Fractures and other chest wall abnormalities after thoracotomy for esophageal cancer: A retrospective cohort study.

BACKGROUND: Chest pain following a thoracotomy for esophageal cancer is frequently reported but poorly understood. This study aimed to (1) determine the prevalence of thoracotomy-related thoracic fractures on postoperative imaging and (2) compare complications, long-term pain, and quality of life in patients with versus without these fractures. METHODS: This retrospective cohort study enrolled patients with esophageal cancer who underwent a thoracotomy between 2010 and 2020 with pre- and postoperative CTs (<1 and/or >6 months). Disease-free patients were invited for questionnaires on pain and quality of life. RESULTS: Of a total of 366 patients, thoracotomy-related rib fractures were seen in 144 (39%) and thoracic transverse process fractures in 4 (2%) patients. Patients with thoracic fractures more often developed complications (89% vs. 74%, p = 0.002), especially pneumonia (51% vs. 39%, p = 0.032). Questionnaires were completed by 77 after a median of 41 (P25 -P75 28-91) months. Long-term pain was frequently (63%) reported but was not associated with thoracic fractures (p = 0.637), and neither were quality of life scores. CONCLUSIONS: Thoracic fractures are prevalent in patients following a thoracotomy for esophageal cancer. These thoracic fractures were associated with an increased risk of postoperative complications, especially pneumonia, but an association with long-term pain or reduced quality of life was not confirmed.

Radiographic rib fracture nonunion and association with fracture classification in adults with multiple rib fractures without flail segment: A multicenter prospective cohort study.

BACKGROUND: Rib fracture nonunion is a probable cause of chronic pain following chest trauma, although its prevalence remains unknown. The aims of this study were to determine rib fracture nonunion prevalence following nonoperative management and to determine if presence of nonunion was associated with the number of rib fractures, or the rib fracture classification of anatomical location, type, and displacement. METHODS: This multicenter prospective cohort study included trauma patients with three or more fractured ribs but without a flail segment, who participated in the nonoperative management group of the FixCon trial between January 2019 and June 2022. The number and classification of rib fractures were assessed on trauma chest CT. Chest CTs conducted six months post-trauma were evaluated for the presence of nonunion. Radiological characteristics of nonunions were compared with normally healed rib fractures using the Mann-Whitney U, χ2 test, and Fisher's exact test as appropriate. A generalized linear model adjusted for multiple observations per patient when assessing the associations between nonunion and fracture characteristics. RESULTS: A total of 68 patients were included with 561 post-traumatic fractures in 429 ribs. Chest CT after six months revealed nonunions in 67 (12 %) rib fractures in 29 (43 %) patients with a median of 2 (P25-P75 1-3) nonunions per patient. Nonunion was most commonly observed in ribs seven to 10 (20-23 %, p < 0.001, adjusted p = 0.006). Nonunion occurred in 14 (5 %) undisplaced, 22 (19 %) offset, and 20 (23 %) displaced rib fractures (p < 0.001). No statistically significant association between rib fracture type and nonunion was found. CONCLUSIONS: Forty-three percent of patients with multiple rib fractures had radiographic nonunion six months after trauma. Fractures in ribs seven to 10 and dislocated fractures had an increased risk of rib fracture nonunion.

Rib fractures and other injuries after cardiopulmonary resuscitation for non-traumatic cardiac arrest: a systematic review and meta-analysis.

PURPOSE: This study aims to ascertain the prevalence of rib fractures and other injuries resulting from CPR and to compare manual with mechanically assisted CPR. An additional aim was to summarize the literature on surgical treatment for rib fractures following CPR. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Embase, Medline Ovid, Cochrane Central, Web of Science, and Google Scholar. REVIEW METHODS: The databases were searched to identify studies reporting on CPR-related injuries in patients who underwent chest compressions for a non-traumatic cardiopulmonary arrest. Subgroup analysis was conducted to compare the prevalence of CPR-related injuries in manual versus mechanically assisted chest compressions. Studies reporting on surgery for CPR-related rib fractures were also reviewed and summarized. RESULTS: Seventy-four studies reporting CPR-related injuries were included encompassing a total of 16,629 patients. Any CPR-related injury was documented in 60% (95% confidence interval [95% CI] 49-71) patients. Rib fractures emerged as the most common injury, with a pooled prevalence of 55% (95% CI 48-62). Mechanically assisted CPR, when compared to manual CPR, was associated with a higher risk ratio for CPR-related injuries of 1.36 (95% CI 1.17-1.59). Eight studies provided information on surgical stabilization of CPR-related rib fractures. The primary indication for surgery was the inability to wean from mechanical ventilation in the presence of multiple rib fractures. CONCLUSION: Rib fractures and other injuries frequently occur in patients who undergo CPR after a non-traumatic cardiopulmonary arrest, especially when mechanical CPR is administered. Surgical stabilization of CPR-related rib fractures remains relatively uncommon. LEVEL OF EVIDENCE: Level III, systematic review and meta-analysis.

Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern?

INTRODUCTION: The progression of pulmonary contusions remains poorly understood. This study aimed to measure the radiographic change in pulmonary contusions over time and evaluate the association of the radiographic change with clinical outcomes and surgical stabilization of rib fractures (SSRF). METHODS: This retrospective cohort study included adults admitted with three or more displaced rib fractures or flail segment on trauma CT and when a chest CT was repeated within one week after trauma. Radiographic severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion Score (BPC18). Logistic regression was performed to evaluate the relation between SSRF and worsening contusions on repeat CT, adjusted for potential confounders. RESULTS: Of 231 patients, 56 (24%) had a repeat CT scan. Of these, 55 (98%) had pulmonary contusion on the first CT scan with a median BPC18 score of 5 (P25-P75 3-7). Repeat CTs showed an overall decrease of the median BPC18 score to 4 (P25-P75 2-6, P = .02), but demonstrated a worsening of the pulmonary contusion in 16 patients (29%). All repeat CTs conducted within 12 hours post-injury demonstrated increasing BPC18. Radiographic worsening of pulmonary contusions was not associated with SSRF, nor with worse respiratory outcomes or intensive care length of stay, compared to patients with radiographically stable or improving contusions. DISCUSSION: In patients with severe rib fracture patterns who undergo repeat imaging, pulmonary contusions are prevalent and become radiographically worse within at least the first 12 hours after injury. No association between radiographic worsening and clinical outcomes was found.

Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries.

INTRODUCTION: The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries. PATIENTS AND METHODS: In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups. RESULTS: Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups. CONCLUSIONS: SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

Rib Fixation for Multiple Rib Fractures: Healthcare Professionals Perceived Barriers and Facilitators to Clinical Implementation.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is associated with improved respiratory symptoms and shorter intensive care admission in patients with flail chest. For multiple rib fractures, the benefit of SSRF remains a topic of debate. This study investigated barriers and facilitators of healthcare professionals to SSRF as treatment for multiple traumatic rib fractures. METHODS: Dutch healthcare professionals were asked to complete an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators of SSRF. If ≥ 20% of participants responded negatively, the item was considered a barrier, and if ≥ 80% responded positively, the item was considered a facilitator. RESULTS: Sixty-one healthcare professionals participated; 32 surgeons, 19 non-surgical physicians, and 10 residents. The median experience was 10 years (P25-P75 4-12). Sixteen barriers and two facilitators for SSRF in multiple rib fractures were identified. Barriers included lack of knowledge, experience, evidence on (cost-)effectiveness, and the implication of more operations and higher medical costs. Facilitators were the assumption that SSRF alleviates respiratory problems and the feeling that surgeons are supported by colleagues for SSRF. Non-surgeons and residents reported more and several different barriers than surgeons (surgeons: 14; non-surgical physicians: 20; residents: 21; p < 0.001). CONCLUSION: For adequate implementation of SSRF in patients with multiple rib fractures, implementation strategies should address the identified barriers. Especially, improved clinical experience and scientific knowledge of healthcare professionals, and high-level evidence on the (cost-) effectiveness of SSRF potentially increase its use and acceptance.

Surgical strategy for treating multiple symptomatic rib fracture malunions with bridging heterotopic ossifications: A case report.

Rib fractures are common and serious injuries, which can negatively impact long-term quality of life. Here we present a woman in her early twenties who was referred to our trauma surgery outpatient clinic five years after a motor vehicle collision in which she sustained upper extremity injury and multiple displaced rib fractures. The rib fractures were initially managed non-operatively. At the time of the outpatient consultation, she endured persistent severe pain located between the left scapula and the thoracic spine. The pain worsened on repetitive motion and deep respiration. A new chest CT revealed left-sided posterior rib fracture malunions of ribs 4 to 8 with heterotopic ossifications (HO) that formed an osseous bridge between these ribs. Surgical excision of the bridging HO and remodeling of the angulated rib malunions resulted in significant alleviation of symptoms, which allowed her to return to work and other activities. Given the dramatic improvement after surgery, we suggest considering surgical remodeling and excision for rib fracture malunions and associated HO that cause local mechanical symptoms.

Biomechanical characteristics of rib fracture fixation systems.

BACKGROUND: The primary aim of this study was to determine and compare the biomechanical properties of a fractured or intact rib after implant fixation on an embalmed thorax. METHODS: Five systems were fixated on the bilateral fractured or intact (randomly allocated) 6th to 10th rib of five post-mortem embalmed human specimens. Each rib underwent a four-point bending test to determine the bending structural stiffness (Newton per m2), load to failure (Newton), failure mode, and the relative difference in bending structural stiffness and load to failure as compared to a non-fixated intact rib. FINDINGS: As compared to a non-fixated intact rib, the relative difference in stiffness of a fixated intact rib ranged from -0.14 (standard deviation [SD], 0.10) to 0.53 (SD 0.35) and for a fixated fractured rib from -0.88 (SD 0.08) to 0.17 (SD 0.50). The most common failure mode was a new fracture at the most anterior drill hole for the plate and screw systems and a new fracture within the anterior portion of the implant for the clamping systems. INTERPRETATION: The current fixation systems differ in their design, mode of action, and biomechanical properties. Differences in biomechanical properties such as stiffness and load to failure especially apply to fractured ribs. Insight in the differences between the systems might guide more specific implant selection and increase the surgeon's awareness for localizing hardware complaints or failure.

Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe?

BACKGROUND: Pulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions. METHODS: This retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses. RESULTS: A total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted ß , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted ß , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management. CONCLUSION: In patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Interobserver agreement for the Chest Wall Injury Society taxonomy of rib fractures using computed tomography images.

BACKGROUND: In 2020, a universal nomenclature for rib fractures was proposed by the international Chest Wall Injury Society taxonomy collaboration. The purpose of this study is to validate this taxonomy. We hypothesized that there would be at least moderate agreement, regardless of the observers' background. METHODS: An international group of independent observers evaluated axial, coronal, and sagittal computed tomography images on an online platform from 11 rib fractures for location (anterior, lateral, or posterior), type (simple, wedge, or complex), and displacement (undisplaced, offset, or displaced) of rib fractures. The multirater κ and Gwet's first agreement coefficient (AC1) were calculated to estimate agreement among the observers. RESULTS: A total of 90 observers participated, with 76 complete responses (84%). Strong agreement was found for the classification of fracture location ( κ = 0.83 [95% confidence interval (CI) 0.69-0.97]; AC1, 0.84 [95% CI, 0.81-0.88]), moderate for fracture type ( κ = 0.46 [95% CI, 0.32-0.59]; AC1, 0.50 [95% CI, 0.45-0.55]), and fair for rib fracture displacement ( κ = 0.38 [95% CI, 0.21-0.54], AC1, 0.38 [95% CI, 0.34-0.42]). CONCLUSION: Agreement on rib fracture location was strong and moderate for fracture type. Agreement on displacement was lower than expected. Evaluating strategies such as comprehensive education, additional imaging techniques, or further specification of the definitions will be needed to increase agreement on the classification of rib fracture type and displacement as defined by the Chest Wall Injury Society taxonomy. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level IV.

Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls.

INTRODUCTION: Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. METHODS: We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. RESULTS: A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15-0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36-7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15-2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06-1.87) compared to controls. CONCLUSION: Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

Outcome after surgical stabilization of symptomatic rib fracture nonunion: a multicenter retrospective case series.

PURPOSE: This study aimed to determine the long-term level of pain after surgical treatment of one or more symptomatic rib fracture nonunions. Secondary aims were to evaluate the occurrence of adverse events, satisfaction, and activity resumption. The final aim was to assess the association between pain and the presence of bridging callus at the nonunified fracture. Hypothesized was that thoracic pain would diminish after surgery. METHODS: This retrospective case series included adults who underwent surgery for a symptomatic rib fracture nonunion from three hospitals. Symptomatic nonunion was defined as persistent pain associated with nonbridging callus of ≥1 rib fractures on a chest CT scan at ≥3 months after the initial injury. Patients completed questionnaires about pain, satisfaction, and activity resumption ≥3 months postoperatively. RESULTS: Thirty-six patients (26 men, 10 women), with a median age of 55 (P25-P75 49-62) years and 169 acute rib fractures were included. Nonunion occurred in 98 (58%) fractures of which 70 (71%) were treated surgically. After a median of 11 months (P25-P75 7-21), 13 (36%) patients reported severe pain, in contrast to 26 (72%) preoperatively. Patients who underwent intercostal neurectomy or neurolysis in addition to surgical stabilization less often reported pain reduction. Twenty-six (72%) had postoperative complications, for which 12 (33%) underwent additional surgery, mostly for persistent pain. The majority (n = 27; 75%) was satisfied with their functional recovery. Of patients who had paid work pre-trauma, 65% had resumed working. CONCLUSION: Most patients reported less pain and better daily functioning after surgical stabilization of symptomatic rib fracture nonunions, although causality cannot be proven with this retrospective case series. Additional intercostal nerve treatment was not associated with pain relief. Despite surgery-related complications being common, patient satisfaction was high. LEVEL OF EVIDENCE: Level V. STUDY TYPE: Therapeutic.

Chest wall injuries due to cardiopulmonary resuscitation and the effect on in-hospital outcomes in survivors of out-of-hospital cardiac arrest.

BACKGROUND: This study aimed to assess the prevalence of chest wall injuries due to cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA) and to compare in-hospital outcomes in patients with versus without chest wall injuries. METHODS: A retrospective cohort study of all intensive care unit (ICU)-admitted patients who underwent cardiopulmonary resuscitation for OHCA between January 1, 2007, and December 2019 was performed. The primary outcome was the occurrence of chest wall injuries, as diagnosed on chest computed tomography. Chest wall injury characteristics such as rib fracture location, type, and dislocation were collected. Secondary outcomes were in-hospital outcomes and subgroup analysis of patients with good neurological recovery to identify those who could possibly benefit from the surgical stabilization of rib fractures. RESULTS: Three hundred forty-four patients were included, of which 291 (85%) sustained chest wall injury. Patients with chest wall injury had a median of 8 fractured ribs (P25-P75, 4-10 ribs), which were most often undisplaced (on chest computed tomography) (n = 1,574 [72.1%]), simple (n = 1,948 [89.2%]), and anterior (n = 1,785 [77.6%]) rib fractures of ribs 2 to 7. Eight patients (2.3%) had a flail segment, and 136 patients (39.5%) had an anterior flail segment. Patients with chest wall injury had fewer ventilator-free days (0 days [P25-P75, 0-16 days] vs. 13 days [P25-P75, 2-22 days]; p = 0.006) and a higher mortality rate (n = 102 [54.0%] vs. n = 8 [22.2%]; p < 0.001) than those without chest wall injury. For the subgroup of patients with good neurological recovery, the presence of six or more rib fractures or a single displaced rib fracture was associated with longer hospital and ICU length of stay, respectively. CONCLUSION: Cardiopulmonary resuscitation-related chest wall injuries in survivors of OHCA and especially rib fractures are common. Patients with chest wall injury had fewer ventilator-free days and a higher mortality rate. Patients with good neurological recovery might represent a subgroup of patients who could benefit from surgical stabilization of rib fractures. LEVEL OF EVIDENCE: Therapeutic, level IV; Epidemiological, Level IV.

Feasibility and barriers of treating clubfeet in four countries.

PURPOSE: The purpose of this study was to elucidate why neglected clubfeet still exists despite the availability of a highly (cost)-effective treatment-the Ponseti treatment. METHODS: A qualitative and partly quantitative study with semi-structured interviews was conducted in four countries: the Netherlands, South Africa, Argentina and Indonesia with both caregivers, mostly parents, of children with clubfoot and practitioners treating clubfoot. The topics discussed with the caregivers (n = 51) were the conceptions of the cause of clubfeet, received information, accessibility, financial aspects, and social stigma. With the practitioners (n = 11) the focus of the interviews was the treatment protocol and finance. RESULTS: Several barriers towards the start of the treatment were highlighted. At all places treatment was financed by the government, insurance or charity. Nevertheless, the cost of transport and missed working days formed a barrier, although there is a large difference between and within countries. Poverty, long travel duration, and beliefs of supernatural causes for the clubfoot result in delay in the start of treatment. CONCLUSION: These are problems we need to address when making effective treatment available for every child to diminish the burden of neglected clubfoot; especially accessible clinics in rural areas can be a good alternative to highly specialized hospitals in large cities. We as a community should try to find and overcome the barriers to treat these patients, because we have a relatively easy and highly cost-effective treatment option which can be given by trained non-physicians supervised by an interested medical doctor.