MULTIDETECTOR COMPUTED TOMOGRAPHY IN BLUNT CHEST TRAUMA SINGLE TERTIARY CARE TRAUMA CENTRE EXPERIENCE.

Thoracic injuries are significant causes of morbidity and mortality in trauma patients, second only to head injuries. In addition to conventional radiography, multidetector computed tomography (CT) is increasingly being used, since it can quickly and accurately help diagnose a wide variety of injuries in trauma patients. Furthermore, multiplanar and MiNIP, volumetric reformatted CT images provide improved visualization of injuries, increased understanding of trauma-related diseases, and enhanced communication between the radiologist and the referring clinician. To identify and accurately a Aims: ssess variety of injuries in blunt thoracic trauma with multidetector Computed Tomography (MDCT). To find commonest pattern of intrathoracic injury related to blunt chest trauma. This Method: retrospective observational study included 50 patients who underwent Multidetector CT examination during the period from November 2020 to April 2021 at tertiary care trauma centre, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai. Blunt chest Conclusion: trauma injuries were classified into pleural injury, lung parenchymal injury, bony thorax, tracheobronchial and vascular injuries. The commonest injury detected was pleural (70%) followed by lung parenchymal injury (52%) and bony thorax injury in 50% cases. 50% of the pleural injury cases were associated with rib fractures. Multiple injuries were seen in the 47 patients, stating the importance of a detail evaluation of all chest components. No oesophageal and cardiac injury was detected in our CT studies' with its multiplanar, MinIP and volume reconstruction images increases the confidence in imaging diagnosis and play a critical role in understanding thoracic trauma related complications.

Research progress in pulmonary electrical impedance tomography for ventilation functional evaluation following multiple rib fracture / 中华创伤杂志

Multiple rib fracture is a common chest injury that can cause severe pain and seriously affect life quality of the patients. The traditional pulmonary function test can only assess changes in total lung volume and ventilation of the multiple rib fracture, but fails to reveal regional ventilation status in rib fracture area and ventilation differences within the whole lung. Instead, pulmonary electrical impedance tomography (EIT), as a novel bedside technique for ventilation monitoring, has advantages of non-invasiveness, non-use of radiative rays and dynamic visualization of regional ventilation, enabling to quantify ventilation defects and heterogeneity in space and time. Starting with the assessment of ventilation changes and research status of ventilation function in multiple rib fracture and the characteristics of EIT, the authors review the research progress in the evaluation of ventilation function following multiple rib fracture based on EIT, with the aim to provide new insight into the research on ventilation changes after multiple rib fracture.

Efficacy evaluation of open reduction and internal fixation in the treatment of multiple rib fractures at different timing: a Meta-analysis / 中华创伤杂志

Objective:To evaluate the effect of early and late open reduction and internal fixation on multiple rib fractures.Methods:The related literatures of early and late open reduction and internal fixation of multiple rib fractures were searched in PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, WanFang database, VIP database and China Biology Medicine database. The retrieved literatures were screened according to the inclusion criteria and exclusion criteria. The quality of the literature was strictly evaluated and Meta analysis was carried out by using Stata 15.0 software. The open reduction and internal fixation within 72 hours after injury (early operation group) and more than 72 hours after injury (late operation group) were compared in the incidence of pulmonary complications, chest pain improvement rate, duration of postoperative ventilator-assisted ventilation, postoperative chest X-ray improvement time, postoperative bed rest time, duration of postoperative chest tube retention, length of hospitalization, operation time and mortality rate.Results:A total of 11 studies with 712 patients were included. There were 360 patients in early operation group and 352 patients in late operation group. The two groups showed significant differences in the incidence of pulmonary complications ( OR=0.25, 95% CI 0.16-0.37, P<0.01), chest pain improvement rate ( OR=6.15, 95% CI 1.63-23.27, P<0.01), duration of postoperative ventilator-assisted ventilation ( SMD=-0.97, 95% CI -1.70--0.24, P<0.01), postoperative chest X-ray improvement time ( SMD=-15.91, 95% CI -18.42--13.41, P<0.01), postoperative bed rest time ( SMD=-11.07, 95% CI -12.31--9.84, P<0.01), duration of post-operative chest tube retention ( SMD=-0.98, 95% CI -1.77--0.20, P<0.05) and length of hospitalization ( SMD=-0.96, 95% CI -1.26--0.66, P<0.01). The operation time ( SMD=-2.44, 95% CI -4.89-0.02, P>0.05) and mortality rate ( OR=0.24, 95% CI 0.04-1.51, P>0.05) were not statistically different between the two groups. Conclusion:Early open reduction and internal fixation in the treatment of multiple rib fractures can reduce pulmonary complications and chest pain and shorten postoperative ventilator-assisted ventilation time, postoperative chest X-ray improvement time, postoperative bed rest time, duration of postoperative chest tube retention and hospital stay, but cannot shorten operation time or reduce mortality.

Correlation of rib fracture patterns with abdominal solid organ injury: A retrospective observational cohort study / 中华创伤杂志(英文版)

PURPOSE@#Rib fractures are one of the most common causes of morbidity and mortality and are associated with abdominal solid organ injury (ASOI). The purpose of this study was to investigate the correlation of ASOI with the number, location, and involved segments of rib fracture(s) in blunt chest trauma.@*METHODS@#This retrospective cohort study was conducted on patients with blunt chest trauma over the age of 15 years, who were hospitalized with the diagnosis of rib fractures from July 2015 to September 2020. After ethic committee approval, a retrospective chart review was designed and patients with a diagnosis of rib fractures were selected. Patients who had chest and abdominopelvic CT scan were included in the study and additional data including age, gender, injury severity score, trauma mechanism, number and sides of the fractured ribs (left/right/bilateral), rib fracture segments (upper, middle, lower zone) and results of chest and abdominal spiral CT scan were recorded. The correlation between ASOI and the sides, segments and number of rib fracture(s) was assessed by Pearson's correlation coefficient.@*RESULTS@#Altogether 1056 patients with rib fracture(s) were included. The mean age was (42.76 ± 13.35) years and 85.4% were male. The most common mechanism of trauma was car accident (34.6%). Most fractures occurred in the middle rib zone (60.44%) and the most commonly involved ribs were the 6th and 7th ones (15.7% and 16.4%, respectively). Concurrent abdominal injuries were observed in 103 patients (34.91%) and were significantly associated with middle zone rib fractures.@*CONCLUSION@#There is a significant relationship between middle zone rib fractures and ASOI. Intra-abdominal injuries are not restricted to fractures of the lower ribs and thus should always be kept in mind during management of blunt trauma patients with rib fractures.

Research progress in pain control and respiratory management in patients with flail chest / 中华创伤杂志

Flail chest is a severe chest trauma that is commonly associated with lung contusion, resulting in acute respiratory distress syndrome and respiratory failure, which brings challenges in clinical management. It has become a clinical consensus that surgical treatment of flail chest can rapidly restore thoracic stability, eliminate paradoxical breathing, and maintain stability of respiratory and circulatory functions. However, non-surgical interventions continue to be crucial in further improving the prognosis of patients with flail chest, such as pain management and respiratory management. In this study, the authors review the research progress in pain control and respiratory management during comprehensive treatment of patients with flail chest for better understanding of pain management and lung injury care, which may provide references for clinical treatment and further improvement of clinical prognosis and quality of life for patients with flail chest.

Efficacy comparison of early and late open reduction and internal fixation for severe rib fracture combined with respiratory failure / 中华创伤杂志

Objective:To investigate the effect of timing of rib internal fixation on early curative effect of patients with severe rib fracture complicated with respiratory failure.Methods:A retrospective cohort study was conducted on clinical data of 33 patients with multiple rib fracture complicated with respiratory failure admitted to 909th Hospital of Joint Logistics Support Force (Affiliated Dongnan Hospital of Xiamen University Medical College) from January 2018 to October 2019.There were 26 males and 7 females; aged 60-87 years [(67.9±6.7)years]. The time interval from injury to open reduction and internal fixation was within 3 days in 16 patients (early operation group) and over 3 days in 17 patients (later operation group). The number of fixed ribs, operation time, duration of mechanical ventilation, length of ICU stay, chest tube indwelling time and lenghth of hospital stay were compared in the two groups. The numeric rating scale (NRS) pain score was assessed at postoperative 1, 3 and 7 days. Postoperative complications were detected as well.Results:All patients were followed up for 8-24 months [(16.5±4.3)months]. Number of fixed ribs was not statistically different between the two groups ( P>0.05). The operation time, duration of mechanical ventilation, length of ICU stay, chest tube indwelling time and length of hospital stay in early operation group [(67.3±11.2)minutes, (103.9±28.2)hours, (5.2±1.9)days, (6.4±2.8)days, (12.5±3.5)days] were shorter than those in late operation group [(108.4±18.4)minutes, (160.8±89.3)hours, (10.1±2.3)days, (9.5±2.2)days, (18.0±4.5)days] ( P<0.05 or 0.01). The NRS score was (6.6±0.6)points, (3.3±0.6)points and (2.7±0.8)points in early operation group at postoperative 1, 3 and 7 days, significantly lower than those in late operation group [(7.4±1.1)points, (4.9±1.1)points, (3.9±0.7)points] ( P<0.05 or 0.01). The total complication rate was 25.0%(4/16) in early operation group, lower than 70.6%(12/17) in late operation group ( P<0.05). Conclusion:For severe rib fracture complicated with respiratory failure, early open reduction and internal fixation can effectively reduce operation time, duration of mechanical ventilation, lenghth of ICU stay, chest tube indwelling time and lenghth of hospital stay, early relieve pain and decrease complications rate when compared with late operation.

Efficacy comparison of 3D printing technology-assisted and conventional open reduction and internal fixation for multiple rib fracture / 中华创伤杂志

Objective:To compare the efficacy of 3D printing technology-assisted and conventional open reduction and internal fixation of multiple rib fracture.Methods:A retrospective cohort study was conducted to analyze the clinical data of 61 patients with multiple rib fracture admitted to Mindong Hospital Affiliated to Fujian Medical University and Fujian Provincial Hospital from July 2018 to March 2020. There were 44 males and 17 females, with age range of 18-73 years [(45.1±12.9)years]. Unilateral lung contusion and laceration occurred in 31 patients, while bilateral in 30. There were 19 patients accompanied by hempneumothorax and 16 by flail chest. Totally, 31 patients received 3D printing technology assisted open reduction and internal fixation (3D-assisted incision group) and 30 patients received conventional open reduction and internal fixation (conventional incision group). The incision length, operation time, intraoperative blood loss, postoperative 3-day visual analogue scale (VAS), duration of pain, indwelling time of chest tube, total length of hospital stay, postoperative bone callus formation time and rate of rib bone plate loosening were comapared in two groups. The short form 36 health survey (SF-36) score (ie, physical function, physical function, physical pain, general health, energy, social function, emotional function, mental health) preoperatively, at postoperative 6-month and at the last follow-up was compareted between two groups. Complications were observed at the same time.Results:All patients were followed up for 18-38 months [(26.4±5.5)months]. In 3D-assisted incision group, the incision length was (5.9±1.3)cm, with operation time for (84.6±7.8)minutes, intraoperative blood loss for (85.5±13.9)ml, postoperative 3-day VAS for (2.5±0.5)points, duration of pain for (5.9±0.7)days, indwelling time of chest tube for (3.4±0.7)days, total length of hospital stay for (7.0±1.0)days, postoperative callus formation time for (2.6±0.7)weeks and rate of rib bone plate loosening for 3.2%(1/31). By contrast, in conventional incision group, the incision length was (10.9±2.4)cm, with operation time for (127.1±12.5)minutes, intraoperative blood loss for (183.0±30.9)ml, postoperative 3-day VAS for (6.5±0.9)points, duration of pain for (11.2±1.8)days, indwelling time of chest tube for (7.8±0.8)days, total length of hospital stay for (15.1±1.2)days, postoperative callus formation time for (4.6±0.8)weeks and rate of rib bone plate loosening for 20.0%(6/30) ( P<0.05 or 0.01). There was no significant difference in preoperative SF-36 score between the two groups ( P>0.05). At 6 months after surgery, the subscores of SF-36 in 3D-assisted incision group were higher than those in conventional incision group except for "mental health" ( P<0.05 or 0.01). At the last follow-up, all the subscores of SF-36 in 3D-assisted incision group were higher than those in conventional incision group ( P<0.05 or 0.01). There were no obvious complications such as pulmonary infection or atelectasis. Conclusions:For multiple rib fracture, 3D printing technology-assisted open reduction and internal fixation is superior to conventional open reduction and internal fixation for it can shorten incision length, operation time, indwelling time of chest tube, total length of hospital stay and postoperative bone callus formation time, reduce intraoperative blood loss, relieve postoperative pain, reduce rate of rib bone plate loosening and improve quality of life of the patients.

Efficacy comparison of standardized incision and conventional incision for reduction and internal fixation of multiple rib fracture / 中华创伤杂志

Objective:To compare the efficacy of standardized incision and conventional incision for reduction and internal fixation of multiple rib fracture.Methods:A retrospective cohort study was conducted to analyze the clinical data of 192 patients with multiple rib fracture treated in 909th Hospital of Joint Logistics Support Force (Affiliated Dongnan Hospital of Xianmen University Medical College) from January 2020 to January 2022. There were 101 males and 91 females; aged 32-94 years [(51.5±16.6)years]. The patients underwent open reduction and internal fixation with nickel-titanium shape memory alloy embracer via standard incision such as anterior axillary longitudinal incision (standard incision group, n=96) or conventional incision such as posterolateral incision (conventional incision group, n=96). The incision length, operation time, intraoperative blood loss, number of fixed fractures, indwelling time of closed thoracic drainage tube, postoperative thoracic drainage volume, postoperative spontaneous ambulation time and length of hospital stay were compared in the two groups. The visual analogue scale (VAS) was used to evaluate pain at 1 month after operation. Postoperative complications were recorded. Results:All patients were followed up for 1-16 months [4.0(3.0, 10.5)months]. The operation time, intraoperative blood loss, indwelling time of closed thoracic drainage tube, postoperative thoracic drainage volume, postoperative spontaneous ambulation time, length of hospital stay and VAS at postoperative 1 month in standard incision group [(12.1±1.6)cm, (51.4±13.0)minutes, (191.5±16.8)ml, (2.8±0.6)days, (568.9±109.0)ml, (4.1±0.7)days, (11.4±1.7)days, (2.5±0.7)points] were better than those in conventional incision group [(13.7±1.9)cm, (62.0±8.8)minutes, (248.9±65.4)ml, (4.8±1.1)days, (655.9±121.9)ml, (5.2±0.9)days, (15.3± 1.7)days, (3.5±0.7)points] ( P<0.05 or 0.01). There was no statistical difference in the number of fixed fractures between standard incision group and conventional incision group (5.1±0.8 vs. 5.4±0.9) ( P>0.05). In standard incision group, there were 3 patients with poor wound healing, 5 with pulmonary infection, 3 with atelectasis and 3 with small pleural effusion. In conventional incision group, there were 11 patients with poor wound healing, 9 with pulmonary infection, 7 with atelectasis and 7 with small pleural effusion. The incidence of postoperative complications was 14.6% (14/96) in standard incision group and 35.4% (34/96) in conventional incision group ( P<0.01). Conclusion:For multiple rib fracture, standard incision is superior to conventional incision reduction in shortening the incision length, operation time, indwelling time of drainage tube, postoperative spontaneous ambulation time and length of hospital stay, reducing the intraoperative blood loss and postoperative thoracic drainage volume, alleviating the pain and reducing the postoperative complications.

Progresses in clinical treatment of multiple rib fractures and flail chest / 中国胸心血管外科临床杂志

@#The incidence of rib fracture in patients with chest trauma is about 70%. Simple rib fractures do not need special treatment. Multiple rib fractures and flail chest are critical cases of blunt trauma, which often cause serious clinical consequences and need to be treated cautiously. Nowadays, there is a controversy about the diagnosis and treatment of multiple rib fractures and flail chest. In the past, most of the patients were treated by non-operative treatment, and only less than 1% of the patients with flail chest underwent surgery. In recent years, studies have confirmed that surgical reduction and internal fixation can shorten the hospital stay, and reduce pain and cost for patients with flail chest, but there is still a lack of relevant clinical consensus and guidelines for diagnosis and treatment, which leads to great differences in clinical diagnosis and treatment plans. This article reviewed the treatment, surgical indications and surgical timing of multiple rib fractures and flail chest.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021) / 中华创伤杂志(英文版)

Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.

Risk factors of hemothorax after rib fracture / 中华创伤杂志

Objective:To explore the risk factors of hemothorax after rib fracture and evaluate its predictive value for hemothorax.Methods:A retrospective case control study was made on the data of 449 patients with rib fracture admitted to Jiangsu Shengze Hospital affiliated to Nanjing Medical University from January 2018 to November 2019. There were 308 males and 141 females，with the age range of 19-97 years［（57.4±14.0）years］. The hemothorax was defined as pleural effusion on chest CT or X examination on admission or within one week after admission. There were 330 patients in hemothorax group and 119 patients in non-hemothorax group. Indices were compared between the two groups，including gender，age，occupation，weight，height，underlying diseases［diabetes，chronic obstructive pulmonary disease（COPD），hypertension，hyperlipidemia］，causes of injury，imaging findings［number of rib fracture，flail chest，bilateral rib fractures，locations of rib fracture and intramural injuries（pneumothorax，pulmonary contusion，mediastinal emphysema and myocardial contusion）］，thoracic cavity drainage，injury to admission time，vital signs（blood pressure and heart rate），routine blood［white blood cell，hemoglobin（Hb），platelet，hematocrit（Hct）］，blood type，urine routine（urinary occult blood，urinary protein，urinary ketone body），biochemical examination［total cholesterol（TCHO），triglyceride（TG），high density lipoprotein（HDL-C），low-density lipoprotein（LDL-C），albumin（ALB），total bilirubin（TBIL），glutamic oxalacetic transaminase（AST），alanine transaminase（ALT），urea nitrogen（BUN），creatinine（CRE），glycosylated hemoglobin（HbA1C）］，coagulation tests［prothrombin time（PT），fibrinogen（FIB），plasma D-dimer（D-D），thrombin time（TT）］after admission，trauma score［chest wall injury score（CIS），injury severity score（ISS），new injury severity score（NISS）］and length of hospital stay. The univariate analysis was used to observe the correlation between each factor and hemothorax after rib fracture and to screen the significant correlation factors，followed by multivariate logistic regression analysis to further identify the independent risk factors. The receiver operating characteristic（ROC）curve was used to analyze the predictive value of continuous variables in independent risk factors and to calcuate the optimal threshold.Results:The two groups showed no significant differences in gender，occupation，weight，height，diabetes，COPD，hyperlipidemia，injury to admission time，blood pressure，heart rate，platelet，urine protein，urine ketone body，TCHO，HDL-C，TBIL，ALT，CRE，HbA1C or PT（ P>0.05）. The hemothorax group showed significantly decreased Hb，Hct，TG，LDL-C and TT and significantly increased age，number of rib fracture，white blood cell count，AST，FIB，D-D，trauma score（CIS，ISS，NISS）and length of hospital stay when compared to non-hemothorax group（ P<0.05）. There were significant differences in hypertension，causes of injury，flail chest，bilateral rib fractures and locations of rib fracture and urinary occult blood between the two groups（ P<0.05）. The univariate analysis showed that age，hypertension，number of rib fractures，flail chest，bilateral rib fractures，locations of rib fracture（upper chest anterolateral segment，middle chest anterolateral segment，middle chest posterolateral segment，middle chest proximal spinal segment，lower chest posterolateral segment，lower chest proximal spinal segment），pneumothorax，pulmonary contusion，myocardial contusion，thoracic cavity drainage，white blood cell count，urinary occult blood，BUN，FIB，trauma score（CIS，ISS，NISS）and length of hospital stay were significantly associated with hemothorax（ P<0.05）. The multivariate Logistic regression analysis showed that locations of rib fracture（including middle chest posterolateral segment，middle chest proximal spinal segment，lower chest posterolateral segment and lower chest proximal spinal segment），pulmonary contusion，thoracic cavity drainage，BUN and trauma score（CIS，ISS，NISS）were significantly associated with hemothorax after rib fracture（ P<0.05）. The ROC curve analysis of continous variables in independent risk factors showed BUN area under the curve（AUC）of 0.587（95% CI 0.529-0.645），CIS AUC of 0.824（95% CI 0.779-0.870），ISS AUC of 0.789（95% CI 0.739-0.840）and NISS AUC of 0.876（95% CI 0.835-0.917）（ P<0.05），and the optimal thresholds for the above variables were 5.0 mmol/L，2.5 points，15 points and 21.5 points，respectively. Conclusion:Locations of rib fracture（including the middle chest posterolateral segment，middle chest proximal spinal segment，lower chest posterolateral segment，lower chest proximal spinal segment），pulmonary contusion，thoracic cavity drainage，BUN，trauma score（CIS，ISS，NISS）are independent risk factors for hemothorax after rib fracture. BUN>5.0 mmol/L and trauma score（CIS>2.5 points，ISS>15 points，NISS>21.5 points）have significant values in predicting hemothorax.

Chinese consensus on surgical treatment of traumatic rib fractures (2021) / 中华创伤杂志

Traumatic rib fractures are the most common injury in thoracic trauma. Previously，the patients with traumatic rib fractures were mostly treated non-surgically，of which 50%，especially those combined with flail chest presented chronic pain or chest wall deformities and over 30% had long-term disabilities，being unable to retain a full-time job. In the past two decades，thanks to the development of internal fixation material technology，the surgical treatment of rib fractures has achieved good outcomes. However，there are still some problems in clinical treatment，including inconsistency in surgical treatment and quality control in medical services. The current consensuses on the management of regional traumatic rib fractures published at home and abroad mainly focus on the guidance of the overall treatment decisions and plans，and relevant clinical guidelines abroad lacks progress in surgical treatment of rib fractures in recent years. Therefore，the Chinese Society of Traumatology affiliated to Chinese Medical Association and Chinese College of Trauma Surgeons affiliated to Chinese Medical Doctor Association，in conjunction with national multidisciplinary experts，formulate the Chinese Consensus for Surgical Treatment of Traumatic Rib Fractures（2021）following the principle of evidence-based medicine，scientific nature and practicality. This expert consensus puts forward some clear，applicable，and graded recommendations from aspects of preoperative imaging evaluation，surgical indications，timing of surgery，surgical methods，rib fracture sites for surgical fixation，internal fixation methods and material selections，treatment of combined injuries in rib fractures，in order to provide references for surgical treatment of traumatic rib fractures.

Analysis of timing and prognostic factors of early tracheotomy in patients with multiple rib fractures / 中华创伤杂志

Objective:To investigate the related factors that affect the timing and prognosis of early tracheostomy in patients with multiple rib fractures.Methods:A retrospective case series study was conducted on medical data of 222 patients with multiple rib fractures who underwent tracheostomy in Affiliated Hospital of Yangzhou University from February 2013 to October 2019，including 160 males and 66 females，with the age of 18 to 85 years ［（49.5 ± 16.3）years］. According to the practice management guidelines for tracheostomy timing and the use of propensity score matching technology，there were 118 patients with tracheostomy within 7 days of tracheal intubation （early group） and 104 patients with tracheostomy after 7 days of tracheal intubation （late group） before matching，and there were 87 patients in early group and 87 patients in late group after matching. Data were compared between groups including the gender，age，underlying disease，injury severity score （ISS），Glasgow coma score （GCS），number of fractured ribs，total number of rib fractures （NTRF），first rib fracture，flail chest，traumatic brain injury，combined injuries （spine，maxillofacial，sternum），acute respiratory distress syndrome （ARDS），volume fraction of pulmonary contusion（VPC），blood lactic acid （within 24 hours of admission），hemothorax，pneumothorax，mechanical ventilation time，duration of tracheostomy，time from tracheal intubation to incision，length of hospital stay，length of stay in ICU，closed thoracic drainage，number of fiberoptic bronchoscopy，multi-drug resistant bacteria infection，ventilator-associated pneumonia，antibiotic use time，duration of sedative and analgesic drugs used and 28-day mortality. The multivariate Logistic regression analysis was used to predict independent risk factors for early tracheostomy. The Pearson method was used to compare the relationship between multiple factors. The receiver operating characteristic （ROC） curve was used to predict indicators that affect the prognosis of patients with early tracheostomy，and calculate the best cut-off value. The Kaplan-Meier single factor and COX multivariate survival were used to analyze the relevant factors affecting the 28-day mortality of patients.Results:（1） In early group，the NTRF，ARDS and VPC were higher than those in late group，and the time from tracheal intubation to incision and 28-day mortality rate were lower than those in late group （ P < 0.05），while the two groups showed no significant differences in the gender，age，underlying diseases and ISS （ P > 0.05）. （2） The multivariate Logistic regression analysis showed that there was statistical significance in NTRF （ OR = 1.775，95% CI 1.439-2.188），ARDS（ OR = 3.740，95% CI 1.441-9.711），VPC （ OR = 1.087，95% CI 1.052-1.124） （ P < 0.05）； the Pearson method analysis showed a significant correlation between VPC and NTRF （ r = 0.369， P < 0.05） and a low degree of correlation between ARDS and VPC （ r = 0.179， P < 0.05），but there was no significant correlation between ARDS and NTRF （ r = 0.132， P > 0.05）. （3） The ROC curve analysis showed that the area under the curve （AUC） of the VPC and NTRF ［AUC = 0.832 （95% CI 0.770-0.893），AUC = 0.804 （95% CI 0.740-0.868）］ were significantly higher than those of the number of rib fractures ［AUC = 0.437（95% CI 0.352-0.523），GCS ［AUC = 0.519 （95% CI 0.432-0.605）］ and ISS ［AUC = 0.484 （95% CI 0.398-0.571）］ （ P < 0.05）. After calculating the Yorden index，the best cut-off value for VPC was 23.9，and the best cut-off value for NTRF was 8.5. （4） The Kaplan-Meier single factor and multivariate COX model survival analysis showed that the 28-day survival ratio of patients with early tracheostomy was significantly better than that of late tracheostomy （ P < 0.05）. Conclusions:The NTRF，ADRS and VPC are independent risk factors for the timing and prognosis of early tracheostomy. There is a significant correlation between VPC and NTRF. The VPC ≥ 23.9% and or NTRF ≥ 8.5 can be used to predict early tracheostomy in patients with multiple rib fractures. Early tracheostomy may benefit the 28-day survival of patients with multiple rib fractures.

Study of the Various Factors which Influence the Outcome of Patients with Blunt Injury Chest

Introduction: Injury is the most common cause of death among people aged 1–34 years. The most common cause of injury is a road traffic accident and the majority is confined to the thoracic cage. These consist of rib fractures with underlying pulmonary contusion. When ignored, underestimated or inadequately treated chest injuries may cause the death of a patient during surgical intervention for seemingly more pressing intracranial or abdominal hemorrhage. Aim: This study aims to study the outcome of blunt injury chest patients in emergency and various modalities of treatment to identify possible risk factors for mortality. Materials and Methods: A prospective review of all cases of trauma with blunt chest injuries evaluated with X-ray or computed tomography scan. The cases were examined for age, type of injuries, presence or absence of rib fractures, hemothorax, or pneumothorax. Results: There were 50 patients included in this study. All had rib fractures and hemo/pneumothorax, 3 had lung contusion, 19 patients had associated injuries, 1 patient underwent emergency thoracotomy, 3 patients were kept on ventilator support, and 3 expired. Conclusion: Close attention to improving gas exchange and early management of hemo/pneumothorax might improve outcomes in blunt injury chest.

Blunt trauma related chest wall and pulmonary injuries: An overview / 中华创伤杂志(英文版)

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Clinical Application and Mechanical Analysis of the Treatment of Multiple Rib Fractures and Flail Chest Using Three-wings Rib Plate / 中国医疗器械杂志

This research evaluated the clinical efficacy of three-wings rib plate in the treatment of multiple rib fractures and flail chest with mechanical analysis and clinical verification. The model of rib and three-wings rib plate was reconstructed. The contact simulation with pretension stress was applied to the plate's fixation, and it was found that the bearable stress of the rib fractures after fixation increased from the result which indicated a good fixation efficacy of the plate. Clinical data of 53 cases of rib fractures and flail chest treated with three-wings rib plate in Shanghai Pudong Hospital of Fudan University were retrospectively analyzed. After the operation, the pain of the patients was relieved. Postoperative CT reconstruction of the chest showed good restoration of the rib fractures, which verified the clinical efficacy of three-wings rib plate. The three-wings rib plate showed a high value in clinical use for treatment of rib fractures.

Risk factors for mechanical ventilation in patients with severe multiple trauma / 北京大学学报(医学版)

OBJECTIVE@#To eludicate the risk factors of mechanical ventilation and prolonged mechanical ventilation in patients with severe multiple injuries.@*METHODS@#Consecutive patients with severe multiple injures who were treated in Peking University People's Hospital Trauma Medical Center between December 2016 and December 2019 were enrolled in this restropective chart-review study. According to mechanical ventilation and ventilatory time, the patients were divided into mechanical ventilation (MV) group and non-mechanical ventilation (NMV) groups, prolonged mechanical ventilation (PMV) group and shortened mechanical ventilation (SMV) groups. Clinical data such as gender, age, base excess, mechanism of injury, Glasgow Coma Scale (GCS), abbreviated injury scale (AIS) and injury severity score (ISS) were collected. To indentify the risk factors of mechanical ventilation and prolonged mecha-nical ventilation, univariate and multivariate Logistic analyses were carried out.@*RESULTS@#In the present study, 112 patients (82 male, 30 female) with severe multiple injuries having a median age of 52 (range: 16-89 years) and a median ISS of 34 (range: 16-66) were enrolled. The primary mechanism of injury was traffic accident injury and falling injury. In the study, 62 and 50 patients were assigned to MV and NMV groups, respectively. Logistic analysis showed that GCS (OR=0.72, 95%CI: 0.53-0.92, P=0.03), base excess (OR=0.56, 95%CI: 0.37-0.88, P=0.002) and multiple rib fracture (OR=1.72, 95%CI: 1.60-2.80, P=0.012) were independent significant risk factors for mechanical ventilation after severe multiple injuries. Within the mechanical ventilation group, 38 and 24 patients were assigned to PMV and SMVgroups, respectively. Compared with the SMV group, the PMV group had a higher ISS and higher rate of severe head trauma. The length of hospital stay of PMV group was longer than that of SMV groups. Meanwhile, the incidence of tracheotomy in PMV group was high.@*CONCLUSIONS@#GCS, base excess and rib fracture might be independent risk factors for mechanical ventilation. Higher ISS and lower GCS might prolong the ventilatory time and the length of hospital stay. Meanwhile, the incidence of tracheotomy was high in PMV group because of the longer ventilatory time and poor consciousness.

Surgical and traditional methods for the treatment of multiple rib fractures: A systematic review and meta-analysis of randomized controlled trials / 中国胸心血管外科临床杂志

@#Objective    To evaluate the effect of surgical and traditional treatments for multiple rib fractures through systematic review and meta-analysis. Methods    CNKI, Wanfang, VIP, PubMed, OVID, EMbase, The Cochrane Library, Thieme and Springer Link database for information from inception to July 2019 were screened by computer. Randomized controlled trials (RCTs) of surgical and conventional methods for the treatment of multiple rib fractures were screened, assessed and extracted. RevMan 5.3 software was used for meta-analysis. Results    Twelve studies were included, including 1 039 patients. There were 512 patients in the operation group and 527 patients in the traditional treatment group. The results of meta-analysis showed that there was a significant difference between the two groups in the incidence of pneumonia (RR=0.41, 99%CI 0.29 to 0.58, P<0.000 01), incidence of atelectasis (RR=0.24, 99%CI 0.06 to 0.94, P=0.007), duration of mechanical ventilation (SMD=–2.64, 99%CI –4.38 to –0.91, P<0.000 1), duration of intensive care unit stay (SMD=–1.33, 99%CI –2.26 to –0.40, P=0.000 2), duration of hospital stay (SMD=–2.25, 99%CI –3.30 to –1.19, P<0.000 01) and incidence of chest wall deformity (RR=0.08, 99%CI 0.04 to 0.17, P<0.000 01). There was no significant difference between the two groups in the hospital mortality (RR=0.75, 99%CI 0.23 to 2.46, P=0.53), incidence of tracheostomy (RR= 0.69, 99%CI 0.39 to 1.21, P=0.09), ventilator support rate (RR=0.65, 99%CI 0.41 to 1.05, P=0.02) and chest drainage time (SMD=–2.58, 99%CI –6.41 to 1.25, P=0.08). Conclusion    Surgical treatment of multiple rib fractures can reduce pulmonary complications, shorten hospital stay, and reduce the incidence of chest wall deformity, which is conducive to rapid recovery and improves quality of life.

Exploring of the Mechanism of Rib Fracture Caused by Landing on Different Parts of the Trunk after Falls from Height Using Finite Element Method / 法医学杂志

Objective To study the mechanism of rib fracture caused by landing on different parts of the trunk using finite element method, and to provide some new techniques and new ideas for the reconstruction of the whole process of falls from height. Methods The finite element method was used to study the rib fracture of human security model THUMS4.0 caused by landing on different parts of the trunk. Then the model was compared with actual cases and the mechanism of rib fracture caused by falls from height was analyzed from a biomechanical point of view. Results There were some differences in the stress and strain distribution as well as the rib fracture sites when different parts touched the ground. Ribs on both sides of the body were fractured when the front of the trunk touched the ground, and the fractures were mainly located in the junction of the ribs and costal cartilage and the midaxillary line area. When the right anterior part of the trunk touched the ground, rib fracture occurred first on the side that touched the ground, and rib fractures were mainly located in the area from the right midaxillary line to the posterior axillary line, and junction of ribs on both sides and costal cartilage. When the back of the trunk touched the ground, the fracture sites were mainly located on the back of the ribs on both sides. When the right posterior part of the trunk touched the ground, multiple rib fractures were likely to occur in the parts that touched the ground. The plastic strains were mainly concentrated at the fracture sites, while the von Mises stresses were not only concentrated at the fracture sites, but also at other sites. Conclusion There are some differences in rib fracture location sites and injury mechanisms when different parts of the trunk touch the ground.

Pattern and management of penetrating and nonpenetrating thoracic injuries

Background: Chest trauma constitutes a major public health problem which  includes the injuries to chest wall, pleura, tracheobronchial tree, lungs, diaphragm, oesophagus, heart and great vessels. It consist of more than ten percent of all traumas and twenty five percent of death due to trauma occurs because of chest injury. Chest trauma is increasing in frequency in urban hospitals. Penetrating and nonpenetrating thoracic injuries the most serious injuries leading to significant morbidity and mortality.Methods: This study was prospective observational study of 220 patients of thoracic trauma both penetrating and non-penetrating. These patients admitted in general surgical units from August 2017 to May 2018  of Pandit Bhagwat Dayal  Sharma,  PGIMS  Rohtak Haryana India. The study was pertaining to both penetrating  and non-penetrating chest trauma.Results: Out of 220 chest injury patients who were studied during the said period, Males were 203 and females 17 by a ratio of 12:1 and age ranged from lowest 18 years to 85 years of age. Majority of the patients (90.45%) sustained blunt injuries. RTA was the common mechanism of blunt injury affecting (50.45%) of patients. Multiple Rib fractures was the commonest type of chest injury (21.36%) followed by head injury (17.27%). Head injury was the commonest associated injury seen in our patients. Conclusions: Chest trauma resulting from road traffic accident remains a major mechanism of chest injury. The  measures to decrease the trauma are, educating people about traffic rules and regulations and strictly implementing them is necessary to reduce incidence of chest injuries.