Livingston David H, Shogan Benjamin, John Preeti, Lavery Robert F
Division of Trauma, Department of Surgery, New Jersey Medical School, Newark, New Jersey, USA.
J Trauma. 2008 Apr;64(4):905-11. doi: 10.1097/TA.0b013e3181668ad7.
The number of rib fractures has been reported to correlate with mortality after blunt chest trauma. These reports, however, predate routine truncal helical computed tomographic (CT) scanning and their conclusions are based on data derived from plain chest radiographs (CXR). CT scan provides better anatomic definition of chest injuries than plain CXR, and we hypothesized CT evaluation of rib fracture number and patterns would provide a better prediction of respiratory failure and mortality after chest injury than the data derived from the initial CXR.
The charts on all patients of 16 years or older with one or more rib fractures after blunt trauma admitted from January 2003 through December 2005 were reviewed. Both the initial CXR and the helical CT scans were systematically re-read for the number and location of rib fractures and presence of pulmonary contusions. Anatomic fracture location (anterior, posterior, lateral) was determined using a standardized template. Outcomes data included pneumonia, respiratory failure (>/=3 ventilator days), need for trachestomy, and mortality. Logistic regression was performed to identify factors that predicted pulmonary morbidity.
Three hundred and eighty eight patients had >/=1 rib fracture. The mean (+/-standard deviation) age was 44 +/- 18. injury severity score was 21 +/- 11. Mortality was 6% (22 of 388). Sixty-three (16%) patients developed respiratory failure. The mean number of rib fractures per patient was four (range, 1-23); 21% of patients had one rib fracture and 17% had six or more fractures. 208 (54%) of the initial CXRs were read as having no rib fractures. The mean number of rib fractures per patient in this group was 3.1 (CI95 2.9-3.2). In 43% (179 of 388) of patients, the CT radiology report incorrectly identified the number and location of the fractured ribs. Of these reports, 72% (129 of 179) differed from the prospective review by more than one fracture. The number of fractures was higher in patients who died (7 +/- 5 vs. 4 +/- 3; p = 0.02) and in those developing respiratory failure (6 +/- 4 vs. 3 +/- 3; p = 0.02). Any rib fracture or pulmonary contusion visible on the initial plain CXR significantly increased the incidence of pulmonary morbidity or mortality. CT determination of fracture location had no effect on respiratory failure, pneumonia, or mortality when fractures were confined to one anatomic location. The presence of rib fracture in more than anatomic region doubled the incidence of respiratory failure (24% vs. 12%; p = 0.002) but had no effect on mortality. Logistic regression identified only injury severity score and presence of a parenchymal injury on plain CXR as independent predictors of subsequent respiratory failure.
Rib fracture mortality was lower than that in the previously published studies and is likely reflect the increased sensitivity of CT scan in diagnosing rib fractures. Screening CXRs miss rib fractures more than 50% of the time. Radiology reports are often not sufficiently descriptive or are incomplete with respect to the number and location fracture and reliance on these data will lead to erroneous conclusions. Using CT scanning, only the finding of rib fractures in multiple locations was associated with increased incidence of respiratory failure. In contrast, the presence of any parenchymal injury or visible rib fracture on the screening CXR significantly increases the risk for subsequent pulmonary morbidity (odds ratio, 3.8; CI95, 2.2-6.6). Although truncal CT scanning markedly improved the diagnosis and delineation of rib fractures, the screening CXR was a better predictor of subsequent pulmonary morbidity and mortality.
据报道，肋骨骨折数量与钝性胸部创伤后的死亡率相关。然而，这些报道早于常规的躯干螺旋计算机断层扫描（CT），其结论基于胸部X线平片（CXR）获得的数据。CT扫描比胸部X线平片能更好地对胸部损伤进行解剖学定义，我们推测，与最初胸部X线平片获得的数据相比，通过CT评估肋骨骨折数量和类型能更好地预测胸部损伤后的呼吸衰竭和死亡率。
回顾了2003年1月至2005年12月期间收治的所有16岁及以上钝性创伤后有一处或多处肋骨骨折患者的病历。对最初的胸部X线平片和螺旋CT扫描进行系统重新阅片，以确定肋骨骨折的数量、位置以及肺挫伤情况。使用标准化模板确定骨折的解剖位置（前部、后部、外侧）。结果数据包括肺炎、呼吸衰竭（≥3天机械通气）、气管切开需求和死亡率。进行逻辑回归分析以确定预测肺部并发症的因素。
388例患者有≥1处肋骨骨折。平均（±标准差）年龄为44±18岁，损伤严重程度评分为21±11分。死亡率为6%（388例中的22例）。63例（16%）患者发生呼吸衰竭。每位患者肋骨骨折的平均数量为4处（范围为1 - 23处）；21%的患者有1处肋骨骨折，17%的患者有6处或更多处骨折。最初的胸部X线平片中208例（54%）被读为无肋骨骨折。该组中每位患者肋骨骨折的平均数量为3.1处（95%CI 2.9 - 3.2）。在43%（388例中的179例）的患者中，CT放射学报告错误地识别了肋骨骨折的数量和位置。在这些报告中，72%（179例中的129例）与前瞻性复查的差异超过1处骨折。死亡患者的骨折数量更高（7±5处 vs. 4±3处；p = 0.02），发生呼吸衰竭的患者也是如此（6±4处 vs. 3±3处；p = 0.02）。最初的胸部X线平片上可见的任何肋骨骨折或肺挫伤均显著增加肺部并发症或死亡率的发生率。当骨折局限于一个解剖区域时，CT确定的骨折位置对呼吸衰竭、肺炎或死亡率无影响。肋骨骨折存在于多个解剖区域使呼吸衰竭的发生率加倍（24% vs. 12%；p = 0.002），但对死亡率无影响。逻辑回归分析仅确定损伤严重程度评分和胸部X线平片上实质损伤的存在是随后呼吸衰竭的独立预测因素。
肋骨骨折死亡率低于先前发表的研究，这可能反映了CT扫描在诊断肋骨骨折方面的敏感性增加。筛查胸部X线平片超过50%的时间会漏诊肋骨骨折。放射学报告通常描述不够充分或在骨折数量和位置方面不完整，依赖这些数据会导致错误结论。使用CT扫描，仅发现多处肋骨骨折与呼吸衰竭发生率增加相关。相比之下，筛查胸部X线平片上任何实质损伤或可见肋骨骨折显著增加随后肺部并发症的风险（优势比，3.8；95%CI，2.2 - 6.6）。尽管躯干CT扫描显著改善了肋骨骨折的诊断和描绘，但筛查胸部X线平片是随后肺部并发症和死亡率的更好预测指标。
