Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers

Choi, Jeff; Kaghazchi, Aydin; Dickerson, Katherine L.; Tennakoon, Lakshika; Spain, David A.; Forrester, Joseph D.

doi:10.1016/j.amjsurg.2021.02.013

Cited by 20 publications

(25 citation statements)

References 21 publications

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“…Even with improved critical care technology and widespread adoption of adjunctive pain management techniques, outcomes after multiple severe rib fractures have not significantly improved over the past 15 years (30). To date, the practice of rib fixation or surgical stabilization of rib fractures (SSRF) has increased exponentially and is now implemented in most international Trauma Centers (31)(32)(33)(34)(35). Despite increased use, many controversies within the field of SSRF remain.…”

Section: Review Articlementioning

confidence: 99%

What is the optimal timing to perform surgical stabilization of rib fractures?

Prins

Wijffels²,

Pieracci

2021

J Thorac Dis

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The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.

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Section: Review Articlementioning

confidence: 99%

What is the optimal timing to perform surgical stabilization of rib fractures?

Prins

Wijffels²,

Pieracci

2021

J Thorac Dis

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“…The information can be used for decision making on treatment strategies, including the need for long-term ventilation, 36 and the necessity of transfer to a higher-level medical institution, particularly those that can perform SSRF. 2 This study has some limitations. First, the findings have limited generalizability because data were obtained from a single institution.…”

Section: Discussionmentioning

confidence: 91%

A new quantitative assessment method for predicting pneumonia caused by chest wall injury

Kawai

Konishi

Miyazaki

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:The severity of rib fractures has been previously evaluated by combining categorical data, but these methods have only low predictive capability for respiratory complications and mortality. This study aimed to establish a more accurate method for predicting the development of pneumonia, a frequent complication in chest injuries, using anatomical relationships. METHODS:We analyzed three-dimensional reconstructed images of 644 consecutive trauma patients who underwent whole-body computed tomography (CT) in our institution within a 36-month study period from April 2017. The anatomical relationship between the right and left thoracic volumes of non-rib fracture patients was used to estimate thoracic volume changes on the injured side in unilateral rib fracture patients. The predictive capability of changes in thoracic volume for the development of pneumonia was evaluated according to the area under the receiver operating characteristic curve and compared with that of previous chest wall severity evaluation methods. RESULTS:Of the 644 patients, 133 and 478 patients had unilateral rib fractures and non-rib fractures, respectively. The amount of change in thoracic volume due to unilateral rib fractures was significantly greater in pneumonia patients (400 mL vs. 160 mL, p < 0.01). The area under the receiver operating characteristic curve for the development of pneumonia was 0.83, which tended to be higher than that of the previous severity scoring methods. CONCLUSION:The amount of change in chest volume, which can be estimated using CT images, has better predictive capability for pneumonia than previous severity assessment methods based on categorical data. The amount of change in chest volume measured using whole-body CT can be used to rapidly determine the optimal treatment for severe chest wall injuries.

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“…32 Previous literature has demonstrated trauma center level as an independent predictor of mortality and adverse outcomes in patients with rib fractures. 33 In one study, Level II centers had the highest rates of mortality with Levels I and III have equal rates, which was attributed to complex CWS being transferred from Level III to Level I centers for a higher level of care. 11 Notably, we found that patients undergoing CWS in centers that performed less than or equal to 12 procedures annually had higher rates of flail chest, ISS >16, and a diagnosis of alcohol use disorder.…”

Section: Discussionmentioning

confidence: 99%

Lucky Number Thirteen: Association Between Center-Specific Chest Wall Stabilization Volumes and Patient Outcomes

Tillman¹,

Martin²,

Lueckel³

et al. 2022

J Trauma Acute Care Surg

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BACKGROUND:Chest wall stabilization (CWS) improves outcomes for patients with chest wall injury (CWI). We hypothesized that patients treated at centers with higher annual CWS volumes experience superior outcomes. METHODS:A retrospective study of adults with acute CWI undergoing surgical stabilization of rib or sternal fractures within the 2019 Trauma Quality Improvement Program database, excluding those with 24-hour mortality or any Abbreviated Injury Scale body region of six, was conducted. Hospitals were grouped in quartiles by annual CWS volume. Our primary outcome was a composite of in-hospital mortality, ventilator-associated pneumonia, acute respiratory distress syndrome, sepsis, and unplanned intubation or intensive care unit readmission. Regression was controlled for age, sex, Injury Severity Scale, flail chest, medical comorbidities, and Abbreviated Injury Scale chest. We performed cut-point analysis and compared patient outcomes from high-and low-volume centers. RESULTS:We included 3,207 patients undergoing CWS at 430 hospitals with annual volumes ranging from 1 to 66. There were no differences between groups in age, sex, or Injury Severity Scale. Patients in the highest volume quartile (Q4) experienced significantly lower rates of the primary outcome (Q4, 14%; Q3, 18.4%; Q2, 17.4%; Q1, 22.1%) and significantly shorter hospital and intensive care unit lengths of stay. Q4 versus Q1 had lower adjusted odds of the primary outcome (odds ratio, 0.58; 95% confidence interval, 0.43-0.80). An optimal cut point of 12.5 procedures annually was used to define high-and low-volume centers. Patients treated at high-volume centers experienced significantly lower rates of the primary composite outcome, in-hospital mortality, and deep venous thrombosis with shorter lengths of stay and higher rates of home discharge. CONCLUSION:Center-specific CWS volume is associated with superior in-hospital patient outcomes. These findings support efforts to establish CWI centers of excellence. Further investigation should explore the impact of center-specific volume on patient-reported outcomes including pain and postdischarge quality of life.

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Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers

Cited by 20 publications

References 21 publications

What is the optimal timing to perform surgical stabilization of rib fractures?

What is the optimal timing to perform surgical stabilization of rib fractures?

A new quantitative assessment method for predicting pneumonia caused by chest wall injury

Lucky Number Thirteen: Association Between Center-Specific Chest Wall Stabilization Volumes and Patient Outcomes

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