BACKGROUND: Prior work has demonstrated utility in using operative time to measure surgeon learning for surgical stabilization of rib fractures (SSRF); however, no studies have used operative time to evaluate the benefit of proctoring in subsequent generations of surgeons. We sought to evaluate whether there is a difference in learning between an original series (TOS) of self-taught surgeons versus the next generation (TNG) of proctored surgeons using cumulative summation (CUSUM) analysis. We hypothesized that TNG would have a comparatively accelerated learning curve.
METHODS: A single-center retrospective review of all SSRF at a level 1 trauma center was performed. Data were collected from the beginning of an operative chest injury program to include at least 2 y of TNG experience. Operative time was used to determine success and misstep based on prior methods. Learning curves using CUSUM analysis were calculated based on an anticipated success rate of 90% and compared between TOS and TNG groups.
RESULTS: Over 7 y, 163 patients with a median Injury Severity Score of 24 underwent SSRF. Median operative time was 165 min with a 0.5 plate-to-fracture ratio. All three TOS surgeons experienced a positive slope indicative of early missteps for their first 15-20 cases. By contrast, all three TNG surgeons demonstrated a series of early successes resulting in negative CUSUM slopes which coincided with a period of proctoring. By the end of TNG series, the composite cumulative score was less than half of the TOS surgeon\' scores.
CONCLUSIONS: Operative time continues to be a useful surrogate for observing SSRF learning curves. In a mature institutional program, proctored novice surgeons appear to have an accelerated learning curve compared to novice surgeons developing a new operative rib program.

Rib fractures are one of the most common injuries following blunt trauma. When associated with penetrating trauma, the projectile velocity and immense energy transfer cause significant rib fracture displacement and fragmentation. As a result, these patients are potentially exposed to an even higher risk of complications compared to those seen in more simple rib fractures. Unfortunately, there is limited research regarding technical considerations for surgical stabilization of rib fractures (SSRF) in severely displaced rib fractures with bone loss following penetrating injury. We present the case of a 21-year-old male gunshot wound victim with severely displaced and comminuted rib fractures in which we utilized an autologous bone graft bridge during SSRF to enhance fracture unionization, chest wall stability, and cosmesis. Unfortunately, the bone graft failed to incorporate into surrounding tissue.

UNASSIGNED: Lung herniation following trauma is a rare occurrence, and consensus on optimal surgical repair techniques remains limited. While small herniations may resolve without surgery, intervention becomes necessary in cases of unsuccessful non-operative management or concurrent rib fracture stabilization. Mesh application in repair poses a dilemma, often providing physical support but raising infection concerns, particularly in trauma scenarios with delayed closure. Surgical stabilization of rib fractures, employing hardware similar to orthopedic procedures, may necessitate prophylactic antibiotics, though empirical evidence supporting routine use is scant. Polytrauma patients often resort to delayed chest closure techniques during methodical surgical planning, but these carry potential consequences compared to immediate closure.
METHODS: Presented is a case involving a patient in a motorcycle collision sustaining multiple injuries, necessitating a massive transfusion protocol, multiple surgeries, including delayed chest closure, and eventual surgical rib fixation four days post-injury. During rib stabilization, exacerbation of traumatic lung herniation mandated mesh repair, prompting the cautious use of prophylactic vancomycin powder to mitigate infection risks.
CONCLUSIONS: A review of the literature revealed a scarcity of similar cases, particularly those involving lung herniation with delayed chest closure, the use of prophylactic antibiotics and mesh in polytrauma.
CONCLUSIONS: This case underscores the lack of depth of comprehensive research guiding surgical decisions concerning lung herniation and the prophylactic use of vancomycin powder in trauma patients.

Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.

暂无摘要。

BACKGROUND: With reported improvements in patient outcomes, surgical stabilization of rib fractures (SSRF) has been increasingly adopted. While institutional series have sought to define the role of early SSRF, large scale analysis remains lacking. The present study evaluated clinical and financial outcomes of SSRF in a nationally representative cohort.
METHODS: Patients (≥16 years) admitted with multiple rib fractures were identified using the 2016-2020 National Inpatient Sample. Those who underwent rib plating >14 days following admission were omitted. Using restricted cubic spline analysis, patients who underwent SSRF within 2 days of hospitalization were classified as Expedited while fixation >2 days were deemed Routine. Multivariable regressions were used to evaluate the association of operative timing on outcomes of interest.
RESULTS: Of 8150 patients meeting final inclusion criteria, 4090 (50.2%) were Expedited. Compared to Routine, Expedited tended to be older but were of comparable race, primary payer, and income quartile. Traumatic mechanism was also similar but rates of concomitant sternal fracture as well as intra-abdominal and cardiac injuries were higher in Routine. After adjustment, Expedited was associated with lower odds of respiratory complications, which included need for mechanical ventilation, prolonged mechanical ventilation, and pneumonia, compared to Routine. Expedited was associated with similar hospitalization duration but had lower incremental costs (β: -$19.1 K, 95% CI: -24.1 to -14.2).
CONCLUSIONS: Early SSRF was associated with lower likelihood of a number of respiratory complications and in-hospital costs. While patient selection criteria may limit our findings, expeditious fixation may limit morbidity while enhancing value of care.

Rib fractures in the elderly are one of the most common injuries in trauma patients admitted to the hospital, accounting for over 350,000 patients annually in the United States. Rib plating has been shown to be most beneficial among certain populations. Early surgical intervention is important to utilize approaches that limit the use of pain medications. This is a retrospective data analysis to determine the efficacy of rib plating in elderly trauma patients with rib fractures. A total of 253 patients were seen with rib fractures, 63% were male and 37% were female. The mean age is 64 ± 18.5 years. Of these patients analyzed, 76% had an associated comorbid condition. A majority of patients (95%) presented to the emergency department (ED) with mild GCS range (13-15). Moderate GCS range (9-12) was 4%, and 3% of patients were with severe GCS (3-8.) The mean ISS was 10. The overall mortality rate was 4.5%. Patients were divided into 2 groups: group I consisted of patients who received open reduction and fixation of the fractured ribs, and group II was patients managed conservatively without surgery. Statistical analyses using Student\'s t-test and Chi-square test were performed. Institutional Review Board approval was obtained for this study. Rib plating in elderly trauma patients with multiple rib fractures has shown to be beneficial in terms of mortality. Furthermore, geriatric patients with comorbidities will benefit from early open reduction and fixation of rib fractures, though a larger study is needed to establish clearer criteria for rib plating.

Rib plating has been shown to be beneficial among certain populations, such as patients with flail chest and failure to wean from the ventilator in patients without primary pulmonary pathology. Surgical intervention has been shown to decrease ventilatory requirements, decrease pain management modalities, and lower costs. A retrospective data analysis was done to determine the efficacy of rib plating in elderly trauma patients with rib fractures on a total of 244 patients, 63% male and 37% female, mean age is 64 ± 18.5 years, 76% had an associated comorbid condition, such as Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Chronic Kidney Disease (CKD), or any combination, with 111 (46%) on anticoagulant therapy. 95% patients presented to the emergency department (ED) with Mild GCS range (13-15). Moderate GCS (9-12) was 4% and 3% of patients Severe GCS (3-8). The overall mortality rate was 4.5%.

Rib fractures are present in 15% of all traumas and 60% of patients with chest traumas. Rib fractures are not life-threatening in isolation, but they can be quite painful which leads to splinting and compromise of respiratory function. Splinting limits the ability of a patient to take a deep breath, which leads to atelectasis, atelectasis to poor secretion removal, and poor secretion removal leads to pneumonia. Pneumonia is the common pathway to respiratory failure in patients with rib fractures. It is noted that in the elderly, each rib fracture increases developing pneumonia by 27% and the risk of dying by 19%. From a public health perspective, rib fractures have long-term implications with only 59% of patients returning to work at 6 months. In this review we will examine the state of art as it currently exists with regard to the management of pain associated with rib fractures. Included in this overview will be a brief review of the anatomy of the thorax and some important physiologic concepts, the latest trends in pharmacologic and noninvasive means of managing rib pain, a special section on epidural anesthesia, some other alternative invasive methods of pain control, and a review of the recent literature on rib plating. Finally, a practical, easy to follow guideline, to manage the patient with pain from rib fractures will be presented.

Rib fractures are common injuries observed in trauma patients that will often heal without operative intervention. However, patients can infrequently have continued pain. Operative fixation of these symptomatic rib fractures has traditionally led to the patient requiring hospital admission for observation and pain control. The purpose of this study was to review three cases of outpatient rib fracture, open reduction and internal fixation (ORIF) surgery. Three patients with symptomatic rib fractures treated with ORIF at a single urban level one trauma center underwent outpatient same-day surgery. Pertinent demographic, clinical, radiographic, and surgical data were collected. All patients had decreased preoperative pain and no complications. This case series demonstrates that outpatient surgery for rib fracture ORIF can be performed safely in a select patient population. Additionally, it has similar efficacy as inpatient operative fixation with the main added benefit being decreased costs to both the patient and the healthcare system. We suggest that outpatient operative fixation of rib fractures should be considered for select patients.