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Emergency (Tehran, Iran) 2016The potential benefit of ultrasonography for detection of thoracic bone fractures has been proven in various surveys but no comprehensive conclusion has been drawn yet;... (Review)
Review
INTRODUCTION
The potential benefit of ultrasonography for detection of thoracic bone fractures has been proven in various surveys but no comprehensive conclusion has been drawn yet; therefore, the present study aimed to conduct a thorough meta-analytic systematic review on this subject.
METHODS
Two reviewers independently carried out a comprehensive systematic search in Medline, EMBASE, ISI Web of Knowledge, Scopus, Cochrane Library, and ProQuest databases. Data were summarized as true positive, false positive, true negative and false negative and were analyzed via STATA 11.0 software using a mixed-effects binary regression model. Sources of heterogeneity were further assessed through subgroup analysis.
RESULTS
Data on 1667 patients (807 subjects with and 860 cases without thoracic fractures), whose age ranged from 0 to 92 years, were extracted from 17 surveys. Pooled sensitivity and specificity of ultrasonography in detection of thoracic bone fractures were 0.97 (95% CI: 0.90-0.99; I2= 88.88, p<0.001) and 0.94 (95% CI: 0.86-0.97; I2= 71.97, p<0.001), respectively. The same measures for chest radiography were found to be 0.77 (95% CI: 0.56-0.90; I2= 97.76, p<0.001) and 1.0 (95% CI: 0.91-1.00; I2= 97.24, p<0.001), respectively. The sensitivity of ultrasonography was higher in detection of rib fractures, compared to fractures of sternum or clavicle (97% vs. 91%). Moreover, the sensitivity was found to be higher when the procedure was carried out by a radiologist in comparison to an emergency medicine specialist (96% vs. 90%).
CONCLUSION
Base on the findings of the present meta-analysis, screening performance characteristic of ultrasonography in detection of thoracic bone fractures was found to be higher than radiography. However, these characteristics were more prominent in detection of rib fractures and in cases where was performed by a radiologist.
PubMed: 27274514
DOI: No ID Found -
Systematic Reviews Aug 2020A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures.
METHODS
We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used.
RESULTS
Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types.
CONCLUSIONS
Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42015020805.
Topics: Adult; Clavicle; Fracture Fixation; Fractures, Bone; Humans; Quality of Life
PubMed: 32792014
DOI: 10.1186/s13643-020-01424-4 -
Academic Emergency Medicine : Official... Jan 2021Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries...
OBJECTIVES
Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age.
METHODS
A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis.
RESULTS
Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively.
CONCLUSION
Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).
Topics: Aged; Child; Child Abuse; Child, Preschool; Humans; Infant; Retrospective Studies; Rib Fractures
PubMed: 32888348
DOI: 10.1111/acem.14122 -
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 -
Cureus Jan 2024Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic... (Review)
Review
Rib fractures, common among trauma victims, lead to significant morbidity and mortality. Managing the associated pain is challenging, with IV opioids and thoracic epidural analgesia (TEA) being utilized. While epidural analgesia is often preferred for fractured rib pain, existing data encompasses both lumbar and thoracic approaches. This review aimed to compare TEA and IV opioids for persistent rib fracture pain. A comprehensive search across five databases yielded 987 articles, of which seven met the eligibility criteria. Outcomes were categorized into primary (pain reduction) and secondary (mortality, hospital/ICU stays, analgesia-related complications) endpoints. Analyzed with Review Manager (RevMan) Version 5.4.1 (2020; The Cochrane Collaboration, London, United Kingdom), the pooled data from two sources showed TEA significantly more effective in reducing pain than IV opioids (standardized mean difference SMD): 2.23; 95%CI: 1.65-2.82; p < 0.00001). Similarly, TEA was associated with shorter ICU stays (SMD: 0.73; 95%CI: 0.33-1.13; p = 0.0004), while hospitalization duration showed no substantial difference (SMD: 0.82; 95%CI: -0.34-1.98). Mortality rates also did not significantly differ between TEA and IV opioids (risk ratio (RR): 1.20; 95%CI: 0.36-4.01; p = 0.77). Subgroup analysis revealed fewer pneumonia cases with TEA (RR: 2.06; 95%CI: 1.07-3.96; P = 0.03), with no notable disparities in other complications. While TEA's superiority in pain relief for rib fractures suggests it is the preferred analgesic, the recommendation's strength is tempered by the low methodological quality of supporting articles.
PubMed: 38318591
DOI: 10.7759/cureus.51740 -
European Journal of Trauma and... Apr 2017Flail chest is a life-threatening complication of severe chest trauma with a mortality rate of up to 15 %. The standard non-operative management has high comorbidities... (Comparative Study)
Comparative Study Review
PURPOSE
Flail chest is a life-threatening complication of severe chest trauma with a mortality rate of up to 15 %. The standard non-operative management has high comorbidities with pneumonia and often leads to extended Intensive Care Unit (ICU) stay, due to insufficient respiratory function and complications. The aim of this literature study was to investigate how operative management improves patient care for adults with flail chest.
METHODS
Randomized-controlled trials comparing operative management versus non-operative management of flail chest were included in this systematic review and meta-analysis. PubMed, Trip Database, and Google Scholar were used for study identification. We compared operative-to-non-operative management in adult flail chest patients. Mean difference and risk ratio for mortality, pneumonia rate, duration of mechanical ventilation, duration of ICU stay, duration of hospital stay, tracheostomy rate, and treatment costs were calculated by pooling these publication results.
RESULTS
Three randomized-controlled trials were included in this systematic review. In total, there were 61 patients receiving operative management compared to 62 patients in the non-operative management group. A positive effect of surgical rib fracture fixation was observed for pneumonia rate [ES 0.5, 95 % CI (0.3, 0.7)], duration of mechanical ventilation (DMV) [ES -6.5 days 95 % CI (-11.9, -1.2)], duration of ICU stay [ES -5.2 days 95 % CI (-6.2, -4.2)], duration of hospital stay (DHS) [ES -11.4 days 95 % CI (-12.4, -10.4)], tracheostomy rate (TRCH) [ES 0.4, 95 % CI (0.2, 0.7)], and treatment costs (saving $9.968,00-14.443,00 per patient). No significant difference was noted in mortality rate [ES 0.6, 95 % CI (0.1, 2.4)] between the two treatment strategies.
CONCLUSIONS
Despite the relatively small number of patients included, different methodologies and differences in presentation of outcomes, operative management of flail chest seems to be a promising treatment strategy that improves patients' outcomes in various ways. However, the effect on mortality rate remains inconclusive. Therefore, research should continue to explore operative management as a viable method for flail chest injuries.
Topics: Flail Chest; Fracture Fixation, Internal; Humans; Intensive Care Units; Length of Stay; Pain Measurement; Randomized Controlled Trials as Topic; Respiration, Artificial; Rib Fractures; Survival Rate; Thoracic Surgical Procedures; Treatment Outcome
PubMed: 27572897
DOI: 10.1007/s00068-016-0721-2 -
Pediatric Emergency Care Feb 2019We aimed to estimate the prevalence of abuse in young children presenting with rib fractures and to identify demographic, injury, and presentation-related...
OBJECTIVES
We aimed to estimate the prevalence of abuse in young children presenting with rib fractures and to identify demographic, injury, and presentation-related characteristics that affect the probability that rib fractures are secondary to abuse.
METHODS
We searched PubMed/MEDLINE and CINAHL databases for articles published in English between January 1, 1990, and June 30, 2014 on rib fracture etiology in children 5 years or younger. Two reviewers independently extracted predefined data elements and assigned quality ratings to included studies. Study-specific abuse prevalences and the sensitivities, specificities, and positive and negative likelihood ratios of patients' demographic and clinical characteristics for abuse were calculated with 95% confidence intervals.
RESULTS
Data for 1396 children 48 months or younger with rib fractures were abstracted from 10 articles. Among infants younger than 12 months, abuse prevalence ranged from 67% to 82%, whereas children 12 to 23 and 24 to 35 months old had study-specific abuse prevalences of 29% and 28%, respectively. Age younger than 12 months was the only characteristic significantly associated with increased likelihood of abuse across multiple studies. Rib fracture location was not associated with likelihood of abuse. The retrospective design of the included studies and variations in ascertainment of cases, inclusion/exclusion criteria, and child abuse assessments prevented further meta-analysis.
CONCLUSIONS
Abuse is the most common cause of rib fractures in infants younger than 12 months. Prospective studies with standardized methods are needed to improve accuracy in determining abuse prevalence among children with rib fractures and characteristics associated with abusive rib fractures.
Topics: Child Abuse; Child, Preschool; Female; Humans; Infant; Male; Prevalence; Rib Fractures; Sensitivity and Specificity
PubMed: 27749806
DOI: 10.1097/PEC.0000000000000911 -
Current Oncology (Toronto, Ont.) Aug 2020Radiation-induced chest wall pain (cwp) and rib fracture (rf) are late adverse effects after stereotactic body radiation therapy (sbrt) for stage i non-small-cell lung...
BACKGROUND
Radiation-induced chest wall pain (cwp) and rib fracture (rf) are late adverse effects after stereotactic body radiation therapy (sbrt) for stage i non-small-cell lung cancer (nsclc); however, the literature about their incidence and risk factors shows variability. We performed a systematic review to determine the pooled incidence of cwp and rf in the relevant population.
METHODS
A literature search using the prisma (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines considered English publications in medline and embase from January 1996 to August 2017. Abstracts were screened, followed by full-text review and data extraction.
RESULTS
The database searches identified 547 records. Twenty-eight publications comprising 3892 patients met the inclusion criteria. Median reported ages and follow-up durations fell into the ranges 67-82 years and 12-84 months. Prescriptions fell into the range of 40-70 Gy in 3-10 fractions. Despite study heterogeneity, the pooled incidences of cwp and rf were estimated to be 8.94% and 5.27% respectively. Nineteen studies reported cwp grade: 58 of 308 patients (18.8%) experienced grades 3-4 cwp (no grade 5 events reported). Thirteen studies reported rf grade: grades 3-4 rf were observed in 9 of 113 patients (7.96%). A high chest wall was an important predictor of cwp and rf.
CONCLUSIONS
In patients with stage i nsclc, rates of cwp and rf after sbrt are low; however, tumour location, accurate toxicity reporting, and dose-fractionation schemes might alter those rates. Prospective correlation with dosimetry and quality of life assessment will further improve the understanding of cwp and rf after sbrt.
Topics: Aged; Aged, 80 and over; Female; Humans; Lung Neoplasms; Male; Radiosurgery; Thoracic Wall
PubMed: 32905234
DOI: 10.3747/co.27.5959 -
Journal of Cardiothoracic Surgery Feb 2019Rib fractures are common injuries sustained by patients who experience high-impact chest trauma, and they result in severe respiratory compromise because of the altered... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Rib fractures are common injuries sustained by patients who experience high-impact chest trauma, and they result in severe respiratory compromise because of the altered mechanics of respiration. Several studies have shown that the ventilation requirements and incidence of pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate the effect of surgical fixation treatments for rib fractures through systematic review and meta-analysis.
METHODS
A literature search was performed in the PubMed, EMBASE, Web of Science and Cochrane Library databases for information from February 1958 to April 2018. Studies comparing the benefits of surgical management with that of non-surgical management of rib fractures were included. Statistical heterogeneity was evaluated by the X test with the significance set to P < 0.10 or I > 50%.
RESULTS
Fourteen studies consisting of 839 patients were included (407 patients in the surgical management group; 432 patients in the non-surgical management group). The results showed that the surgical management group experienced a significant decrease in hospitalization time, intensive care time, mechanical ventilation time, mortality rate, pulmonary infection rate and tracheotomy rate compared with the non-surgical management group. However, the surgical management group incurred extra costs, and there was no significant difference in the duration of antibiotic use between the two groups.
CONCLUSIONS
Compared with non-surgical management, surgical management methods are of great value in the treatment of rib fractures despite the added expense.
Topics: Conservative Treatment; Female; Flail Chest; Fracture Fixation; Humans; Length of Stay; Male; Respiration, Artificial; Rib Fractures; Tracheostomy; Treatment Outcome
PubMed: 30813961
DOI: 10.1186/s13019-019-0865-3 -
Archives of Disease in Childhood Jan 2021Electronic health records (EHRs) are routinely used to identify family violence, yet reliable evidence of their validity remains limited. We conducted a systematic... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Electronic health records (EHRs) are routinely used to identify family violence, yet reliable evidence of their validity remains limited. We conducted a systematic review and meta-analysis to evaluate the positive predictive values (PPVs) of coded indicators in EHRs for identifying intimate partner violence (IPV) and child maltreatment (CM), including prenatal neglect.
METHODS
We searched 18 electronic databases between January 1980 and May 2020 for studies comparing any coded indicator of IPV or CM including prenatal neglect defined as neonatal abstinence syndrome (NAS) or fetal alcohol syndrome (FAS), against an independent reference standard. We pooled PPVs for each indicator using random effects meta-analyses.
RESULTS
We included 88 studies (3 875 183 individuals) involving 15 indicators for identifying CM in the prenatal period and childhood (0-18 years) and five indicators for IPV among women of reproductive age (12-50 years). Based on the International Classification of Disease system, the pooled PPV was over 80% for NAS (16 studies) but lower for FAS (<40%; seven studies). For young children, primary diagnoses of CM, specific injury presentations (eg, rib fractures and retinal haemorrhages) and assaults showed a high PPV for CM (pooled PPVs: 55.9%-87.8%). Indicators of IPV in women had a high PPV, with primary diagnoses correctly identifying IPV in >85% of cases.
CONCLUSIONS
Coded indicators in EHRs have a high likelihood of correctly classifying types of CM and IPV across the life course, providing a useful tool for assessment, support and monitoring of high-risk groups in health services and research.
Topics: Adolescent; Adult; Child; Child Abuse; Child, Preschool; Diagnosis-Related Groups; Electronic Health Records; Female; Humans; Infant; Infant, Newborn; Intimate Partner Violence; Male; Middle Aged; Predictive Value of Tests; Pregnancy; Young Adult
PubMed: 32788201
DOI: 10.1136/archdischild-2020-319027