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The Journal of Trauma and Acute Care... Dec 2021Chest computed tomography (CT) scans are important for the management of rib fracture patients, especially when determining indications for surgical stabilization of rib... (Comparative Study)
Comparative Study
BACKGROUND
Chest computed tomography (CT) scans are important for the management of rib fracture patients, especially when determining indications for surgical stabilization of rib fractures (SSRFs). Chest CTs describe the number, patterns, and severity of rib fracture displacement, driving patient management and SSRF indications. Literature is scarce comparing radiologist versus surgeon rib fracture description. We hypothesize there is significant discrepancy between how radiologists and surgeons describe rib fractures.
METHODS
This was an institutional review board-approved, retrospective study conducted at a Level I academic center from December 2016 to December 2017. Adult patients (≥18 years of age) suffering rib fractures with a CT chest where included. Basic demographics were obtained. Outcomes included the difference between radiologist versus surgeon description of rib fractures and differences in the number of fractures identified. Rib fracture description was based on current literature: 1, nondisplaced; 2, minimally displaced (<50% rib width); 3, severely displaced (≥50% rib width); 4, bicortically displaced; 5, other. Descriptive analysis was used for demographics and paired t test for statistical analysis. Significance was set at p = 0.05.
RESULTS
Four hundred and ten patients and 2,337 rib fractures were analyzed. Average age was 55.6(±20.6); 70.5% were male; median Injury Severity Score was 16 (interquartile range, 9-22) and chest Abbreviated Injury Scale score was 3 (interquartile range, 3-3). For all descriptive categories, radiologists consistently underappreciated the severity of rib fracture displacement compared with surgeon assessment and severity of displacement was not mentioned for 35% of rib fractures. The mean score provided by the radiologist was 1.58 (±0.63) versus 1.78 (±0.51) by the surgeon (p < 0.001). Radiologists missed 138 (5.9%) rib fractures on initial CT. The sensitivity of the radiologist to identify a severely displaced rib fracture was 54.9% with specificity of 79.9%.
CONCLUSION
Discrepancy exists between radiologist and surgeon regarding rib fracture description on chest CT as radiologists routinely underappreciate fracture severity. Surgeons need to evaluate CT scans themselves to appropriately decide management strategies and SSRF indications.
LEVEL OF EVIDENCE
Prognostic/Diagnostic Test, level III.
Topics: Clinical Competence; Current Procedural Terminology; Female; Humans; Injury Severity Score; Male; Middle Aged; Patient Selection; Prognosis; Radiologists; Retrospective Studies; Rib Fractures; Surgeons; Tomography, X-Ray Computed
PubMed: 34407008
DOI: 10.1097/TA.0000000000003377 -
Pediatric Radiology May 2020The presumed mechanism of rib fractures in abuse is violent grasping of the torso causing anterior-posterior chest compression. We hypothesized an asymmetrical...
BACKGROUND
The presumed mechanism of rib fractures in abuse is violent grasping of the torso causing anterior-posterior chest compression. We hypothesized an asymmetrical distribution of rib fractures in abused infants given the greater incidence of right-hand dominance within the general population.
OBJECTIVE
The objective of this study was to characterize rib fractures in abused children, particularly sidedness; additionally, we evaluated the sidedness of other abusive skeletal fractures.
MATERIALS AND METHODS
We reviewed medical records from abused children (0-18 months old) with rib fractures. We also retrospectively reviewed their radiographs to determine characteristics of rib fractures (number, side, rib region, level, acuity) and other skeletal fractures (number, side, location), as well as differences in the distribution of rib and other skeletal fractures.
RESULTS
A total of 360 rib fractures were identified on 273 individual ribs involving 78 abused children. Sixty-three children (81%) had multiple rib fractures. There was a significantly greater number of left-side rib fractures (67%) than right-side fractures (P<0.001). Fractures were most often identified in the posterior and lateral regions and mid level of the ribcage (Ribs 5 through 8). Fifty-four percent of subjects had other skeletal fractures; these non-rib fractures were also predominantly on the left side (P=0.006).
CONCLUSION
In our study of abused children, there was a higher incidence of rib fractures in the posterior, lateral and mid-level locations. Additionally, we found a predominance of left-side rib and other skeletal fractures. Further research is needed to understand whether factors such as perpetrator handedness are associated with these unequal distributions of fractures in abused children.
Topics: Child Abuse; Female; Humans; Infant; Infant, Newborn; Male; Radiography; Retrospective Studies; Rib Fractures; Ribs
PubMed: 31925459
DOI: 10.1007/s00247-019-04599-8 -
The American Surgeon Nov 2019Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor...
Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor of mortality, but rarely contribute to cause death. We performed a retrospective study (2008-2015) of blunt trauma patients admitted to our urban, Level I trauma center with one or more rib fractures. Medical records were reviewed in detail. Rib fracture deaths were those from any respiratory sequelae or hemorrhage from rib fractures. There were 4413 blunt trauma patients who sustained one or more rib fractures and 295 (6.8%) died. Rib fracture patients who died had a mean Injury Severity Score = 38 and chest Abbreviated Injury Score = 3.4. Rib fractures were the cause of death in only 21 patients (0.5%). After excluding patients who were dead on arrival, patients dying as a result of their rib fractures were found to be older ( < 0.0001) and had a higher admission respiratory rate ( = 0.02). Multivariable logistic regression found that age ≥65 was the only variable independently associated with mortality directly related to rib fractures (odds ratio 4.1, 95% confidence interval = 1.3-13.3, value < .0001). Mortality in patients with rib fractures is uncommon (7%), and mortality directly related to rib fractures is rare (0.5%). Older patients are four times more likely to die as a direct result of rib fractures and may require additional resources to avoid mortality.
Topics: Abbreviated Injury Scale; Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Cause of Death; Female; Glasgow Coma Scale; Humans; Injury Severity Score; Logistic Models; Male; Middle Aged; Respiratory Rate; Retrospective Studies; Rib Fractures; Wounds, Nonpenetrating; Young Adult
PubMed: 31775963
DOI: No ID Found -
Developmental Biology Dec 2020The importance of skeletal muscle for rib development and patterning in the mouse embryo has not been resolved, largely because different experimental approaches have...
The importance of skeletal muscle for rib development and patterning in the mouse embryo has not been resolved, largely because different experimental approaches have yielded disparate results. In this study, we utilize both gene knockouts and muscle cell ablation approaches to re-visit the extent to which rib growth and patterning are dependent on developing musculature. Consistent with previous studies, we show that rib formation is highly dependent on the MYOD family of myogenic regulatory factors (MRFs), and demonstrate that the extent of rib formation is gene-, allele-, and dosage-dependent. In the absence of Myf5 and MyoD, one allele of Mrf4 is sufficient for extensive rib growth, although patterning is abnormal. Under conditions of limiting MRF dosage, MyoD is identified as a positive regulator of rib patterning, presumably due to improved intercostal muscle development. In contrast to previous muscle ablation studies, we show that diphtheria toxin subunit A (DTA)-mediated ablation of muscle progenitors or differentiated muscle, using MyoD or HSA-Cre drivers, respectively, profoundly disrupts rib development. Further, a comparison of three independently derived Rosa26-based DTA knockin alleles demonstrates that the degree of rib perturbations in MyoD/DTA embryos is markedly dependent on the DTA allele used, and may in part explain discrepancies with previous findings. The results support the conclusion that the extent and quality of rib formation is largely dependent on the dosage of Myf5 and Mrf4, and that both early myotome-sclerotome interactions, as well as later muscle-rib interactions, are important for proper rib growth and patterning.
Topics: Alleles; Animals; Body Patterning; Gonadotropin-Releasing Hormone; Mice, Transgenic; Muscle, Skeletal; MyoD Protein; Myogenic Regulatory Factor 5; Myogenic Regulatory Factors; Ribs
PubMed: 32768399
DOI: 10.1016/j.ydbio.2020.07.015 -
Annals of Emergency Medicine Dec 2017With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be...
STUDY OBJECTIVE
With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be accurate. We seek to determine rates of rib fracture observed on chest CT only; admission and mortality of patients with isolated rib fractures, rib fractures observed on CT only, and first or second rib fractures; and first or second rib fracture-associated great vessel injury.
METHODS
We conducted a planned secondary analysis of 2 prospectively enrolled cohorts of the National Emergency X-Radiography Utilization Study chest studies, which evaluated patients with blunt trauma who were older than 14 years and received chest imaging in the emergency department. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine outcomes.
RESULTS
Of 8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had rib fractures, and rib fractures were observed on chest CT only in 1,368 cases (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%; mean difference 42.9%; 95% confidence interval [CI] 41.4% to 44.4%) and mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than patients without rib fracture. The mortality of patients with rib fracture observed on chest CT only was not statistically significantly different from that of patients with fractures also observed on chest radiograph (4.8% versus 5.7%; mean difference -0.9%; 95% CI -3.1% to 1.1%). Patients with first or second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%) than patients with fractures of ribs 3 to 12, and the odds ratio of great vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4).
CONCLUSION
Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury.
Topics: Adult; Aged; Aorta; Female; Humans; Male; Middle Aged; Radiography, Thoracic; Rib Fractures; Thorax; Tomography, X-Ray Computed; Wounds, Nonpenetrating
PubMed: 28559032
DOI: 10.1016/j.annemergmed.2017.04.011 -
British Journal of Hospital Medicine... Nov 2017
Topics: Chest Pain; Humans; Male; Middle Aged; Multiple Trauma; Osteotomy; Radiography, Thoracic; Rib Fractures; Ribs; Thoracic Injuries; Thoracoplasty; Tuberculosis, Pulmonary
PubMed: 29111813
DOI: 10.12968/hmed.2017.78.11.654 -
Environmental Science and Pollution... Mar 2023Rib spalling is one of the main factors restricting the safe and efficient production of the fully mechanized mining face in gangue-bearing coal seams, and the gangue...
Rib spalling is one of the main factors restricting the safe and efficient production of the fully mechanized mining face in gangue-bearing coal seams, and the gangue has significant influence on the occurrence of rib spalling. In this study, the instability process and mechanical mechanism of rib spalling in gangue-bearing coal seams were studied, and the sensitivity of gangue parameters to rib spalling was analyzed. The simulation test of rib spalling under different gangue parameters was carried out by orthogonal tests. The width and depth of rib spalling were taken as evaluation indexes, and the influence of gangue parameters on the rib spalling was analyzed by variance analysis and significance tests. The results show that the failure process of rib spalling is characterized by the fracturing failure of the lower coal body, shear failure of the gangue layer, and the falling off of the upper coal body caused by the gravity; the gangue parameters (thickness, density, joint inclination, and internal friction angle) have an important influence on the sliding instability of the coal wall. In the sensitivity analysis, the influence of gangue parameters on the width of rib spalling is ordered as gangue density > joint inclination > gangue thickness > internal friction angle; the influence of gangue parameters on the depth of rib spalling is ordered as gangue density > joint inclination > internal friction angle > gangue thickness. Besides, the greater the gangue density, the less damage caused by stress concentration, and the lower the risk of rib spalling.
Topics: Coal; Mining; Ribs
PubMed: 36585591
DOI: 10.1007/s11356-022-25033-x -
Clinical Biomechanics (Bristol, Avon) Dec 2020High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious...
INTRODUCTION
High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation.
METHODS
One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes.
FINDINGS
Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating.
INTERPRETATION
This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.
Topics: Biomechanical Phenomena; Bone Plates; Cadaver; Flail Chest; Fracture Fixation, Internal; Humans; Mechanical Phenomena; Rib Fractures; Thoracic Injuries
PubMed: 33045492
DOI: 10.1016/j.clinbiomech.2020.105191 -
The Journal of Trauma and Acute Care... Dec 2023Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a...
Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma.
BACKGROUND
Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists.
METHODS
The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation.
RESULTS
No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection.
CONCLUSION
This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion.
LEVEL OF EVIDENCE
Therapeutic/Care Management; Level IV.
Topics: Humans; Rib Fractures; Opiate Alkaloids; Thoracic Wall; Thoracic Injuries; Ribs; Fractures, Ununited; Acute Pain
PubMed: 37728432
DOI: 10.1097/TA.0000000000004083 -
European Journal of Trauma and... Aug 2019Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is...
PURPOSE
Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures.
METHODS
All adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone.
RESULTS
Of the 864 patients admitted with ≥ 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18-34) and 21 (IQR 16-29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62-1) and 0.79 (0.62-0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal.
CONCLUSIONS
We show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.
Topics: Aged; Conservative Treatment; Female; Flail Chest; Follow-Up Studies; Fracture Fixation, Internal; Fractures, Multiple; Hospitalization; Humans; Male; Middle Aged; Netherlands; Retrospective Studies; Rib Fractures
PubMed: 30229337
DOI: 10.1007/s00068-018-1009-5