Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis

Purpose: Many studies report on outcomes of analgesic therapy for (suspected) traumatic rib fractures. However, the literature is inconclusive and diverse regarding the management of pain and its effect on pain relief and associated complications. This systematic review and meta-analysis summarizes and compares reduction of pain for the different treatment modalities and as secondary outcome mortality during hospitalization, length of mechanical ventilation, length of hospital stay, length of intensive care unit stay (ICU) and complications such as respiratory, cardiovascular, and/or analgesia-related complications, for four different types of analgesic therapy: epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks. Methods: PubMed, EMBASE and CENTRAL databases were searched to identify comparative studies investigating epidural, intravenous, paravertebral and intercostal interventions for traumatic rib fractures, without restriction for study type. The search strategy included keywords and MeSH or Emtree terms relating blunt chest trauma (including rib fractures), analgesic interventions, pain management and complications. Results: A total of 19 papers met our inclusion criteria and were finally included in this systematic review. Significant differences were found in favor of epidural analgesia for the reduction of pain. No significant differences were observed between epidural analgesia, intravenous analgesia, paravertebral blocks and intercostal blocks, for the secondary outcomes. Conclusions: Results of this study show that epidural analgesia provides better pain relief than the other modalities. No differences were observed for secondary endpoints like length of ICU stay, length of mechanical ventilation or pulmonary complications. However, the quality of the available evidence is low, and therefore, preclude strong recommendations

Cardiovascular parameters on computed tomography are independently associated with in-hospital complications and outcomes in level-1 trauma patients

Background: In-hospital complications after trauma may result in prolonged stays, higher costs, and adverse functional outcomes. Among reported risk factors for complications are pre-existing cardiopulmonary comorbidities. Objective and quick evaluation of cardiovascular risk would be beneficial for risk assessment in trauma patients. Studies in non-trauma patients suggested an independent association between cardiovascular abnormalities visible on routine computed tomography (CT) imaging and outcomes. However, whether this applies to trauma patients is unknown.Purpose: To assess the association between cardiopulmonary abnormalities visible on routine CT images and the development of in-hospital complications in patients in a level-1 trauma center.Methods: All trauma patients aged 16 years or older with CT imaging of the abdomen, thorax, or spine and admitted to the UMC Utrecht in 2017 were included. Patients with an active infection upon admission or severe neurological trauma were excluded. Routine trauma CT images were analyzed for visible abnormalities: pulmonary emphysema, coronary artery calcifications, and abdominal aorta calcification severity. Drug-treated complications were scored. The discharge condition was measured on the Glasgow Outcome Scale.Results: In total, 433 patients (median age 50 years, 67% male, 89% ASA 1–2) were analyzed. Median Injury Severity Score and Glasgow Coma Scale score were 9 and 15, respectively. Seventy-six patients suffered from at least one complication, mostly pneumonia (n = 39, 9%) or delirium (n = 19, 4%). Left main coronary artery calcification was independently associated with the development of any complication (OR 3.9, 95% CI 1.7–8.9). An increasing number of calcified coronary arteries showed a trend toward an association with complications (p = 0.07) and was significantly associated with an adverse discharge condition (p = 0.02). Pulmonary emphysema and aortic calcifications were not associated with complications.Conclusion: Coronary artery calcification, visible on routine CT imaging, is independently associated with in-hospital complications and an adverse discharge condition in level-1 trauma patients. The findings of this study may help to identify trauma patients quickly and objectively at risk for complications in an early stage without performing additional diagnostics or interventions.</p

The value of chest radiography after chest tube removal in nonventilated trauma patients:A post hoc analysis of a multicenter prospective cohort study

BACKGROUND: Chest tubes are commonly placed in trauma care to treat life-threatening intrathoracic injuries by evacuating blood or air from the pleural cavity. Currently, it is common practice to routinely obtain chest radiographs between 1 to 8 hours after chest tube removal, while the necessity of it has been questioned. This study describes the “ins-and-outs” of chest tubes and evaluates the value of routine postremoval chest radiography in nonventilated trauma patients. METHODS: A post hoc analysis of a multicenter observational prospective cohort study was performed in blunt chest trauma patients admitted with multiple rib fractures to two level 1 trauma centers between January 2018 and March 2021 and treated with one or more chest tubes. Exclusion criteria were mechanical ventilation during chest tube removal, missing reports of postremoval chest radiography, transfer to another hospital, or mortality before chest tube removal. Descriptive analyses were performed to calculate the number of findings on postremoval chest radiographs and reinterventions. RESULTS: A total of 207 patients were included for analysis of whom 14 underwent bilateral chest tube placement, resulting in 221 chest tube removals investigated in this study. The mean ± SD age was 58 ± 17 years, 71% were male, 73% had American Society of Anesthesiologists scores of 1 or 2, and the median Injury Severity Score was 19 (interquartile range, 14–29). In 68 of 221 chest tube removals (31%), postremoval chest radiography showed increased or recurrent intrathoracic pathology (i.e., 13% pneumothorax, 18% pleural fluid, and 8% atelectasis). Only two (3%) of these patients underwent a same-day reintervention based on these findings, of whom one had signs or symptoms of recurrent pathology and one was asymptomatic. CONCLUSION: It seems safe to omit routine use of postremoval chest radiography in nonventilated blunt chest trauma patients and to selectively use imaging in those patients presenting with clinical signs or symptoms after chest tube removal.</p

Epidemiology of combined clavicle and rib fractures:a systematic review

Purpose The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. Methods A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14(th) of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant-Murley score, union and complications. Results Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56-60.6% versus 29% in patients without clavicle fractures. Vice versa, 14-18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 +/- 1.5 versus 21 +/- 13.6 days). Conclusion Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury

Functional Outcomes and Quality of Life in Patients With Post-Traumatic Arthrosis Undergoing Open or Arthroscopic Talocrural Arthrodesis—A Retrospective Cohort With Prospective Follow-Up

Fusion remains the gold standard for post-traumatic osteoarthritis after ankle fractures in many institutes. Patient-reported outcomes on long-term quality of life and functionality of talocrural arthrodesis remain relatively unknown. In literature, low patient numbers and inadequate outcome measures provide a poor foundation for patient expectation management. Additionally, the surgical approach is often omitted. This study presents a retrospective cohort of patients who underwent open or arthroscopic talocrural arthrodesis for post-traumatic arthritis between 2008 and 2019 with prospective follow-up by questionnaire. Participants completed the EuroQol 5-dimensional 3-level questionnaire (EQ-5D-3LTM), EuroQol Visual Analogue Scale (EQ-VASTM), Foot and Ankle Outcome Score Dutch Language Version (FAOS-DLV), and 4 additional questions. Thirty-five patients were included in the cohort and 32 were included for follow-up. Trauma mechanism was mainly a low fall or motor vehicle accident causing a talocrural fracture-dislocation in most cases. For open versus arthroscopic treatment respectively, patients reported a median EQ-5D-3LTM index of 0.775 and 0.775, EQ-VASTM of 80 and 88, FAOS-DLV of 57.0 and 63.9, and satisfaction of 90 and 88 out of 100 after a median of 6.0 and 6.5 years. This study is unique as it is the largest series on patient-reported outcomes in patients with post-traumatic arthrosis with validated questionnaires. In general, patients were satisfied with relatively high questionnaire scores, especially concerning pain and daily living. These functional scores are of importance when setting patient expectations regarding talocrural arthrodesis and recovery. Additionally, the subscale values may help preoperatively in weighing the intervention's advantages and disadvantages for individual patients

Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review

PURPOSE The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients. METHODS A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal. RESULTS Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention. CONCLUSION In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed. LEVEL OF EVIDENCE Systematic review study, level IV

Epidemiology and outcome of rib fractures:a nationwide study in the Netherlands

Purpose Rib fractures following thoracic trauma are frequently encountered injuries and associated with a significant morbidity and mortality. The aim of this study was to provide current data on the epidemiology, in-hospital outcomes and 30-day mortality of rib fractures, and to evaluate these results for different subgroups. Methods A nationwide retrospective cohort study was performed with the use of the Dutch Trauma Registry which covers 99% of the acutely admitted Dutch trauma population. All patients aged 18 years and older admitted to the hospital between January 2015 and December 2017 with one or more rib fractures were included. Incidence rates were calculated using demographic data from the Dutch Population Register. Subgroup analyses were performed for flail chest, polytrauma, primary thoracic trauma, and elderly patients. Results A total of 14,850 patients were admitted between 2015 and 2017 with one or more rib fractures, which was 6.0% of all trauma patients. Of these, 573 (3.9%) patients had a flail chest, 4438 (29.9%) were polytrauma patients, 9273 (63.4%) were patients with primary thoracic trauma, and 6663 (44.9%) were elderly patients. The incidence rate of patients with rib fractures for the entire cohort was 29 per 100.000 person-years. The overall 30-day mortality was 6.9% (n = 1208) with higher rates observed in flail chest (11.9%), polytrauma (14.8%), and elderly patients (11.7%). The median hospital length of stay was 6 days (IQR, 3-11) and 37.3% were admitted to the intensive care unit (ICU). Conclusions Rib fractures are a relevant and frequently occurring problem among the trauma population. Subgroup analyses showed that there is a substantial heterogeneity among patients with rib fractures with considerable differences regarding the epidemiology, in-hospital outcomes, and 30-day mortality

Global changes in mortality rates in polytrauma patients admitted to the ICU - A systematic review

Background: Many factors of trauma care have changed in the last decades. This review investigated the effect of these changes on global all-cause and cause-specific mortality in polytrauma patients admitted to the intensive care unit (ICU). Moreover, changes in trauma mechanism over time and differences between continents were analyzed. Main body: A systematic review of literature on all-cause mortality in polytrauma patients admitted to ICU was conducted. All-cause and cause-specific mortality rates were extracted as well as trauma mechanism of each patient. Poisson regression analysis was used to model time trends in all-cause and cause-specific mortality. Thirty studies, which reported mortality rates for 82,272 patients, were included and showed a decrease of 1.8% (95% CI 1.6-2.0%) in all-cause mortality per year since 1966. The relative contribution of brain injury-related death has increased over the years, whereas the relative contribution of death due to multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome, and sepsis decreased. MODS was the most common cause of death in North America, and brain-related death was the most common in Asia, South America, and Europe. Penetrating trauma was most often reported in North America and Asia. Conclusions: All-cause mortality in polytrauma patients admitted to the ICU has decreased over the last decades. A shift from MODS to brain-related death was observed. Geographical differences in cause-specific mortality were present, which may provide region-specific learning possibilities resulting in improvement of global trauma care

Study methodology in trauma care: towards question-based study designs

The randomized controlled trial (RCT) in surgery may not always be ethical, feasible, or necessary to address a particular research question about the effect of a surgical intervention. If so, properly designed and conducted observational (non-randomized) studies may be valuable alternatives for an RCT and produce credible results. In this paper, we discus differences between RCTs and observational studies and differentiate between three types of comparisons of surgical interventions. We assert that results of different designs should be regarded as complementary to each other when evaluating surgical interventions. Criteria for credible observational research are presented to provide guidance for future observational research of surgical interventions. We argue that the research question that is being asked should guide the discussion about the value of a particular study design

Epidemiology and outcomes of traumatic chest injuries in children: a nationwide study in the Netherlands

Thoracic injuries are infrequent among children, but still represent one of the leading causes of pediatric mortality. Studies on pediatric chest trauma are dated, and little is known of outcomes in different age categories. This study aims to provide an overview of the incidence, injury patterns, and in-hospital outcomes of children with chest injuries. A nationwide retrospective cohort study was performed on children with chest injuries, using data from the Dutch Trauma Registry. All patients admitted to a Dutch hospital between January 2015 and December 2019, with an abbreviated injury scale score of the thorax between 2 and 6, or at least one rib fracture, were included. Incidence rates of chest injuries were calculated with demographic data from the Dutch Population Register. Injury patterns and in-hospital outcomes were assessed in children in four different age groups. A total of 66,751 children were admitted to a hospital in the Netherlands after a trauma between January 2015 and December 2019, of whom 733 (1.1%) sustained chest injuries accounting for an incidence rate of 4.9 per 100,000 person-years. The median age was 10.9 (interquartile range (IQR) 5.7–14.2) years and 62.6% were male. In a quarter of all children, the mechanisms were not further specified or unknown. Most prevalent injuries were lung contusions (40.5%) and rib fractures (27.6%). The median hospital length of stay was 3 (IQR 2–8) days, with 43.4% being admitted to the intensive care unit. The 30-day mortality rate was 6.8%. Conclusion: Pediatric chest trauma still results in substantial adverse outcomes, such as disability and mortality. Lung contusions may be inflicted without fracturing the ribs. This contrasting injury pattern compared to adults underlines the importance of evaluating children with chest injuries with additional caution.What is Known:• Chest injuries are rare among children, but represent one of the leading causes of pediatric mortality.• Children show distinct injury patterns in which pulmonary contusions are more prevalent than rib fractures.What is New:• The proportion of chest injuries among pediatric trauma patients is currently lower than reported in previous literature, but still leads to substantial adverse outcomes, such as disabilities and death.• The incidence of rib fractures gradually increases with age and in particular around puberty when ossification of the ribs becomes completed. The incidence of rib fractures among infants is remarkably high, which is strongly suggestive for nonaccidental trauma