associated with multiple rib fractures differs according to the age of the patient and is associated with different chest wall injury patterns and extra-thoracic injuries.
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Affiliation(s)
- Eva-Corina Caragounis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Per Dubbsgatan 15, 413 45, Gothenburg, Sweden.
| | - Yao Xiao
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Per Dubbsgatan 15, 413 45, Gothenburg, Sweden
| | - Hans Granhed
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Per Dubbsgatan 15, 413 45, Gothenburg, Sweden
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Richman AP, Brahmbhatt TS, Litle VR. Let's not fail the flail chest. Ann Thorac Surg 2021; 113:1865-1866. [PMID: 34270969 DOI: 10.1016/j.athoracsur.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Aaron P Richman
- Division of Trauma and Acute Care Surgery, Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Tejal S Brahmbhatt
- Division of Trauma and Acute Care Surgery, Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Virginia Ruth Litle
- Division of Thoracic Surgery, Department of Cardiovascular Surgery, Intermountain Healthcare, 5169 S Cottonwood St, Ste 640, Murray, UT 84107.
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28
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Di Napoli M, Doben AR, DeVoe WB, Eriksson E. Reversed contour rib plate for surgical stabilization of juxtaspinal rib fractures: Description of a novel surgical technique. J Trauma Acute Care Surg 2021; 90:e163-e168. [PMID: 34016934 DOI: 10.1097/ta.0000000000003150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Marissa Di Napoli
- From the Division of General and Acute Care Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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Choi J, Mulaney B, Laohavinij W, Trimble R, Tennakoon L, Spain DA, Salomon JA, Goldhaber-Fiebert JD, Forrester JD. Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups. J Trauma Acute Care Surg 2021; 90:451-458. [PMID: 33559982 DOI: 10.1097/ta.0000000000003021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE Economic/decision, level II.
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Affiliation(s)
- Jeff Choi
- From the Department of Surgery (J.C., L.T., D.A.S., J.D.F.), Division of General Surgery, Department of Epidemiology and Population Health (J.C.), Surgeons Writing About Trauma (J.C., B.M., R.T., L.T., D.A.S., J.D.F.), and School of Medicine (B.M., R.T.), Stanford University, Stanford, California; Department of Surgery, Chulalongkorn University (W.L.), Bangkok, Thailand; and Stanford Health Policy (J.A.S., J.D.G.-F.), Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
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Apampa AA, Ali A, Kadir B, Ahmed Z. Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2021; 48:1025-1034. [PMID: 33547910 PMCID: PMC7866961 DOI: 10.1007/s00068-021-01606-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/11/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE The objective of this systematic review is to compare the safety and efficacy of surgical fixation of rib fractures against non-surgical interventions for the treatment of flail chest in the adult population. METHODS A search was performed on the 22nd of July 2020 to identify articles comparing surgical fixation versus clinical management for flail chest in adults, with a description of the outcome parameters (resource utility, mortality, adverse effects of the intervention and adverse progression in pulmonary status). Relevant randomised controlled trials were selected, their risk of bias assessed, and the data then extracted and analysed. RESULTS 157 patients were included from four studies in the analyses, with 79 and 78 patients in the surgical and non-surgical groups, respectively. The pooled effects of all outcomes tended towards favouring surgical intervention. Surgical intervention was associated with lower rates of pneumonia (I2 = 46%, Tau2 = 0.16, p = 0.16), significantly lower rates of tracheostomy (I2 = 76%, Tau2 = 0.67, p = 0.02), and a significantly lower duration of mechanical ventilation (I2 = 88%, Tau2 = 33.7, p < 0.01) in comparison to the non-surgical management methods. CONCLUSION Our results suggest that surgical intervention reduces the need for tracheostomy, reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event. There is a need for further well-designed studies with sufficient sample sizes to confirm the results of this study and also detect other possible effects of surgical intervention in the treatment of traumatic flail chest in adults.
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Affiliation(s)
- Ayobobola A Apampa
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ayesha Ali
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Bryar Kadir
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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Spering C, von Hammerstein-Equord A, Lehmann W, Dresing K. [Osteosynthesis of the unstable thoracic wall]. Oper Orthop Traumatol 2020; 33:262-284. [PMID: 33289872 PMCID: PMC7722258 DOI: 10.1007/s00064-020-00688-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 03/08/2020] [Accepted: 03/29/2020] [Indexed: 11/27/2022]
Abstract
Operationsziel Wiederherstellung einer normalen Atemmechanik und Vermeidung beatmungsassoziierter Komplikationen durch operative Stabilisierung eines instabilen Thorax bei dislozierten Rippenserien- und Sternumfrakturen, posttraumatischer Thoraxwanddeformierung, Weaning-Versagen und symptomatischen Rippenpseudarthrosen. Indikationen Kombination mehrerer klinischer und radiologischer Parameter wie das Ausmaß der Rippenserien- und Sternumfrakturen, der Grad der Dislokation, pathophysiologische Veränderungen der Atemmechanik, Versagen eines konservativen Therapieansatzes. Kontraindikationen Akute hämodynamische Instabilität und Zeichen einer systemischen Infektion. Operationstechnik Detaillierte präoperative Planung. Offene, möglichst minimalinvasive Reposition und winkelstabile Osteosynthese mit anatomisch vorgeformten Low-profile-Platten und/oder intramedullären Splints. Vorsichtige Repositionsmanöver und Einbringen der Implantate aufgrund enger Lagebeziehung zu Pleuraspalt, Lunge und Perikard. Weiterbehandlung Möglichst frühzeitiges postoperatives Entwöhnen vom Respirator sowie frühzeitige Therapie eines perioperativen Pneumothorax. Eine Implantatentfernung ist in der Regel nicht notwendig. Ergebnisse In einer retrospektiven Untersuchung profitierten 15 Polytraumapatienten mit instabilem Thorax von der frühen operativen Stabilisierung des Thorax innerhalb von 24–48 h und einer differenzierten, interdisziplinären Behandlungsstrategie. Beatmungsdauer und Pneumonierate waren in der Subgruppe der frühzeitig operierten signifikant niedriger als in der Gruppe der später operativ an der Thoraxwand stabilisierten Patienten. In den Subgruppen der lebensgefährlich Verletzten mit Thoraxtrauma (LVK-Thx und LOTX [LVK-Thx mit Osteosynthese am Thorax]) konnten eine längere Beatmungszeit, Intensivtherapie, Krankenhausverweildauer sowie eine erhöhte beatmungsassoziierte Komplikationsrate als in der Subgruppe der Schwerverletzten ohne Thoraxtrauma (AIS [Abbreviated Injury Scale] ≥ 3) gezeigt werden.
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Affiliation(s)
- Christopher Spering
- Klink für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | | | - Wolfgang Lehmann
- Klink für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Klaus Dresing
- Klink für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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Myers DM, McGowan SP, Taylor BC, Sharpe BD, Icke KJ, Gandhi A. A model for evaluating the biomechanics of rib fracture fixation. Clin Biomech (Bristol, Avon) 2020; 80:105191. [PMID: 33045492 DOI: 10.1016/j.clinbiomech.2020.105191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation. METHODS One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes. FINDINGS Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating. INTERPRETATION This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.
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Affiliation(s)
- Devon M Myers
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA.
| | - Sean P McGowan
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Benjamin C Taylor
- Fellowship Director, Orthopaedic Trauma and Reconstructive Surgery, Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - B Dale Sharpe
- Department Orthopedic Surgery, OhioHealth Grant Medical Center, 285 E. State Street, Suite 500, Columbus, OH 43125, USA
| | - Kyle J Icke
- ZimmerBiomet Research Department, 1520 Tradeport Dr., Jacksonville, FL 32218, USA
| | - Anup Gandhi
- ZimmerBiomet Laboratory Department, 10225 Westmoor Dr., Westminster, CO 80021, USA
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Li J, Wang D, Wang X, Wang C, Wang S. [Clinical Application and Mechanical Analysis of the Treatment of Multiple Rib Fractures and Flail Chest Using Three-wings Rib Plate]. Zhongguo Yi Liao Qi Xie Za Zhi 2020; 44:395-398. [PMID: 33047560 DOI: 10.3969/j.issn.1671-7104.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This research evaluated the clinical efficacy of three-wings rib plate in the treatment of multiple rib fractures and flail chest with mechanical analysis and clinical verification. The model of rib and three-wings rib plate was reconstructed. The contact simulation with pretension stress was applied to the plate's fixation, and it was found that the bearable stress of the rib fractures after fixation increased from the result which indicated a good fixation efficacy of the plate. Clinical data of 53 cases of rib fractures and flail chest treated with three-wings rib plate in Shanghai Pudong Hospital of Fudan University were retrospectively analyzed. After the operation, the pain of the patients was relieved. Postoperative CT reconstruction of the chest showed good restoration of the rib fractures, which verified the clinical efficacy of three-wings rib plate. The three-wings rib plate showed a high value in clinical use for treatment of rib fractures.
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Affiliation(s)
- Jianming Li
- Department of Aeronautics and Astronautics&Institute of Biomechanics, Fudan University, Shanghai, 200433
| | - Dongdong Wang
- Department of Thoracic Surgery, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399
| | - Xiaoqi Wang
- Department of Thoracic Surgery, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399
| | - Changtao Wang
- Department of Thoracic Surgery, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399
| | - Shengzhang Wang
- Department of Aeronautics and Astronautics&Institute of Biomechanics, Fudan University, Shanghai, 200433
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ChudÁČek J, Szkorupa M, Zborovjan P, GregoŘÍk M, StaŠek M, Hanuliak J. [Evolution of Opinions on Chest Wall Stabilisation and Our Experience]. Acta Chir Orthop Traumatol Cech 2020; 87:155-161. [PMID: 32773015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE OF THE STUDY Rib fractures represent one of the most common fractures sustained by 10-40% of all patients with blunt chest trauma, their incidence increases with age. In the current literature, however, new indication criteria continue to emerge. The purpose of this study is to assess the indication criteria, the timing of surgery and the use of individual plates in dependence on fracture location in our patients after the chest wall stabilisation in a retrospective analysis. MATERIAL AND METHODS Our group of patients (n = 349) included the patients who were hospitalised in the Trauma Centre of the University Hospital Olomouc from 1 January 2015 to 31 January 2019, of whom 16 patients were indicated for a surgery. In case of polytrauma, spiral CT was performed, while all patients with a more serious wall chest trauma underwent 3D CT chest wall reconstruction. The surgical approach was chosen based on the fracture location, most frequently posterolateral thoracotomy was opted for. The type of plates was chosen based on the location and type of the fracture. The most common was the lateral type of fracture. RESULTS The most common indication for surgery was multiple rib fractures with major chest wall disfiguration with the risk of injury to intrathoracic organs, present hemothorax or pneumothorax. The age of patients ranged from 44 to 92 years. 8 patients sustained a thoracic monotrauma, the remaining patients suffered multiple injuries, mostly craniocerebral trauma, pelvic or long bone fractures or parenchymal organ injury. The patients were indicated for surgery between 1 hour and 7 days after the hospital admission, on average 3 plates per patient were used and the most commonly used type of plate was the newly modified Judet plate made by Medin. All the patients underwent a surgical revision of pleural cavity, in 3 patients diaphragmatic rupture was found despite a negative preoperative CT scan. The duration of mechanical ventilation in polytrauma patients was 16 days, in thoracic monotrauma patients it was 2 days. CONCLUSIONS Prevailing majority of patients with a blunt chest trauma with rib fractures is still treated non-operatively, which is confirmed also by our group of patients. Nonetheless, correctly and early indicated stabilisation of the chest wall based on accurate indication criteria is of a great benefit to the patients. The aim of each and every trauma centre should be to develop a standardised protocol for the management of blunt chest trauma (the so-called "rib fracture protocol"), which comprises precisely defined criteria for patient admission, multimodal analgesia, indications for surgery, comprehensive perioperative and postoperative care and a subsequent rehabilitation of patients. Key words: rib fracture protocol, chest wall stabilisation, flail chest.
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Affiliation(s)
- J ChudÁČek
- I. chirurgická klinika Fakultní nemocnice Olomouc a Lékařské fakulty Univerzity Palackého v Olomouci
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Beks RB, de Jong MB, Sweet A, Peek J, van Wageningen B, Tromp T, IJpma F, Wouters R, Lansink K, Bemelman M, van Baal M, Hoogendoorn J, Saltzherr T, Groenwold R, Leenen L, Houwert RM. Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol. BMJ Open 2019; 9:e023660. [PMID: 31462458 PMCID: PMC6720131 DOI: 10.1136/bmjopen-2018-023660] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/15/2019] [Accepted: 06/07/2019] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER NTR6833.
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Affiliation(s)
- Reinier B Beks
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Arthur Sweet
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Jesse Peek
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | | | - Tjarda Tromp
- Trauma Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Frank IJpma
- Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Roderick Wouters
- Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Koen Lansink
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Mike Bemelman
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Mark van Baal
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | | | - Teun Saltzherr
- Trauma Surgery, Medisch Centrum Haaglanden, Den Haag, The Netherlands
| | | | - Luke Leenen
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
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Pouwels NSA, van Embden D, Hoogendoorn JM. [Rib fixation for flail chest after resuscitation]. Ned Tijdschr Geneeskd 2018; 162:D1861. [PMID: 30040261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Rib fractures are a common complication caused by chest compressions during resuscitation. Flail chest may occur as a consequence, leading to respiratory failure. CASE DESCRIPTION We present two cases in which surgical rib fixation was performed to treat flail chest after resuscitation. CONCLUSION Based on a literature search, surgical rib fixation may be considered for flail chest after resuscitation in carefully selected patients.
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Affiliation(s)
- Nieck S A Pouwels
- Haaglanden Medisch Centrum (locatie Westeinde), afd. Traumachirurgie, Den Haag
- Contact: N.S.A. Pouwels
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Langenbach A, Pinther M, Krinner S, Grupp S, Ekkernkamp A, Hennig FF, Schulz-Drost S. Surgical Stabilization of Costoclavicular Injuries - A Combination of Flail Chest Injuries and a Clavicula Fracture. Chirurgia (Bucur) 2018; 112:595-606. [PMID: 29088559 DOI: 10.21614/chirurgia.112.5.595] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2017] [Indexed: 11/23/2022]
Abstract
Background: Flail chest injuries (FCI) are associated with a high morbidity and mortality rate. As a concomitant clavicle fracture in FCI even worsens the outcome, the question is how can those costoclavicular injuries (CCI) be managed surgically. Methods: 11 patients with CCI were surgically treated by a locked plate osteosynthesis of the Clavicle and the underlying ribs through limited surgical approaches under general anesthesia. Patients were followed up after 2, 6, 12, 26 and 52 weeks. Results: All patients showed severe chest wall deformity due to severely displaced fractures of the ribs and the clavicle. They were suffering from pain and restriction of respiratory movements. The chest wall could be restored to normal shape in all cases with uneventful bone healing and a high patient convenience. Fractures of the clavicle and the second rib were managed through an innovative clavipectoral approach, the others through standard approaches to the anterolateral and the posterolateral chest wall. Two patients complained about numbness around the lateral approach and lasting periscapular pain. Conclusions: Surgical stabilization might be the appropriate therapy in CCI with dislocated fractures since they would cause severe deformity and loss of function of the chest wall and the shoulder.
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Schulz-Drost S, Krinner S, Langenbach A, Merschin D, Grupp S, Hennig FF, Ekkernkamp A, Mauerer A. The Operative Management of Flail Chest Injuries with Concomitant Sternal Fracture. Chirurgia (Bucur) 2018; 112:573-593. [PMID: 29088557 DOI: 10.21614/chirurgia.112.5.573] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2017] [Indexed: 11/23/2022]
Abstract
Background: Flail Chest Injuries (FCI) are one of the most severe thoracic injuries. Moreover, an additional sternal fracture (SF) even worsens the outcome, such as the duration of mechanical ventilation, therefore an surgical fixation of the fractures could be considered in certain cases to improve the weaning from the ventilator. This paper aims to emphasize on the management of different types of SF in FCI. Methods: All surgically treated cases (2012-2016) that showed the combination of FCI and SF have been evaluated for their clinical details, the morphology of the fractures and the technical aspects of the surgical procedure in a retrospective investigation. Results: All of the SF (n=15) had been fixed by locked plate osteosynthesis through a median approach in a supine position. Three main regions of the sternum showed the need for different fixation strategies: the upper manubrium, central and lower corpus sterni. Concomitant rib fractures were addressed either through the same approach or through additional limited incisions. Conclusions: Combinations of SF and FCI are high risc injuries with high demand on surgical skills. They can be properly fixed with a locking plate osteosynthesis through a combination of limited incisions employing different types of plates depending on the type of SF.
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Neckelmann K, Hagelberg R. [Osteosynthesis of rib fractures, unstable chest wall, pseudoarthroses, and acquired defects of the chest wall]. Ugeskr Laeger 2018; 180:V06170455. [PMID: 29429475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Several patients suffer from rib fractures after traumas, and in severe cases it can be life-threatening. Until recently, attempts to perform surgical fixation in patients with instability have been unsuccessful. Chronic non-union causes persistent pain, disability and loss of quality of life. Implementation of surgical stabilization of rib fractures with tailored plates seems to improve pain relief, especially in cases of non-union but also in patients with instability of the chest wall after severe traumas, where advanced pain treatment (epidural catheter) is insufficient or weaning off fails.
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Vyhnánek F, Jírava D, Očadlík M, Škrabalová D, Šáber M, Michal P. [Innovated Judet Ribs Plates - Preclinical Study, First Clinical Experience]. Acta Chir Orthop Traumatol Cech 2018; 85:226-230. [PMID: 30257784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE OF THE STUDY Based on the experience with using the Judet plates in stabilization of rib fractures an innovated Judet plate was constructed in cooperation with the Development Department of Medin company. During the preclinical part of the project, following the construction of the new Judet plate, a surgical technique was elaborated. Subsequently, the clinical application of rib osteosynthesis with innovated plates was commenced. MATERIAL AND METHODS In the course of the last three years the innovated Judet rib plate including the instruments were constructed by the Development Department of Medin company in cooperation with the Trauma Centre and the Department of Surgery of the University Hospital Královské Vinohrady. The goal of the innovation was the changes in technical parameters of rib plates which are compared with the new plates of other companies: 1. Adequate plate stability along the rib axis. 2. Creation of fixation clips for a stable, but not traumatized fixation of the plate around the rib. 3. Decreased robustness of the plate with sufficient stiffness. 4. Working out of a new technique of plate fixation with the use of new instruments. 5. Ensuring plate fixation with cortical locking screws. In the preclinical part of the project osteosynthesis of the broken rib was performed with a plate on a chest model for the basic types of rib fractures. Subsequently, the plate was used for rib osteosynthesis in a cadaver. The goal of the new instruments was besides temporarily maintaining the rib fracture reduction also the subsequent temporary application of plates with the assistance of fixation tongs before the final fixation of plates. In 2017, the clinical part of the project on the stabilisation of flail chest with the innovative Judet plates was launched. This type of innovative Judet plates has so far been used in 3 patients. RESULTS As to the surgical technique of ribs osteosynthesis: The profile of the plate has been adapted to the rib profile and can be further adjusted to rib curvature, also the fixation shoulders of the plates have been reshaped. The innovated plate has been complemented with a new configuration of fixation clips and the possibility to fix the plate with locking screws. The used cortical locking screws enable appropriate stabilisation of plates. They were tested on a laboratory model of ribs and on a cadaver using the new set of instruments. The plates can be easily shaped with tongs. The anchorage of fixation clips is adequately provided for also by means of tongs. The plates can be fixed to the rib without any significant compression of intercostal nerves. The essential change of the innovated Judet plate is its weight, which meets the contemporary trends in construction of rib plates designed for anatomical fixation. The first experience with the innovated plates in flail chest injury confirmed the safety of the procedure for stable osteosynthesis of rib fractures. Adequate stability of the chest wall facilitated an early withdrawal of ventilatory support. Osteosynthesis of rib fractures with innovated plates performed in the first three patient was without complications, including in the postoperative period. DISCUSSION A series of prospective studies prove the correctness of the indications of early rib osteosynthesis in flail chest. Further indications for rib osteosynthesis are postinjury chest deformity, dislocation of rib fracture fragments with a lung injury, and malunion of rib fracture. According to these studies the surgical stabilisation of the chest is a safe and efficient method resulting in pain reduction, decrease of ventilatory support time, and also in reduced morbidity. For rib osteosynthesis anatomical plates, Judet plates and intramedullary plates are used. Our innovation of the Judet plate aimed to improve the technical parameters of the plate. The innovative Judet plate means a significant improvement in technical parameters and stands comparison with the plates of others companies, which are used in the Czech Republic. This is also evidenced by preliminary clinical results. CONCLUSIONS Surgical stabilisation of the flail chest segment is considered to be he method of choice in treating selected patients, leading to the improvement of respiratory function and shortening of the ventilatory support time. The new technical parameters of the plate, including its weight, new fixation clips, locking screws and instruments are the priorities of the innovated Judet plates. The innovation of Judet plates represents an important step towards the extension of indications for surgical stabilisation of the chest. Key words:innovative Judet plates, preclinical study, osteosynthesis of rib fractures.
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Affiliation(s)
- F Vyhnánek
- Traumatologické centrum Fakultní nemocnice Královské Vinohrady, Praha
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Taketani S, Makimoto Y, Kunitake M, Anegawa T. [Surgically Managed Flail Chest Caused by Resuscitation]. Kyobu Geka 2016; 69:1013-1016. [PMID: 27821827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A 84-year-old man who had experienced cardiac arrest in the ambulance was brought to the emergency room. He had been followed at outpatient after surgery for colon cancer and known to be suffered from mild renal impairment. The cardio pulmonary arrest was likely to be caused by acute exacerbation of that. He was resuscitated and immediately recovered without severe hypoxic encephalopathy or deterioration of renal function. However, the flail chest by manual cardiac compression sustained. It urged him to be managed under the ventilator and he seemed difficult to leave from that within a couple of weeks. So we decided to perform surgery. The course after surgery was favorable.
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Affiliation(s)
- Sonofu Taketani
- Division of Surgery, Tobata Kyoritsu Hospital, Kitakyushu, Japan
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Nolasco-de la Rosa AL, Mosiñoz-Montes R, Matehuala-García J, Cuautle-Ramírez AA, Román-Guzmán E, Reyes-Miranda AL, Quero-Sandoval F. [Thoracic inestability fixed with bioabsorbable screws and plates]. Acta Ortop Mex 2016; 30:311-315. [PMID: 28549363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Flail chest is managed with mechanical ventilation or inhaloteraphy and analgesia. Little has been published on the use of bioabsorbable material and its evolution in flail chest fixation. METHODS This is a descriptive study of patients with unstable chest undergoing fixation with bioabsorbable plates and screws in a period from February 2009 to December 2011. RESULTS We report 18 cases, aged 33-74 years (mean 53), three with bilateral involvement; rib fixation was performed between 1-21 days of the accident (mean 1.5). They started walking the next day in 14 cases; postoperative stay was four days (range 3-14). The heart rate of patients prior to surgery was 90 per minute (range 82-100) and lowered to 84 after fixation (range 82-92), preoperative respiratory rate was 26 per minute (range 22-28) and below 22 per minute (range 20 to 26) in postoperative period. CONCLUSIONS The use of bioabsorbable material for osteosynthesis of costal fractures did not show side effects in our period of study.
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Affiliation(s)
- A L Nolasco-de la Rosa
- Servicio de Cirugía General y Tórax. Centro Médico ISSEMyM Ecatepec (CMIE). Av. del Trabajo s/n, esq. Av. Revolución No. 3030, Del Carmen, 55000 Ecatepec de Morelos, Estado de México. México
| | - R Mosiñoz-Montes
- Servicio de Oncocirugía. Centro Médico ISSEMyM Ecatepec (CMIE). Av. del Trabajo s/n, esq. Av. Revolución No. 3030, Del Carmen, 55000 Ecatepec de Morelos, Estado de México. México
| | - J Matehuala-García
- Servicio de Ortopedia. Centro Médico ISSEMyM Ecatepec (CMIE). Av. del Trabajo s/n, esq. Av. Revolución No. 3030, Del Carmen, 55000 Ecatepec de Morelos, Estado de México. México
| | - A A Cuautle-Ramírez
- Servicio de Cirugía. Centro Médico ISSEMyM Ecatepec (CMIE). Av. del Trabajo s/n, esq. Av. Revolución No. 3030, Del Carmen, 55000 Ecatepec de Morelos, Estado de México. México
| | - E Román-Guzmán
- Servicio de Cirugía. Centro Médico ISSEMyM Ecatepec (CMIE). Av. del Trabajo s/n, esq. Av. Revolución No. 3030, Del Carmen, 55000 Ecatepec de Morelos, Estado de México. México
| | - A L Reyes-Miranda
- Cirugía General. Centro Médico ISSEMyM Ecatepec (CMIE). Av. del Trabajo s/n, esq. Av. Revolución No. 3030, Del Carmen, 55000 Ecatepec de Morelos, Estado de México. México
| | - F Quero-Sandoval
- Cirugía General. Centro Médico ISSEMyM Ecatepec (CMIE). Av. del Trabajo s/n, esq. Av. Revolución No. 3030, Del Carmen, 55000 Ecatepec de Morelos, Estado de México. México
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Abstract
BACKGROUND Rib fractures are common after chest wall trauma. For patients with flail chest, surgical stabilization is a promising technique for reducing morbidity. Anatomical difficulties often lead to an inability to completely repair the flail chest; thus, the result is partial flail chest stabilization (PFS). We hypothesized that patients with PFS have outcomes similar to those undergoing complete flail chest stabilization (CFS). METHODS A prospectively collected database of all patients who underwent rib fracture stabilization procedures from August 2009 until February 2013 was reviewed. Abstracted data included procedural and complication data, extent of stabilization, and pulmonary function test results. RESULTS Of 43 patients who underwent operative stabilization of flail chest, 23 (53%) had CFS and 20 (47%) underwent PFS. Anterior location of the fracture was the most common reason for PFS (45%). Age, sex, operative time, pneumonia, intensive care unit and hospital length of stay, and narcotic use were the same in both groups. Total lung capacity was significantly improved in the CFS group at 3 months. No chest wall deformity was appreciated on follow-up, and no patients underwent additional stabilization procedures following PFS. CONCLUSION Despite advances in surgical technique, not all fractures are amenable to repair. There was no difference in chest wall deformity, narcotic use, or clinically significant impairment in pulmonary function tests among patients who underwent PFS compared with CFS. Our data suggest that PFS is an acceptable strategy and that extending or creating additional incisions for CFS is unnecessary.
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Affiliation(s)
- Terry P Nickerson
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Cornelius A Thiels
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Brian D Kim
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Martin D Zielinski
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Donald H Jenkins
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Henry J Schiller
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Tonglet M, Desiron Q, Marechal H, Pitance F, Degesves S. [Surgical fixation in flail chest : a local first encouraging experience]. Rev Med Liege 2016; 71:356-359. [PMID: 28383845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We report the case of a young woman who suffered from a severe traffic accident with major thoracic trauma consisting of hemopneumothorax and flail chest. At day 5 of mechanical ventilation, a surgical reduction and fixation of the fractured ribs were performed; the patient was liberated from mechanical ventilation the next day and discharged from the intensive care unit two days later. The success of this local first case incites us to further a similar approach in such challenging trauma cases.
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Affiliation(s)
- M Tonglet
- Service des Urgences, CHR Citadelle, Liège
| | - Q Desiron
- Service de Chirurgie cardiothoracique, CHR Citadelle, Liège
| | - H Marechal
- Service des Soins intensifs, CHR Citadelle, Liège
| | - F Pitance
- ) Service d'Anesthésie, CHR Citadelle, Liège
| | - S Degesves
- Service des Urgences, CHR Citadelle, Liège
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Abstract
BACKGROUND Thoracic trauma (TT) is common among people with multiple traumatic injuries. One of the injuries caused by TT is the loss of thoracic stability resulting from multiple fractures of the rib cage, otherwise known as flail chest (FC). A person with FC can be treated conservatively with orotracheal intubation and mechanical ventilation (internal pneumatic stabilization) but may also undergo surgery to fix the costal fractures. OBJECTIVES To evaluate the effectiveness and safety of surgical stabilization compared with clinical management for people with FC. SEARCH METHODS We ran the search on the 12 May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), EMBASE Classic and EMBASE (OvidSP), CINAHL Plus (EBSCO), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), and clinical trials registers. We also screened reference lists and contacted experts. SELECTION CRITERIA Randomized controlled trials of surgical versus nonsurgical treatment for people diagnosed with FC. DATA COLLECTION AND ANALYSIS Two review authors selected relevant trials, assessed their risk of bias, and extracted data. MAIN RESULTS We included three studies that involved 123 people. The methods used for blinding the participants and researchers to the treatment group were not reported, but as the comparison is surgical treatment with medical treatment this bias is hard to avoid. There was no description of concealment of the randomization sequence in two studies.All three studies reported on mortality, and deaths occurred in two studies. There was no clear evidence of a difference in mortality between treatment groups (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.13 to 2.42); however, the analysis was underpowered to detect a difference between groups. Out of the 123 people randomized and treated, six people died; the causes of death were pneumonia, pulmonary embolism, mediastinitis, and septic shock.Among people randomized to surgery, there were reductions in pneumonia (RR 0.36, 95% 0.15 to 0.85; three studies, 123 participants), chest deformity (RR 0.13, 95% CI 0.03 to 0.67; two studies, 86 participants), and tracheostomy (RR 0.38, 95% CI 0.14 to 1.02; two studies, 83 participants). Duration of mechanical ventilation, length of intensive care unit stay (ICU), and length of hospital stay were measured in the three studies. Due to differences in reporting, we could not combine the results and have listed them separately. Chest pain, chest tightness, bodily pain, and adverse effects were each measured in one study. AUTHORS' CONCLUSIONS There was some evidence from three small studies that showed surgical treatment was preferable to nonsurgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical ventilation, and length of ICU stay. Further well-designed studies with a sufficient sample size are required to confirm these results and to detect possible surgical effects on mortality.
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Affiliation(s)
- Antonio José Maria Cataneo
- São Paulo State UniversityDepartment of Surgery & OrthopedicsDistrito de Rubião Júnior, s/nSão PauloBrazil18618‐970
| | - Daniele C Cataneo
- São Paulo State UniversityDepartment of Surgery & OrthopedicsDistrito de Rubião Júnior, s/nSão PauloBrazil18618‐970
| | - Frederico HS de Oliveira
- São Paulo State UniversityDepartment of Surgery & OrthopedicsDistrito de Rubião Júnior, s/nSão PauloBrazil18618‐970
| | - Karine A Arruda
- São Paulo State UniversityDepartment of Surgery & OrthopedicsDistrito de Rubião Júnior, s/nSão PauloBrazil18618‐970
| | - Regina El Dib
- Botucatu Medical School, Universidade Estadual Paulista (UNESP)Department of AnaesthesiologyDistrito de Rubião Júnior, s/nBotucatu, São PauloBrazil18603‐970
| | - Paulo Eduardo de Oliveira Carvalho
- Marilia Medical SchoolEvidence Based Health Actions Department and Thoracic Surgery DepartmentAvenida Monte Carmelo, 800Bairro FragataMariliaSao PauloBrazil17519‐030
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Vyhnánek F, Jirava D, Očadlík M, Škrabalová D. [Surgical Stabilisation of Flail Chest Injury: Indications, Technique and Results]. Acta Chir Orthop Traumatol Cech 2015; 82:303-307. [PMID: 26516736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE OF THE STUDY Multiple rib fractures with segmental chest wall instability are caused by high-energy chest trauma and are associated with significant morbidity and mortality. Flail chest injuries are mostly combined with lung injury (contusion, rupture, laceration) and subsequent pneumothorax or haemothorax. Early mechanical ventilation with internal pneumatic splinting is a conservative treatment for flail chest in patients with respiratory insufficiency. The surgical stabilisation of a flail chest is an effective method of treatment and is beneficial for selected patients. It shortens the duration of mechanical ventilation and thus reduces morbidity associated with prolonged ventilatory support. In addition, it decreases long-term pain and the inability of a flail chest to heal due to malunion, non-union or progressive collapse of the flail segment. Surgical stabilisation of a flail chest is indicated when the clinical examination shows progressive respiratory dysfunction confirmed by the results of multiple detector computer tomography (MDCT) of the thorax. MATERIAL AND METHODS Thirty-three consecutive patients who underwent surgical stabilisation of a flail chest at the Trauma Centre between 2010 and 2014 were retrospectively evaluated. This included patient demographics, chest injury extent, results of pre-operative chest imaging (MDCT), surgical stabilisation technique and post-operative outcome. In addition to providing a radiographic finding of respiratory failure, the result of MDCT chest examination was considered an important criterion for surgical intervention. Surgical stabilisation of the chest wall was performed at an interval ranging from 2 hours to 11 days after injury. Intra-thoracic procedures were indicated in patients with lung injury (pulmonary laceration). The surgical procedure was completed by chest tube placement. RESULTS Surgical stabilisation was carried out using 3 to 8 plates for flail segment fixation involving 3 to 4 ribs. The duration of post- operative mechanical ventilation was 5 days on the average. It was longer in patients with associated injuries such as craniocerebral trauma or severe pulmonary contusion. Tracheostomy was performed in seven patients requiring prolonged mechanical ventilation. Two patients had superficial surgical site infection. No death was recorded in the follow-up period. CONCLUSIONS Surgical stabilisation of the flail chest segment is considered an effective procedure in selected patients, leading to improvement of respiratory function. By allowing for a shorter period of time on mechanical ventilation, it reduces the occurrence of complications due to ventilatory support. The result of MDCT chest examination in patients with fail chest is an important indication criterion for surgical fixation.
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Lozano-Corona R, Loyola-Garcia U, Partida IC, Rodriguez-Ortega F. Successful treatment of flail chest with chondrosternal disruption and traumatic parasternal lung hernia with titanium rib bridges. BMJ Case Rep 2013; 2013:bcr2013008887. [PMID: 23608852 PMCID: PMC3645800 DOI: 10.1136/bcr-2013-008887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The surgical principles for the treatment of flail chest have yet to be fully established. Furthermore, the relationship between flail chest and lung hernias is unclear. We report here a rare case of chondrosternal traumatic disruption and lung hernia that was treated with a novel technique using titanium rib bridges and clips, which successfully reduced the hernia defect and provided stability to the chest wall. This procedure was beneficial in minimising the patient's ventilation time and time away from work.
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Affiliation(s)
- Rodrigo Lozano-Corona
- Department of Thoracic Surgery and Pneumology Service, General Surgery Service, Medical Center of Instituto de Seguridad Social del Estado de México y Municipios (ISSEMYM), San Jerónimo Chicahualco, Metepec, Estado de México
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Vyhnánek F, Skála P, Skrabalová D. [A contribution of multidetector computed tomography to indications for chest wall stabilisation in multiple rib fractures]. Acta Chir Orthop Traumatol Cech 2011; 78:258-261. [PMID: 21729644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE OF THE STUDY Multidetector computed tomography (MDCT) is more sensitive for the detection of injury to the thoracic wall and intra-thoracic organs than a plain chest radiograph. The chest wall deformity and instability following multiple rib fracture involves fractures of four or more adjacent ribs at two levels, sometimes including a sternal fracture. It may also be associated with lung trauma (pneumothorax, haemothorax, rupture, laceration or pulmonary contussion). An isolated multiple-rib fracture can successfully be treated conservatively. Early intubation and mechanical ventilation are indicated in patients with progressive respiratory insufficiency. Indications for surgical stabilisation of this fracture are based on the signs of respiratory failure and the results of imagining methods (MDCT at the present time). MATERIAL AND METHODS Examination by MDCT was carried out in patients with severe thoracic trauma. In five patients with multiple rib fractures, the CT findings were included in indication criteria for open rib osteosynthesis and thoracotomy. A clinical indication criterion was respiratory insufficiency after the patient's weaning from a ventilator, manifested by paradoxical chest motion. A radiographic indication included an extensive chest deformity with rib displacement into the pleural cavity in 3D reconstruction from MDCT images. Surgery was performed within one hour to five days of admission. Access was gained through an oblique skin incision and by cutting though the chest wall muscles to release fractured ribs. To explore the thoracic cavity, a defect in the intercostal muscles was extended by an incision at the site of rib fracture. Suction of a haemothorax was done and lung ruptures were sutured in three patients. After chest drain insertion, the fractured ribs were stabilized by plate osteosynthesis (fy Medin). RESULTS In the post-operative period, mechanical ventilation was continued for 3 to 6 days in four patients. There were no complications. In the patients with flail chest, the 3D reconstruction from MDCT images allowed us to make more exact pre- operative decisions concerning the extent of rib osteosynthesis and the method of exposure. If lung injury was also shown, this was an indication for thoracic cavity exploration. DISCUSSION The pathophysiological effects of flail chest involve several factors including the size of a flail segment, change in intra-thoracic pressure during spontaneous breathing and multiple injuries to the intra-thoracic organs. Therapy is related to the seriousness of respiratory disorder associated with flail chest, the degree of chest wall deformity and other complications of conservative treatment (dependence on mechanical ventilation with no possibility of weaning). Surgical stabilization of the chest wall is the most reliable method of treatment which allows us to avoid or interrupt the adverse effect of rib displacement and chest instability. A contribution of MDCT examination to the indication for surgical stabilization lies in that MDCT provides imagining of the details decisive for the classification of fracture types including their tendency to displacement. MDCT permits a better visualisation of chest injury and a better understanding of the respiratory disorder. CONCLUSIONS Based on 3D reconstruction from MDCT images, it is possible to make the pre-operative considerations for rib osteo- synthesis more specific and to choose the best approach. At the same time MDCT enables us to diagnose associated intra-thoracic injuries and provides indications for their treatment. In addition, it gives us a possibility to evaluate the role of a flail segment in breathing dysfunction and to establish indications for surgical stabilization in multiple rib fractures. Rib osteosynthesis allowed for early stabilization of the chest wall and improved the mechanics of breathing, thus requiring a shorter period of mechanical ventilation. The evaluation of statistical significance of these facts will be made when a larger group of patients examined by MDCT is available.
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Thomasson J, Maxwell R. Intercostal hernias. Am Surg 2010; 76:E125-E127. [PMID: 21513632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Chittawatanarat K, Chotirodniramit N, Chandacham K, Molloy R, Laokul C. Frame-composite mesh: a new method to treat complex unstable flail chest: a case report. J Med Assoc Thai 2010; 93:123-127. [PMID: 20196421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A middle aged Thai male was admitted suffering from a severely unstable flail chest caused by an elephant having trampled on the upper right part of his chest. He failed to respond to conservative treatment and conventional surgery could not be performed due to the bony defect in the chest wall. Consequently, a frame-composite mesh was designed and constructed in close collaboration with Chiang Mai University's Biomedical Polymers Technology Unit. After implantation, the patient could be taken off a mechanical ventilator successfully without any adverse event. Two weeks after surgery, he was found to have good pulmonary function and so the clinical outcome was judged to be successful.
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Affiliation(s)
- Kaweesak Chittawatanarat
- Division of Trauma and Critical Care Medicine, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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