Mapping of common rib fracture patterns and the subscapular flail chest associated with operative scapula fractures.

BACKGROUND: Rib fractures occur in approximately 10% of trauma patients and are associated with more than 50% of patients with scapula fractures. This study investigates the location and patterns of rib fractures and flail chest occurring in patients with operatively treated scapula fractures. Novel frequency mapping techniques of rib fracture patterns in patients who also injure the closely associated scapula can yield insight into surgical approaches and fixation strategies for complex, multiple injuries patients. We hypothesize that rib fractures have locations of common occurrence when presenting with concomitant scapula fracture that requires operative treatment. METHODS: Patients with one or more rib fractures and a chest computed tomography scan between 2004 and 2018 were identified from a registry of patients having operatively treated scapula fractures. Unfurled rib images were created using Syngo-CT Bone Reading software (Siemens Inc., Munich, Germany). Rib fracture and flail segment locations were marked and measured for standardized placement on a two-dimensional chest wall template. Location and frequency were then used to create a gradient heat map. RESULTS: A total of 1,062 fractures on 686 ribs were identified in 86 operatively treated scapula fracture patients. The mean ± SD number of ribs fractured per patient was 8.0 ± 4.1 and included a mean ± SD of 12.3 ± 7.2 total fractures. Rib fractures ipsilateral to the scapula fracture occurred in 96.5% of patients. The most common fracture and flail segment location was ipsilateral and subscapular; 51.4% of rib fractures and 95.7% of flail segments involved ribs 3 to 6. CONCLUSION: Patients indicated for operative treatment of scapula fractures have a substantial number of rib fractures that tend to most commonly occur posteriorly on the rib cage. There is a pattern of subscapular rib fractures and flail chest adjacent to the thick bony borders of the scapula. This study enables clinicians to better evaluate and diagnose scapular fracture patients with concomitant rib fractures. LEVEL OF EVIDENCE: Diagnostic test, level IV.

Three-dimensional volume-rendered computed tomography application for follow-up fracture healing and volume measurements pre-surgical rib fixation and post-surgical rib fixation.

BACKGROUND: Surgical rib fixation (SRF) is being used increasingly in trauma centers for stabilization of chest wall injuries, in line with new and evolving surgical techniques. Our institution has developed a pathway for the management of chest wall injuries and SRF, which includes a follow-up low-volume, noncontrast computed tomography (CT) scan at 12 months. METHODS: This study was a single-center retrospective study conducted on 25 consecutive patients who underwent SRF between February 2019 and February 2020. All CT measurements were done by a CT radiographer under the supervision of a board-certified radiologist and included the use of three-dimensional volume-rendered images. RESULTS: There were no patients with SRF who experienced hardware failure at 12 months in either flail or nonflail groups. For fractured ribs treated with SRF, complete or partial union occurred in 75 of 76 ribs plated (98.7%). The median ratio for improvement in lung volumes was 1.71 for flail SRF and 1.69 for nonflail SRF in our study. CONCLUSION: Three-dimensional volume-rendered CT at 12 months post-SRF showed good alignment (no hardware failure) and fracture healing of fixed ribs in both flail and nonflail groups. Lung volumes also improved pre-SRF and post-SRF for both flail and nonflail patients. More studies are needed to define how the pattern of rib fracture healing of fixed and nonfixed ribs affects lung volumes. LEVEL OF EVIDENCE: Therapeutic, Level V.

Pediatric surgical rib fixation: A collected case series of a rare entity.

BACKGROUND: Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data. METHODS: Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up. RESULTS: Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months. CONCLUSION: Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma. LEVEL OF EVIDENCE: Collected case series, level V.

Long-term pulmonary function, thoracic pain, and quality of life in patients with one or more rib fractures.

BACKGROUND: Long-term outcomes after rib fractures and the effect of treatment modality or chest wall injury severity on these outcomes remains uncertain. This retrospective cohort study evaluated the long-term pulmonary function, thoracic pain, and quality of life in patients admitted with rib fractures. METHODS: Patients admitted with rib fractures between January 1, 2012, and December 1, 2019, were included. Data on long-term outcomes were collected during one follow-up visit. Patients were stratified by chest wall injury severity (one or two rib fractures, ≥3 rib fractures, or a flail chest) and treatment modality (surgical stabilization of rib fractures [SSRF] or nonoperative management). Multivariable analysis was performed to compare outcomes after SSRF with nonoperative treatment in patients with three or more rib fractures. RESULTS: In total, 300 patients were included. The median follow-up was 39 months (P25-P75, 18-65 months). At follow-up, the corrected forced vital capacity returned to 84.7% (P25-P75, 74.3-93.7) and the forced expiratory volume in 1 second to 86.3% (P25-P75, 75.3-97.0) of the predicted reference values. Quality of life was determined using the Short Form-12 version 2 and EuroQoL-5D-5L. The Short Form-12 version 2 physical and mental component summary were 45 (P25-P75, 38-54) and 53 (P25-P75, 43-60), respectively. The EuroQoL-5D-5L utility score was 0.82 (P25-P75 0.66-0.92) and visual analog scale score 75 (P25-P75 70-85). This indicated a quality of life within normal population ranges. Moderate to severe thoracic pain was reported by 64 (21.3%) patients. Long-term outcomes returned to values within population ranges and were similar across chest wall injury severity and for patients treated with SSRF or nonoperatively. CONCLUSION: While long-term pulmonary function and quality of life recover to values considered normal, subjective thoracic complaints, such as pain and dyspnea, remain frequently present following rib fractures. No effect of chest wall injury severity or treatment modality on long-term outcomes was demonstrated. LEVEL OF EVIDENCE: Therapeutic, level III.

Intercostal nerve cryoablation during surgical stabilization of rib fractures.

BACKGROUND: Intercostal nerve cryoablation (IC) offers potential for targeted and durable analgesia for patients with traumatic rib fractures. Our pilot study aimed to investigate thoracoscopic IC's safety, feasibility, and preliminary efficacy for patients undergoing surgical stabilization of rib fractures (SSRF). We hypothesized that concurrent surgical stabilization of rib fractures and intercostal nerve cryoablation (SSRF-IC) is a safe and feasible procedure without immediate or long-term complications. METHODS: We retrospectively evaluated patients 18 years or older who underwent SSRF (with or without IC) for acute rib fractures at our level I trauma center between September 1, 2019, and September 30, 2020. We performed IC under thoracoscopic visualization (-70°C for 2 minutes per intercostal nerve bundle). Among patients whose only operative procedure during hospitalization was SSRF, we evaluated post-SSRF length of stay, operative times, opioid requirements (oral morphine equivalents), and pain scores (Numerical Rating Scale). Generalized estimating equations compared SSRF and SSRF-IC group outcomes (population mean [robust standard error]). We assessed long-term outcomes of patients who underwent SSRF-IC. RESULTS: Thirty-four patients (144 ribs) underwent SSRF; of these, 20 patients (135 ribs) underwent SSRF-IC. Patients who did and did not undergo concurrent IC had no significant difference demographic, injury, or hospitalization characteristics. Among 20 patients who did not undergo other operations, 12 underwent SSRF-IC. We did not find significant difference between SSRF and SSRF-IC groups' median operative times or post-SSRF length of stay. Compared with SSRF group, SSRF-IC group did not have statistically significant change in pain score (0.2 [1.5] lower) or opioid use (43.9 [86.1] mg/d greater) between 12 hours before SSRF and last 24 admission hours. Among 17 SSRF-IC patients who followed-up postdischarge (median [range], 160 [9-357] days), one reported mild chest wall paresthesia; no other complications were reported. CONCLUSION: This pilot study performing 135 intercostal nerve cryoablations on 20 patients suggests that IC is safe and feasible for patients undergoing SSRF. Evaluating IC's analgesic efficacy for rib fractures requires further study. LEVEL OF EVIDENCE: Therapeutic, Level V.

Preliminary study of the characteristics of rib fractures and their impact on pulmonary ventilatory function.

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 rib fractures with multiple locations and those with non-multiple locations (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.

A clinical practice guideline using percentage of predicted forced vital capacity improves resource allocation for rib fracture patients.

BACKGROUND: Predicting rib fracture patients that will require higher-level care is a challenge during patient triage. Percentage of predicted forced vital capacity (FVC%) incorporates patient-specific factors to customize the measurements to each patient. A single institution transitioned from a clinical practice guideline (CPG) using absolute forced vital capacity (FVC) to one using FVC% to improve triage of rib fracture patients. This study compares the outcomes of patients before and after the CPG change. METHODS: A review of rib fracture patients was performed over a 3-year retrospective period (RETRO) and 1-year prospective period (PRO). RETRO patients were triaged by absolute FVC. Percentage of predicted FVC was used to triage PRO patients. Demographics, mechanism, Injury Severity Score, chest Abbreviated Injury Scale score, number of rib fractures, tube thoracostomy, intubation, admission to intensive care unit (ICU), transfer to ICU, hospital length of stay (LOS), ICU LOS, and mortality data were compared. A multivariable model was constructed to perform adjusted analysis for LOS. RESULTS: There were 588 patients eligible for the study, with 269 RETRO and 319 PRO patients. No significant differences in age, gender, or injury details were identified. Fewer tube thoracostomy were performed in PRO patients. Rates of intubation, admission to ICU, and mortality were similar. The PRO cohort had fewer ICU transfers and shorter LOS and ICU LOS. Multivariable logistic regression identified a 78% reduction in odds of ICU transfer among PRO patients. Adjusted analysis with multiple linear regression showed LOS was decreased 1.28 days by being a PRO patient in the study (B = -1.44; p < 0.001) with R2 = 0.198. CONCLUSION: Percentage of predicted FVC better stratified rib fracture patients leading to a decrease in transfers to the ICU, ICU LOS, and hospital LOS. By incorporating patient-specific factors into the triage decision, the new CPG optimized triage and decreased resource utilization over the study period. LEVEL OF EVIDENCE: Therapeutic/Care Management. Trauma, Rib, Triage, level IV.

Analysis of the therapeutic effect and prognosis in 86 cases of rib fractures and atelectasis.

BACKGROUND: The aim of the present study was to explore the therapeutic effect and prognosis in patients with rib fractures and atelectasis after thoracic trauma in order to provide a basis for clinical decision-making in primary hospitals. METHODS: A retrospective study was conducted on 86 patients admitted to our hospital between January 2016 and May 2020 with rib fractures and atelectasis after thoracic trauma. On the basis of the chest computed tomography scans taken at the time of discharge, the patients were divided into two groups: the reexpansion group and the non-reexpansion group. The two groups were compared with respect to the changes observed in the patients' levels of blood oxygen saturation (SpO2) and pulmonary function, the presence of secondary pulmonary or thoracic infection, the time of chest tube drainage, the length of hospitalization, the cost of hospitalization, and the patients' level of satisfaction with their quality of life 3 months after discharge. RESULTS: In the reexpansion group, there were significant differences in the levels of SpO2 and pulmonary function measured before and after pulmonary reexpansion (P < 0.05). Compared with the non-reexpansion group, the patients in the reexpansion group had a lower incidence of secondary pulmonary and thoracic infection and a higher level of satisfaction with their quality of life after discharge; these differences were statistically significant (P < 0.05). There was no statistical significance between the two groups with respect to the time of chest tube drainage or the length of hospitalization (P > 0.05). However, the cost of hospitalization was significantly higher in the reexpansion group than in the non-reexpansion group (P < 0.05). CONCLUSIONS: The patients in the pulmonary reexpansion group had a lower incidence of complications and a better prognosis than the patients in the non-reexpansion group.

Prevalence of chronic post-thoracotomy pain in patients with traumatic multiple rib fractures in South Korea: a cross-sectional study.

Chronic post-thoracotomy pain is a debilitating condition after traumatic multiple rib fractures and surgery. We aimed to estimate the prevalence of chronic post-thoracotomy pain after traumatic multiple rib fractures in South Korea and explore factors associated with it. From October 2017 to June 2019, a cross-sectional survey of 100 adults, who had undergone thoracotomy due to traumatic fractures of two or more ribs 2 years to 3 months prior to the survey, was conducted in the regional trauma center in South Korea. In total, 80% and 65% patients reported any level and above moderate chronic pain, respectively. Quality of life was mostly below the normative value of the US general population. Forty-six percent patients had restrictive respiratory dysfunction, and 47% and 59% patients were classified as being at risk of above mild-level anxiety and depression, respectively. More than 70% of patients had a current opioid prescription. Multivariable logistic regression analysis showed weak evidence of association between acute, severe postoperative pain and chronic postsurgical pain (adjusted odds ratio 2.4, 95% confidence intervals 0.9 to 6.4). Collectively, chronic post-thoracotomy pain and associated incomplete recovery regarding respiratory, functional, and psychological outcomes were prevalent in patients with traumatic multiple rib fractures in South Korea.

Stop flailing: The impact of bicortically displaced rib fractures on pulmonary outcomes in patients with chest trauma - an American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Current evaluation of rib fractures focuses almost exclusively on flail chest with little attention on bicortically displaced fractures. Chest trauma that is severe enough to cause fractures leads to worse outcomes. An association between bicortically displaced rib fractures and pulmonary outcomes would potentially change patient care in the setting of trauma. We tested the hypothesis that bicortically displaced fractures were an important clinical marker for pulmonary outcomes in patients with nonflail rib fractures. METHODS: This nine-center American Association for the Surgery of Trauma multi-institutional study analyzed adults with two or more rib fractures. Admission computerized tomography scans were independently reviewed. The location, degree of rib fractures, and pulmonary contusions were categorized. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia, acute respiratory distress syndrome (ARDS), and tracheostomy. Analyses were performed in nonflail patients and also while controlling for flail chest to determine if bicortically displaced fractures were independently associated with outcomes. RESULTS: Of the 1,110 patients, 103 (9.3%) developed pneumonia, 78 (7.0%) required tracheostomy, and 30 (2.7%) developed ARDS. Bicortically displaced fractures were present in 277 (25%) of patients and in 206 (20.3%) of patients without flail chest. After adjusting for patient demographics, injury, and admission physiology, negative pulmonary outcomes occurred over twice as frequently in those with bicortically displaced fractures without flail chest (n = 206) when compared with those without bicortically displaced fractures-pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.6), ARDS (OR, 2.6; 95% CI, 1.0-6.8), and tracheostomy (OR, 2.7; 95% CI, 1.4-5.2). When adjusting for the presence of flail chest, bicortically displaced fractures remained an independent predictor of pneumonia, tracheostomy, and ARDS. CONCLUSION: Patients with bicortically displaced rib fractures are more likely to develop pneumonia, ARDS, and need for tracheostomy even when controlling for flail chest. Future studies should investigate the utility of flail chest management algorithms in patients with bicortically displaced fractures. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Is the number of rib fractures a risk factor for delayed complications? A case-control study.

AIM: To analyse factors that may predict the appearance of rib fracture complications during the first days of evolution and determine whether the number of fractures is related to these complications. METHOD: Retrospective case-control study of patients admitted with a diagnosis of rib fractures between 2010 and 2014. Two groups were established depending on the appearance or not of pleuropulmonary complications in the first 72 h, and the following were compared: age, sex, Charlson comorbidity index (CCI), number and uni- or bilateral involvement, mechanism of trauma, days of hospital stay, haemoglobin on discharge minus haemoglobin on admission, pleuropulmonary complications during admission (pneumothorax, haemothorax or pulmonary contusion) and placement of pleural drainage. RESULTS: One hundred and forty-one cases of rib fractures were admitted in the period mentioned. There were no differences in the patients' baseline characteristics (age, sex and Charlson Comorbidity Index) between the two groups. Differences were found in the number of fractures (2.98 ± 1.19 in the group without complications vs 3.55 ± 1.33 in the group with complications, p = 0.05) and in the drop in the level of haemoglobin (0.52 ± 0.91 mg/dl vs 1.22 ± 1.29 mg/dl, p = 0.01). The length of hospital stay varied considerably in each group (5.35 ± 4.05 days vs 7.86 ± 6.96 days), but without statistical significance (p = 0.11). CONCLUSIONS: The number of fractured ribs that best predicted the appearance of complications (delayed pleuropulmonary complications and greater bleeding) was 3 or more.

Early risk stratification of in hospital mortality following a ground level fall in geriatric patients with normal physiological parameters.

BACKGROUND: The purpose of this study was to identify risk factors of mortality for geriatric patients who fell from ground level at home and had a normal physiological examination at the scene. METHODS: Patients aged 65 and above, who sustained a ground level fall (GLF) with normal scene Glasgow Coma Scale (GCS) score 15, systolic blood pressure (SBP) > 90 and <160 mmHg, heart rate ≥ 60 and ≤100 beats per minute) from the 2012-2014 National Trauma Data Bank (NTDB) data sets were included in the study. Patients' characteristics, existing comorbidities [history of smoking, chronic kidney disease (CKD), cerebrovascular accident (CVA), diabetes mellitus (DM), and hypertension (HTN) requiring medication], injury severity scores (ISS), American College of Surgeons' (ACS) trauma center designation level, and outcomes were examined for each case. Risks factors of mortality were identified using bivariate analysis and logistic regression modeling. RESULTS: A total of 40,800 patients satisfied the study inclusion criteria. The findings of the logistic regression model for mortality using the covariates age, sex, race, SBP, ISS, ACS trauma level, smoking status, CKD, CVA, DM, and HTN were associated with a higher risk of mortality (p < .05). The fitted model had an Area under the Curve (AUC) measure of 0.75. CONCLUSION: Cases of geriatric patients who look normal after a fall from ground level at home can still be associated with higher risk of in-hospital death, particularly those who are older, male, have certain comorbidities. These higher-risk patients should be triaged to the hospital with proper evaluation and management.

Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial.

Background: Multiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures. Methods: The proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months. Discussion: With favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures. Trial registration: www.trialregister.nl, NTR7248. Registered May 31, 2018.

The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients.

BACKGROUND: Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients. METHODS: Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve. RESULTS: Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage. CONCLUSION: Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2. LEVEL OF EVIDENCE: Prognostic study, level II.

Comparison of the Effectiveness of Surgical Versus Nonsurgical Treatment for Multiple Rib Fractures Accompanied with Pulmonary Contusion.

OBJECTIVE: To compare the effectiveness of surgical versus nonsurgical treatment for multiple rib fractures accompanied with pulmonary contusion. METHODS: The clinical records of consecutive 167 patients with multiple rib fractures accompanied with pulmonary contusion, who were treated from June 2014 to June 2017, were retrospectively analyzed. Of them, 75 and 92 underwent surgery (surgery group) and non-surgical treatment (non-surgery group), respectively. Patient pain score, complications, length of hospital stay, cost of hospitalization, and post-treatment 3-month follow-up results were compared. RESULTS: The mean number of days and moderate pain in the surgery group was significantly lower than that of the non-surgery group (p <0.01). The incidence of post-treatment complications was significantly lower in the surgery group than in the non-surgery group. The length of hospital stay of the surgery group was also significantly shorter than that of the non-surgery group (p <0.01). The cost of hospitalization was significantly higher in the surgery group than in the non-surgery group (p <0.01). The chest computed tomography (CT) scan which was performed 3 months after the treatment revealed that the surgery group had a better recovery than the non-surgery group. Physical recovery of the surgery group was also significantly better than that of the non-surgery group. CONCLUSION: Surgery to treat multiple rib fractures (≥ 4 fractures) accompanied with pulmonary contusion is safe and effective.

Acute rib fracture caused by preoperative positioning for direct lateral interbody fusion: A case report.

RATIONALE: Degenerative spondylolisthesis is defined as forward slippage of a vertebra with respect to the underlying vertebra and is associated with the induction of lumbar canal stenosis. The use of anterior column support for degenerative lumbar conditions has been well documented. Direct lateral interbody fusion (DLIF) gains access via a lateral approach through the retroperitoneal fat and psoas muscle. It avoids many of the access-related complications yet comes with its own risks and limitations. The location of the iliac wing precludes exposure of the L5-S1 disc space and may make L4-5 surgery difficult. Therefore, accurate preoperative patient positioning is essential. PATIENT CONCERNS: A 71-year-old female with a body mass index (BMI) of 39.2 kg/m (height 155.9 cm, weight 79.5 kg) presented with lumbar pain radiating to the left lower limb. She complained of neurologic claudication with more than 100 m ambulation. DIAGNOSIS: Plain standing view on spine radiography revealed L4-5 spondylolisthesis and disc-space narrowing. Magnetic resonance imaging (MRI) revealed severe L4-5 bilateral foraminal stenosis. After the first surgery, simple rib cage radiography was performed to examine the source of her right-sided flank pain and it revealed acute fracture of the right ninth and tenth ribs. INTERVENTIONS: The patient was laterally positioned on the table in an extreme bending position. The intervertebral cage was inserted in the L4-5 disc space and disc height was restored. With respect to the rib fracture, treatment was conservative. OUTCOMES: The patient's radiating pain was immediately relieved and her lower back pain disappeared at 3 months after surgery. The patient reported right-sided flank pain after the first surgery. Simple rib cage radiography was performed and revealed fracture of the right ninth and tenth ribs. Follow-up assessments conducted 2 months later revealed complete bony union. LESSONS: DLIF avoids many access-related complications. However, it is associated with other intraoperative complications, including injury to the lumbar nerve root and plexus. In addition, there are preoperative complications associated with improper patient placement on the table. In this case, the patient's obesity and strict positional requirements resulted in rib fracture. We suggest that surgeons consider this complication and exercise care in preoperative positioning.

[Innovated Judet Ribs Plates - Preclinical Study, First Clinical Experience]. / Inovované zeberní dlahy Judetova typu ­ preklinická studie, první klinické zkusenosti.

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.

Forced vital capacity less than 1: A mark for high-risk patients.

BACKGROUND: Rib fractures (RFx) continue to be a source of morbidity and mortality. A RFx care pathway has been used based on forced vital capacity (FVC). The objective of this study was to test the hypothesis that deterioration of FVC to less than 1 after admission is a marker for high-risk patients and affects outcomes. METHODS: A retrospective study of patients enrolled in an RFx care pathway at a Level 1 trauma center from 2009 to 2014. All patients had an admission FVC greater than 1. 2 groups were analyzed: patients with a lowest inpatient FVC less than 1 (Group A) compared to patients with lowest inpatient FVC of 1 or greater (Group B). Complications [pneumonia, upgrade to the intensive care unit, readmission, and intubation] and demographics were examined. Patients without documented admission FVCs were excluded. p < 0.05 was considered significant. RESULTS: A total of 1,106 patients were analyzed (Group A, 187; Group B, 919). Patients whose FVC dropped less than 1 (Group A) had a higher complication rate [15% (Group A) vs 3.2% (Group B); p < 0.001]. Rates of pneumonia, readmission, unplanned upgrade, and intubation were all significantly higher in Group A [pneumonia: 9% (Group A) vs 1.4% (Group B), p < 0.001; readmission: 4% (Group A) vs 1.7% (Group B), p = 0.04; upgrade; 3.7% (Group A) vs 0.2% (Group B), p < 0.001; intubation: 1.6% (Group A) vs 0.1% (Group B), p = 0.02]. Hospital length of stay was longer in Group A [10 days (Group A) vs 4 days (Group B), p < 0.001]. CONCLUSIONS: Forced vital capacity predicts complications in patients with RFx. Patients whose FVC falls less than 1 during admission are at high risk for pulmonary complications. Daily FVC testing for patients admitted with RFx can predict outcomes. Forced vital capacity less than 1 should be considered as a marker for complications. Once FVC drops less than 1, patients should be considered for increased interventions. Even if the patient has not yet clinically deteriorated, consideration for higher level of care is warranted. LEVEL OF EVIDENCE: Prognostic study, level III.

Systemic administration of mesenchymal stem cells combined with parathyroid hormone therapy synergistically regenerates multiple rib fractures.

BACKGROUND: A devastating condition that leads to trauma-related morbidity, multiple rib fractures, remain a serious unmet clinical need. Systemic administration of mesenchymal stem cells (MSCs) has been shown to regenerate various tissues. We hypothesized that parathyroid hormone (PTH) therapy would enhance MSC homing and differentiation, ultimately leading to bone formation that would bridge rib fractures. METHODS: The combination of human MSCs (hMSCs) and a clinically relevant PTH dose was studied using immunosuppressed rats. Segmental defects were created in animals' fifth and sixth ribs. The rats were divided into four groups: a negative control group, in which animals received vehicle alone; the PTH-only group, in which animals received daily subcutaneous injections of 4 µg/kg teriparatide, a pharmaceutical derivative of PTH; the hMSC-only group, in which each animal received five injections of 2 × 106 hMSCs; and the hMSC + PTH group, in which animals received both treatments. Longitudinal in vivo monitoring of bone formation was performed biweekly using micro-computed tomography (µCT), followed by histological analysis. RESULTS: Fluorescently-dyed hMSCs were counted using confocal microscopy imaging of histological samples harvested 8 weeks after surgery. PTH significantly augmented the number of hMSCs that homed to the fracture site. Immunofluorescence of osteogenic markers, osteocalcin and bone sialoprotein, showed that PTH induced cell differentiation in both exogenously administered cells and resident cells. µCT scans revealed a significant increase in bone volume only in the hMSC + PTH group, beginning by the 4th week after surgery. Eight weeks after surgery, 35% of ribs in the hMSC + PTH group had complete bone bridging, whereas there was complete bridging in only 6.25% of ribs (one rib) in the PTH-only group and in none of the ribs in the other groups. Based on the µCT scans, biomechanical analysis using the micro-finite element method demonstrated that the healed ribs were stiffer than intact ribs in torsion, compression, and bending simulations, as expected when examining bone callus composed of woven bone. CONCLUSIONS: Administration of both hMSCs and PTH worked synergistically in rib fracture healing, suggesting this approach may pave the way to treat multiple rib fractures as well as additional fractures in various anatomical sites.

The role of a video-assisted thoracic approach for rib fixation.

PURPOSE: Rib fixation remains a contentious issue in the current practice of orthopaedic, trauma and thoracic surgeons. Whilst rib fractures are undoubtedly associated with high levels of morbidity and mortality, the optimal surgical approach has not yet been fully elucidated in prospective trials and the volume of procedures performed remains low. METHODS: We evaluated 21 consecutive patients who underwent surgical rib fixation either via a standard thoracotomy approach or following the introduction of a video-assisted technique with minimal thoracic incisions. RESULTS: The average age of patients undergoing rib fixation was 47 and the median length of post-operative stay was 4 days. More than 70 % of patients were found to have concurrent haemothoraces, and 19 % had significant injuries to underlying intra-thoracic structures requiring repair. One patient returned to theatre for persistent blood loss; however, there were no other immediate complications or mortalities. CONCLUSIONS: We discuss the involvement of thoracic surgeons, early assessment of the thoracic cavity with video assistance and optimal peri-operative management with particular reference to cases which demonstrate recent changes in our practice.