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Annals of the Royal College of Surgeons... Apr 2022Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Multiple traumatic rib fractures are associated with significant morbidity and mortality. The last decade has seen a significant increase in rates of surgical fixation for both flail and non-flail rib fractures; the evidence for this has come from largely retrospective studies. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management.
METHODS
A systematic search of the literature was performed to identify randomised controlled trials (RCTs) comparing surgical stabilisation to non-operative management. Both flail and non-flail injuries were included.
RESULTS
Five RCTs reported the results of 286 patients. Only one study assessed non-flail fractures. The studies were heterogenic in nature and of mixed quality. Surgical stabilisation was associated with a reduction in pneumonia (RR 0.46, 95% confidence intervals (CI) 0.29 to 0.73, I=42%, =0.001). The duration of mechanical ventilation (mean difference (MD) -6.3, 95% CI -12.16 to -0.43, I=95%, =0.05) and critical care length of stay was also shorter after surgery (mean difference -6.46 days, 95% CI 9.73 to -3.19, <0.001); however, the overall length of stay in hospital was not (MD -7.18, 95% CI -15.63 to -1.28, I=94%, =0.1). No study demonstrated a significant reduction in mortality (RR 0.54, 95% CI 0.18 to 1.8, I=0%, =0.28).
CONCLUSIONS
Surgical stabilisation of rib fractures is associated with some improved clinical outcomes. Further large RCTs are still needed to confirm if there is also a survival benefit.
Topics: Flail Chest; Humans; Length of Stay; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Wounds, Nonpenetrating
PubMed: 34928718
DOI: 10.1308/rcsann.2021.0148 -
Physical Therapy Jan 2022The purposes of this study were to evaluate the effect of positive expiratory pressure (PEP) therapy on lung volumes and health outcomes in adults with chest trauma and... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The purposes of this study were to evaluate the effect of positive expiratory pressure (PEP) therapy on lung volumes and health outcomes in adults with chest trauma and to investigate any adverse effects and optimal dosages leading to the greatest positive impact on lung volumes and recovery.
METHODS
Data sources were MEDLINE/PubMed, Embase, Cochrane Library, Physiotherapy Evidence Database, CINAHL, Open Access Thesis/Dissertations, EBSCO Open Dissertations, and OpenSIGLE/Open Grey. Randomized controlled trials investigating PEP therapy compared with usual care or other physical therapist interventions were included. Participants were >18 years old and who were admitted to the hospital with any form of chest trauma, including lung or cardiac surgery, blunt chest trauma, and rib fractures. Methodological quality was assessed using the Physiotherapy Evidence Database Scale, and the level of evidence was downgraded using the Grading of Recommendations Assessment, Development and Evaluation approach.
RESULTS
Eleven studies involving 661 participants met inclusion eligibility. There was very low-level evidence that PEP improved forced vital capacity (standardized mean difference = -0.50; 95% CI = -0.79 to -0.21), forced expiratory volume in 1 second (standardized mean difference = -0.38; 95% CI = -0.62 to -0.13), and reduced the incidence of pneumonia (relative risk = 0.16; 95% CI = 0.03 to 0.85). Respiratory muscle strength also significantly improved in all 3 studies reporting this outcome. There was very low-level evidence that PEP did not improve other lung function measures, arterial blood gases, atelectasis, or hospital length of stay. Both PEP devices and dosages varied among the studies, and no adverse events were reported.
CONCLUSION
PEP therapy is a safe intervention with very low-level evidence showing improvements in forced vital capacity, forced expiratory volume in 1 second, respiratory muscle strength, and incidence of pneumonia. It does not improve arterial blood gases, atelectasis, or hospital length of stay. Because the evidence is very low level, more rigorous physiological and dose-response studies are required to understand the true impact of PEP on the lungs after chest trauma.
IMPACT
There is currently no strong evidence for physical therapists to routinely use PEP devices following chest trauma. However, there is no evidence of adverse events; therefore, in specific clinical situations, PEP therapy may be considered.
Topics: Adult; Humans; Lung Injury; Lung Volume Measurements; Outcome Assessment, Health Care; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Therapy; Thoracic Injuries
PubMed: 34723337
DOI: 10.1093/ptj/pzab254 -
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 European Respiratory Journal Apr 2022Our purpose was to summarise the prognostic associations between various clinical risk factors and development of acute respiratory distress syndrome (ARDS) following... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Our purpose was to summarise the prognostic associations between various clinical risk factors and development of acute respiratory distress syndrome (ARDS) following traumatic injury.
METHODS
We conducted this review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) guidelines. We searched six databases from inception through December 2020. We included English language studies describing the clinical risk factors associated with development of post-traumatic ARDS, as defined by either the American-European Consensus Conference or Berlin definition. We pooled adjusted odds ratios for prognostic factors using the random effects method. We assessed risk of bias using the QUIPS (Quality in Prognosis Studies) tool and certainty of findings using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.
RESULTS
We included 39 studies involving 5 350 927 patients. We identified the amount of crystalloid resuscitation as a potentially modifiable prognostic factor associated with development of post-traumatic ARDS (adjusted OR 1.19, 95% CI 1.15-1.24 for each additional litre of crystalloid administered within the first 6 h after injury; high certainty). Non-modifiable prognostic factors with a moderate or high certainty of association with post-traumatic ARDS included increasing age, non-Hispanic White race, blunt mechanism of injury, presence of head injury, pulmonary contusion or rib fracture and increasing chest injury severity.
CONCLUSIONS
We identified one important modifiable factor, the amount of crystalloid resuscitation within the first 24 h of injury, and several non-modifiable factors associated with development of post-traumatic ARDS. This information should support the judicious use of crystalloid resuscitation in trauma patients and may inform development of risk stratification tools.
Topics: Crystalloid Solutions; Humans; Odds Ratio; Prognosis; Respiratory Distress Syndrome; Risk Factors
PubMed: 34625477
DOI: 10.1183/13993003.00857-2021 -
The Journal of Trauma and Acute Care... Dec 2021Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative...
BACKGROUND
Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data.
METHODS
Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up.
RESULTS
Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months.
CONCLUSION
Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma.
LEVEL OF EVIDENCE
Collected case series, level V.
Topics: Adolescent; Aftercare; Airway Extubation; Child; Fracture Fixation; Humans; Length of Stay; Male; Outcome and Process Assessment, Health Care; Patient Selection; Preoperative Period; Rib Fractures; Thoracic Injuries; Trauma Severity Indices; Wounds, Nonpenetrating
PubMed: 34407006
DOI: 10.1097/TA.0000000000003376 -
The Journal of Surgical Research Dec 2021Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.
METHODS
Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.
RESULTS
Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.
CONCLUSIONS
SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.
Topics: Adult; Bone Plates; Equipment Failure; Hospitalization; Humans; Retrospective Studies; Rib Fractures
PubMed: 34333416
DOI: 10.1016/j.jss.2021.06.054 -
Which traumatic spinal injury creates which degree of instability? A systematic quantitative review.The Spine Journal : Official Journal of... Jan 2022Traumatic spinal injuries often require surgical fixation. Specific three-dimensional degrees of instability after spinal injury, which represent criteria for optimum... (Review)
Review
BACKGROUND CONTEXT
Traumatic spinal injuries often require surgical fixation. Specific three-dimensional degrees of instability after spinal injury, which represent criteria for optimum treatment concepts, however, are still not well investigated.
PURPOSE
The aim of this review therefore was to summarize and quantify multiplanar instability increases due to spinal injury from experimental studies.
STUDY DESIGN/SETTING
Systematic review.
METHODS
A systematic review of the literature was performed using keyword-based search on PubMed and Web of Science databases in order to detect all in vitro studies investigating the destabilizing effect of simulated and provoked traumatic injury in human spine specimens. Together with the experimental designs, the instability parameters range of motion, neutral zone and translation were extracted from the studies and evaluated regarding type and level of injury.
RESULTS
A total of 59 studies was included in this review, of which 43 studies investigated the effect of cervical spine injury. Range of motion increase, which was reported in 58 studies, was generally lower compared to the neutral zone increase, given in 37 studies, despite of injury type and level. Instability increases were highest in flexion/extension for most injury types, while axial rotation was predominantly affected after cervical unilateral dislocation injury and lateral bending solely after odontoid fracture. Whiplash injuries and wedge fractures were found to increase instability equally in all motion planes.
CONCLUSIONS
Specific traumatic spinal injuries produce characteristic but complex three-dimensional degrees of instability, which depend on the type, level, and morphology of the injury. Future studies should expand research on the cervicothoracic, thoracic, and lumbosacral spine and should additionally investigate the destabilizing effects of the injury morphology as well as concomitant rib cage injuries in case of thoracic spinal injuries. Moreover, neutral zone and translation should be measured in addition to the range of motion, while mechanical injury simulation should be preferred to resection or transection of structures to ensure high comparability with the clinical situation.
Topics: Biomechanical Phenomena; Cadaver; Cervical Vertebrae; Fractures, Compression; Humans; Range of Motion, Articular; Spinal Injuries
PubMed: 34116217
DOI: 10.1016/j.spinee.2021.06.004 -
Trauma Surgery & Acute Care Open 2021There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic...
BACKGROUND
There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma.
METHODS
A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed.
RESULTS
Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low.
CONCLUSIONS
Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence.
LEVEL OF EVIDENCE
Level IV systematic reviews and meta-analyses.
PubMed: 34079913
DOI: 10.1136/tsaco-2021-000690 -
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 -
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