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Rib fractures occur most commonly because of blunt thoracic trauma and occur in up to 12% of all trauma patients. Adequate analgesia is paramount in enhancing pulmonary hygiene aimed at preventing atelectasis and pneumonia. Erector spinae plane block, one of the novel multiple thoracic ultrasound-guided techniques, can provide analgesia to both the anterior and posterior hemithorax, making it particularly useful in the management of pain after extensive thoracic trauma. This work aimed to compare the analgesic efficacy and safety of ultrasound-guided erector spinae plane block versus ultrasound-guided thoracic paravertebral block in patients suffering multiple rib fractures. A double blinded randomized clinical trial. A university hospital. The study was conducted with 60 patients with multiple fracture ribs. Patients were randomly allocated into 2 equal groups of 30 patients. Both techniques were effective in reducing pain scores and opioid consumption with no significant difference between the 2 groups. Time to first analgesic administration was comparable between the 2 groups. Twenty patients in the thoracic erector spinae plane group required rescue morphine compared to 17 patients in the thoracic paravertebral block group (P > 0.05). Visual Analog Scale scores at rest and on coughing were also comparable between the groups at all measuring points except at 0.5 hours following the block performance. Occurrence of hypertension was higher in the thoracic paravertebral block group compared to the thoracic erector spinae plane group (P = 0.024). There was no catheter inserted and we use intermittent injections, which is not the ideal, continuous block with fixed catheter is the ideal. We use dexamethasone as adjuvant with local anesthetics, which delay the need for booster dose of local anesthetics and make comparison between the 2 techniques not ideal. The sample size is small to some extent. We did not exclude addict patients. Ultrasound-guided thoracic erector spinae plane block was as effective as thoracic paravertebral block for pain alleviation in patients with unilateral multiple fractured ribs with a comparable duration of analgesic effect, reduction of opioid consumption, and stable hemodynamic profile. However, thoracic erector spinae plane block had the advantage of a lower adverse effect incidence. Clinicians could choose either of the 2 techniques according to their clinical experience and personal choice.

IntroductionRib fractures are common injuries in trauma patients that often heal without intervention. Infrequently, symptomatic rib fracture nonunions are a complication after rib fractures. There is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe the efficacy of rib fracture nonunion operative fixation with particular focus on surgical technique, healing rates, and complications.Materials and methodsPatients aged ≥ 18 years with symptomatic rib fracture nonunions treated with open reduction and internal fixation (ORIF) with locking plates at a single urban level 1 trauma center were retrospectively reviewed. Pertinent demographic, clinical, radiographic, and surgical data were collected and analyzed.ResultsA total of 18 patients met inclusion criteria. The mean time from injury to undergoing ORIF for rib fracture nonunion was just under a year and the number of ribs plated was 2.95 ± 1.16 (1–5 ribs) with bone grafting used in six cases. All patients (100%) showed evidence of healing at an average of 2.65 ± 1.50 months (2–8 months). All patients reported a decrease in pain. No narcotic pain medication was used at an average of 3.88 ± 3.76 weeks (0–10 weeks) post-operatively. Intraoperative and postoperative complications were found in 4 (22.2%) patients.ConclusionThis study concluded that operative fixation of symptomatic rib fracture nonunion demonstrated favorable outcomes with reduction in preoperative pain levels, decreased use of narcotic pain medication, minimal complications, and a high rate of fracture union. This described method provides symptomatic relief, reduction in pain, and promotes bony healing of the fracture nonunion without development of major complications. We suggest that operative fixation should be considered as the primary method of treatment of symptomatic rib nonunions.

Background Persistent pain and disability following rib fractures result in a large psycho-socio-economic impact for health-care system. Benefits of rib osteosynthesis are well documented in patients with flail chest that necessitates invasive ventilation. In patients with uncomplicated and simple rib fractures, indication for rib osteosynthesis is not clear. The aim of this trial is to compare pain at 2 months after rib osteosynthesis versus medical therapy. Methods This trial is a pragmatic multicenter, randomized, superiority, controlled, two-arm, not-blinded, trial that compares pain evolution between rib fixation and standard pain medication versus standard pain medication alone in patients with uncomplicated rib fractures. The study takes place in three hospitals of Thoracic Surgery of Western Switzerland. Primary outcome is pain measured by the brief pain inventory (BPI) questionnaire at 2 months post-surgery. The study includes follow-up assessments at 1, 2, 3, 6, and 12 months after discharge. To be able to detect at least 2 point-difference on the BPI between both groups (standard deviation 2) with 90% power and two-sided 5% type I error, 46 patients per group are required. Adjusting for 10% drop-outs leads to 51 patients per group. Discussion Uncomplicated rib fractures have a significant medico-economic impact. Surgical treatment with rib fixation could result in better clinical recovery of patients with uncomplicated rib fractures. These improved outcomes could include less acute and chronic pain, improved pulmonary function and quality of life, and shorter return to work. Finally, surgical treatment could then result in less financial costs. Trial registration ClinicalTrials.gov NCT04745520 . Registered on 8 February 2021.

Introduction Multiple rib fractures (≥ 3 displaced rib fractures and/or flail chest) are severe chest trauma with high morbidity and mortality. Rib fixation has become the first choice for multiple rib fracture treatment. However, the timing of surgical rib fixation is unclear. Materials and methods The present study explored whether early rib fracture fixation can improve the outcome of multiple rib fractures. The present research included patients who were hospitalized in three Jiangsu hospitals following diagnosis with multiple rib fractures. Patients received early rib fracture fixation (≤ 48 h) or delayed rib fracture fixation (> 48 h) utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures included hospital length of stay, intensive care unit (ICU) stay, mechanical ventilation, inflammatory cytokine levels, infection marker levels, infection, and mortality. Results A total of 403 individuals were classified into two groups, namely, the early group (n = 201) and the delayed group (n = 202). Patients belonging to the two groups had similar baseline clinical data, and there were no statistically significant differences between them. Early rib fracture fixation greatly decreased the length of stay in the ICU (4.63 days vs. 6.72 days, p  < 0.001), overall hospital stay (10.15 days vs. 12.43 days, p  < 0.001), ventilation days (3.67 days vs. 4.55 days, p  < 0.001), and hospitalization cost (6900 USD vs. 7600 USD, p  = 0.008). Early rib fracture fixation can decrease inflammatory cytokine levels and infection marker levels, prevent hyperinflammation and improve infection in patients with multiple rib fractures. The timing of rib fracture fixation does not influence the surgical procedure time, operative blood loss, 30-day all-cause mortality, or surgical site infection. Conclusion The findings from the present research indicated that early rib fracture fixation (≤ 48 h) is a safe, rational, effective and economical strategy and worth clinical promotion.

Background The utilization of stereotactic body radiation therapy (SBRT) is increasing for primary and secondary lung neoplasms. Despite encouraging results, SBRT is associated with an increased risk of osteoradionecrosis-induced rib fracture. We aimed to (1) evaluate potential clinical, demographic, and procedure-related risk factors for rib fractures and (2) describe the radiographic features of post-SBRT rib fractures. Methods We retrospectively identified 106 patients who received SBRT between 2015 and 2018 for a primary or metastatic lung tumor with at least 12 months of follow up. Exclusion criteria were incomplete records, previous ipsilateral thoracic radiation, or relevant prior trauma. Computed tomography (CT) images were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was employed to determine clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location). Results A total of 106 patients with 111 treated tumors met the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total fractured ribs). The highest number of fractured ribs per patient was five. Multivariate regression identified posterolateral tumor location as the only independent risk factor for rib fracture. On CT, fractures showed discontinuity between healing edges in 77% of affected patients. Conclusions Nearly one third of patients receiving SBRT for lung tumors experienced rib fractures, 34% of whom experienced pain. Many patients developed multiple fractures. Post-SBRT fractures demonstrated a unique discontinuity between the healing edges of the rib, a distinct feature of post-SBRT rib fractures. The only independent predictor of rib fracture was tumor location along the posterolateral chest wall. Given its increasing frequency of use, describing the risk profile of SBRT is vital to ensure patient safety and adequately inform patient expectations.

BackgroundLumbar ribs (LR) are a rare and relatively unknown anatomical abnormality of the lumbar spine. The literature provides better understanding regarding other spinal congenital variations like cervical ribs or lumbosacral transitional vertebrae, which are rather commonly recognised conditions. Thus, this meta-analysis aimed to provide data on prevalence and key characteristics of LR.MethodsRelevant databases were systematically searched for studies reporting the prevalence, laterality and geographic distribution of LR. No exclusion criteria based on language and date of original articles were employed. The pooled prevalence estimates (PPE) were calculated using a random-effects model. To assess the between-study heterogeneity, the I2 statistic and Chi-square test were utilized. Throughout the investigation, the PRISMA guidelines were adhered to scrupulously. Evaluation of the included studies’ reliability was made with the AQUA tool.ResultsIn total, 9 studies were included in this meta-analysis. The pooled prevalence estimate (PPE) of LR was 2.1% (95%CI: 1.0-4.6). In studies based on CT imaging, LR were found in 1.6% (95%CI: 0.6–4.3) of patients and in Xray based studies in 2.1% (95%CI: 0.4–11.1) of patients. Lumbar ribs were bilateral in majority of individuals (65.4%, 95%CI: 39.4–84.6) and could be most frequently encountered in Europe with PPE of 2.8% (95%CI: 3.0–20.0), then in East Asia with PPE of 1.5% (95%CI: 1.0-19.2) and Middle East with PPE of 1.1% (95%CI: 0.6–20.0).ConclusionsThe findings of our study indicate that LR are a common anatomical variation of lumbar spine, contrary to previous beliefs. In a clinical practice, when a patient presents with a non-specific low back pain, a possible occurrence of LR should be taken into consideration. The presence of LR may be misleading for surgeons and result in wrong-level spine surgeries.

This study examined the impact of frailty on in-hospital outcomes in patients undergoing surgical stabilization of multiple rib fractures and flail chest (SSRF). This retrospective study used U.S. Nationwide Inpatient Sample data (2005–2020) to analyze patients ≥20 years old who underwent SSRF for multiple rib fractures. In-hospital outcomes (mortality, discharge status, complications) were compared between frail and non-frail groups using 1:4 propensity score matching (PSM). After PSM, 2690 patients were included in the analyses. Frail patients had a higher likelihood of being transferred to SNF or ICF (adjusted odds ratio [aOR] ​= ​1.88; 95 ​% confidence interval [CI]: 1.46–2.43), higher total hospital costs (144.56 thousand USD; 95 ​% CI: 140.66–148.47), and increased risks of postoperative complications (aOR ​= ​1.59; 95 ​% CI: 1.24–2.05), including tracheostomy, respiratory failure, and pneumonia. Frailty increases the risk of adverse outcomes after SSRF, highlighting the importance of incorporating frailty assessment into perioperative care. •Frailty increases non-routine discharge, hospital stay, costs, and postoperative complications after SSRF.•Findings support incorporating frailty assessment into preoperative planning for better perioperative care.

At our institution, SSRF is prioritized for patients with 3 or more consecutive rib fractures, any number of rib fractures with significant malalignment, clinical diagnosis of chest wall instability such as “clicking” on examination, radiologic diagnosis of 30% loss of hemithorax, and patients with a radiologic finding of three or more ribs fractured in two or more places (radiographic flail segment), and worsening pain with regional analgesia and multimodal pain control. Patients undergoing extrathoracic SSRF took longer to get to the operating room, had more ventilator days, ICU days, and hospital length of stay compared to the intrathoracic patients. There was a temporal evolution over the study period that showed increased preference for the intrathoracic system.

Background Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. Methods This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. Results A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. Conclusion This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Rib fractures represent the most common bone fracture, occurring in 10-20% of all blunt trauma patients and leading to concomitant injuries of the inner organs in severe cases. The purpose of this study was to identify specific serial rib fracture patterns after blunt chest trauma. 380 serial rib fracture cases were investigated. Fractures were assigned to five different locations within the transverse plane. Rib level, fracture type, and dislocation grades were recorded and related to the cause of accident. In total, 3735 rib fractures were identified (9.8 per patient). 54% of the rib fractures were detected on the left thorax. Rib fracture distribution exhibited a hotspot at rib levels 4 to 7 in the lateral and posterolateral segments. On average, most rib fractures occurred in crush/burying injuries (15.8, n = 13) and pedestrian accidents (12.8, n = 13), least in car/truck accidents (8.9, n = 75). In the car/truck accident group, 47% of all rib fractures were in the lateral segment, in case of frontal collision (n = 24) even 60%. Fall injuries (n = 141) entailed mostly posterolateral rib fractures (35%). In case of falls >3 m (n = 45), 48% more rib fractures were detected on the left thorax. In cardiopulmonary resuscitation related serial rib fractures (n = 33), 70% of all rib fractures were located anterolaterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all rib fractures were dislocated (15% ≥ rib width). Serial rib fractures showed distinct fracture patterns depending on the cause of accident. When developing a serial rib fracture classification system, data regarding patterns, fracture types, dislocation grades, and associated fractures should be included.