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Mean lengths of stay and DMV for SSRF group with flail chest versus MCG with flail chest, and SSRF group without flail chest versus MCG without flail chest.
Source publication
Objectives:
To compare outcomes in patients with rib fractures (RFX) who underwent surgical stabilization of rib fractures (SSRF) to those treated non-operatively.
Design:
Retrospective cohort study SETTING:: Two Level 1 Trauma Centers. Florida, USA PATIENTS:: 174 patients with multiple rib fractures divided in 2 groups: Patients with Surgically...
Contexts in source publication
Context 1
... our study, the incidence of flail chest was 5 times higher in SSRF patients, and it was statistically significant (Table 1). We also found that SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV with the MCG patients with flail chest (Fig. 3). SSRF patients without flail chest had statistically significantly longer HLOS and ICULOS compared with the MCG patients without flail chest (Fig. 3). In recent study, Farguhar et al 17 observed longer hospital and ICU stays in patients with flail chest after surgical fixation. DeFreest et al 18 also reported longer hospitalization in ...
Context 2
... higher in SSRF patients, and it was statistically significant (Table 1). We also found that SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV with the MCG patients with flail chest (Fig. 3). SSRF patients without flail chest had statistically significantly longer HLOS and ICULOS compared with the MCG patients without flail chest (Fig. 3). In recent study, Farguhar et al 17 observed longer hospital and ICU stays in patients with flail chest after surgical fixation. DeFreest et al 18 also reported longer hospitalization in polytrauma patients with flail chest treated with SSRF compared to those treated with nonoperative ...
Context 3
... our study, the incidence of flail chest was 5 times higher in SSRF patients, and it was statistically significant (Table 1). We also found that SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV with the MCG patients with flail chest (Fig. 3). SSRF patients without flail chest had statistically significantly longer HLOS and ICULOS compared with the MCG patients without flail chest (Fig. 3). In recent study, Farguhar et al 17 observed longer hospital and ICU stays in patients with flail chest after surgical fixation. DeFreest et al 18 also reported longer hospitalization in ...
Context 4
... higher in SSRF patients, and it was statistically significant (Table 1). We also found that SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV with the MCG patients with flail chest (Fig. 3). SSRF patients without flail chest had statistically significantly longer HLOS and ICULOS compared with the MCG patients without flail chest (Fig. 3). In recent study, Farguhar et al 17 observed longer hospital and ICU stays in patients with flail chest after surgical fixation. DeFreest et al 18 also reported longer hospitalization in polytrauma patients with flail chest treated with SSRF compared to those treated with nonoperative ...
Citations
... On admission to the ICU, median ISS and SAPS II were 32 [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] and 24 [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] (Table S1). Spine injuries were detected in 28 (17.6%) ...
... On admission to the ICU, median ISS and SAPS II were 32 [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] and 24 [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] (Table S1). Spine injuries were detected in 28 (17.6%) ...
... We referred to surgery patients with (I) need of urgent thoracotomy; (II) evident clinical or CT scan chest wall deformation; (III) presence of a paradoxical ventilation with respiratory insufficiency and (IV) failure of adequate analgesia management complicated with ineffective cough and bronchial congestion. Using these guidelines also reported by other authors, less than 10% of chest wall trauma would require surgery (14,(26)(27)(28) with evident clinical benefits compared to conservative treatment. ...
Background:
Surgical rib fixation for multiple rib fractures and flail chest has become more common in the 2000s with interesting results in selected patients. However, surgical rib fixation lacks a consensus on the delay to surgery and the benefits on postoperative clinical outcomes. Our goal was to determine if delay to surgery can affect postoperative outcomes.
Methods:
We analyzed a retrospective database including all consecutive patients referred for surgical rib fixation. All outcomes were explored according to trauma mechanism, associated lesions, initial ventilatory status, delay to surgery, surgical technique and a specific focus was made towards post-operative care and pulmonary complications. Logistic regressions were performed to evaluate the association between delay to surgery [before 48 hours (early group), 48 hours to 7 days (mid group), more than 7 days (late group)] and pneumonia and failure of extubating.
Results:
From 2010 to 2020, 159 patients underwent surgical rib fixation. The median hospital length of stay was 18 days (interquartile range, 13-30 days). Pulmonary infections were encountered in 67 patients (42.2%) with about two third of early pneumonia (<5 days). The one-month mortality rate was 1.9%. Delay to surgery was not associated with either pneumonia (P>0.05) or failure of extubating (P>0.05).
Conclusions:
Surgical rib fixation can be delayed without increasing the risk of pulmonary complications. Stabilizing other clinical situations can be safely prioritized if needed. A global evaluation including characteristics of trauma and lung evaluation must be considered before surgical stabilization of rib fracture.
... Other signs of respiratory distress may also be present. Flail chest is an emergent condition necessitating transport to the emergency department and may require mechanical ventilation and surgical fixation [6,24,28,54,58]. ...
Most injuries in American football are orthopedic, but the medical team must also be prepared to recognize and manage injuries beyond the musculoskeletal system that may result from trauma to the face, chest, abdomen, and pelvic regions. Failure to promptly identify such injuries in athletes can be life-threatening or permanently disabling. The literature on many of the nonorthopedic sports injuries is limited but can aid in understanding injury presentation, imaging modalities of choice, and initial management. Safe return-to-play decision-making requires a thoughtful approach through the use of available data and an understanding of pathophysiology and tissue healing.
... Discussions on surgical timing have been extensively covered in the literature. Many studies recommend that operative repair occurs within the first 48-72 hours post-trauma as inflammation and callus formation have yet to occur, resulting in an easier operation [12, 35,39]. When comparing surgical timing in patients undergoing rib fixation within three, six, or 10 days after hospital admission, Otaka et al. found that surgical rib fixation within three days after admission was associated with a shorter duration of mechanical ventilation (percent difference, -42.9%; 95% CI, -57.4 to -23.3) and shorter HLOS (percent difference, -19.6%; 95% CI, -31.8 to -5.2) [40]. ...
Timely repair is essential to maximizing outcomes in patients with traumatic rib injuries, whether in the presence or absence of flail chest (FC) or existing as single or multiple rib fractures (MRF), due to its high morbidity and mortality rate. This review focuses primarily on the plating system as an effective surgical approach to stabilizing these injuries.
Literature was surveyed using the Google Scholar, PLOS One, and PubMed search engines between August 2021 and April 2022. A total of 34 articles were included herein, and primary and secondary outcomes were assessed. The primary outcomes of interest were intensive care unit length-of-stay (ICU LOS), hospital length-of-stay (HLOS), ventilatory requirements, and mortality rate. The secondary outcomes of interest were postoperative pain level and postoperative complications.
The majority of the studies included herein reported lower ICU LOS, HLOS, and ventilation requirements in surgical patients when compared to conservatively managed patients. However, variables such as the presence or absence of FC also impacted outcomes in certain studies. Mortality rate and postoperative pain were largely underreported in the selected studies, but limited data from these studies suggest that these outcomes tend to be lower in surgical patients compared to those treated conservatively. When present, postoperative complications were often less severe amongst surgical patients compared to conservatively managed patients. Results further suggest that surgical repair is associated with lower pain severity as early as 72 hours postop. Likewise, findings suggest that early rib fracture stabilization is superior to late stabilization and often yields a sooner return to a baseline health status.
Few studies report little to no statistical difference in primary and secondary outcomes between operative and conservative treatment. However, there is greater evidence that suggests the contrary, with better short-term and potential for better long-term outcomes in patients who undergo rib fixation.
... Multiple studies [7,35,36] have reported that lung contusions were associated with worse outcomes and prolonged ICU and hospital LOS. Fokin et al. and Dhar et al. did not find differences in ICU LOS with or without lung contusions in major trauma patients [37,38]. e findings of this study can add weight to their argument that lung contusions do not increase ICU LOS. ...
... It is likely associated with the presence or absence of a flail chest. Fokin et al. have reported longer ICU LOS for those who had surgical rib stabilization [37]. In 3 subsequent meta-analyses, surgical rib stabilization of multiple rib fractures with flail chest was associated with a decrease in the ICU LOS [15,16,40]. ...
Background:
Chest injury with multiple rib fractures is the most common injury among major trauma patients in New South Wales (23%) and is associated with a high rate of mortality and morbidity. The aim of this study was to determine the intensive care unit (ICU) length of stay (LOS) among major trauma patients with multiple rib fractures and to identify factors associated with a prolonged ICU LOS.
Materials and methods:
Single-centre, retrospective observational cohort study of adult patients with 3 or more traumatic rib fractures, who were admitted to ICU between June 2014 and June 2019. A comparison was made between patients who stayed in ICU for less than 7 days and those that stay for 7 or more days.
Results:
Among 215 patients who were enrolled, 150 (69.7%) were male, the median Injury Severity Score (ISS) was 24 (interquartile range (IQR): 17-32). The median ICU LOS was 4 (IQR: 2-7) days and the average ICU LOS was 6.5 (SD 8.5; 95% CI 5.3-7.6) days. The median number of rib fractures was 6 (IQR: 5-9) and 76 (35.3%) patients had a flail chest. Patients who stayed longer than 7 days in ICU had higher ISS, higher APACHE-II score, greater number of rib fractures, higher rate of lung contusions, and required more respiratory support of any type.
Conclusions:
ISS, number of rib fractures, lung contusion, and flail chest were associated with prolonged ICU LOS in patients with traumatic multiple rib fractures.
... The main contraindications were severe traumatic brain injury and unstable cervical spine injury. These guidelines were based on the experience of participating trauma surgeons and also on the available literature [6,22,23]. Combination of multiple rib fractures (especially upper rib fractures) with ipsilateral clavicle fractures reduces the stability of the hemithorax. In the presence of concomitant ipsilateral rib fractures, there is a significant increase in midshaft clavicle fracture displacement rates, especially when upper ribs are involved [23][24][25]. ...
... Combination of multiple rib fractures (especially upper rib fractures) with ipsilateral clavicle fractures reduces the stability of the hemithorax. In the presence of concomitant ipsilateral rib fractures, there is a significant increase in midshaft clavicle fracture displacement rates, especially when upper ribs are involved [23][24][25]. Our tracheostomized patients in comparison with intubated patients had statistically significantly higher incidence of clavicle fractures, which also coalesced with a statistically higher number of fractured ribs. ...
Purpose
Patients with rib fractures (RF) may require prolonged mechanical ventilation and tracheostomy. Indications for tracheostomy in trauma patients with RF remain debatable. The goal was to delineate characteristics of patients who underwent tracheostomy due to thoracic versus extra-thoracic causes, such as maxillofacial–mandibular injury (MFM), traumatic brain injury (TBI), and cervical vertebrae trauma (CVT), and to analyze clinical outcomes. The predictive values of chest trauma scoring systems for tracheostomy were also evaluated. We hypothesized that tracheostomized patients were more severely injured with more ribs fractured and had more pulmonary co-injuries.
Methods
Retrospective review included 471 patients with RF admitted to two Level 1 trauma centers. Patients with tracheostomy (n = 124, 26.3%) were compared to patients with endotracheal intubation (n = 347, 73.7%). Analyzed variables included age, gender, injury severity score (ISS), Glasgow Coma Scale, number of ribs fractured, total fractures of ribs, prevalence of bilateral rib fractures, flail chest, clavicle fractures, MFM, TBI, CVT, co-injuries, comorbidities, RF treatment options, hospital length of stay (HLOS), intensive care unit LOS (ICULOS), duration of mechanical ventilation (DMV).
Results
Tracheostomized compared to intubated patients had statistically higher ISS, more ribs fractured, total fractures of the ribs, bilateral and clavicle fractures, MFM, spine, chest, and orthopedic co-injuries and longer HLOS, ICULOS and DMV. Tracheostomy for thoracic reasons was performed in 64 patients (51.6%) and for extra-thoracic reasons in 60 patients (48.4%). Mean tracheostomy timing was 9.9 days and was significantly shorter in the extra-thoracic compared to the thoracic group (8.0 versus 11.6 days, p < 0.001). All chest trauma scoring system values were significantly higher in tracheostomized patients. Predictive values of scoring systems for tracheostomy increased in patients with thoracic trauma only.
Conclusions
A quarter of mechanically ventilated patients with RF required tracheostomy. Tracheostomized compared to intubated patients were more severely injured with more ribs fractured and were intubated longer. An increased amount of RF was associated with an increase in tracheostomies, especially for thoracic reasons.
... The clinical signi cance of rib fracture internal xation for patients with ail chest has been con rmed [23], but the indications for patients without ail chest are still controversial [18,[24][25][26]. Considering that the degree of decline in PVF is often closely related to adverse prognosis, the degree of change in PVF could be an indication for the internal xation for rib fractures. ...
Background: This study aimed to investigate the pulmonary ventilation function (PVF) according to different types of rib fractures and pain levels.
Methods: This was a retrospective study of patients with thoracic trauma admitted to our ward from May 1, 2015, to February 1, 2017. Vital capacity (VC), forced expiratory volume in 1 s (FEV1), and peak expiratory flow (PEF) were measured on admission. A numerical rating scale (NRS) was used for pain assessment.
Results: A total of 118 (85 males and 33 females) were included. The location of rib fractures did not affect the PVF. When the number of rib fractures was ≥ 5, the PVF was lower than in those with ≤ 4 fractures (VC: 0.40 vs. 0.47, P = 0.009; FEV1: 0.37 vs. 0.44, P = 0.012; PEF: 0.17 vs. 0.20, P = 0.031). There were no difference in PVF values between multiple and non-multiple rib fractures (VC: 0.41 vs. 0.43, P = 0.202; FEV1: 0.37 vs. 0.39, P = 0.692; PEF: 0.18 vs. 0.18, P = 0.684). When there were ≥ 5 breakpoints, the PVF parameters were lower than those with ≤ 4 breakpoints (VC: 0.40 vs. 0.50, P = 0.030; FEV1: 0.37 vs. 0.45, P = 0.022; PEF: 0.18 vs. 0.20, P = 0.013). When the NRS ≥ 7, the PVF values were lower than for those with NRS ≤ 6 (VC: 0.41 vs. 0.50, P = 0.003; FEV1: 0.37 vs. 0.47, P = 0.040; PEF: 0.18 vs. 0.20, P = 0.027).
Conclusions: When the total number of fractured ribs is ≥ 5, there are ≥ 5 breakpoints, or NRS is ≥ 7, the VC, FEV1, and PEF are more affected.
Trial registration: The trial was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Ethics Committee of Shanghai Jiao Tong University Affiliated Sixth People’s Hospital and individual consent for this retrospectively registered analysis was waived.
... 5-7 However, recent studies comparing SSRF with non-operative management have not undergone evidence synthesis. [8][9][10][11][12][13][14][15][16] Conventional frequentist meta-analysis may be suboptimal because few randomized controlled trials (RCTs) have compared SSRF with nonoperative management. [17][18][19][20][21] Bayesian meta-analysis has distinct advantages over conventional meta-analysis for comparing SSRF with nonoperative management: it allows intuitive interpretation (eg, there is an x% probability that SSRF is associated with lower mortality than non-operative management); it incorporates inherent bias of observational evidence rather than equally pooling observational and RCT evidence, and it accurately presents uncertainty of pooled effect estimates. ...
... [5][6][7] However, recent studies comparing SSRF with non-operative management have not undergone evidence synthesis. [8][9][10][11][12][13][14][15][16] Conventional frequentist meta-analysis may be suboptimal because few randomized controlled trials (RCTs) have compared SSRF with nonoperative management. [17][18][19][20][21] Bayesian meta-analysis has distinct advantages over conventional meta-analysis for comparing SSRF with nonoperative management: it allows intuitive interpretation (eg, there is an x% probability that SSRF is associated with lower mortality than non-operative management); it incorporates inherent bias of observational evidence rather than equally pooling observational and RCT evidence, and it accurately presents uncertainty of pooled effect estimates. ...
... Although no significant difference was found in the mortality rates between surgical and conservative treatments, the former resulted in reduced pneumonia rate, duration of mechanical ventilation, and intensive care unit (ICU) stay. 2 In particular, several studies reported that early surgical fixation (≤3 days) reduced the duration of mechanical ventilator support, ICU stay, hospital stay and tracheostomy than late surgical fixation (≥3 days). 3,4 The purpose of the surgical treatment of flail chest is to fix the fracture site. However, extensive plate fixation is required with a large incision and wide chest wall dissection. ...
A flail chest can occur when cardiopulmonary resuscitation causes extensive rib fractures. Despite successful cardiopulmonary resuscitation, if the flail chest is not treated, the patient may not survive regardless of the correction of the primary condition that caused the cardiac arrest. Therefore, if flail chest persists despite the appropriate conservative management to correct the flail chest, active surgical management is essential. We present a successful surgical treatment with a pectus bar for a patient with flail chest, caused by extensive segmental rib fractures sustained during cardiopulmonary resuscitation for a massive pulmonary thromboembolism.
... Traditionally, the majority of these patients have been managed nonoperatively. With advances in the surgical technique and the growing utilization of SSRF, paralleled by improved outcomes, the indications for a surgical procedure are expanding from flail chest to multiple displaced rib fractures, and even include patients with pulmonary contusion 15,16,31,32 . It was reported that SSRF results in decreased length of hospital stay, increased critical care benefits, improved pulmonary function, and reduced rates of complications and mortality 31,33 . ...
Background: Rib fractures are a common thoracic injury that is encountered in 20% to 39% of patients with blunt chest trauma and is associated with
1,2
substantial morbidity and mortality . Traditionally, the majority of patient
with rib fractures have been managed nonoperatively. Recently, the utilization
of surgical stabilization of rib fractures has increased considerably because the
3-5 procedure has shown improved outcomes .
Description: Surgical stabilization should be considered in cases of multiple bicortically displaced rib fractures, especially in those with a flail chest and/or a concomitant ipsilateral displaced midshaft clavicular fracture or sternal frac- ture, as such cases may result in thoracic wall instability. For surgical stabili- zation of rib fractures, we classify rib fractures by location, type of fracture, and degree of displacement after obtaining thin-sliced chest computed tomography (CT) scans. The incision is selected depending on the fracture location, and the surgical technique is chosen relevant to the type of fracture. Single-lung intubation is preferred if there is no severe contralateral pulmonary contusion. We favor performing video-assisted thoracoscopy if possible to control bleeding, evacuate hematomas, repair a lung, and perform cryoablation of the intercostal nerves. A lateral approach is considered to be the main surgical approach because it allows access to the majority of rib fractures. A curvilinear skin incision is made overlying the fractured ribs. Posterior rib fractures are exposed through a vertical incision within the triangle of auscultation, and anterior fractures, through a transverse inframammary incision. The muscle- sparing technique, splitting alongside fibers without transection, should be utilized if possible and supplemented by muscle retraction. For surgical sta- bilization of rib fractures, we currently prefer precontoured side and rib-specific plates with threaded holes and self-tapping locking screws. Polymer cable cerclage is used to enhance plating of longitudinal fractures, rib fractures near the spine, osteoporotic ribs, and injuries of rib cartilage. The third to eighth ribs are plated most often. Intercostal
muscle deficit, if present, is repaired with a xenograft patch. In comminuted rib fractures, the bone gap is bridged with
bone graft. Surgical stabilization of rib fractures is recommended within the first 7 days after trauma, preferably within 6-8
.
Alternatives: Nonoperative treatment alternatives include (1) epidural analgesia when not contraindicated because of anticoagulant venous thromboembolism prophylaxis9,10; (2) thoracic paravertebral blockage, e.g., serratus anterior or erector spinae plane nerve block11,12; (3) intercostal nerve block; (4) intravenous or enteral analgesics, e.g., opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs); (5) intrapleural analgesia, e.g., bupivacaine infusion; and (6) multimodal analgesia that incorporates regional techniques, systemic analgesics, and analgesic
9 adjuncts .
Rationale: Surgical stabilization of rib fractures is a safe and effective method to treat displaced rib fractures. The procedure provides definitive stabilization of fractures, improves pulmonary function, lessens pain medication requirements, prevents deformity formation, and results in reduced morbidity and mortality.
Purpose
The technical advancement of surgical stabilization of ribs often prevents the surgeons from fixation, despite the procedure`s documented improved outcomes. The aim of this study was to evaluate a less invasive approach involving a simplified monocortical rib fixation technique.
Methods
Eighteen frozen human ribs obtained intraoperatively from young individuals aged 13-18 were employed for this study. First, the ribs were fractured under three-point bending, with their intrathoracic side put under tensile stress. Following this, the ChM 4.0 rib fixation system was utilized. The specimens were categorized into two groups: bicortical fixation (n=9), monocortical fixation (n=9). Subsequently, bicortical and monocortical fixation groups underwent dynamic testing over 400,000 cycles under combined sinusoidal tensile bending and torsional loading (2 N-5 N at 3Hz). In the final stage, all samples were subjected to a destructive load to failure.
Results
Our analysis revealed that the fixation method did not demonstrate statistically significant differences in terms of preliminary bending stiffness (p=0.379). Similarly, undergoing a course of 400,000 cycles involving combined tensile and torsional loading did not constitute a statistically significant factor affecting the monocortical and the bicortical fixation groups (p=0.894). In the monocortical fixation group, all specimens failed due to screws pulled out from the bone. In contrast, all specimens in the bicortical fixation group exhibited failure attributed to fractures occurring just behind the plate. Nonetheless, the fixation method was not a significant factor affecting bending strength (p=0.863).
Conclusions
The monocortial fixation could be a reasonable option among younger populations with comparable stability of fixation.
