Surgical stabilization of multiple rib fractures in an Asian population: a systematic review and meta-analysis.

Background: There is no consensus on the effectiveness of surgical stabilization in multiple rib fractures in Asia, especially among patients with a non-flail rib fracture pattern. We aim to synthesize the evidence on the effectiveness of surgical stabilization of rib fractures (SSRF) in an Asian population with multiple non-flail rib fractures. Methods: The MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched in this systematic literature review and meta-analysis to identify studies conducted in Asia that included patients with multiple non-flail rib fractures in at least one of their treatment groups. The intervention of interest was SSRF, and the comparator was a nonoperative treatment. The duration of mechanical ventilation (DMV) was the primary outcome. Posttreatment pain score, pneumonia, atelectasis, intensive care unit length of stay (ICU LOS), hospital length of stay (HLOS), need for tracheostomy, respiratory function, functional outcomes, quality of life (QoL), and mortality were identified as the secondary outcomes. A random effects model (REM) was used to pool data for outcomes reported in two or more studies. Results: A total of 12 studies (n=2,440 patients) were included. There was a significantly shorter DMV {mean difference (MD): -5.23 [95% confidence interval (CI): -9.64 to -0.81], P=0.02}, lower 4-week post-treatment pain score [standard mean difference (SMD): -2.24 (95% CI: -3.18 to -1.31), P<0.00001], lower risk for pneumonia [risk ratio (RR): 0.46 (95% CI: 0.23 to 0.95), P=0.04], lower risk for atelectasis [RR: 0.44, (95% CI: 0.29 to 0.65), P<0.0001], shorter ICU LOS [MD: -4.00 (95% CI: -6.33 to -1.66), P=0.0008], and shorter HLOS [MD: -6.54 (95% CI: -9.28 to -3.79), P<0.00001] in favor of SSRF. Effect estimates for the need for tracheostomy [RR: 0.67 (95% CI: 0.42 to 1.08), P=0.10] and mortality [RR: 0.94 (95% CI: 0.37 to 2.41), P=0.90] were nonsignificant. Conclusions: In the Asian population with mainly non-flail rib fracture patterns, SSRF was associated with shorter DMV, ICU LOS, and HLOS as well as lower risks for atelectasis and pneumonia, and pain scores after 4 weeks. The risk of mortality was comparable between treatment groups.

A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL).

BACKGROUND: The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. METHODS: Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. RESULTS: One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). CONCLUSION: In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. LEVEL OF EVIDENCE: Therapeutic, level II.

Experience with acute diaphragmatic trauma and multiple rib fractures using routine thoracoscopy.

BACKGROUND: Diaphragmatic injury is mostly caused by blunt or penetrating traumas. It is an uncommon diagnosis and therefore carries the risk of being misdiagnosed or delayed in diagnosis. In our institution, we perform routine thoracoscopy for the management of patients with traumatic rib fractures. We have noted several cases of occult diaphragmatic injuries and hypothesize that these injuries may be more of a penetrating injury from rib fractures as opposed to the high velocity blunt trauma typically associated with diaphragmatic injuries. METHODS: A retrospective review of medical records was performed on all patients admitted to our facility with rib fractures and traumatic diaphragmatic injuries. We looked at our trauma experience between January 2015 and January 2018. RESULTS: Twenty-three patients with traumatic diaphragmatic injuries were found. Twenty-one of the diaphragmatic injuries were from blunt trauma. A total of 15 had associated rib fractures. Six of the blunt traumatic diaphragm injuries did not have rib fractures but had evidence of intra-abdominal injuries. The rib fracture pattern in the diaphragmatic injury group consistently involved rib fractures at or below the fifth rib. CONCLUSIONS: We conclude that thoracoscopy may prove to be helpful in the algorithm for the work up of an occult diaphragmatic injury. The diagnostic yield appears to be greatest in patients with multiple rib fractures involving the lower chest wall even in the absence of intra-abdominal injuries or radiographic evidence of diaphragmatic abnormalities.

Noninvasive monitoring of hemodynamic stress using quantitative near-infrared frequency-domain photon migration spectroscopy.

Hemorrhagic hypovolemia and inotropic agent administration were used to manipulate cardiac output (CO) and oxygen delivery in rabbits to investigate the correlation between noninvasive frequency domain photon migration (FDPM) spectroscopy and invasive hemodynamic monitoring parameters. Frequency-domain photon migration provides quantitative measurements of light absorption and reduced scattering (mu(a) and mu(s)(prime prime or minute), respectively) in tissue. Wavelength dependent mu(a) values were used to calculate in vivo tissue concentration of deoxyhemoglobin [Hb], oxyhemoglobin [HbO(2)], total hemoglobin [TotHb], and water [H(2)O] as well as mixed arterial-venous oxygen saturation (S(t)O(2)) in tissue. FDPM-derived physiologic properties were correlated with invasive measurements of CO and mean pulmonary artery pressure (mPAP), FDPM-derived [TotHb] and S(t) O(2) correlated significantly with hemorrhaged volume (HV), mPAP, and CO. Correlation coefficients for [TotHb] vs HV, mPAP, and CO were -0.77, 0.86, and 0.70, respectively. Correlation coefficients of S(t)O( 2) vs HV, mPAP, and CO were -0.71, 0.55, and 0.61, respectively. Dobutamine induced changes resulted in correlation coefficients between FDPM-derived and invasively measured physiologic parameters that are comparable to those induced by hypovolemia. FDPM spectroscopy is sensitive to changes in mPAP and CO of as little as 15%. These results suggest that FDPM spectroscopy may be used in clinical settings to noninvasively monitor central hemodynamic parameters and to directly assess oxygenation of tissues.