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BMJ Open Apr 2019Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains...
OBJECTIVES
Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical rib fracture fixation as evidenced by systematic reviews.
DESIGN
A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or unifocal non-flail rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and Science Citation Index were last searched 17 March 2017. Risk of bias was assessed using the Risk Of Bias In Systematic reviews (ROBIS) tool. The primary outcome was duration of mechanical ventilation.
RESULTS
Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials and 19 non-randomised studies. Length of mechanical ventilation was shorter in the fixation group compared with the non-operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI (-5.54 to -3.5) to -7.5 days, 95% CI (-9.9 to -5.5). Pneumonia, length of hospital and intensive care unit stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of unifocal non-flail rib fracture population; due to limited evidence the benefits with surgery are uncertain.
CONCLUSIONS
Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence is required before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, unifocal non-flail rib fractures.
PROSPERO REGISTRATION NUMBER
CRD42016053494.
Topics: Adult; Flail Chest; Fracture Fixation, Internal; Humans; Length of Stay; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Systematic Reviews as Topic
PubMed: 30940753
DOI: 10.1136/bmjopen-2018-023444 -
Archives of Orthopaedic and Trauma... Feb 2023Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in... (Review)
Review
BACKGROUND
Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates.
METHODS
Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered.
RESULTS
Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%).
CONCLUSION
It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.
Topics: Humans; Aged; Rib Fractures; Flail Chest; Length of Stay; Fracture Fixation; Spinal Fractures; Pneumonia; Retrospective Studies
PubMed: 35137253
DOI: 10.1007/s00402-022-04362-z -
European Journal of Trauma and... Aug 2021The primary aim of this retrospective cohort study was to evaluate the pulmonary function after rib fixation for patients with multiple rib fractures and flail chest....
PURPOSE
The primary aim of this retrospective cohort study was to evaluate the pulmonary function after rib fixation for patients with multiple rib fractures and flail chest. Secondary, a systematic review was performed to give an overview of the current literature and to allow comparison with our results.
METHODS
All adult (≥ 18 years) patients who underwent rib fixation for multiple rib fractures or flail chest between 2010 and 2018 and who received a control pulmonary function test during the postoperative follow-up at our level-1 trauma center were retrospectively reviewed. Secondary, the PubMed, EMBASE and Cochrane databases were searched to identify studies reporting on the pulmonary function after rib fixation. The primary outcome parameters were the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV), FEV/FVC ratio, maximum vital capacity (VC), total lung capacity (TLC), residual volume (RV), and RV/TC ratio.
RESULTS
Of the 103 patients who underwent rib fixation, a total of 61 (59%) patients underwent a pulmonary function test in our hospital and were ultimately included. In the majority of patients all pulmonary function parameters fell within the normal range of the reference values. Obstructive impairment was predominantly seen in patients with pre-existing chronic obstructive pulmonary disease (COPD). Patients with multiple rib fractures had better recovery compared to those with a flail chest. The systematic review included a total of 15 studies and showed comparable results.
CONCLUSION
The present study demonstrates that rib fixation for multiple rib fractures or flail chest results in adequate recovery of the pulmonary function within 3 months after surgery. In addition, based on the current literature, further gradual improvement to maximum pulmonary values appears to occur during the first 12 months after rib fixation.
Topics: Adult; Flail Chest; Fracture Fixation, Internal; Fractures, Multiple; Humans; Retrospective Studies; Rib Fractures; Ribs
PubMed: 31768585
DOI: 10.1007/s00068-019-01274-3 -
Pediatrics Aug 2012To systematically review the literature to determine which clinical and radiographic characteristics are associated with abusive head trauma (AHT) and nonabusive head... (Comparative Study)
Comparative Study Review
BACKGROUND AND OBJECTIVE
To systematically review the literature to determine which clinical and radiographic characteristics are associated with abusive head trauma (AHT) and nonabusive head trauma (nAHT) in children.
METHODS
We searched MEDLINE, EMBASE, PubMed, conference proceedings, and reference lists to identify relevant studies. Two reviewers independently selected studies that compared clinical and/or radiographic characteristics including historical features, physical exam and imaging findings, and presenting signs or symptoms in hospitalized children ≤ 6 years old with AHT and nAHT.
RESULTS
Twenty-four studies were included. Meta-analysis was complicated by inconsistencies in the reporting of characteristics and high statistical heterogeneity. Notwithstanding these limitations, there were 19 clinical and radiographic variables that could be meta-analyzed and odds ratios were determined for each variable. In examining only studies deemed to be high quality, we found that subdural hemorrhage(s), cerebral ischemia, retinal hemorrhage(s), skull fracture(s) plus intracranial injury, metaphyseal fracture(s), long bone fracture(s), rib fracture(s), seizure(s), apnea, and no adequate history given were significantly associated with AHT. Epidural hemorrhage(s), scalp swelling, and isolated skull fracture(s) were significantly associated with nAHT. Subarachnoid hemorrhage(s), diffuse axonal injury, cerebral edema, head and neck bruising, any bruising, and vomiting were not significantly associated with either type of trauma.
CONCLUSIONS
Clinical and radiographic characteristics associated with AHT and nAHT were identified, despite limitations in the literature. This systematic review also highlights the need for consistent criteria in identifying and reporting clinical and radiographic characteristics associated with AHT and nAHT.
Topics: Brain Injuries; Child Abuse; Child, Preschool; Cohort Studies; Craniocerebral Trauma; Cross-Sectional Studies; Diagnosis, Differential; Diagnostic Errors; Female; Hospitalization; Humans; Incidence; Infant; Magnetic Resonance Imaging; Male; Neurologic Examination; Physical Examination; Sensitivity and Specificity; Skull Fractures; Tomography, X-Ray Computed
PubMed: 22778309
DOI: 10.1542/peds.2011-1545 -
European Radiology Sep 2021To assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA). (Meta-Analysis)
Meta-Analysis
The diagnostic performance of chest computed tomography in the detection of rib fractures in children investigated for suspected physical abuse: a systematic review and meta-analysis.
OBJECTIVES
To assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA).
METHODS
Medline, Web of Science and Cochrane databases were searched from January 1980 to April 2020. The QUADAS-2 tool was used to assess the quality of the eligible English-only studies following which a formal narrative synthesis was constructed. Studies reporting true-positive, false-positive, true-negative, and false-negative results were included in the meta-analysis. Overall sensitivity and specificity of chest CT for rib fracture detection were calculated, irrespective of fracture location, and were pooled using a univariate random-effects meta-analysis. The diagnostic accuracy of specific locations along the rib arc (anterior, lateral or posterior) was assessed separately.
RESULTS
Of 242 identified studies, 4 met the inclusion criteria. Of these, 2 were included in the meta-analysis. Chest CT identified 142 rib fractures compared to 79 detected by initial skeletal survey chest radiographs in live children with SPA. Post-mortem CT (PMCT) has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures when compared to the autopsy reference standard. PMCT has low sensitivity (45%, 21% and 42%) but high specificity (99%, 97% and 99%) at anterior, lateral and posterior rib locations, respectively.
CONCLUSIONS
Chest CT detects more rib fractures than initial skeletal survey chest radiographs in live children with SPA. PMCT has low sensitivity but high specificity for detecting rib fractures in children investigated for SPA.
KEY POINTS
• PMCT has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures; extrapolation to CT in live children is difficult. • No studies have compared chest CT with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for SPA.
Topics: Autopsy; Child; Humans; Physical Abuse; Rib Fractures; Sensitivity and Specificity; Tomography, X-Ray Computed
PubMed: 33725188
DOI: 10.1007/s00330-021-07775-3 -
Sports Health 2024A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during...
A nationally ranked Division One female collegiate tennis player presented with pain in the chest and right posterior rib region after feeling a popping sensation during a routine overhead movement. The patient was eventually diagnosed with 2 lower rib stress fractures. After unsuccessful conservative management, the player underwent an open reduction and internal fixation and autologous bone grafting of the sixth and seventh ribs with a muscle-sparing approach and was able to return to full competition. We present this case along with a systematic review of the literature regarding rib stress fractures, which included 6 separate online data sources (PubMed, EMBASE, Cochrane, CINAHL, SportDiscus, and Medline). The successful surgical intervention demonstrates a significant option for elite athletes who wish to return to competition but have been unable to with standard of care conservative management of rib stress fractures.
Topics: Humans; Fractures, Stress; Female; Rib Fractures; Tennis; Fracture Fixation, Internal; Bone Plates; Bone Transplantation; Young Adult; Return to Sport
PubMed: 37688535
DOI: 10.1177/19417381231195271 -
Annals of Surgery Dec 2013To perform a systematic review and meta-analysis of studies comparing operative to nonoperative therapy in adult FC patients. Outcomes were duration of mechanical... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To perform a systematic review and meta-analysis of studies comparing operative to nonoperative therapy in adult FC patients. Outcomes were duration of mechanical ventilation (DMV), intensive care unit length of stay (ICULOS), hospital length of stay (HLOS), mortality, incidence of pneumonia, and tracheostomy.
BACKGROUND
Flail chest (FC) results in paradoxical chest wall movement, altered respiratory mechanics, and frequent respiratory failure. Despite advances in ventilatory management, FC remains associated with significant morbidity and mortality. Operative fixation of the flail segment has been advocated as an adjunct to supportive care, but no definitive clinical trial exists to delineate the role of surgery.
METHODS
A comprehensive search of 5 electronic databases was performed to identify randomized controlled trials and observational studies (cohort or case-control). Pooled effect size (ES) or relative risk (RR) was calculated using a fixed or random effects model, as appropriate.
RESULTS
Nine studies with a total of 538 patients met inclusion criteria. Compared with control treatment, operative management of FC was associated with shorter DMV [pooled ES: -4.52 days; 95% confidence interval (CI): -5.54 to -3.50], ICULOS (-3.40 days; 95% CI: -6.01 to -0.79), HLOS (-3.82 days; 95% CI: -7.12 to -0.54), and decreased mortality (pooled RR: 0.44; 95% CI: 0.28-0.69), pneumonia (0.45; 95% CI: 0.30-0.69), and tracheostomy (0.25; 95% CI: 0.13-0.47).
CONCLUSIONS
As compared with nonoperative therapy, operative fixation of FC is associated with reductions in DMV, LOS, mortality, and complications associated with prolonged MV. These findings support the need for an adequately powered clinical study to further define the role of this intervention.
Topics: Flail Chest; Humans; Orthopedic Procedures; Randomized Controlled Trials as Topic; Rib Fractures
PubMed: 23511840
DOI: 10.1097/SLA.0b013e3182895bb0 -
European Journal of Trauma and... Aug 2019The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled... (Meta-Analysis)
Meta-Analysis
PURPOSE
The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.
METHODS
MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy.
RESULTS
Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies.
CONCLUSIONS
Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs.
Topics: Aged; Conservative Treatment; Critical Care; Female; Flail Chest; Fracture Fixation; Humans; Length of Stay; Male; Middle Aged; Observational Studies as Topic; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Tracheostomy
PubMed: 30276722
DOI: 10.1007/s00068-018-1020-x -
Canadian Journal of Anaesthesia =... Mar 2009A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
A consensus group recently proposed epidural analgesia as the optimal analgesic modality for patients with multiple traumatic rib fractures. However, its beneficial effects are not consistently recognized in the literature. We performed a systematic review and a meta-analysis of randomized controlled trials (RCT) of epidural analgesia in adult patients with traumatic rib fractures.
METHODS
A systematic search strategy was applied to MEDLINE, EMBASE, the Cochrane Library and to the annual meeting of relevant societies (up to July 2008). All randomized controlled trials comparing epidural analgesia with other analgesic modalities in adult patients with traumatic rib fractures were included. Primary outcomes were mortality, ICU length of stay (LOS), hospital LOS and duration of mechanical ventilation.
RESULTS
Eight studies (232 patients) met eligibility criteria. Epidural analgesia did not significantly affect mortality (odds ratio [OR] 1.6, 95% CI, 0.3, 9.3, 3 studies, n = 89), ICU LOS (weighted mean difference [WMD] -3.7 days, 95% CI, -11.4, 4.0, 4 studies, n = 135), hospital LOS (WMD -6.7, 95% CI, -19.8, 6.4, 4 studies, n = 140) or duration of mechanical ventilation (WMD -7.5, 95% CI, -16.3, 1.2, 3 studies, n = 101). Duration of mechanical ventilation was decreased when only studies using thoracic epidural analgesia with local anesthetics were evaluated (WMD -4.2, 95% CI, -5.5, -2.9, 2 studies, n = 73). However, hypotension was significantly associated with the use of thoracic epidural analgesia with local anesthetics (OR 13.76, 95% CI, 2.89, 65.51, 3 studies, n = 99).
CONCLUSIONS
No significant benefit of epidural analgesia on mortality, ICU and hospital LOS was observed compared to other analgesic modalities in adult patients with traumatic rib fractures. However, there may be a benefit on the duration of mechanical ventilation with the use of thoracic epidural analgesia with local anesthetics. Further research is required to evaluate the benefits and harms of epidural analgesia in this population before being considered as a standard of care therapy.
Topics: Adult; Analgesia, Epidural; Data Interpretation, Statistical; Humans; Intensive Care Units; Length of Stay; Pain; Publication Bias; Randomized Controlled Trials as Topic; Reproducibility of Results; Respiration, Artificial; Respiratory Mechanics; Rib Fractures; Treatment Outcome; Wounds and Injuries
PubMed: 19247744
DOI: 10.1007/s12630-009-9052-7 -
European Review For Medical and... Feb 2023The aim of the study was to assess the efficacy of different peripheral nerve blocks, compared to conventional methods (analgesics and epidural block), for pain relief... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of the study was to assess the efficacy of different peripheral nerve blocks, compared to conventional methods (analgesics and epidural block), for pain relief in rib fracture patients.
MATERIALS AND METHODS
PubMed, Embase, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched. The review included studies that were either randomized controlled trials (RCTs) or observational in design with propensity matching. The primary outcome of interest was patient's reported pain scores, both at rest and on coughing/movement. The secondary outcomes were length of hospital stay, length of stay at intensive care unit (ICU), need for rescue analgesic, arterial blood gas values and parameters of lung function test. STATA was used for statistical analysis.
RESULTS
The meta-analysis was conducted with 12 studies. Compared to conventional methods, peripheral nerve block was associated with better pain control at rest 12 hours (SMD -4.89, 95% CI: -5.91, -3.86) and 24 hours (SMD -2.58, 95% CI: -4.40, -0.76) after institution of block. At 24 hours after block, the pooled findings indicate better pain control on movement/coughing for the peripheral nerve block group (SMD -0.78, 95% CI: -1.48, -0.09). There were no significant differences in the patient's reported pain scores at rest and on movement/coughing at 24 hours post-block. There were no differences in the overall risk of any complications (RR 0.48, 95% CI: 0.20, 1.18), pulmonary complication (RR 0.71, 95% CI: 0.35, 1.41) and in-hospital mortality (RR 0.62, 95% CI: 0.20, 1.90) between the two groups. Peripheral nerve block was also associated with a relatively lower need for rescue analgesic (SMD -0.31, 95% CI: -0.54, -0.07). There were no differences in the length of ICU and hospital stay, risk of complications, arterial blood gas values or functional lung parameters, i.e., PaO2 and forced vital capacity between the two management strategies.
CONCLUSIONS
Peripheral nerve blocks may be better than conventional pain management strategies for immediate pain control (within 24 hours of initiation of block) in patients with fractured ribs. This method also reduces the need for rescue analgesic. The skills and experience of the health personnel, facilities for care available and the cost involved should guide the decision on which management strategy to utilize.
Topics: Humans; Pain Management; Rib Fractures; Nerve Block; Pain, Postoperative; Peripheral Nerves; Analgesics
PubMed: 36808336
DOI: 10.26355/eurrev_202302_31183