Erector Spinae Plane Blocks for the Early Analgesia of Rib Fractures in Trauma (ESPEAR): protocol for a multicentre pilot randomised controlled trial with feasibility and embedded qualitative assessment.

INTRODUCTION: Patients with rib fractures commonly experience significant acute pain and are at risk of hypoxia, retained secretions, respiratory failure and death. Effective analgesia improves these outcomes. There is widespread variation in analgesic treatments given to patients including oral, intravenous and epidural routes of administration. Erector spinae plane (ESP) blockade, a novel regional analgesic technique, may be effective, but high-quality evidence is lacking. METHODS AND ANALYSIS: To determine if a definitive trial of ESP blockade in rib fractures is possible, we are conducting a multicentre, randomised controlled pilot study with feasibility and qualitative assessment. Fifty adult patients with rib fractures will be randomised in a 1:1 ratio to ESP blockade with multimodal analgesia or placebo ESP blockade with multimodal analgesia. Participants and outcome assessors will be blinded. The primary feasibility outcomes are recruitment rate, retention rate and trial acceptability assessed by interview. ETHICS AND DISSEMINATION: The study was approved by the Oxford B Research Ethics Committee on 22 February 2022 (REC reference: 22/SC/0005). All participants will provide written consent. Trial results will be reported via peer review and to grant funders. TRIAL REGISTRATION NUMBER: ISRCTN49307616.

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.

Assessment of Discharge Analgesic Prescription Patterns for Hospitalized Patients With Rib Fractures.

INTRODUCTION: There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as well as potential variables predictive of opioid prescribing. METHODS: A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge. RESULTS: The majority of patients were male (68.8%) with a median age of 53 y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P < 0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P < 0.01) were predictive of high MME prescribed on discharge. CONCLUSIONS: For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.

A new quantitative assessment method for predicting pneumonia caused by chest wall injury.

BACKGROUND: The severity of rib fractures has been previously evaluated by combining categorical data, but these methods have only low predictive capability for respiratory complications and mortality. This study aimed to establish a more accurate method for predicting the development of pneumonia, a frequent complication in chest injuries, using anatomical relationships. METHODS: We analyzed three-dimensional reconstructed images of 644 consecutive trauma patients who underwent whole-body computed tomography (CT) in our institution within a 36-month study period from April 2017. The anatomical relationship between the right and left thoracic volumes of non-rib fracture patients was used to estimate thoracic volume changes on the injured side in unilateral rib fracture patients. The predictive capability of changes in thoracic volume for the development of pneumonia was evaluated according to the area under the receiver operating characteristic curve and compared with that of previous chest wall severity evaluation methods. RESULTS: Of the 644 patients, 133 and 478 patients had unilateral rib fractures and non-rib fractures, respectively. The amount of change in thoracic volume due to unilateral rib fractures was significantly greater in pneumonia patients (400 mL vs. 160 mL, p < 0.01). The area under the receiver operating characteristic curve for the development of pneumonia was 0.83, which tended to be higher than that of the previous severity scoring methods. CONCLUSION: The amount of change in chest volume, which can be estimated using CT images, has better predictive capability for pneumonia than previous severity assessment methods based on categorical data. The amount of change in chest volume measured using whole-body CT can be used to rapidly determine the optimal treatment for severe chest wall injuries. LEVEL OF EVIDENCE: Prognostic study, level IV.

"Do You Need a Doctor's Note?" Factors Leading to Delayed Return to Work after Blunt Chest Trauma.

BACKGROUND: Blunt chest trauma is associated with significant morbidity, but the long-term functional status for these patients is less well-known. Return to work (RTW) is a benchmark for functional recovery in trauma patients, but minimal data exist regarding RTW following blunt chest trauma. MATERIALS AND METHODS: Patients ≥ 18 y old admitted to a Level 1 trauma center following blunt chest trauma with ≥ 3 rib fractures and length of stay (LOS) ≥ 3 d were included. An electronic survey assessing RTW was administered to patients after discharge. Patients were stratified as having delayed RTW (> 3 mo after discharge) or self-reported worse activities-of-daily-living (ADL) function after injury. Patient demographics, outcomes, and injury characteristics were compared between groups. RESULTS: Median time to RTW was 3 mo (IQR 2,5). Patients with delayed RTW had higher odds of having more rib fractures than those with RTW ≤ 3 mo (median 10 versus 7; OR:1.24, 95%CI:1.04,1.48) as well as a longer LOS (median 13 versus 7 d; OR:1.15, 95% CI:1.04,1.30). Patients with stable ADL after trauma returned to work earlier than those reporting worse ADL (median 2 versus 3.5 mo, P < 0.01). 23.6% of respondents took longer than 5 mo to return to independent functioning, and 50% of respondents' report limitations in daily activities due to physical health after discharge. CONCLUSIONS: The significant proportion of patients with poor physical health and functional status suggests ongoing burden of injury after discharge. Patients with longer LOS and greater number of rib fractures may be at highest risk for delayed RTW after injury.

Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups.

BACKGROUND: Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS: This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS: Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS: Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE: Economic/decision, level II.

Ketorolac Use for Pain Management in Trauma Patients With Rib Fractures Does not Increase of Acute Kidney Injury or Incidence of Bleeding.

INTRODUCTION: Ketorolac is useful in acute pain management to avoid opiate-related complications; however, some surgeons fear associated acute kidney injury (AKI) and bleeding despite a paucity of literature on ketorolac use in trauma patients. We hypothesized that our institution's use of intravenous ketorolac for rib fracture pain management did not increase the incidence of bleeding or AKI. METHODS: Rib fracture patients aged 15 years and above admitted between January 2016-June 2018 were identified in our trauma registry along with frequency of bleeding events. AKI was defined as ≥ 1.5x increase in serum creatinine from baseline measured on the second day of admission (after 24 hours of resuscitation) or an increase of ≥ .3 mg/dL over a 48-hour period. Patients receiving ketorolac were compared to patients with no ketorolac use. RESULTS: Two cohorts of 199 control and 205 ketorolac patients were found to be similar in age, gender, admission systolic blood pressure (SBP), injury severity score, intravenous radiocontrast received, and transfusion requirements. Analysis revealed no difference in frequency of AKI using both definitions (8% vs. 7.3%, P = .79) and (19.6% vs. 15.1%, P = .24), respectively, or bleeding events (2.5% vs. 0%, P = .03). Logistic regression demonstrated that ketorolac use was not an independent predictor for AKI but age and admission SBP < 90 were. CONCLUSION: Use of ketorolac in this cohort of trauma patients with rib fractures did not increase the incidence of AKI or bleeding events.

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.

A Statewide Assessment of Rib Fixation Patterns Reveals Missed Opportunities.

BACKGROUND: Rib fractures are a common consequence of traumatic injury and can result in significant debilitation. Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments. However, commercial rib fixation has only recently become clinically prevalent, and we hypothesize that significant variability exists in its utilization based on injury pattern and trauma center. METHODS: The Pennsylvania Trauma System Foundation database was queried for all multiple rib fracture patients occurring statewide in 2016 and 2017. Demographics including the presence of flail and the occurrence of rib fixation was abstracted. Outcomes were compared between the fixation group and all other rib fracture patients. Deidentified treating trauma center was used to elicit center-level disparities. RESULTS: During the study period, there were 12,910 patients with multiple rib fractures, of which 135 had flail segments. 57 patients underwent rib fixation, and 10 of which had a flail segment. Compared with the nonoperative cohort, those who underwent rib fixation were younger (52.5 versus 61.5, P = 0.0009), similar in gender (68% versus 62% male, P = 0.373), and race (80% versus 86% White, P = 0.239). The rib fixation group had higher Injury Severity Scores (19.4 versus 15.4 P = 0.0011). The timing of rib fixation was most frequent within 1 wk of injury but extended out through 3 wk; the occurrence of pulmonary complications had a similar distribution. The frequency of rib fixation rates within trauma centers was not associated with rib fracture patient volume, and 37.1% of multiple rib fracture patients were cared for at centers that did not perform rib fixation. CONCLUSIONS: Rib fixation is infrequently used at trauma centers in Pennsylvania. It is used more frequently in nonflail injuries, and its use may be associated with the occurrence of pulmonary complications. Significant center-level variation exists in rib fixation rates among multiple fractured patients. A significant number of patients are cared for at centers that do not perform rib fixation. Further research is needed to illicit better-defined indications for operative fixation, and opportunities exist to further the penetrance of this practice to all trauma centers.

Early versus late surgical stabilization of severe rib fractures in patients with respiratory failure: A retrospective study.

INTRODUCTION: The timing of surgical stabilization of rib fractures remains controversial. We hypothesized that early surgical stabilization (within 3 days of injury) can improve clinical outcome in patients with severe rib fractures and respiratory failure. The aim of this study was to analyze the impact of early surgical stabilization of rib fractures on the perioperative results, clinical outcomes, and medical costs of patients with severe rib fractures and respiratory failure. METHODS: This was a retrospective comparative study based on a prospectively collected database at a single institute. Patients with severe rib fractures and respiratory failure who underwent surgical stabilization were classified into early (within 3 days of injury) and late (more than 3 days after injury) groups. Outcome measures included operation time, duration of mechanical ventilation, intensive care unit stay, hospital stay, complication rate, mortality rate, and medical cost. RESULTS: A total of 33 patients were enrolled (16 and 17 in the early and late groups, respectively). The demographics, trauma mechanism, associated injuries, and severity of trauma were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (median 36 vs. 90 hours, p = 0.03), intensive care unit stay (median 123 vs. 230 hours, p = 0.004), and hospital stay (median 12 vs. 18 days, p = 0.005); and lower National Health Insurance costs (median 6,617 vs. 10,017 US dollars, p = 0.031). The early group tended to have lower rates of morbidity and mortality, but the difference was not statistically significant. CONCLUSION: Early surgical stabilization of rib fractures in selected patients may significantly shorten their duration of mechanical ventilation, and intensive care unit and hospital stays, while incurring less medical costs.

Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: a randomized controlled trial.

BACKGROUND: An incentive spirometer (IS) is a mechanical device that promotes lung expansion. It is commonly used to prevent postoperative lung atelectasis and decrease pulmonary complications after cardiac, lung, or abdominal surgery. This study explored its effect on lung function and pulmonary complication rates in patients with rib fractures. METHODS: Between June 2014 and May 2017, 50 adult patients with traumatic rib fractures were prospectively investigated. Patients who were unconscious, had a history of chronic obstructive pulmonary disease or asthma, or an Injury Severity Score (ISS) ≥ 16 were excluded. Patients were randomly divided into a study group (n = 24), who underwent IS therapy, and a control group (n = 26). All patients received the same analgesic protocol. Chest X-rays and pulmonary function tests (PFTs) were performed on the 5th and 7th days after trauma. RESULTS: The groups were considered demographically homogeneous. The mean age was 55.2 years and 68% were male. Mean pretreatment ISSs and mean number of ribs fractured were not significantly different (8.23 vs. 8.08 and 4 vs. 4, respectively). Of 50 patients, 28 (56%) developed pulmonary complications, which were more prevalent in the control group (80.7% vs. 29.2%; p = 0.001). Altogether, 25 patients had delayed hemothorax, which was more prevalent in the control group (69.2% vs. 29.2%; p = 0.005). Two patients in the control group developed atelectasis, one patient developed pneumothorax, and five patients required thoracostomy. PFT results showed decreased forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) in the control group. Comparing pre- and posttreatment FVC and FEV1, the study group had significantly greater improvements (p < 0.001). CONCLUSIONS: In conclusion, the use of an IS reduced pulmonary complications and improved PFT results in patients with rib fractures. The IS is a cost-effective device for patients with rib fractures and its use has clinical benefits without harmful effects. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04006587. Registered on 3 July 2019.

Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients.

Objective: Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). Methods: We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. Results: After eliminating patients who were not eligible to receive TEA, the average patient bill was $59,123 ($10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -$21,429.55- -$7,794.66) and a 24% reduction in per-day billing (99% CI = -$3,745.99- -$1,276.14). Conclusions: Patients who received TEA were more severely injured and required longer treatments; controlling for these variables, the use of TEA associated with reductions in the cost of receiving care. From an administrative and insurance perspective, more frequent reliance on TEA may be indicated.

[Assessment of traumatic rib fractures caused by traffic accident].

We reviewed 66 cases of traumatic rib fracture by traffic accident between January 2009 and December 2011. The age of patients ranged from 18 to 88 years, with an average age of 55.6, and they were predominantly male. They met with traffic accident when driving automobiles in 30 cases, driving motorcycles in 15 cases, and walking in 9 cases. The average number of fractured ribs was 4.1±3.2.Multiple rib fractures were observed in 75.8% of patients. Injuries other than rib fractures were involved in all patients who suffered over 7 rib fractures. Except one who died of pneumonia 62 days after traffic accident, 7 of 8 patients died within 48 hours:6 in a shock state and 1 in cardiac pulmonary arrest on arrival. About 80 % of the patients with rib fractures were hospitalized. As traffic accidents could cause any type of injuries including rib fractures, it is important to examine the whole body when patients were transported to a hospital.

Rib fracture fixation for flail chest: what is the benefit?

BACKGROUND: Recently, rib fracture fixation for flail chest has been used increasingly at both academic and nonacademic trauma centers. Although a few small non-US studies have demonstrated a clinical benefit, it is unclear whether this benefit outweighs the added expense and potential perioperative complications related to the procedure. We therefore sought to determine if open reduction and internal fixation of ribs for flail chest (ORIF-FC) represents a cost-effective means for managing these patients. STUDY DESIGN: A Markov transition state analysis was performed modeling the outcomes of the standard of care or ORIF-FC for flail chest. The incidences of ventilator-associated pneumonia, tracheostomy, sepsis, prolonged ventilation, deep vein thrombosis, pulmonary embolism, wound infection, and postoperative hemorrhage were obtained based on literature review. Medicare 2010 reimbursement costs were used for diagnoses and procedures. A quality of life improvement factor ranging from 0 to 15% improvement was used to estimate the improvement in pain and functional outcomes related to ORIF-FC. The most cost-effective treatment was then determined, ranging the incidences of ventilator-associated pneumonia and quality of life improvement factor. RESULTS: Cost effectiveness was $15,269 for ORIF-FC compared with $16,810 for standard of care. Even when the quality of life improvement factor was set to 0%, ORIF-FC remained the most cost-effective strategy. Similarly, ORIF-FC remained the most cost-effective strategy by $8,400 when the incidence of ventilator-associated pneumonia after ORIF was as high as 22%. CONCLUSIONS: Despite the additional cost of surgery, rib fracture fixation dominates the standard of care and should be considered in the management of appropriate flail chest patients.

[Closed traumas of the thorax. Assessment of two years activity at the Dakar Trauma Center]. / Traumatismes fermés du thorax. Bilan de deux années d'activité au Centre de Traumatologie de Dakar.

Two years after opening the Dakar Trauma Center has received 179 cases of blunt chest trauma without prehospital treatment. Road accidents were the leading cause. The initial mortality was 29 patients (16.20%) and 150 patients arrived alive and were treated. The initial mortality was primarily due to the associated extrathoracic injuries mainly hemorrhagic with hemoperitoneum in 44.82% and brain hemorrhage in 24.14% of cases. Secondly, it was due to the thoracic injuries with 41.37% of anterior flail chest and massive hemothorax in 65.51% of cases. Among the 150 patients treated, 42% had extrathoracic injuries, mainly head trauma. 56% were admitted to intensive care units with 39 chest drainages and 6 thoracotomies were performed. The mortality in this group was about 11.33%. The very high initial mortality could be reduced by the organisation of prehospital treatment to take better care of patients involved in road accidents.

Sternal fractures--the natural history.

A five-year retrospective study was undertaken to analyze the natural history of sternal fractures and to scrutinize the current method of management. Sixty-six patients with documented sternal fractures were evaluated. The most common mechanism of injury was motor vehicle accidents (59%). Most of these victims did not wear seat belts. Thirty-five patients (53%) had associated injuries, of which rib fractures were the most common. Thirty-one patients (47%) had sternal fractures with no associated injury. The incidence of myocardial contusion in our study was 18%. Of the patients without associated injuries, the incidence of myocardial contusion was 6%. There were no mortalities in our study population, and there was no significant morbidity necessitating mechanical or pharmacologic support. The majority of these patients were managed by admission, observation, IV therapy, and placement of monitored beds. Our findings of no life-threatening sequelae suggest that we might question the necessity of current management criteria. This proves to be of special interest in view of the economic restraints imposed on health care today.

Rib radiographs for trauma: useful or wasteful?

In trauma to the chest, the clinical impression and the physical findings of rib fractures are nonspecific. Fractures often are not seen on initial films. The principal diagnostic goal should be the detection of significant complications (pneumothorax, hemothorax, major vascular injury, or pulmonary contusion) requiring admission. The therapeutic effort should be to provide pain relief and prevent the delayed development of atelectasis or pneumonia in patients with painful chest wall injuries, whether or not a fracture is detected initially. An upright posteroanterior chest radiograph has the greatest yield in detecting fractures and complications resulting from them. Tomograms and expiratory, oblique, and "coned-down" views should not be done routinely. The use of these more specific examinations may be indicated, however, in such cases as trauma to ribs 1 to 3 or 9 to 12. Their selective use in isolated cases (trauma to ribs 1 to 3 or 9 to 12) and suspected child abuse may indicate the need for these more specific examinations. Because detection of pulmonary complications of chest trauma is most important, a delayed or repeat upright posteroanterior chest radiograph may be the most cost-effective second radiograph. Significant medical care cost savings may be appreciated by limiting the use of specific rib views to instances in which it might influence the patient's therapy.