Comprehensive approach to the management of the patient with multiple rib fractures: a review and introduction of a bundled rib fracture management protocol

Abstract Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89–0.9995) and 0.83 (0.70–0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76–0.92) and 0.98 (0.85–0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.

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Rib fractures, a public health issue-a multi regional retrospective study

Jurnalul de Chirurgie ◽

10.7438/jsurg.2021.01.03 ◽

2021 ◽

Vol 17 (1) ◽

pp. 14-19

Author(s):

Irina Drăgan ◽

Ioan Adrian Petrache ◽

Valerian Cristian Păvăloiu ◽

Petruț Giuliano ◽

Ion Mîndrilă ◽

...

Keyword(s):

Retrospective Study ◽

Individual Case ◽

Rib Fractures ◽

Rib Fracture ◽

Public Health Issue ◽

Average Hospital Stay ◽

Average Hospital ◽

Social Reintegration ◽

Multiple Rib Fractures ◽

Total Average

We performed a retrospective study focusing on examining all rib fracture cases discharged from 4 thoracic surgery clinics in Romania. Over a period of 3 years, we analyzed data regarding the patients, diagnosis and number of days spent in the hospital. 2.417 patients were included in this study and all patient evolutions were taken into account. The most patients suffered from multiple rib fractures, involving four or more ribs. In total average hospital stay was 5.46 days. The pneumothorax was the most common encountered complication followed by hemo-pneumothorax, hemothorax and lung contusion. Men seem to be at a higher risk to develop a rib fracture than women. Fracture incidence increased with age in both sexes. The main goal when treating thoracic traumatic pathology is attaining less impairment of pulmonary functions and fast social reintegration. Management of rib fractures must be tailored to each individual case.

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Management of multiple rib fractures-results from a Major Trauma Centre with review of the existing literature

10.21203/rs.3.rs-118238/v2 ◽

2020 ◽

Author(s):

Debkumar Chowdhury ◽

P. Okoh ◽

H. Dambappa

Keyword(s):

Major Trauma ◽

Significant Proportion ◽

Fragility Fractures ◽

Trauma Centre ◽

Rib Fractures ◽

Rib Fracture ◽

Analgesic Requirement ◽

Multiple Rib Fractures ◽

Major Trauma Centre ◽

The Impact

Abstract Introduction Rib fractures are amongst the most common fractures following major trauma presenting to the Emergency Department. It accounts for more than 15% of ED presentations (1) on a global scale. As the population ages the incidence of rib fractures also rises often following falls from a relatively small height being part of fragility fractures. The impact of rib fractures is even more significant in the patient with underlying chronic respiratory conditions.Aim To assess our current management of rib fractures at our trauma centreMethod We collected our data from the TARN Registry primarily focussing on patients with multiple rib fractures. The main components were the analgesic requirement of our patients. We also studied the number of rib fracture stabilisation procedures and the average number of ribs fixed.Results The data was collected retrospectively over a period of 12 months. There were 313 patients identified as having chest wall injuries. From the data, 41.9% (131) of patients were over the age of 65 years. A significant proportion of our patients 34.5% (108) were noted to have multiple rib fractures (>3 Ribs). It was noted that 3% (9) of the 313 patients required operations. The average of the patients included in the study was noted to be 61 years with an age range of 17-92 years.Conclusion The mainstay management of rib fracture is provision of adequate analgesia and the prevention of respiratory complications that can all stem from poor ventilatory function amongst other patient factors and injury patterns. Through the decades, surgical stabilisation has gained pace and has found its niche in the management of rib fractures.

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State of Rib Fracture Care: A NTDB Review of Analgesic Management and Surgical Stabilization

The American Surgeon ◽

10.1177/000313481908500523 ◽

2019 ◽

Vol 85 (5) ◽

pp. 474-478 ◽

Cited By ~ 3

Author(s):

Fareed A. Cheema ◽

Edward Chao ◽

Joseph Buchsbaum ◽

Katie Giarra ◽

Afshin Parsikia ◽

...

Keyword(s):

Data Bank ◽

Medication Administration ◽

Rib Fractures ◽

Rib Fracture ◽

Regional Analgesia ◽

Icu Length Of Stay ◽

National Trauma ◽

Fracture Management ◽

National Trauma Data Bank ◽

Recent Trends

Thoracic analgesia plays a key role in management and outcomes of rib fractures and can generally be broken down into oral or parenteral medication administration and regional analgesia. Surgical stabilization of rib fractures (SSRF) may be an underused resource in the management of rib fractures. This study describes recent trends in rib fracture management and outcomes. National Trauma Data Bank datasets from 2008 to 2014 were reviewed. Patients with three or more rib fractures were identified, and the frequencies of epidural analgesia (EA), other regional analgesia, and SSRF were analyzed. Those older than 65 years were more likely to be admitted to the ICU but had shorter ICU length of stay, lower intubation, and need for tracheostomy rates. In addition, those older than 65 years had about 2.5 times higher mortality (6.3% vs 2.6%, P < 0.001). EA was used in only 3 per cent of the population and more commonly in the older than 65 years group (3.7% vs 2.8%, P < 0.001). Regardless of age, SSRF was more commonly performed when compared with the placement of EA (5.8% vs 3%). This difference was even greater in the younger than 65 years group, where 7 per cent underwent SSRF. Utilization of EA remains low nationally. SSRF should be considered not only for chest wall stabilization but also as an analgesic modality in selected patients. A more complete accounting of analgesic care in rib fracture patients is needed to allow a more detailed analysis of analgesia for rib fracture–related pain to elucidate optimal treatment.

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New horizons in rib fracture management in the older adult

Age and Ageing ◽

10.1093/ageing/afz157 ◽

2019 ◽

Vol 49 (2) ◽

pp. 161-167 ◽

Cited By ~ 1

Author(s):

Roisin Coary ◽

Conor Skerritt ◽

Anthony Carey ◽

Sarah Rudd ◽

David Shipway

Keyword(s):

Older Adults ◽

Injury Severity ◽

Scoring Systems ◽

Pulmonary Complications ◽

Research Literature ◽

Rib Fractures ◽

Rib Fracture ◽

Mortality And Morbidity ◽

Severity Scores ◽

Fracture Management

Abstract Adults aged ≥60 years now represent the majority of patients presenting with major trauma. Falls are the most common cause of injury, accounting for nearly three-quarters of all traumas in this population. Trauma to the thorax represents the second most common site of injury in this population, and is often associated with other serious injuries. Mortality rates are 2–5 times higher in older adults compared to their younger counterparts, often despite equivalent injury severity scores. Risk scoring systems have been developed to identify rib fracture patients at high risk of deterioration. Overall mortality from rib fractures is high, at approximately 10% for all ages. Mortality and morbidity from rib fractures primarily derive from pain-induced hypoventilation, pneumonia and respiratory failure. The main goal of care is therefore to provide sufficient analgesia to allow respiratory rehabilitation and prevent pulmonary complications. The provision of analgesia has evolved to incorporate novel regional anaesthesia techniques into conventional multimodal analgesia. Analgesia algorithms may aid early aggressive management and escalation of pain control. The current role for surgical fixation of rib fractures remains unclear for older adults who have been underrepresented in the research literature. Older adults with rib fractures often have multi-morbidity and frailty which complicate their injuries. Trauma services are evolving, and increasingly geriatricians will be embedded into trauma services to deliver comprehensive geriatric assessment. This review aims to provide an evidence-based overview of the management of rib fractures for the physician treating older patients who have sustained trauma.

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Management of multiple rib fractures-results from a Major Trauma Centre with review of the existing literature

10.21203/rs.3.rs-118238/v1 ◽

2020 ◽

Author(s):

Debkumar Chowdhury ◽

P. Okoh ◽

H. Dambappa

Keyword(s):

Major Trauma ◽

Significant Proportion ◽

Fragility Fractures ◽

Trauma Centre ◽

Rib Fractures ◽

Rib Fracture ◽

Analgesic Requirement ◽

Multiple Rib Fractures ◽

Major Trauma Centre ◽

The Impact

Abstract Introduction Rib fractures are amongst the most common fractures following major trauma presenting to the Emergency Department. It accounts for more than 15% of ED presentations (1) on a global scale. As the population ages the incidence of rib fractures also rises often following falls from a relatively small height being part of fragility fractures. The impact of rib fractures is even more significant in the patient with underlying chronic respiratory conditions.Aim To assess our current management of rib fractures at our trauma centreMethod We collected our data from the TARN Registry primarily focussing on patients with multiple rib fractures. The main components were the analgesic requirement of our patients. We also studied the number of rib fracture stabilisation procedures and the average number of ribs fixed.Results The data was collected retrospectively over a period of 12 months. There were 313 patients identified as having chest wall injuries. From the data, 41.9% (131) of patients were over the age of 65 years. A significant proportion of our patients 34.5% (108) were noted to have multiple rib fractures (>3 Ribs). It was noted that 3% (9) of the 313 patients required operations. The average of the patients included in the study was noted to be 61 years with an age range of 17-92 years.Conclusion The mainstay management of rib fracture is provision of adequate analgesia and the prevention of respiratory complications that can all stem from poor ventilatory function amongst other patient factors and injury patterns. Through the decades, surgical stabilisation has gained pace and has found its niche in the management of rib fractures.

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Multiple rib fractures: A novel and prognostic CT-based classification system

Trauma ◽

10.1177/1460408619895683 ◽

2020 ◽

Vol 22 (4) ◽

pp. 265-272

Author(s):

Rosalind B Simpson ◽

Jessica R Dorman ◽

William J Hunt ◽

John G Edwards

Keyword(s):

Clinical Outcomes ◽

Classification System ◽

Wide Spectrum ◽

Flail Chest ◽

Derived Categories ◽

Rib Fractures ◽

Rib Fracture ◽

Observer Agreement ◽

Multiple Rib Fractures ◽

The Impact

Background The accepted classification for multiple rib fractures is binary: flail chest or not. There is a wide spectrum of morphology with subsequent variation in the impact on chest wall mechanics and clinical outcomes. As the practice of surgical stabilisation of rib fractures evolves, there is a need for a better taxonomy. The aim of this study was to create a data-driven radiological classification system for multiple rib fractures, prognostic of both complications and surgical stabilisation of rib fracture. Methods The radiological pattern of injury was assessed for cases undergoing surgical stabilisation of rib fracture (n = 48) over a five-year period and a consecutive sample of non-operative controls (n = 48). Every rib fracture (n = 1032) was assessed on CT scans for location, displacement and comminution. An iterative classification system was developed and tested for inter-observer agreement and outcome prediction. Results The fractures occurred in a ‘series’ (≥3 consecutive ribs at a similar location) in 72% of cases: these were more likely to be displaced (p < 0.001). Variables included in the classification were the anatomical pattern (presence, length and overlap of series) and degree of displacement. The classification was prognostic for complications (p < 0.001), discriminated for fixation (C = 0.907) and had acceptable inter-observer agreement (k = 0.50). Conclusions The Sheffield Multiple Rib Fracture Classification derived categories of short/long series, and short/long flail chest, with sub-division according to the presence of displacement. It was prognostic for clinical outcomes and of surgical fixation. It may facilitate communication, comparison of outcomes and selection for management protocols.

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Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults

BMJ Open ◽

10.1136/bmjopen-2018-023444 ◽

2019 ◽

Vol 9 (4) ◽

pp. e023444 ◽

Cited By ~ 5

Author(s):

Helen MA Ingoe ◽

Elizabeth Coleman ◽

William Eardley ◽

Amar Rangan ◽

Catherine Hewitt ◽

...

Keyword(s):

Mechanical Ventilation ◽

Systematic Reviews ◽

Fracture Fixation ◽

Flail Chest ◽

Risk Of Bias ◽

Rib Fractures ◽

Rib Fracture ◽

Multiple Rib Fractures ◽

Significant Difference ◽

The Impact

ObjectivesMultiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews.DesignA systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation.ResultsTwelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non–operative group in flail chest; pooled estimates ranged from −4.52 days, 95% CI (−5.54 to –3.5) to −7.5 days, 95% CI (−9.9 to –5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain.ConclusionsSynthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures.PROSPERO registration numberCRD42016053494.

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Guideline-Driven Care Improves Outcomes in Patients with Traumatic Rib Fractures

The American Surgeon ◽

10.1177/000313481708300940 ◽

2017 ◽

Vol 83 (9) ◽

pp. 1012-1017 ◽

Cited By ~ 5

Author(s):

Kathleen Flarity ◽

Whitney C. Rhodes ◽

Andrew J. Berson ◽

Brian E. Leininger ◽

Paul E. Reckard ◽

...

Keyword(s):

Length Of Stay ◽

Pulmonary Function ◽

Hospital Length ◽

Rib Fractures ◽

Rib Fracture ◽

Hospital Length Of Stay ◽

National Standard ◽

Separate Analysis ◽

Fracture Management ◽

Multivariable Regression

There is no established national standard for rib fracture management. A clinical practice guideline (CPG) for rib fractures, including monitoring of pulmonary function, early initiation of aggressive loco-regional analgesia, and early identification of deteriorating respiratory function, was implemented in 2013. The objective of the study was to evaluate the effect of the CPG on hospital length of stay. Hospital length of stay (LOS) was compared for adult patients admitted to the hospital with rib fracture(s) two years before and two years after CPG implementation. A separate analysis was done for the patients admitted to the intensive care unit (ICU). Over the 48-month study period, 571 patients met inclusion criteria for the study. Pre-CPG and CPG study groups were well matched with few differences. Multivariable regression did not demonstrate a difference in LOS (B = -0.838; P = 0.095) in the total study cohort. In the ICU cohort (n = 274), patients in the CPG group were older (57 vs 52 years; P = 0.023) and had more rib fractures (4 vs 3; P = 0.003). Multivariable regression identified a significant decrease in LOS for those patients admitted in the CPG period (B = -2.29; P = 0.019). Despite being significantly older with more rib fractures in the ICU cohort, patients admitted after implementation of the CPG had a significantly reduced LOS on multivariable analysis, reducing LOS by over two days. This structured intervention can limit narcotic usage, improve pulmonary function, and decrease LOS in the most injured patients with chest trauma.

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The complex case of rib fracture management in older people

Nursing and Residential Care ◽

10.12968/nrec.2020.22.5.7 ◽

2020 ◽

Vol 22 (5) ◽

pp. 1-3

Author(s):

Sarah Jane Palmer

Keyword(s):

Older People ◽

Rib Fractures ◽

Rib Fracture ◽

Morbidity And Mortality ◽

Complex Case ◽

Preventative Measures ◽

Fracture Management ◽

Effective Analgesia

Rib fractures remain a common result of falls, increasing morbidity and mortality. Effective analgesia is crucial in the management of such cases, and preventative measures are essential. Sarah Jane Palmer elaborates

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