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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. [ABSTRACT FROM AUTHOR]

Purpose: Nonunion of traumatic rib fractures is a clinical/radiological diagnosis caused by an alteration of bone healing reparative process. Since it is a painful condition, nonunion has a significative impact on patient's morbidity and quality of life. The aim of this study was to evaluate the outcomes after surgical stabilization of ribs affected by nonunion after traumatic fractures. Methods: We conducted a retrospective cohort analysis of all patients who were treated with surgical stabilization of nonunion after traumatic rib fractures. We analyzed demographic data as well as clinical and patient-reported outcomes. Results: Nineteen patients were identified and included in this analysis. Median age was 49 years (range 25–69 years). Mean length of stay was 5.4 days. No in-hospital mortality was observed. After a median follow-up of 46.94 months (range 0–103), 16 (84.2%) patients were completely asymptomatic, while 3 (15.8%) were still suffering from pain after surgery. Conclusions: Surgical stabilization in patients affected by rib nonunion can be safely performed with few complications, good clinical outcomes and satisfactory quality of life. [ABSTRACT FROM AUTHOR]

Background: The utility of routine x-rays after the osteosynthesis of distal radius fractures and ankle fractures is questionable. We performed a trial to determine whether such x-rays are justified in patients who have undergone standardized imaging with C-arm fluoroscopy during surgery. Methods: Patients requiring surgery for a distal radius fracture or an ankle fracture were candidates for inclusion in this prospective, randomized, controlled, non-blinded trial. Standardized intraoperative images were obtained with C-arm fluoroscopy and stored at the end of the operation. The next day, patients in the control group underwent imaging with a standard postoperative x-ray, while those in the intervention group did not. The primary endpoint was a change in the treatment plan, defined as additional imaging or a second operation. The secondary endpoints included the range of motion, pain as rated on the Visual Analog Scale, and a functional outcome analysis (PRWE/FAOS). Results: 316 patients were included in the trial (163 in the control group, 153 in the intervention group), of whom 202 (64%) had radius fractures and 114 (36%) had ankle fractures. The treatment plan changed in twelve patients (3.8%; four in the control group and eight in the intervention group), seven of whom (2.2%; three in the control group and four in the intervention group) underwent a second operation. The frequency of changes in the treatment plan and of reoperations was comparable in the two groups (p = 0.36). On follow-up at six weeks and one year, the results with respect to functional outcomes and pain were comparable. Conclusion: In this trial, routine postoperative x-rays after the osteosynthesis of distal radial fractures and ankle fractures did not improve the care of patients who had undergone standardized intraoperative imaging. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim of this study was to assess the long-term quality of life and functional outcome after rib fracture fixation for patients with multiple rib fractures or flail chest. Secondarily, this study sought to identify risk factors associated with the quality of life. Methods: A retrospective cohort study with a follow-up by questionnaire was performed at a level-1 trauma center in Switzerland. All adult patients with three or more rib fractures treated with rib fixation between 2010 and 2018 were eligible for inclusion. All outcomes were independently assessed for patients with multiple rib fractures and patients with a flail chest. The outcome measures were quality of life, level of dyspnea, return to work, implant irritation, and implant removal after a minimum of 12 months of follow-up. Quality of life was assessed using the EuroQol five-dimensional five-level questionnaire (EQ-5D-5L) and level of dyspnea was determined with the modified Medical Research Council dyspnea (mMRC) scale. Results: The survey was completed by 74 out of 102 patients (73%) at a median follow-up of 26 months (IQR 15–37). The median EQ-5D utility index score was 0.91 (0.89–1.0), which was equivalent to the reference population (0.902, p = 0.523). The vast majority of patients experienced 'no problems' or 'slight problems' in any of the EQ-5D-5L dimensions. The complication rate associated with rib fracture fixation was low, implant-related irritation was the most common long-term sequela and occurred in 31% of patients. In multivariable regression analyses, total length of stay on the intensive care unit (ICU-LOS) was independently associated with a worse quality of life. Conclusions: Patients who underwent rib fracture fixation for multiple rib fractures or flail chest after severe chest trauma experienced a good quality of life at least 1 year after surgery. A longer ICU-LOS was independently associated with impaired quality of life. In addition, there were no significant differences in the long-term quality of life and functional outcome between patients with multiple rib fractures and a flail chest. Implant-related irritation was the most important long-term sequela and occurred in one-third of patients. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim of this retrospective cohort study was to evaluate the pulmonary function after rib fixation for patients with multiple rib fractures and flail chest. Secondary, a systematic review was performed to give an overview of the current literature and to allow comparison with our results. Methods: All adult (≥ 18 years) patients who underwent rib fixation for multiple rib fractures or flail chest between 2010 and 2018 and who received a control pulmonary function test during the postoperative follow-up at our level-1 trauma center were retrospectively reviewed. Secondary, the PubMed, EMBASE and Cochrane databases were searched to identify studies reporting on the pulmonary function after rib fixation. The primary outcome parameters were the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, maximum vital capacity (VCmax), total lung capacity (TLC), residual volume (RV), and RV/TC ratio. Results: Of the 103 patients who underwent rib fixation, a total of 61 (59%) patients underwent a pulmonary function test in our hospital and were ultimately included. In the majority of patients all pulmonary function parameters fell within the normal range of the reference values. Obstructive impairment was predominantly seen in patients with pre-existing chronic obstructive pulmonary disease (COPD). Patients with multiple rib fractures had better recovery compared to those with a flail chest. The systematic review included a total of 15 studies and showed comparable results. Conclusion: The present study demonstrates that rib fixation for multiple rib fractures or flail chest results in adequate recovery of the pulmonary function within 3 months after surgery. In addition, based on the current literature, further gradual improvement to maximum pulmonary values appears to occur during the first 12 months after rib fixation. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this systematic review and meta-analysis was to present current evidence on rib fixation and to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. Methods: MEDLINE, Embase, CENTRAL, and CINAHL were searched on June 16th 2017 for both RCTs and observational studies comparing rib fixation versus nonoperative treatment. The MINORS criteria were used to assess study quality. Where possible, data were pooled using random effects meta-analysis. The primary outcome measure was mortality. Secondary outcome measures were hospital length of stay (HLOS), intensive care unit length of stay (ILOS), duration of mechanical ventilation (DMV), pneumonia, and tracheostomy. Results: Thirty-three studies were included resulting in 5874 patients with flail chest or multiple rib fractures: 1255 received rib fixation and 4619 nonoperative treatment. Rib fixation for flail chest reduced mortality compared to nonoperative treatment with a risk ratio of 0.41 (95% CI 0.27, 0.61, p < 0.001, I2 = 0%). Furthermore, rib fixation resulted in a shorter ILOS, DMV, lower pneumonia rate, and need for tracheostomy. Results from recent studies showed lower mortality and shorter DMV after rib fixation, but there were no significant differences for the other outcome measures. There was insufficient data to perform meta-analyses on rib fixation for multiple rib fractures. Pooled results from RCTs and observational studies were similar for all outcome measures, although results from RCTs showed a larger treatment effect for HLOS, ILOS, and DMV compared to observational studies. Conclusions: Rib fixation for flail chest improves short-term outcome, although the indication and patient subgroup who would benefit most remain unclear. There is insufficient data regarding treatment for multiple rib fractures. Observational studies show similar results compared with RCTs. [ABSTRACT FROM AUTHOR]

Background: Adequate pain control is essential in the treatment of patients with traumatic rib fractures. Although epidural analgesia is recommended in international guidelines, the use remains debatable and is not undisputed. The aim of this study was to describe the efficacy and safety of epidural analgesia in patients with multiple traumatic rib fractures.Methods: A retrospective cohort study was performed. Patients with ≥3 rib fractures following blunt chest trauma who received epidural analgesia between January 2015 and January 2018 were included. The main outcome parameters were the success rate of epidural analgesia and the incidence of medication-related side effects and catheter-related complications.Results: A total of 76 patients were included. Epidural analgesia was successful in a total of 45 patients (59%), including 22 patients without and in 23 patients with an additional analgesic intervention. In 14 patients (18%), epidural analgesia was terminated early without intervention due to insufficient sensory blockade (n=4), medication-related side effects (n=4), and catheter-related complications (n=6). In 17 patients (22%), the epidural catheter was removed after one or multiple additional interventions due to insufficient pain control. Minor epidural-related complications or side effects were encountered in 36 patients (47%). One patient had a major complication (opioid intoxication).Conclusion: Epidural analgesia was successful in 59% of patients; however, 30% needed additional analgesic interventions. As about half of the patients had epidural-related complications, it remains debatable whether epidural analgesia is a sufficient treatment modality in patients with multiple rib fractures. [ABSTRACT FROM AUTHOR]

First rib resection for thoracic outlet syndrome (TOS) is clinically successful and safe in most patients. However, long-term functional outcomes are still insufficiently known. Long-term functional outcome was assessed using a validated questionnaire. A multicenter retrospective cohort study including all patients who underwent operations for TOS from January 2005 until December 2016. Clinical records were reviewed and the long-term functional outcome was assessed by the 11-item version of the Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Sixty-two cases of TOS in 56 patients were analyzed: 36 neurogenic TOS, 13 arterial TOS, 7 venous TOS, and 6 combined TOS. There was no 30-day mortality. One reoperation because of bleeding was performed and five patients developed a pneumothorax. Survey response was 73% (n = 41) with a follow-up ranging from 1 to 11 years. Complete relief of symptoms was reported postoperatively in 27 patients (54%), symptoms improved in 90%, and the mean QuickDASH score was 22 (range, 0-86). Long-term functional outcome of surgical treatment of TOS was satisfactory, and surgery was beneficial in 90% of patients, with a low risk of severe morbidity. However, the mean QuickDASH scores remain higher compared with the general population, suggesting some sustained functional impairment despite clinical improvement of symptoms. [ABSTRACT FROM AUTHOR]