Rib Fractures: To Fix or Not to Fix? An Evidence-Based Algorithm.
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ABSTRACT:
SUBMITTER: Bemelman M
PROVIDER: S-EPMC5548197 | biostudies-other | 2017 Aug
REPOSITORIES: biostudies-other
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Project description:ObjectiveTo assess the diagnostic performance of a deep learning-based algorithm for automated detection of acute and chronic rib fractures on whole-body trauma CT.Materials and methodsWe retrospectively identified all whole-body trauma CT scans referred from the emergency department of our hospital from January to December 2018 (n = 511). Scans were categorized as positive (n = 159) or negative (n = 352) for rib fractures according to the clinically approved written CT reports, which served as the index test. The bone kernel series (1.5-mm slice thickness) served as an input for a detection prototype algorithm trained to detect both acute and chronic rib fractures based on a deep convolutional neural network. It had previously been trained on an independent sample from eight other institutions (n = 11455).ResultsAll CTs except one were successfully processed (510/511). The algorithm achieved a sensitivity of 87.4% and specificity of 91.5% on a per-examination level [per CT scan: rib fracture(s): yes/no]. There were 0.16 false-positives per examination (= 81/510). On a per-finding level, there were 587 true-positive findings (sensitivity: 65.7%) and 307 false-negatives. Furthermore, 97 true rib fractures were detected that were not mentioned in the written CT reports. A major factor associated with correct detection was displacement.ConclusionWe found good performance of a deep learning-based prototype algorithm detecting rib fractures on trauma CT on a per-examination level at a low rate of false-positives per case. A potential area for clinical application is its use as a screening tool to avoid false-negative radiology reports.
| S-EPMC7289702 | biostudies-literature
Project description:PurposeRib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures.MethodsAll adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone.ResultsOf the 864 patients admitted with ≥ 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18-34) and 21 (IQR 16-29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62-1) and 0.79 (0.62-0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal.ConclusionsWe show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.
| S-EPMC6689022 | biostudies-literature
Project description:BackgroundPulmonary contusion has been considered a contraindication to surgical stabilization of rib fractures (SSRFs). This study aimed to evaluate the association between pulmonary contusion severity and outcomes after SSRF. We hypothesized that outcomes would be worse in patients who undergo SSRF compared with nonoperative management, in presence of varying severity of pulmonary contusions.MethodsThis retrospective cohort study included adults with three or more displaced rib fractures or flail segment. Patients were divided into those who underwent SSRF versus those managed nonoperatively. Severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion 18 (BPC18) score. Outcomes (pneumonia, tracheostomy, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, mortality) were retrieved from patients' medical records. Comparisons were made using Fisher's exact and Kruskal-Wallis tests, and correction for potential confounding was done with regression analyses.ResultsA total of 221 patients were included; SSRF was performed in 148 (67%). Demographics and chest injury patterns were similar in SSRF and nonoperatively managed patients. Surgical stabilization of rib fracture patients had less frequent head and abdominal/pelvic injuries ( p = 0.017 and p = 0.003). Higher BPC18 score was associated with worse outcomes in both groups. When adjusted for ISS, the ICU stay was shorter (adjusted β , -2.511 [95% confidence interval, -4.87 to -0.16]) in patients with mild contusions who underwent SSRF versus nonoperative patients. In patients with moderate contusions, those who underwent SSRF had fewer ventilator days (adjusted β , -5.19 [95% confidence interval, -10.2 to -0.17]). For severe pulmonary contusions, outcomes did not differ between SSRF and nonoperative management.ConclusionIn patients with severe rib fracture patterns, higher BPC18 score is associated with worse respiratory outcomes and longer ICU and hospital admission duration. The presence of pulmonary contusions is not associated with worse SSRF outcomes, and SSRF is associated with better outcomes for patients with mild to moderate pulmonary contusions.Level of evidenceTherapeutic/Care Management; Level IV.
| S-EPMC9671593 | biostudies-literature
Project description:ImportanceRib fractures are sustained by nearly 15% of patients who experience trauma and are associated with significant morbidity and mortality. Evidence-based practice (EBP) rib fracture management guidelines and treatment algorithms have been published. However, few studies have evaluated trauma center adherence to EBP or the clinical outcomes of each practice within a national cohort.ObjectiveTo examine adherence to 6 EBPs for rib fractures across US trauma centers and the association with in-hospital mortality.Design, setting, and participantsA retrospective cohort study was conducted from January 1, 2007, to December 31, 2014, of 777 US trauma centers participating in the National Trauma Data Bank. A total of 625 617 patients (age, ≥16 years) were evaluated. Patients without rib fractures and those with no signs of life or institutions with poor data quality were excluded. Data analysis was performed from January 1, 2007, to December 31, 2014.Main outcomes and measuresSix EBPs were defined: (1) neuraxial blockade, (2) intensive care unit admission, (3) pneumatic stabilization, (4) chest computed tomographic scans for older adults (≥65 years) with 3 or more rib fractures, (5) surgical rib fixation for flail chest, and (6) tube thoracostomy placement for hemothorax and/or pneumothorax. Multiple imputation was used to account for missing data. Patients were propensity score matched in a 1:1 fashion based on demographic characteristics; injury severity parameters, including the Injury Severity Score (range, 0-75; higher scores indicate more severe injuries); and comorbidities. Logistic regression was used to determine the association of each practice with all-cause in-hospital mortality.ResultsOf the 625 617 patients with rib fractures included in this analysis, 456 196 patients (73%) were white and 432 229 patients (69%) were male; the median age of the patients was 51 (interquartile range, 37-65) years, and the mean (SD) Injury Severity Score was 18.3 (11.1). The mean (SD) number of rib fractures was 4.2 (2.6). On univariate analysis, patients treated at verified level I trauma centers were more likely to receive 5 or 6 EBPs (all but pneumatic stabilization). Of those who met eligibility, only 4578 of 111 589 patients (4%) received neuraxial blockade, 46 456 of 111 589 patients (42%) were admitted to the intensive care unit, 3302 of 24 319 patients (14%) received surgical rib fixation, 1240 of 111 589 patients (1%) received pneumatic stabilization, 109 160 of 258 334 patients (42%) received tube thoracostomy, and 32 405 of 81 417 patients (40%) received chest computed tomographic scans. Three EBPs were associated with decreased mortality: neuraxial blockade (odds ratio [OR], 0.64; 95% CI, 0.51-0.79; P < .001) for patients aged 65 years or older with 3 or more rib fractures, surgical rib fixation (OR, 0.13; 95% CI, 0.01-0.18; P < .001), and intensive care unit admission (OR, 0.93; 95% CI, 0.86-1.00; P = .04) for patients aged 65 years or older with 3 or more rib fractures. Pneumatic stabilization (OR, 1.71; 95% CI, 1.25-2.35; P < .001) and chest tube placement (OR, 1.27; 95% CI, 1.21-1.33; P < .001) were associated with increased mortality in older patients with 3 or more rib fractures. On multivariable analysis, insurance status, race/ethnicity, injury severity, hospital bed size, and trauma center verification level were associated with receiving EBPs for rib fractures.Conclusions and relevanceSignificant variation appears to exist in the delivery of EBPs for rib fractures across US trauma centers. Three EBPs were associated with reduced mortality, but EBP adherence was poor. Multiple factors, including trauma center verification level, appear to be associated with patients receiving EBPs for rib fractures.
| S-EPMC7707110 | biostudies-literature
Project description:PurposeThe 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.MethodsMEDLINE, 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.ResultsThirty-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, I2 = 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.ConclusionsRib 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.
| S-EPMC6689030 | biostudies-literature
Project description:This retrospective study aimed to predict the injury time of rib fractures in distinguishing fresh (30 days) or old (90 days) rib fractures. We enrolled 111 patients with chest trauma who had been scanned for rib fractures at our hospital between January 2018 and December 2018 using gemstone spectral imaging (GSI). The volume of interest of each broken end of the rib fractures was segmented using calcium-based material decomposition images derived from the GSI scans. The training and testing sets were randomly assigned in a 7:3 ratio. All cases were divided into groups distinguishing the injury time at 30 and 90 days. We constructed radiomics-based models to predict the injury time of rib fractures. The model performance was assessed by the area under the curve (AUC) obtained by the receiver operating characteristic analysis. We included 54 patients with 259 rib fracture segmentations (34 men; mean age, 52 years ± 12.02; and range, 19-72 years). Nine features were excluded by the least absolute shrinkage and selection operator logistic regression to build the radiomics signature. For distinguishing the injury time at 30 days, the Support Vector Machine (SVM) model and human-model collaboration resulted in an accuracy and AUC of 0.85 and 0.871 and 0.91 and 0.912, respectively, and 0.81 and 0.804 and 0.83 and 0.85, respectively, at 90 days in the testing set. The radiomics-based model displayed good accuracy in differentiating between the injury time of rib fractures at 30 and 90 days, and the human-model collaboration generated more accurate outcomes, which may help to add value to clinical practice and distinguish artificial injury in forensic medicine.
| S-EPMC9855073 | biostudies-literature
Project description:ObjectivesTo compare outcomes in patients with rib fractures (RFX) who underwent surgical stabilization of rib fractures (SSRF) to those treated nonoperatively.DesignRetrospective cohort study.SettingTwo Level 1 Trauma Centers.PatientsOne hundred seventy-four patients with multiple RFX divided into 2 groups: patients with surgically stabilized RFX (n = 87) were compared with nonoperatively managed patients in the matched control group (MCG) (n = 87).InterventionSSRF.Outcome measurementsAge, sex, injury severity score, RFX, mortality, hospital length of stay (HLOS) and intensive care unit length of stay (ICULOS), duration of mechanical ventilation (DMV), co-injuries, and time to surgery. Patients were further stratified by presence or absence of flail chest and pulmonary contusion (PC).ResultsFlail chest, displaced RFX, and PC were present significantly more often in SSRF patients compared with the MCG. Mortality was lower in SSRF group. HLOS and ICULOS were longer in SSRF group compared with the corresponding MCG patients regardless of timing to surgery (P < 0.01 for all). SSRF patients with flail chest had comparable HLOS, ICULOS, and DMV to MCG patients with flail chest (P > 0.3 for all). SSRF patients without flail chest had significantly longer HLOS and ICULOS than MCG patients without flail chest (P < 0.001 for both). Presence of PC did not affect lengths of stay.ConclusionsSSRF patients had reduced mortality compared with nonoperatively managed patients. HLOS, ICULOS, and DMV were longer in SSRF patients than in MCG. When flail chest was present, lengths of stay were comparable. PC did not seem to affect the surgical outcome.Level of evidenceTherapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
| S-EPMC7002076 | biostudies-literature
Project description:Pain management is the pillar of caring for patients with traumatic rib fractures. Intravenous lidocaine (IVL) is a well-established non-opioid analgesic for post-operative pain, yet its efficacy has yet to be investigated in trauma patients. We hypothesized that IVL is associated with decreased inpatient opioid requirements among patients with rib fractures. We retrospectively evaluated adult patients presenting to our Level 1 trauma center with isolated chest wall injuries. After 1:1 propensity score matching patients who received vs did not receive IVL, we compared the two groups' average daily opioid use, opioid use in the last 24 hours of admission, and pain scores during admissions hours 24-48. We performed multivariable linear regression for these outcomes (with sensitivity analysis for the opioid use outcomes), adjusting for age as a moderating factor and controlling for hospital length of stay and injury severity. We identified 534 patients, among whom 226 received IVL. Those who received IVL were older and had more serious injury. Compared to propensity-score matched patients who did not receive IVL, patients who received IVL had similar average daily opioid use and pain scores, but 40% lower opioid use during the last 24 hours of admission (p = 0.002). Multivariable regression-with and without sensitivity analysis-did not show an effect of IVL on any outcomes. IVL was crudely associated with decreased opioid requirements in the last 24 hours of admission, the time period associated with opioid use at 90 days post-discharge. However, we did not observe beneficial effects of IVL on multivariable adjusted analyses; we are conducting a randomized control trial to further evaluate IVL's opioid-sparing effects for patients with rib fractures.
| S-EPMC7521689 | biostudies-literature
Project description: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.
| S-EPMC5378682 | biostudies-literature
Project description:Choosing an optimal procedure to stabilize the chest wall for multiple rib fractures can be challenging for surgeons. Stabilization with rib plates or intramedullary devices requires exposure of fractured bones, whereas chest stabilization with intercostal Z-suture and mesh does not, yet it offers the chest wall a sufficient level of stability. Here, we report a case of a flail chest due to multiple rib fractures for which a simple chest wall fixation using intercostal Z-suture and mesh was efficient. This method could be a treatment option for multiple rib fractures.
| S-EPMC7256319 | biostudies-literature