Are rib fractures stable? An analysis of progressive rib fracture offset in the acute trauma setting

Abstract

BACKGROUND:Rib fractures serve as both a marker of injury severity and a guide for clinical decision making for trauma patients. Although recent studies have suggested that rib fractures are dynamic, the degree of progressive offset remains unknown. The purpose of this study was to further characterize the change that takes place in the acute trauma setting. METHODS:A 4-year (2016-2019) retrospective assessment of adult trauma patients with rib fracture(s) admitted to a level I trauma center was performed. Initial and follow-up computed tomography scans were analyzed to determine the magnitude of offset. Relevant clinical course variables were examined, and location of chest wall instability was examined using the difference of interquartile range of median change. Statistical Product and Services Solutions (Version 25, IBM Corp. Armonk, NY) was then used to generate a neural network-multilayer perceptron that highlighted independent variable importance. RESULTS:Fifty-three patients met the inclusion criteria for severe injury. Clinical course variables that either trended or significantly predicted the occurrence of progressive offset were Abbreviated Injury Scale Thoracic Scores (3.1 ± 0.4 no progression vs. 3.4 ± 0.6 yes progression; p = 0.121), flail segment (14% no progression vs. 43% yes progression; p = 0.053), and number of ribs fractured (4 [2-8] no progression vs. 7 [5-9] yes progression; p = 0.023). The location of progressive offset largely corresponded to the posterolateral region as demonstrated by the differences of interquartile range of median change. The neural network demonstrated that ribs 4 to 6 (normalized importance [NI], 100%), the posterolateral region (NI, 87.9%), and multiple fractures per rib (NI, 66.6%) were valuable in predicting whether progressive offset occurred (receiver operating characteristic curve − area under the curve = 0.869). CONCLUSION:Rib fractures are not stable, particularly for those patients with multiple fractures in the mid-to-upper ribs localized to the posterolateral region. These findings may identify both trauma patients with worse outcomes and help develop better management strategies for rib fractures.

Novel nomogram for predicting pulmonary complications in patients with blunt chest trauma with rib fractures: a retrospective cohort study

“…However, in clinical situations, not all flail chests—precisely, a flail segment of the chest wall composed of segmental rib fractures—initially exhibit paradoxical chest wall motions. Respiratory failure by muscle fatigue can even occur several days after the initial trauma 11 – 14 . Several recent studies have also concluded that the presence of the flail chest does not affect adverse outcomes 15 , 32 .…”

“…According to the guidelines suggested by the Chest Wall Injury Society and former studies, we classified the degree of rib displacement into four categories as follows: grade 0, no rib fractures; grade 1, rib fractures with displacement of < 50% of rib width on axial CT; grade 2, between > 50% and < 100%; and grade 3, displacement of ≥ 100% 17 , 21 , 22 . The rib fracture location was divided into three segments by anatomic landmarks: anterior, lateral, and posterior 11 , 17 , 22 , 23 . However, in the cases of the upper 1st–3rd ribs and lower 9th–12th ribs, they do not follow the anatomic landmarks.…”

“…Flail chest is classified as physiologic, diagnosed based on clinical findings in patients with the paradoxical motion of a chest wall segment; or anatomical (or flail segment), diagnosed by identifying three or more consecutive segmental rib fractures via radiographic examinations such as computed tomography (CT) 10 . Considering that some patients with anatomical flail segments demonstrate normal, symmetrical chest wall motion, or a delayed type of paradoxical chest wall motion, flail chest should be distinguished according to those two types 11 – 14 . However, the definitions varied among previous studies, and some did not differentiate between the flail motion and flail segment 15 .…”

Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report

“…[6][7][8] Additionally, the severity of initially observed rib fractures can worsen in the days following the injury, leading to a delayed onset of flail motion. 9 Although flail chest may not be detected early, in most cases, it is diagnosed within a few days after the injury. 8,10 We present the case of a patient with multiple torso injuries in whom sudden onset of respiratory distress and severe flail motion of the chest wall were observed 3 weeks after the injury occurred.…”

“… 6 – 8 Additionally, the severity of initially observed rib fractures can worsen in the days following the injury, leading to a delayed onset of flail motion. 9 Although flail chest may not be detected early, in most cases, it is diagnosed within a few days after the injury. 8 , 10…”