Chest Wall Injury Research Articles

Improving rib fracture management in Morriston hospital: using QI to develop an erector spinae plane catheter service

IntroductionTrauma audit research network (TARN) data for 2018 indicated that we admitted 100 patients with chest wall injuries in our District General Hospital (DGH). Our own retrospective audit of pain...

Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study

BackgroundThe impact of associated chest wall injuries (CWI) on the complications of clavicle fracture repair is unclear to date. This study aimed to investigate the complications after surgical clavicle fracture fixation in patients with and without different degrees of associated CWI.MethodsA retrospective review over a four-year period of patients who underwent clavicle fracture repair was conducted. A CWI and no-CWI group were distinguished, and the CWI group was subdivided into the minor-CWI (three or fewer rib fractures without flail chest) and complex-CWI (flail chest, four or more rib fractures) subgroup. Demographic data, classification of the clavicle fracture, number of rib fractures, and associated injuries were recorded. Overall complications included surgery-related complications and unplanned hospital readmissions. Univariate analysis and stepwise backward multivariate logistic regression were used to identify potential risk factors for complications.ResultsA total of 314 patients undergoing 316 clavicle fracture operations were studied; 28.7% of patients (90/314) occurred with associated CWI. Patients with associated CWI showed a significantly higher age, body mass index, and number of rib fractures. The overall and surgical-related complication rate were similar between groups. Unplanned 30-day hospital readmission rates were significantly higher in the complex-CWI group (p = 0.02). Complex CWI and number of rib fractures were both independent factor for 30-day unplanned hospital readmission (OR 1.59, 95% CI: 1.00–2.54 and OR 1.33, 95% CI: 1.06–1.68, respectively).ConclusionCWI did not affect surgery-related complications after clavicle fracture repair. However, complex-CWI may increase 30-day unplanned hospital readmission rates.

Early National Landscape of Surgical Stabilization of Sternal Fractures.

Operative management of chest wall injuries aims to restore respiratory mechanics and mitigate pulmonary complications. Extensive studies support surgical stabilization of rib fractures (SSRF) for select patients, but role for surgical stabilization of sternal fractures (SSSF) remains unclear. We aimed to understand national prevalence of SSSF and compare outcomes after surgical stabilization and non-operative management of sternal fractures. We retrospectively analyzed adult patients (age ≥ 18years) admitted with sternal fractures after blunt trauma using the 2016 National Trauma Data Bank. We compared odds of inpatient mortality, pneumonia, and respiratory failure for propensity score matched patients (4:1) who underwent non-operative management vs SSSF. We characterized subgroup of patients with concurrent rib and sternal fractures who underwent concomitant SSRF-SSSF. We identified 14,760 encounters of adults admitted with sternal fractures; 270 (1.8%) underwent SSSF. Compared to matched patients who underwent non-operative management, patients who underwent SSSF had lower odds of mortality (OR [95%CI]: 0.19 [0.06-0.62], p = 0.006). Adjusted for trauma center level, Mantel-Haenszel mortality odds remained lower for patients who underwent SSSF. Odds of pneumonia and respiratory failure were similar between matched groups. Among 46% of patients who had concomitant rib fractures, 0.3% (n = 18) underwent concurrent SSRF-SSSF and these patients survived hospitalization without pneumonia or respiratory failure. A vast majority of patients who suffer sternal fractures undergo non-operative management. Potential mortality benefit of SSSF and concurrent SSRF-SSSF's role for commonly concomitant rib and sternal fractures deserve further study. Our preliminary findings call for delineating heterogeneity of sternal fractures and establishing consensus SSSF indications.

The Chest Wall Injury Society Recommendations for Reporting Studies of Surgical Stabilization of Rib Fractures.

Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic. A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated. The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations. Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.

Blunt Chest Trauma Causing a Displaced Sternal Fracture and ST-elevation Myocardial Infarction: A Case Report.

IntroductionBlunt chest trauma and motor vehicle collisions are common presentations to the emergency department (ED). Chest pain in a trauma patient can usually and reasonably be attributed to chest wall injury, leading to a potential delay in diagnosis and treatment.Case ReportIn this case report, we present a 52-year-old male who was brought to the ED with complaints of chest pain and pressure after a motor vehicle collision. He was subsequently found to have both a displaced sternal fracture and simultaneous acute myocardial infarction with 100% occlusion of the mid left anterior descending artery without dissection requiring stent placement.ConclusionChest pain after blunt cardiac trauma is a common complaint. While rare, acute myocardial infarction must be considered. Most injuries result as direct trauma to the artery causing either dissection or acute thrombosis resulting in a myocardial infarction as opposed to acute plaque rupture with thrombosis, as seen in this case.

Management of multiple rib fractures-results from a Major Trauma Centre with the review of the existing literature

Introduction: Rib fractures are amongst the most common fractures following major traumapresenting to the Emergency Department. The impact of rib fractures is even more significant in thepatient with underlying chronic respiratory conditions. Aim: To assess our current management ofrib fractures at our trauma center. Method: The current study collected our data from the TARNRegistry primarily focussing on patients with multiple rib fractures. The main components were theanalgesic requirement of our patients. The number of rib fracture stabilization procedures and theaverage number of ribs fixed were also studied. Results: The data were collected retrospectivelyover 12 months. There were 313 patients identified as having chest wall injuries. From the data,41.9% (131) of patients were over the age of 65 years. A significant proportion of our patients34.5% (108) were noted to have multiple rib fractures (>3 Ribs). It was noted that 3% (9) of the313 patients required operations. The average of the patients included in the study was noted to be61 years with an age range of 17-92 years. Conclusion: The mainstay management of rib fractureis a provision of adequate analgesia and the prevention of respiratory complications that can allstem from poor ventilatory function amongst other patient factors and injury patterns. Through thedecades, surgical stabilization has gained pace and has found its niche in the management of ribfractures.

Rib Season: Temporal Variation in Chest Wall Injuries

IntroductionTrauma to the chest wall is one of the most common injuries suffered. Knowing whether there are regular and reproducible changes in frequency or severity of certain injury types may help resource allocation and improve prevention efforts or outcomes; however, no prior studies have evaluated seasonal variation in chest wall injuries (CWIs). We aimed to determine if CWIs vary annually in a consistent distinct temporal variation. MethodsUsing an established traumatic blunt CWI database at a single urban level 1 trauma center, patients with a moderate-to-severe (chest wall Abbreviated Injury Score (AIS) ≥2) CWI were reviewed. A subpopulation of predominant chest wall injury (pCWI) was defined as those with a chest wall AIS ≥3 and no other anatomic region having a higher AIS. Demographics, injury patterns, mechanisms of injury, and AIS were collected in addition to date of injury over a 4-y period. Data were analyzed using descriptive statistics as well as Poisson time-series regression for periodicity. Seasonal comparison of populations was performed using Student's t-tests and Analysis of Variance (ANOVA) with significance assessed at a level of P < 0.05. ResultsOver a 4-y period nearly 16,000 patients presented with injury, of which 3042 patients were found to have a blunt CWI. Total CWI patients per year from 2014 to 2017 ranged from 571 to 947. Over this period, August had the highest incidence for patients with any CWI, moderate-to-severe injuries, and pCWI. February had the lowest overall injury incidence as well as lowest moderate-to-severe injury incidence. January had the lowest pCWI incidence. Yearly changes followed a quadratic sinusoid model that predicted a peak between incidence, between June and October, and the low season. A low season was found to be December–April. Comparing low to high seasons of injured patient monthly means revealed significant differences: total injuries (69.94 versus 85.56, P = 0.04), moderate to severe (62.25 versus 78.19, P = 0.06), and pCWI (25.25 versus 34.44, P = 0.01). Analysis of injuries by mechanism revealed a concomitant increase in motorcycle collisions during this period. ConclusionsThere appears to be a significant seasonal variation in the overall incidence of CWI as well as severe pCWI, with a high-volume injury season in summer months (June–October) and low-volume season in winter (December–April). Motorcycle accidents were the major blunt injury mechanism that changed with this seasonality. These findings may help guide resource utilization and injury prevention.

Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures

A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. From 59198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001). The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures.

PurposeThe proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18–64 years old) undergoing SSRF.MethodsThe Trauma Quality Improvement Program (2010–2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.ResultsFrom 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p < 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22, p < 0.001), but had a higher rate of mortality (4.7% vs. 1.2%, p < 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62–6.36, p < 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98–6.32, p < 0.001).ConclusionSpanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk–benefit ratio.Electronic supplementary materialThe online version of this article (10.1007/s00068-020-01526-7) contains supplementary material, which is available to authorized users.

Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons

AimTo report the epidemiology of injury and illness in elite rowers over eight seasons (two Olympiads).MethodsAll athletes selected to the Australian Rowing Team between 2009 and 2016 were monitored prospectively...

A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL)

Surgical stabilization of rib fractures (SSRF) has been studied widely in patients with flail chest and has been accepted as a beneficial procedure for these patients. It is unclear however, if patients with nonflail rib fracture patterns (typically with three or more displaced rib fractures) would also benefit from SSRF. The goal of this study was to determine if SSRF improves clinical outcomes in patients with nonflail rib fracture patterns.

Surgical Stabilization of Rib Fracture Decreases Pain in Geriatric Patients with Severe Non-Flail Fracture Patterns: A Post Hoc Analysis of the Chest Wall Injury Society's NONFLAIL Study

Surgical Stabilization of Rib Fracture Decreases Pain in Geriatric Patients with Severe Non-Flail Fracture Patterns: A Post Hoc Analysis of the Chest Wall Injury Society's NONFLAIL Study

Use of the Internet to Facilitate an Annual Scientific Meeting: A Report of the First Virtual Chest Wall Injury Society Summit

INTRODUCTIONThe COVID-19 pandemic has resulted in cancellation of medical peer meetings. The Chest Wall Injury Society Annual Summit was scheduled for April 2020. Due to safety concerns, the Society altered the meeting to an online format. The purpose of this paper is to describe how this was accomplished and also to highlight its outcomes.METHODSAn online survey of participants was carried out to assess their views on the educational yield and technical difficulties encountered as compared to in-person meetings.RESULTSSixty two of 275 (23%) registered participants filled out the survey. Eighty four percent felt that the educational quality was excellent/good. Seventy five percent and 95% felt in-person meetings are better for education and for networking, respectively. Eighty seven percent preferred in-person meetings in the future but would attend a virtual meeting again. Thirteen percent had technical difficulties accessing the meeting.CONCLUSIONOnline meetings are feasible but in-person meetings have more educational and networking value.

Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures.

IntroductionPain 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.MethodsWe 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.ResultsWe 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.ConclusionIVL 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.

Outcomes of chest wall fixation in cardiopulmonary resuscitation-induced flail chest.

Chest wall injury is a common complication of cardiopulmonary resuscitation. Chest wall fixation of flail chest has been shown to improve outcomes in patients in whom trauma is the primary pathology. Its efficacy in the post-cardiopulmonary resuscitation setting where the primary event is cardiac arrest is yet to be determined. We report outcomes in a series of 4 patients who underwent rib fixation in the setting of cardiopulmonary resuscitation-induced flail chest.

Hypoglossal nerve stimulator implantation via a 2-incision technique

A hypoglossal nerve stimulator currently available for clinical use requires 3 incisions to implant 3 separate components. A substantial modification to operative technique described herein moves the device's respiratory sensing lead from the fifth to the second intercostal space, now inserting it transpectorally through the same incision used for the implantable pulse generator. Elimination of a third incision and second lead tunneling procedure minimizes the risk of breast and chest wall injury, reduces operative time, and decreases postoperative pain. Over 60 hypoglossal nerve stimulators have been implanted by the authors using this new technique without complication. Relevant anatomy, dissection boundaries, and surgical technique are also described.

Research priorities in chest wall injury: A modified Delphi approach.

Research priorities in chest wall injury: A modified Delphi approach.

Current Status of Rib Plating: Hardware Failure When and How?

Surgical stabilization of rib fractures (SSRF) has been shown to decrease morbidity and mortality in patients with multiple rib fractures. This has led to a concomitant increase in the procedure, but the complications are just now being described in the literature. The purpose of this review is to focus on the current understanding of hardware failure after rib fixation. A recent study from the Chest Wall Injury Society (CWIS) found that hardware failure is relatively rare and often asymptomatic thus not requiring routine postoperative imaging or reoperation. When hardware failures occur, they tend to occur on the lateral and posterolateral columns. Patients who undergo fixation for chronic fractures may be at higher risk for complications. Hardware failure is a rare complication of SSRF and rarely requires reoperation. Postoperative imaging should be based on symptoms.

Does chest wall Organ Injury Scale (OIS) or Abbreviated Injury Scale (AIS) predict outcomes? An analysis of 16,000 consecutive rib fractures

BackgroundChest wall injuries have serious clinical consequences. It is presumed a higher severity of injury correlates with worse outcomes. The 2 most common chest wall injury severity scores, the Organ Injury Scale and the Abbreviated Injury Scale, are based on expert opinion with unknown clinical endpoints. Our aim was to determine if either the Organ Injury Scale or the Abbreviated Injury Scale are associated with clinical outcomes. MethodsA single institution, 4-year retrospective study of all patients with rib or sternal fractures was conducted. All patients were assessed for both Organ Injury Scale and Abbreviated Injury Scale scores. Outcomes assessed included mortality, complications, tracheostomy, and readmissions. Receiver operating characteristic areas under the curve were calculated to measure discriminatory accuracy of scoring systems for outcomes in chest wall injury. ResultsOverall, 3,033 patients presented with a total of 16,055 rib fractures. The median chest wall scores were 2 for Organ Injury Scale and 3 for Abbreviated Injury Scale. Abbreviated Injury Scale scores for the same patients were greater than the Organ Injury Scale in 48.7%, equivalent in 46.7%, and lower in 4.6%. The receiver operating characteristic areas under the curve for in-hospital outcomes were weakly predictive for the Organ Injury Scale over the Abbreviated Injury Scale. The receiver operating characteristic areas under the curve for readmissions were very weakly predictive for the Abbreviated Injury Scale over the Organ Injury Scale. ConclusionThere is a very weak association between chest wall Organ Injury Scale score and in-hospital outcomes. The Abbreviated Injury Scale score outperformed the Organ Injury Scale, only being weakly predictive of readmission. Chest wall injury scoring systems may need revision for future outcomes-based research and practice improvements.

Novel Case of Emergency Room to Operation Theatre for Management of Blunt Chest Wall Injury

Novel Case of Emergency Room to Operation Theatre for Management of Blunt Chest Wall Injury