Characterizing re-triage guidelines: A scoping review of states' rules and regulations.

BACKGROUND: State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States. METHODS: All 50 states' Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable. Guideline criteria were abstracted and grouped into domains of Center for Disease Control Field Triage Criteria: pattern/anatomy of injury, vital signs, special populations, and mechanisms of injury. Re-triage criteria were summarized across states using median and interquartile ranges for continuous data and frequencies for categorical data. Demographic data of states with and without re-triage guidelines were compared using the Wilcoxon rank sum test. RESULTS: Re-triage guidelines were identified for 22 of 50 states (44%). Common anatomy of injury criteria included head trauma (91% of states with guidelines), spinal cord injury (82%), chest injury (77%), and pelvic injury (73%). Common vital signs criteria included Glasgow Coma Score (91% of states) ranging from 8 to 14, systolic blood pressure (36%) ranging from 90 to 100 mm Hg, and respiratory rate (23%) with all using 10 respirations/minute. Common special populations criteria included mechanical ventilation (73% of states), age (68%) ranging from <2 or >60 years, cardiac disease (59%), and pregnancy (55%). No significant demographic differences were found between states with versus without re-triage guidelines. CONCLUSION: A minority of US states have re-triage guidelines. Characterizing existing criteria can inform future guideline development.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Safety and efficacy of fixed versus variable-dose prothrombin complex concentrate for emergent reversal of vitamin K antagonists: A systematic review and meta-analysis.

STUDY OBJECTIVE: Four-factor prothrombin complex concentrate (4F-PCC) is standard of care for emergent vitamin K antagonist (VKA) reversal but optimal dosing is uncertain. This meta-analysis estimated the proportion of patients treated with fixed dose (FD) 4F-PCC who achieved adequate reversal and compared safety and efficacy of FD versus weight-based dose (WB) strategies. METHODS: This review was conducted according to PRISMA guidelines. Medline and Scopus were searched and included studies evaluating FD regimens and comparing FD and WB for emergent VKA reversal. Data was pooled using random effects. Subgroup analyses examined heterogeneity. Risk of bias was assessed with Newcastle-Ottawa Scale and RoB2 score. RESULTS: Twenty-three studies (n = 2055) were included with twelve (n = 1143) comparing FD versus WB. The proportion of patients achieving goal INR with FD varied depending on the INR target, being significantly higher for INR <2 (90.9%, 95% Confidence Interval (CI) 87.2, 94.06) compared to INR <1.6 (70.97%, 95%CI 65.33, 76.31). Compared to WB, FD was less likely to achieve a goal INR <1.6 (Risk Difference (RD) -13%, 95% CI -21, -4) but achieved similar reversal for a goal INR <2.0, (RD -1%, 95%CI -7, 4). There was no difference in hospital mortality (RD 4%, 95%CI -2, 9) or thrombosis (RD 0.0%, 95%CI -3, 3). CONCLUSION: FD VKA reversal was associated with significantly lower attainment of goal INR compared to WB with lower INR targets. This did not translate to differences in hospital mortality, but these results should be interpreted cautiously in light of the observational nature of the included studies.

Anatomy of the anterior ribs and the composition of the costal margin: A cadaver study.

BACKGROUND: Traditional rib anatomy and costal margin teaching contends that the costal margin consists of a combined costal cartilage made up of ribs 7 to 10. Variations in 9th and 10th rib anatomy have been observed. We sought to evaluate the variability of interchondral joints and the make-up of the costal margin. METHODS: Cadaveric dissections were performed to evaluate the anatomy of the anterior ribs and the composition of the costal margin. Experienced chest wall surgeons evaluated this anatomy through a standardized dissection and assessment. Dissection videos were performed to allow for further review/assessment. RESULTS: Bilateral chest wall anatomy of 30 cadavers was evaluated (15 male, 15 female). The average age was 78 ± 12 years, and all patients were Caucasian. In all patients, the first rib attached to the manubrium, the second rib attached to the manubriosternal junction, and ribs 3 to 6 attached directly to the sternum. Interchondral joints were present between ribs 4/5-3%, 5/6-68%, 6/7-83%, 7/8-72%. Ribs combining to form a common costal cartilage via cartilaginous unions were observed between 6/7-3%, 7/8-45%, 8/9-30%, and 9/10-20%.The 8th rib attached directly to the sternum without joining the 7th rib in 10% of cadavers. The 8th and 9th ribs had free tips in 45% and 60% of evaluations, respectively. The 10th rib was found to have a hooked tip in 25% of cases and was a floating rib without attachment to the 9th rib 52% of the time. Rib tip mobility was noted in ribs 8, 9, and 10 in 52%, 70%, and 90%, respectively. CONCLUSION: Interchondral joints are common between ribs 5 and 8. Significant variability exists in the chest wall and costal margin compared with traditional teaching. It is important for chest wall surgeons treating diseases of the costal margin to appreciate this anatomic variability.

Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1).

PURPOSE: Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions. METHODS: A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis. RESULTS: Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001). CONCLUSION: Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.

A Novel Approach to Sternal Fracture Repair With the Implementation of a Compression/Distraction Device.

Sternal fractures are common following blunt traumatic injury. Most sternal fractures can be managed successfully nonoperatively; however, surgical fixation should be considered in certain scenarios. Specifically, surgery may be indicated in cases of severe pain, respiratory failure or dependency on mechanical ventilation, cosmetic deformity, malunion, disunion, and compression of the heart. A variety of surgical approaches to sternal fracture fixation have been documented (steel wire, suture materials, a seven-hole aluminum plate, an eight-holed Sternolock X plate, sternum-osteosynthesis plate, t-shaped plate); however, few techniques have been discussed for the initial reduction of the sternal fracture prior to fixation. In this paper, we describe a novel surgical technique used to reduce sternal fractures and approximate the edges of the sternum using a compression/distraction device.

Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case.

BACKGROUND: Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue. OBSERVATIONS: Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery. LESSONS: Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Redefining the costal margin: A pilot study.

BACKGROUND: Classical teaching of rib anatomy contends that the false ribs (7th to 10th) fuse anteriorly to form the costal margin of the chest. Slipped rib syndrome consists of false rib subluxation into the thorax with symptomatic impingement of the intercostal nerve. We sought to determine the incidence of this anatomic finding through anatomic study of the costal margin. METHODS: Cadavers were evaluated for mobility and attachment of the ninth and tenth ribs. Experienced anatomists and chest wall surgeons conducted a standardized dissection and assessed rib tip mobility using predefined criteria. Videos of dissections were submitted to a single investigator who reviewed the findings. RESULTS: Costal margins of 40 cadavers (45% male) were evaluated bilaterally. The average age was 83 years ± 11 years. The ninth rib was found to be attached to the eighth rib 100% of the time by an interchondral cartilaginous attachment along the body of the eighth and ninth ribs. Internal subluxation was noted in 19% (15 of 80), and the tip of the rib was mobile in 86% (69 of 80) evaluations. The tenth rib was attached to the ninth rib in 18%(14/80). A "floating" 10th rib was noted in 59% (47 of 80) of specimens. Subluxation was noted in 33% (26 of 60). Half of the ribs that subluxed moved medially to the ninth rib and half moved externally. An upwardly hooked tip was noted in 10% (8 of 80). Ribs with a hooked tip subluxed in 63% (5 of 8), and all of these ribs (5 of 5) moved to the interior of the chest ( p = 0.020). CONCLUSION: The ninth rib is commonly attached to the eighth rib, but the tenth rib is often not attached to the ninth rib. Most commonly, the tenth rib is a "floating" rib. Internal subluxation of the tenth rib as well as the presence of a hooked tip may predispose individuals to the development of "slipped rib syndrome." LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level III.

The evolution of a chest wall injury and reconstruction clinic during a pandemic.

BACKGROUND: In 2019, we sought to develop a chest wall injury and reconstruction clinic (CWIRC) to treat patients with chest wall pain and rib fractures. This initiative was fueled by the recognition of an unmet need and evolving research demonstrating improved patient care and experience. We will describe the evolution of this clinic program from an acute care surgery/general surgery (ACS/GS) clinic to a CWIRC. METHODS: We identified outpatient encounters generated from a general surgery clinic staffed by a physician and nurse practitioner team. A retrospective cohort review was performed to identify all outpatient encounters and surgeries associated with these encounters from January 1, 2017, to November 30, 2021. Outpatient and operative work relative value unit (wRVU) production as well as payer mix was compared as the primary outcome. RESULTS: Over this time period, the number of clinic interactions decreased (2017-284 vs. 2021-229). Clinic productivity increased however from 181 wRVUs in 2017 to 295 wRVUs in 2021. The CWIRC patient visits increased from 4% to 70%. In addition, telehealth visits increased from 0% to 23% of encounters. The operative wRVU productivity attributable to outpatient clinic visits increased (2017-253 vs. 2021-591). Combined, the CWIRC resulted in an overall growth of 104% in total wRVUs. The payer mixes for patients with rib diagnosis have a higher number of Blue Cross Blue Shield, Medicare, and Managed Care compared with ACS/GS. The most common diagnosis was rib fracture initial evaluation (37%), rib fracture subsequent encounter (25%), rib pain (24%), and flail chest initial evaluation (4%). CONCLUSION: The initiation of a CWIRC increased wRVU production despite a decrease in clinical encounters. These clinics may produce more wRVUs per encounter than ACS/GS clinics. An underserved population has been identified of chest wall pathology patients presenting for initial evaluation as outpatients. Further investigation into this concept is warranted to serve this population. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: An international, retrospective matched case-control study.

BACKGROUND: The presence of six or more rib fractures or a displaced rib fracture due to cardiopulmonary resuscitation (CPR) has been associated with longer hospital and intensive care unit (ICU) length of stay (LOS). Evidence on the effect of surgical stabilization of rib fractures (SSRF) following CPR is limited. This study aimed to evaluate outcomes after SSRF versus nonoperative management in patients with multiple rib fractures after CPR. METHODS: An international, retrospective study was performed in patients who underwent SSRF or nonoperative management for multiple rib fractures following CPR between January 1, 2012, and July 31, 2020. Patients who underwent SSRF were matched to nonoperative controls by cardiac arrest location and cause, rib fracture pattern, and age. The primary outcome was ICU LOS. RESULTS: Thirty-nine operatively treated patient were matched to 66 nonoperatively managed controls with comparable CPR-related characteristics. Patients who underwent SSRF more often had displaced rib fractures (n = 28 [72%] vs. n = 31 [47%]; p = 0.015) and a higher median number of displaced ribs (2 [P 25 -P 75 , 0-3] vs. 0 [P 25 -P 75 , 0-3]; p = 0.014). Surgical stabilization of rib fractures was performed at a median of 5 days (P 25 -P 75 , 3-8 days) after CPR. In the nonoperative group, a rib fixation specialist was consulted in 14 patients (21%). The ICU LOS was longer in the SSRF group (13 days [P 25 -P 75 , 9-23 days] vs. 9 days [P 25 -P 75 , 5-15 days]; p = 0.004). Mechanical ventilator-free days, hospital LOS, thoracic complications, and mortality were similar. CONCLUSION: Despite matching, those who underwent SSRF over nonoperative management for multiple rib fractures following CPR had more severe consequential chest wall injury and a longer ICU LOS. A benefit of SSRF on in-hospital outcomes could not be demonstrated. A low consultation rate for rib fixation in the nonoperative group indicates that the consideration to perform SSRF in this population might be associated with other nonradiographic or injury-related variables. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury.

PURPOSE: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. METHODS: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. RESULTS: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034). CONCLUSION: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation.

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.

Botox, Abdominal Wall Transection, and Body Positioning: A Case of Complex Abdominal Wall Reconstruction With Seat Belt Syndrome.

Seat belt syndrome (SBS) represents all injury profiles associated with seat belt injuries and motor vehicle crashes (MVCs). Seat belt syndrome classically presents with a superficial seat belt sign that may signify deeper intra-abdominal and/or spinal involvement. The amount of force transmitted from the restraint to the passenger ultimately dictates the amount and severity of the injury. We present a unique case of a 59-year-old female involved in a motor vehicle crash with multiple traumatic injuries, including seat belt syndrome, abdominal wall transection, and bowel injuries. She later had reconstruction of her traumatic abdominal wall hernias (TAWHs). Three unique approaches were used in the management of her traumatic abdominal wall hernias: (1) preoperative Botulinum toxin (Botox) injections, (2) operative use of biologic and bioabsorbable meshes in contaminated fields, and (3) postoperative physical therapy and body positioning. The patient did not experience any recurrence of these hernias after her abdominal wall reconstruction and remains alive at the time this case was written. The diagnostic criteria and surgical management of traumatic abdominal wall hernias have yet to be established, and the case presented here provides approaches that should serve as future areas for study.

Decreased Incidence of Rib Fractures in Pregnant Patients After Motor Vehicle Collisions.

BACKGROUND: Rib fractures are common after motor vehicle collisions. The hormonal changes associated with pregnancy decrease the stiffness and increase the laxity of cartilage and tendons. The effect of these changes on injury mechanics is not completely understood. OBJECTIVES: To compare the incidences of chest wall injury following blunt thoracic trauma between pregnant and nonpregnant women. METHODS: The authors conducted a retrospective review of female patients seen at a level I trauma center from 2009 to 2017 after a motor vehicle collision. Patient characteristics were compared to determine if pregnancy affected the incidence of chest wall injury. Statistics were calculated with SPSS version 24 and are presented as mean (SD) or median (interquartile range). RESULTS: In total, 1618 patients were identified. The incidence of rib/sternal fracture was significantly lower in pregnant patients (7.9% vs 15.2%, P = .047), but the incidence of intrathoracic injury was similar between the groups. Pregnant and nonpregnant patients with rib/sternal fractures had similar Injury Severity Score results (21 [13-27] vs 17 [11-22], P = .36), but pregnant patients without fractures had significantly lower scores (1 [0-5] vs 4 [1-9], P < .001). CONCLUSIONS: Pregnant patients have a lower rate of rib fracture after a motor vehicle collision than nonpregnant patients. The difference in injury mechanics may be due to hormonal changes that increase elasticity and resistance to bony injury of the ribs. In pregnant trauma patients, intrathoracic injury without rib fracture should raise concerns about injury severity. A multicenter evaluation of these findings is needed.

Are rib fractures stable? An analysis of progressive rib fracture offset in the acute trauma setting.

BACKGROUND: Rib fractures serve as both a marker of injury severity and a guide for clinical decision making for trauma patients. Although recent studies have suggested that rib fractures are dynamic, the degree of progressive offset remains unknown. The purpose of this study was to further characterize the change that takes place in the acute trauma setting. METHODS: A 4-year (2016-2019) retrospective assessment of adult trauma patients with rib fracture(s) admitted to a level I trauma center was performed. Initial and follow-up computed tomography scans were analyzed to determine the magnitude of offset. Relevant clinical course variables were examined, and location of chest wall instability was examined using the difference of interquartile range of median change. Statistical Product and Services Solutions (Version 25, IBM Corp. Armonk, NY) was then used to generate a neural network-multilayer perceptron that highlighted independent variable importance. RESULTS: Fifty-three patients met the inclusion criteria for severe injury. Clinical course variables that either trended or significantly predicted the occurrence of progressive offset were Abbreviated Injury Scale Thoracic Scores (3.1 ± 0.4 no progression vs. 3.4 ± 0.6 yes progression; p = 0.121), flail segment (14% no progression vs. 43% yes progression; p = 0.053), and number of ribs fractured (4 [2-8] no progression vs. 7 [5-9] yes progression; p = 0.023). The location of progressive offset largely corresponded to the posterolateral region as demonstrated by the differences of interquartile range of median change. The neural network demonstrated that ribs 4 to 6 (normalized importance [NI], 100%), the posterolateral region (NI, 87.9%), and multiple fractures per rib (NI, 66.6%) were valuable in predicting whether progressive offset occurred (receiver operating characteristic curve - area under the curve = 0.869). CONCLUSION: Rib fractures are not stable, particularly for those patients with multiple fractures in the mid-to-upper ribs localized to the posterolateral region. These findings may identify both trauma patients with worse outcomes and help develop better management strategies for rib fractures. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Cardiopulmonary Resuscitation-Induced Hardware Failure After Surgical Stabilization of Flail Chest.

Flail chest occurs when three or more ribs have concurrent fractures in two or more places. Flail chest is a marker of injury severity and is associated with increased morbidity and mortality. The management of flail chest includes multiple nonoperative components in addition to surgical stabilization, which has been shown to lower mortality rates to those of multiple rib fractures with a stable chest wall (i.e., no flail chest). The resulting stability of the chest wall may be a more accurate prognostic indicator than the actual number of ribs fractured. Surgical stabilization has been associated with various complications. The overall incidence of hardware failure is relatively rare and often involves the anterolateral and lateral regions of the chest wall. We present a unique case of a 48-year-old male involved in a motor vehicle accident with multiple traumatic injuries, including flail chest. He ultimately underwent surgical stabilization across six separate ribs in nine total locations. The patient's condition deteriorated several weeks later, and he required cardiopulmonary resuscitation. High impact forces caused hardware failure in three separate locations along the chest wall, i.e., anteriorly, anterolaterally, and posterolaterally. The most significant failure occurred anteriorly with sternal plate and screw separation. We suspect that hardware failure in the anterior and anterolateral regions indicates that the sternum and costochondral junction may be dynamic areas of the chest wall that dissipate forces differently than do the bone of ribs.

Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes?

BACKGROUND: Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older. METHODS: Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management. RESULTS: Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups. CONCLUSION: Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians. LEVEL OF EVIDENCE: Therapeutic, Level IV.