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The Journal of Surgical Research Aug 2022Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse.
METHODS
A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality.
RESULTS
Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation.
CONCLUSIONS
Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.
Topics: Flail Chest; Fracture Fixation, Internal; Humans; Length of Stay; Pneumonia; Retrospective Studies; Rib Fractures; Ribs; Spinal Fractures
PubMed: 35390577
DOI: 10.1016/j.jss.2022.02.055 -
The Journal of Trauma and Acute Care... Mar 2023Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully... (Meta-Analysis)
Meta-Analysis
Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.
BACKGROUND
Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.
METHODS
Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.
RESULTS
Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.
CONCLUSION
We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.
LEVEL OF EVIDENCE
Systematic Review/Meta-analysis; Level IV.
Topics: Humans; Aged; Rib Fractures; Ketamine; Pain; Analgesia, Epidural; Thoracic Injuries; Pneumonia; Neck Injuries; Length of Stay
PubMed: 36730672
DOI: 10.1097/TA.0000000000003830 -
Cureus Jul 2023Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib... (Review)
Review
Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib fractures in this population, the clinical and physiological factors associated with alcohol dependence may influence how these patients recover from thoracic injuries. Therefore, the aim of the systematic review was to examine the effect of alcohol dependence on rib fracture outcomes. The Embase, PubMed and Web of Science databases were searched for studies examining adult patients with rib fractures, with and without a history of alcohol dependency. The outcomes of interest were mortality, pulmonary complications, intensive care length of stay, ventilator days and hospital length of stay. A meta-analysis was performed to combine the data and compare results. Three studies met the criteria for inclusion in the review and all studies were observational in design. Alcohol dependency was associated with increased mortality (OR 1.44 (95% CI: 1.33-1.56)), pneumonia (OR 2.14 (2.02-2.27)) and ARDS (OR 1.71(1.48-1.98)) as well as longer stays in hospital and intensive care (p<0.05). No difference was found in ventilator days between the two groups. Early intensive care review should be considered to reduce complications in this population alongside prompt management of withdrawal symptoms. However, limited primary research exists on this topic and the quality of current evidence is low. Additional primary research is needed to further understand this correlation and draw meaningful conclusions.
PubMed: 37644941
DOI: 10.7759/cureus.42639 -
The Journal of Trauma and Acute Care... Aug 2020In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study...
BACKGROUND
In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study that extensively focused on the incidence of complications associated with rib fracture fixation. Furthermore, there is insufficient knowledge about the short- and long-term outcomes after rib fracture fixation.
METHODS
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The MEDLINE, EMBASE, and Cochrane databases were searched to identify studies reporting on complications and/or outcome of surgical treatment after rib fractures. Complications were subdivided into (1) surgery- and implant-related complications, (2) bone-healing complications, (3) pulmonary complications, and (4) mortality.
RESULTS
Forty-eight studies were included, with information about 1,952 patients who received rib fracture fixation because of flail chest or multiple rib fractures. The overall risk of surgery- and implant-related complications was 10.3%, with wound infection in 2.2% and fracture-related infection in 1.3% of patients. Symptomatic nonunion was a relatively uncommon complication after rib fixation (1.3%). Pulmonary complications were found in 30.9% of patients, and the overall mortality was 2.9%, of which one third appeared to be the result of the thoracic injuries and none directly related to the surgical procedure. The most frequently used questionnaire to assess patient quality of life was the EuroQol-5D (EQ-5D) (n = 4). Four studies reporting on the EQ-5D had a weighted mean EQ-5D index of 0.80 indicating good quality of life after rib fracture fixation.
CONCLUSION
Surgical fixation can be considered as a safe procedure with a considerably low complication risk and satisfactory long-term outcomes, with surgery- and implant-related complications in approximately 10% of the patients. However, the clinically most relevant complications such as infections occur infrequently, and the number of complications requiring immediate (surgical) treatment is low.
LEVEL OF EVIDENCE
Systematic Review, level III.
Topics: Flail Chest; Fracture Fixation, Internal; Fracture Healing; Fractures, Multiple; Fractures, Ununited; Humans; Internal Fixators; Postoperative Complications; Quality of Life; Respiration Disorders; Respiratory Tract Diseases; Rib Fractures; Surgical Wound Infection
PubMed: 32282759
DOI: 10.1097/TA.0000000000002716 -
Resuscitation Dec 2021Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients. (Meta-Analysis)
Meta-Analysis Review
AIM
Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients.
METHODS
Two investigators separately screened the articles of EMBASE, PubMed, and Cochrane Central databases. Cohort studies and randomized clinical trials (RCTs) that evaluated the safety of mechanical (LUCAS or AutoPulse) and manual chest compressions in cardiac arrest patients were included. A meta-analysis was performed using a random effects model to calculate the pooled odds ratios (ORs) and their 95% confidence intervals (CIs). The primary outcome was the rate of overall compression-induced injuries. The secondary outcomes included the incidence of life-threatening injuries, skeletal fractures, visceral injuries, and other soft tissue injuries.
RESULTS
The meta-analysis included 11 trials involving 2,818 patients. A significantly higher rate of overall compression-induced injuries was found for mechanical compressions than manual compressions (OR, 1.29; 95% CI, 1.19-1.41), while there was no significant difference between the two groups in respect of the rate of life-threatening injuries. Furthermore, both modalities shared similar incidences of sternal fractures, vertebral fractures, lung, spleen, and kidney injuries. However, compared to mechanical compressions, manual compressions were shown to present a reduced risk of posterior rib fractures, and heart and liver lesions.
CONCLUSIONS
The findings suggested that manual compressions could decrease the risk of compression-induced injuries compared to mechanical compressions in cardiac arrest patients. Interestingly, mechanical compressions have not increased the risk of life-threatening injuries, whereas additional high-quality RCTs are needed to further verify the safety of mechanical chest devices.
TRIAL REGISTRY
INPLASY; Registration number: INPLASY2020110111; URL: https://inplasy.com/.
Topics: Cardiopulmonary Resuscitation; Heart Arrest; Heart Massage; Humans; Out-of-Hospital Cardiac Arrest; Pressure; Randomized Controlled Trials as Topic; Thoracic Injuries; Thorax
PubMed: 34699924
DOI: 10.1016/j.resuscitation.2021.10.028 -
The Cochrane Database of Systematic... Jun 2015This is a second update of a Cochrane Review originally published in Issue 2, 2009. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is a second update of a Cochrane Review originally published in Issue 2, 2009. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent, based on delivering low voltage electrical currents to the skin. TENS is used by people to treat a variety of pain conditions.
OBJECTIVES
To assess the analgesic effectiveness of TENS, as a sole treatment, for acute pain in adults.
SEARCH METHODS
We searched the following databases up to 3 December 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; EMBASE; CINAHL; and AMED. We also checked the reference lists of included trials.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) of adults with acute pain (< 12 weeks) if they examined TENS given as a sole treatment and assessed pain with subjective pain scales. Trials were eligible if they compared TENS to placebo TENS, no treatment controls, pharmacological interventions or non-pharmacological interventions. We excluded trials on experimental pain, case reports, clinical observations, letters, abstracts or reviews. Also we excluded trials investigating the effect of TENS on pain during childbirth (labour), primary dysmenorrhoea or dental procedures. Studies where TENS was given with another treatment as part of the formal trial design were excluded. We did not restrict any articles based on language of publication.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study eligibility and carried out study selection, data extraction, 'Risk of bias' assessment and analyses of data. We extracted data on the following: types of participants and pain condition, trial design and methods, treatment parameters, adverse effects, and outcome measures. We contacted trial authors for additional information if necessary.
MAIN RESULTS
We included 12 trials in the original review (2009) and included no further trials in the first update (2011). An additional seven new trials met the inclusion criteria in this second update. In total, we included 19 RCTs involving 1346 participants at entry, with 11 trials awaiting classification either because the full text was unavailable or information in the full text failed to clarify eligibility. We excluded most trials because TENS was given in combination with another treatment as part of the formal study design or TENS was not delivered using appropriate TENS technique. The types of acute pain included in this Cochrane Review were procedural pain, e.g. cervical laser treatment, venepuncture, screening flexible sigmoidoscopy and non-procedural pain, e.g. postpartum uterine contractions and rib fractures. We pooled data for pain intensity for six trials (seven comparisons) comparing TENS with placebo but the I(2) statistic suggested substantial heterogeneity. Mean difference (MD) with 95% confidence intervals (CIs) on a visual analogue scale (VAS, 100 mm) was -24.62 mm (95% CI -31.79 to -17.46) in favour of TENS. Data for the proportion of participants achieving ≥ 50% reduction in pain was pooled for four trials (seven comparisons) and relative risk was 3.91 (95% CI 2.42 to 6.32) in favour of TENS over placebo. We pooled data for pain intensity from five trials (seven comparisons) but the I(2) statistic suggested considerable heterogeneity. MD was -19.05 mm (95% CI -27.30 to -10.79) in favour of TENS using a random-effects model. It was not possible to pool other data. There was a high risk of bias associated with inadequate sample sizes in treatment arms and unsuccessful blinding of treatment interventions. Seven trials reported minor adverse effects, such as mild erythema and itching underneath the electrodes and participants disliking TENS sensation.
AUTHORS' CONCLUSIONS
This Cochrane Review update includes seven new trials, in addition to the 12 trials reviewed in the first update in 2011. The analysis provides tentative evidence that TENS reduces pain intensity over and above that seen with placebo (no current) TENS when administered as a stand-alone treatment for acute pain in adults. The high risk of bias associated with inadequate sample sizes in treatment arms and unsuccessful blinding of treatment interventions makes definitive conclusions impossible. There was incomplete reporting of treatment in many reports making replication of trials impossible.
Topics: Acute Pain; Adult; Humans; Pain Measurement; Randomized Controlled Trials as Topic; Transcutaneous Electric Nerve Stimulation
PubMed: 26075732
DOI: 10.1002/14651858.CD006142.pub3 -
European Journal of Trauma and... Oct 2022The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. (Review)
Review
PURPOSE
The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries.
METHODS
A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14 of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant-Murley score, union and complications.
RESULTS
Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56-60.6% versus 29% in patients without clavicle fractures. Vice versa, 14-18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days).
CONCLUSION
Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.
Topics: Clavicle; Humans; Length of Stay; Multiple Trauma; Retrospective Studies; Rib Fractures; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 34075434
DOI: 10.1007/s00068-021-01701-4 -
Archives of Orthopaedic and Trauma... May 2024Rib fractures commonly occur in trauma patients with varying presentations. Though the literature in recent years has moved toward favoring more early intervention of... (Review)
Review
INTRODUCTION
Rib fractures commonly occur in trauma patients with varying presentations. Though the literature in recent years has moved toward favoring more early intervention of acute rib fractures, little has been reported on the matter of surgical fixation for symptomatic rib fracture nonunions.
MATERIALS AND METHODS
We performed a review of PubMed and Cochrane databases for articles published since 2000. Inclusion criteria were studies with greater than six months of follow-up, while case studies were excluded. A thorough analysis was performed on patient outcomes, complications reported, operative techniques utilized, and fixation systems used, among other parameters reported by the articles.
RESULTS
One hundred and thirty-nine studies resulted from our review, and a total of nine studies met our inclusion criteria with a combined total of 182 patients who underwent open reduction and internal fixation for symptomatic rib fracture nonunions. All studies reported a significant reduction of pain with increased satisfaction in the majority of patients. There were a total of 71 postoperative complications, the most common of which included surgical site infections, hardware failure, and hematoma. The most serious complications were insulting injury to the lung parenchyma or pleura; however, these were extremely rare based off the current literature. The use of bone grafting was common with eight of the nine studies mentioning the benefits of grafting.
CONCLUSION
Surgical stabilization of rib fracture nonunions appears to be an appropriate treatment alternative, and various techniques and approaches may be used with similar success. Further studies with higher level of evidence are recommended on the subject.
Topics: Humans; Rib Fractures; Fractures, Ununited; Fracture Fixation, Internal; Postoperative Complications; Bone Transplantation
PubMed: 38492065
DOI: 10.1007/s00402-024-05264-y -
The British Journal of Radiology Feb 2024To review studies on deep learning (DL) models for classification, detection, and segmentation of rib fractures in CT data, to determine their risk of bias (ROB), and to... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To review studies on deep learning (DL) models for classification, detection, and segmentation of rib fractures in CT data, to determine their risk of bias (ROB), and to analyse the performance of acute rib fracture detection models.
METHODS
Research articles written in English were retrieved from PubMed, Embase, and Web of Science in April 2023. A study was only included if a DL model was used to classify, detect, or segment rib fractures, and only if the model was trained with CT data from humans. For the ROB assessment, the Quality Assessment of Diagnostic Accuracy Studies tool was used. The performance of acute rib fracture detection models was meta-analysed with forest plots.
RESULTS
A total of 27 studies were selected. About 75% of the studies have ROB by not reporting the patient selection criteria, including control patients or using 5-mm slice thickness CT scans. The sensitivity, precision, and F1-score of the subgroup of low ROB studies were 89.60% (95%CI, 86.31%-92.90%), 84.89% (95%CI, 81.59%-88.18%), and 86.66% (95%CI, 84.62%-88.71%), respectively. The ROB subgroup differences test for the F1-score led to a p-value below 0.1.
CONCLUSION
ROB in studies mostly stems from an inappropriate patient and data selection. The studies with low ROB have better F1-score in acute rib fracture detection using DL models.
ADVANCES IN KNOWLEDGE
This systematic review will be a reference to the taxonomy of the current status of rib fracture detection with DL models, and upcoming studies will benefit from our data extraction, our ROB assessment, and our meta-analysis.
Topics: Humans; Rib Fractures; Deep Learning; Tomography, X-Ray Computed; Retrospective Studies
PubMed: 38323515
DOI: 10.1093/bjr/tqae014 -
Injury Nov 2019The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is...
PURPOSE
The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is lacking. A systematic review was performed to identify patient reported outcome measures (PROMs) used in the assessment of outcomes following chest wall injury. The quality of evidence for the psychometric properties of the identified PROMs was graded using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.
METHODS
Rib fracture studies measuring patient reported outcomes were identified using PubMed/Medline, EMBASE, AMED and PsycINFO. Methodological quality of measurement properties was evaluated with the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.
RESULTS
A total of 64 studies were identified including 19 different PROM instruments. Domains included in the reported PROMs included pain, breathlessness, general health quality of life, physical function and physiological health. No rib fracture specific PROM was identified. The most frequently reported instrument was the SF-36 reporting overall quality of life (HRQoL) although there was very low quality evidence for its content validity. There was low quality evidence to support good content validity for the Medical Research Council (MRC) dyspnoea scale, Brief Pain Index (BPI) and McGill Pain Questionnaire (MPQ). No PROM had undergone validation in a rib fracture population. The overall quality of the PROM development studies was poor. While we were unable to identify a clear "gold standard", based on the limited current evidence, we recommend that the EQ-5D-5L is used in combination with the MRC and BPI or MPQ for future rib fracture studies.
CONCLUSION
The lack of validated outcome measures for rib fracture patients is a significant limitation of the current literature. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. As interventions for rib fractures have become more common in both research and clinical practice this has become an urgent priority.
Topics: Checklist; Guidelines as Topic; Humans; Patient Reported Outcome Measures; Psychometrics; Quality of Life; Rib Fractures
PubMed: 31353094
DOI: 10.1016/j.injury.2019.07.002