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      The number of displaced rib fractures is more predictive for complications in chest trauma patients

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          Abstract

          Background

          Traumatic rib fractures can cause chest complications that need further treatment and hospitalization. We hypothesized that an increase in the number of displaced rib fractures will be accompanied by an increase in chest complications.

          Methods

          We retrospectively reviewed the trauma registry between January 2013 and May 2015 in a teaching hospital in northeastern Taiwan. Patients admitted with chest trauma and rib fractures without concomitant severe brain, splenic, pelvic or liver injuries were included. The demographic data, such as gender, age, the index of coexistence disease, alcohol consumption, trauma mechanisms were analyzed as potential predictors of pulmonary complications. Pulmonary complications were defined as pneumothorax, hemothorax, flail chest, pulmonary contusion, and pneumonia.

          Results

          In the 29 months of the study period, a total of 3151 trauma patients were admitted to our hospital. Among them, 174 patients were enrolled for final analysis. The most common trauma mechanism was road traffic accidents (58.6%), mainly motorbike accidents ( n = 70, 40.2%). Three or more displaced rib fractures had higher specificity for predicting complications, compared to three or more total rib fractures (95.5% vs 59.1%). Adjusting the severity of chest trauma using TTSS and Ribscore by multivariable logistic regression analysis, we found that three or more rib fractures or any displaced rib fracture was the most significant predictor for developing pulmonary complication (aOR: 5.49 95% CI: 1.82–16.55). Furthermore, there were 18/57 (31.6%) patients with fewer than three ribs fractures developed pulmonary complications. In these 18 patients, only five patients had delayed onset complications and four of them had at least one displaced rib fracture.

          Discussion

          In this retrospective cohort study, we found that the number of displaced or total rib fractures, bilateral rib fractures, and rib fractures in more than two areas were associated with the more chest complications. Furthermore, three or more rib fracture or any displacement were found to be the most sensitive risk factor for chest complications, independent of other risk factors or severity index.

          Conclusion

          The number of displaced rib fractures could be a strong predictor for developing pulmonary complications. For patients with fewer than three rib fractures without rib displacement and initial lung or other organ injuries, outpatient management could be safe and efficient.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13049-017-0368-y) contains supplementary material, which is available to authorized users.

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          Most cited references18

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          Advanced trauma life support (ATLS®): the ninth edition.

          (2013)
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            A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management.

            A rib fracture secondary to blunt thoracic trauma is an important indicator of the severity of the trauma. In the present study we explored the morbidity and mortality rates and the management following rib fractures. Between May 1999 and May 2001, 1417 cases who presented to our clinic for thoracic trauma were reviewed retrospectively. Five hundred and forty-eight (38.7%) of the cases had rib fracture. There were 331 males and 217 females, with an overall mean age of 43 years (range: 5-78 years). These patients were allocated into groups according to their ages, the number of fractured ribs and status, i.e. whether they were stable or unstable (flail chest). The etiology of the trauma included road traffic accidents in 330 cases, falls in 122, assault in 54, and industrial accidents in 42 cases. Pulmonary complications such as pneumothorax (37.2%), hemothorax (26.8%), hemo-pneumothorax (15.3%), pulmonary contusion (17.2%), flail chest (5.8%) and isolated subcutaneous emphysema (2.2%) were noted. 40.1% of the cases with rib fracture were treated in intensive care units. The mean duration of their stay in the intensive care unit was 11.8+/-6.2 days. 42.8% of the cases were treated in the wards whereby their mean duration of hospital stay was 4.5+/-3.4 days, while 17.1% of the cases were followed up in the outpatient clinic. Twenty-seven patients required surgery. Mortality rate was calculated as 5.7% (n=31). Rib fractures can be interpreted as signs of significant trauma. The greater the number of fractured ribs, the higher the mortality and morbidity rates. Patients with isolated rib fractures should be hospitalized if the number of fractured ribs is three or more. We also advocate that elderly patients with six or more fractured ribs should be treated in intensive care units due to high morbidity and mortality.
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              Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis.

              The risk factors for mortality following blunt chest wall trauma have neither been well established or summarised. To summarise the risk factors for mortality in blunt chest wall trauma patients based on available evidence in the literature. A systematic review of English and non-English articles using MEDLINE, EMBASE and the Cochrane Library from their introduction until May 2010. Additional studies were identified by hand-searching bibliographies and contacting relevant clinical experts. Grey literature was sought by searching abstracts from all Emergency Medicine conferences. Broad search terms and inclusion criteria were used to reduce the number of missed studies. A two step study selection process was used. All published and unpublished observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. A two step data extraction process using pre-defined data fields, including study quality indicators. Each study was appraised using a previously designed quality assessment tool and the STROBE checklist. Where sufficient data were available, odds ratios with 95% confidence intervals were calculated using Mantel-Haenszel method for the risk factors investigated. The I(2) statistic was calculated for combined studies in order to assess heterogeneity. Age, number of rib fractures, presence of pre-existing disease and pneumonia were found to be related to mortality in 29 identified studies. Combined odds ratio of 1.98 (1.86-2.11, 95% CI), 2.02 (1.89-2.15, 95% CI), 2.43 (1.03-5.72, 95% CI) and 5.24 (3.51-7.82) for mortality were calculated for blunt chest wall trauma patients aged 65 years or more, with three or more rib fractures, pre-existing conditions and pneumonia respectively. The risk factors for mortality in patients sustaining blunt chest wall trauma were a patient age of 65 years or more, three or more rib fractures and the presence of pre-existing disease especially cardiopulmonary disease. The development of pneumonia post injury was also a significant risk factor for mortality. As a result of the variable quality in the studies, the results of the selected studies should be interpreted with caution. Copyright © 2011 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                hjjiimm@hotmail.com
                8905038@cgmh.org.tw
                adrianhst@gmail.com
                gblaney3@gmail.com
                huangts@cloud.cgmh.org.tw
                kfchen@cgmh.org.tw
                Journal
                Scand J Trauma Resusc Emerg Med
                Scand J Trauma Resusc Emerg Med
                Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
                BioMed Central (London )
                1757-7241
                28 February 2017
                28 February 2017
                2017
                : 25
                : 19
                Affiliations
                [1 ]ISNI 0000 0004 0639 2551, GRID grid.454209.e, , Department of General Surgery, Chang Gung Memorial Hospital, ; Keelung, Taiwan
                [2 ]Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
                [3 ]ISNI 0000 0004 0639 2551, GRID grid.454209.e, , Department of Emergency Medicine, Chang Gung Memorial Hospital, ; Keelung, Taiwan
                [4 ]GRID grid.145695.a, Clinical Informatics and Medical Statistics Research Center, , Chang Gung University, ; Taoyuan, Taiwan
                [5 ]ISNI 0000 0004 0639 2551, GRID grid.454209.e, , Community Medicine Research Center, Chang Gung Memorial Hospital, ; Keelung, Taiwan
                Article
                368
                10.1186/s13049-017-0368-y
                5330007
                28241883
                c9eb1c0f-7069-4e67-b34a-e119f5b6d3c6
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 7 October 2016
                : 21 February 2017
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001868, National Science Council;
                Award ID: 100-2314-B-182A-038-MY3
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100005795, Chang Gung Memorial Hospital, Linkou;
                Award ID: CMRPG2C0201, CMRPG2B0123, CMRPG2B0273, CIRPG2E0022 and CMRPG2B0373
                Award Recipient :
                Categories
                Original Research
                Custom metadata
                © The Author(s) 2017

                Emergency medicine & Trauma
                rib fractures,displaced rib fractures,complications,chest trauma,prognosis,sensitivity and specificity,hospitalization

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