[A Review of 70 Cases of Thoracic Trauma with Rib Fixation:Indications and Practical Innovations of the Procedure].

We summarized the experience of surgical stabilization of rib fractures (SSRF) at a core hospital in eastern Hiroshima, which is a primary center for tertiary emergency medical care, especially for high-energy trauma cases including chest injuries. The study focuses on patients who underwent SSRF from January 2016 to September 2023, analyzing patient characteristics, injury mechanisms, associated injuries, fracture locations, time from injury to surgery, fixation devices used, and postoperative outcomes. Our hospital primarily treats elderly patients, and falls are the most common cause of injury, followed by traffic accidents. The criteria for SSRF in our hospital were clinical manifestations of flail chest, need for lung repair, persistent pain, or improvement of thoracic deformity. We had a high rate of fixation of fractures of the 4th-10th ribs, which have a significant impact on respiratory mechanics; although KANI plates were primarily used, the introduction of MatrixRIB plates offers advantages in certain scenarios. The study also identified challenges with the KANI plate, including cases of plate dislodgement, particularly in patients with multiple fractures and severe thoracic deformities. The combination of video-assisted thoracoscopic surgery and SSRF allows for more effective rib fixation and reduces surgical wound size and muscle damage.

[Surgical Stabilization of Traumatic Multiple Rib Fractures Using Absorbable Osteosynthesis Agent(u-HA/PLLA Composite Material)].

In case that met several indication criteria with 4 or more rib fractures, we performed surgical stabilization of multiple fractured ribs using a plate and screw system( Super FIXORB MX) that was made of uncalcined hydroxyapatite (u-HA)/poly-L-lactic acid (PLLA) composite material with excellent bioactivity and absorbability. We report our clinical experience of 7 cases in which this device was used. Although there is still room for further consideration of the technique and the strength of the device itself, computed tomography( CT) images taken 9 months after surgery showed that the fixative device was almost assimilated with the bone at the fracture repair site in cases where fixation was successful.

[The Surgical Indication of Multiple Rib Fractures of Patients by Traumas and Timing of the Surgical Stabilization of Rib Fractures].

It's reported that 10% of the inpatients by traumas have fractured ribs. It's easy to judge if it's the case of flail chest, or respiratory failure due to airway injury or pulmonary contusion. There is no guideline for treatments of a patient who has multiple ribs fractures without respiratory failure. We did the surgical stabilization of rib fractures for 10 cases from 2020 to October 2023. As a result, we find out useful surgical indication for treatment of rib fractures.

[Outcomes of Surgical Treatment for Chest Trauma].

BACKGROUND: Intra-thoracic organ bleeding and chest wall injury following chest trauma can easily lead to life-threatening emergencies and a delay in treatment may lead to fatal outcomes. Interestingly, the optimal timing, indications, and surgical techniques have not been standardized. METHOD: We retrospectively analyzed 35 patients who underwent surgical treatment for chest trauma. RESULTS: All patients with penetrating trauma (n=4) underwent emergency surgery for a hemothorax. There were no postoperative complications or hospital deaths. All patients with blunt trauma( n= 31) had multiple rib fractures;rib fixation was performed in 29 patients( 94%). Eight patients( 26%) had flail chest. The duration from injury to surgery averaged 7.5 days. The prognosis was generally favorable with no postoperative complications, but two patients died in the hospital due to multiple organ failure caused by high-energy trauma. Patients with flail chest or multiple organ injury had prolonged postoperative hospital stays. CONCLUSIONS: Patients who sustain chest trauma follow various clinical courses. Appropriate timing of surgical intervention at an early stage after injury can be life saving and hasten a functional recovery.

[Experience with Surgical Stabilization for Traumatic Rib Fractures and Sternal Fractures].

The treatment of traumatic rib fractures and sternal fractures have focused on pain and respiratory management, and conservative treatment has been recommended. Recently, however, a number of case series from abroad have been reported and demonstrated the usefulness of surgical stabilization of rib fractures (SSRF) and sternal fractures (SSSF). We have experienced seven cases of SSRF and two cases of SSSF at International University Health and Welfare Narita Hospital and Atami Hospital. Based on our experienced cases, we have outlined the preoperative evaluation, indication for surgery, timing of surgery, surgical techniques, and postoperative course. Of these nine cases, the clinical course of two cases of SSRF and one case of SSSF were detailly presented. The surgical indications and techniques for traumatic rib fractures and sternal fractures vary from institution to institution, and there is no single optimal treatment. We hope that the accumulation of cases, and discussions will help to build a higher quality evidence for surgical treatment of thoracic trauma in Japan.

High sensitivity methods for automated rib fracture detection in pediatric radiographs.

Rib fractures are highly predictive of non-accidental trauma in children under 3 years old. Rib fracture detection in pediatric radiographs is challenging because fractures can be obliquely oriented to the imaging detector, obfuscated by other structures, incomplete, and non-displaced. Prior studies have shown up to two-thirds of rib fractures may be missed during initial interpretation. In this paper, we implemented methods for improving the sensitivity (i.e. recall) performance for detecting and localizing rib fractures in pediatric chest radiographs to help augment performance of radiology interpretation. These methods adapted two convolutional neural network (CNN) architectures, RetinaNet and YOLOv5, and our previously proposed decision scheme, "avalanche decision", that dynamically reduces the acceptance threshold for proposed regions in each image. Additionally, we present contributions of using multiple image pre-processing and model ensembling techniques. Using a custom dataset of 1109 pediatric chest radiographs manually labeled by seven pediatric radiologists, we performed 10-fold cross-validation and reported detection performance using several metrics, including F2 score which summarizes precision and recall for high-sensitivity tasks. Our best performing model used three ensembled YOLOv5 models with varied input processing and an avalanche decision scheme, achieving an F2 score of 0.725 ± 0.012. Expert inter-reader performance yielded an F2 score of 0.732. Results demonstrate that our combination of sensitivity-driving methods provides object detector performance approaching the capabilities of expert human readers, suggesting that these methods may provide a viable approach to identify all rib fractures.

Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report.

We present the case of a victim of a motor vehicle accident in his late 60s who suffered from severe torso injuries. He initially presented with abdominal and chest pain, and underwent emergency laparotomy for hemoperitoneum. After surgery, the patient developed pneumonia and septicemia, which were responsive to antibiotics. The patient was treated with mechanical ventilation in the intensive care unit for approximately 10 days and experienced a severe weight loss of approximately 30%, but slowly recovered without dyspnea. Notably, on hospital day 24, he experienced sudden respiratory distress and flail motion of the chest wall in a general ward. This late presentation of flail chest was attributed to non-union at rib fracture sites, and was likely exacerbated by malnutrition and osteomyelitis. Surgical stabilization of rib fractures and excision of the infected rib were successfully performed. The findings from this case highlight the complexity of managing delayed onset of flail chest. The findings from this case suggest the importance of vigilance for late emerging complications in patients with trauma, even when initial symptoms are absent.

Explaining and predicting the increased thorax injury in aged females: age and subject-specific thorax geometry coupled with improved bone constitutive models and age-specific material properties evaluated in side impact conditions.

Predicting and understanding thorax injury is fundamental for the assessment and development of safety systems to mitigate injury risk to the increasing and vulnerable aged population. While computational human models have contributed to the understanding of injury biomechanics, contemporary human body models have struggled to predict rib fractures and explain the increased incidence of injury in the aged population. The present study enhanced young and aged human body models (HBMs) by integrating a biofidelic cortical bone constitutive model and population-based bone material properties. The HBMs were evaluated using side impact sled tests assessed using chest compression and number of rib fractures. The increase in thoracic kyphosis and the associated change in rib angle with increasing age, led to increased rib torsional moment increasing the rib shear stress. Coupled with and improved cortical bone constitutive model and aged material properties, the higher resulting shear stress led to an increased number of rib fractures in the aged model. The importance of shear stress resulting from torsional load was further investigated using an isolated rib model. In contrast, HBM chest compression, a common thorax injury-associated metric, was insensitive to the aging factors studied. This study proposes an explanation for the increased incidence of thorax injury with increasing age reported in epidemiological data, and provides an enhanced understanding of human rib mechanics that will benefit assessment and design of future safety systems.

Analgesia for rib fractures: a narrative review.

PURPOSE: Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. SOURCE: Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. PRINCIPAL FINDINGS: Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. CONCLUSION: Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

RéSUMé: OBJECTIF: Les fractures des côtes sont des blessures courantes et douloureuses souvent associées à une morbidité importante (p. ex., complications respiratoires) et à des taux de mortalité élevés, surtout chez les personnes âgées. La stratification des risques et la mise en œuvre rapide de voies analgésiques à l'aide d'une approche d'analgésie multimodale constituent un critère d'évaluation principal des soins visant à réduire la morbidité et la mortalité associées aux fractures des côtes. Ce compte rendu narratif a pour objectif de décrire les données probantes les plus récentes et les parcours de soins actuellement disponibles, y compris les outils de stratification des risques et les blocs analgésiques pharmacologiques et régionaux fréquemment utilisés dans le cadre de l'approche analgésique multimodale largement recommandée. SOURCES: La littérature disponible a été recherchée à l'aide des bases de données PubMed et Embase pour chaque sujet abordé dans le présent compte rendu et examinée par des expert·es en contenu. CONSTATATIONS PRINCIPALES: Quatre outils de stratification des risques ont été identifiés, le score de l'Étude de la prise en charge des traumatismes contondants de la paroi thoracique (Study of the Management of Blunt Chest Wall Trauma) étant le plus prédictif. Les données probantes actuelles sur les techniques d'analgésie pharmacologiques (c.-à-d. acétaminophène, anti-inflammatoires non stéroïdiens, gabapentinoïdes, kétamine, lidocaïne et dexmédétomidine) et d'analgésie régionale (c.-à-d. analgésie péridurale thoracique, bloc paravertébral thoracique, bloc du plan des muscles érecteurs du rachis et bloc du plan du muscle grand dentelé) ont été examinées, de même que la physiopathologie de la ou des fractures des côtes et de leurs complications associées, y compris l'apparition de douleurs chroniques et d'incapacités. CONCLUSION: Les fractures des côtes continuent d'être un diagnostic grave, avec des taux élevés de mortalité, de développement de douleurs chroniques et d'invalidité. Il a été démontré qu'une approche multidisciplinaire de la prise en charge, combinée à une analgésie appropriée et à l'adhésion aux ensembles et protocoles de soins, réduit la morbidité et la mortalité. La plupart des parcours de soins de stratification des risques identifiés sont peu performants pour prédire la mortalité et les complications après une ou plusieurs fractures de côtes.

Rib and sternum fracture risks for restrained occupants in frontal car crashes.

OBJECTIVE: Most car occupant fatalities occur in frontal crashes and the thorax is the most frequently injured body region. The objectives of the study were, firstly, to quantify the relation between risk factors (such as speed and occupant age) and rib and sternum fracture injury probability in frontal car crashes, and, secondly, to evaluate whether rib fracture occurrence can predict sternum fractures. METHODS: Weighted German data from 1999-2021 were used to create the injury risk curves to predict both, at least moderate and at least serious, rib and sternum fracture risks. A contingency table for rib and sternum fractures allowed the calculation of sensitivity, specificity, and precision, as well as testing for the association. RESULTS: Elderly occupants (≥65 years old) had increased rib and sternum fracture risk compared to mid aged occupants (18-64 years old). Besides occupant age, delta-V was always and sex sometimes a significant predictor for skeletal thoracic injury. Sternum fractures were more common than rib fractures and more likely to occur at any given delta-V. Sternum fractures occurred often in isolation. Female occupants were at higher risk than males to sustain at least moderate rib and sternum fractures together and sternum fractures in isolation. Rib and sternum fractures were associated, but low sensitivity and precision show that rib fractures do not predict sternum fractures well. CONCLUSIONS: Elderly and female occupants were at the highest risk and should be targeted by thoracic injury criteria and thresholds for frontal crash occupant protection. Rib and sternum fractures were not associated. Therefore, sternum fractures need to be predicted and evaluated separately from rib fractures.

Pulmonary fat embolism in non-survivors after cardiopulmonary resuscitation.

BACKGROUND: Blunt trauma acting against the human body presents the fundamental cause of pulmonary fat embolism (PFE) and fat embolism syndrome. The aim of the present study was to investigate PFE in non-survivors after cardiopulmonary resuscitation (CPR). METHODS: This was a prospective cohort study conducted in University Hospital Ostrava, Czech Republic. Within a 4-year study period, all non-survivors after CPR because of out-of-hospital cardiac arrest were assessed for the study eligibility. The presence/seriousness of PFE was determined by microscopic examination of cryo-sections of lung tissue (staining with Oil Red O). RESULTS: In total, 106 persons after unsuccessful CPR were enrolled in the study. The most frequent cause of death in the study population (63.2% of cases) was cardiac disease (ischemic heart disease); PFE was not determined as the cause of death in any of our study cases. Sternal fractures were identified 66.9%, rib fractures (usually multiple) in 80.2% of study cases; the median number of rib fractures was 10.2 fractures per person. Serious intra-thoracic injuries were found in 34.9% of cases. Microscopic examination of lung cryo-sections revealed PFE in 40 (37.7%) study cases; PFE was most frequently evaluated as grade I or II. Occurrence of sternal and rib fractures was significantly higher in persons with PFE than between persons without PFE (p = 0.033 and p = <0.001). Number of rib fractures was also significantly higher in persons with PFE. The occurrence of serious intra-thoracic injuries was comparable in both our study groups (p = 0.089). CONCLUSIONS: PFE presents a common resuscitation injury which can be found in more than 30% of persons after CPR. Persons with resuscitation skeletal chest fractures have significantly higher risk of PFE development. During autopsy of persons after unsuccessful CPR, it is necessary to distinguish CPR-associated injuries including PFE from injuries that arise from other mechanisms.

Very long-term effects of conservatively treated blunt thoracic trauma: A retrospective analysis.

INTRODUCTION: Despite the high incidence of blunt thoracic trauma and frequently performed conservative treatment, studies on very long-term consequences for these patients remain sparse in current literature. In this study, we identify prevalence of long-term morbidity such as chronic chest pain, shortness of breath, and analyze the effect on overall quality of life and health-related quality of life. METHODS: Questionnaires were send to patients admitted for blunt thoracic trauma at our institution and who were conservatively treated between 1997 and 2019. We evaluated the presences of currently existing chest pain, persistence of shortness of breath after their trauma, the perceived overall quality of life, and health-related quality of life. Furthermore, we analyzed the effect of pain and shortness of breath on overall quality of life and health-related quality of life. RESULTS: The study population consisted of 185 trauma patients with blunt thoracic trauma who were admitted between 1997 and 2019, with a median long term follow up of 11 years. 60 percent still experienced chronic pain all these years after trauma, with 40,7 percent reporting mild pain, 12,1 percent reporting moderate pain, and with 7,7 percent showing severe pain. 18 percent still experienced shortness of breath during exercise. Both pain and shortness of breath showed no improvement in this period. Pain and shortness of breath due to thoracic trauma were associated with a lower overall quality of life and health-related quality of life. CONCLUSION: Chronic pain and shortness of breath may be relatively common long after blunt thoracic trauma, and are of influence on quality of life and health-related quality of life in patients with conservatively treated blunt thoracic trauma.

A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures.

BACKGROUND: Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. METHODS: A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. RESULTS: From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. CONCLUSION: Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. SYSTEMATIC REVIEW REGISTRATION: UMIN Clinical Trials Registry UMIN000049365.

Physiologic parameters and radiologic findings can predict pulmonary complications and guide management in traumatic rib fractures.

BACKGROUND: Traumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures. METHODS: This is a single-center retrospective review (2015-2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC. RESULTS: A total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS. CONCLUSION: VC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study.

Management of Blunt Chest Trauma.

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

Trends in the incidence of rib and sternal fractures: A nationwide study of the global burden of disease database, 1990-2019.

INTRODUCTION: Fractures of the ribs and sternum are associated with significant morbidity and mortality. Characterization of the injury burden across England is necessary to inform and evaluate developments in trauma care and infrastructure, however is yet to be comprehensively undertaken. Therefore, the aim of this study was to describe trends in the incidence of sternal and rib fractures across England between 1990 and 2019. MATERIALS AND METHODS: Age-standardised incidence rates (ASIRs) for rib and sternal fractures in males and females were extracted from the 2019 Global Burden of Disease (GBD) study by all causes, falls and road traffic collisions for 9 sub-regions of England. Temporal trends within the study period were analysed using Joinpoint regression analysis. RESULTS: The overall ASIRs in England in 2019 were 30.34/100,000 and 46.02/100,000 for females and males, respectively. Between 1990 and 2019, the estimated overall percentage change across England was +0.20 % among females and -7.05 % among males. A statistically significant increase in ASIR was observed in all 9 sub-regions of England among females from 2014-2019 (p<0.001). Among males, a statistically significant increase in ASIR was observed in 7 of the 9 regions from 2014-2019 (p<0.001) and in the remaining 2 regions from 2015-2019 (p<0.001). DISCUSSION: Increasing ASIRs of rib and sternal fractures were observed among females and decreasing ASIRs among males, with overall ASIRs higher among males. Developments in trauma infrastructure and associated variations in diagnostic and management strategies over the observation period likely contribute to changes in the national injury burden. The findings are suggestive of the importance of ongoing financial investment in trauma infrastructure and of clear clinical guidelines to manage an increasing national injury burden.