Pieracci Fredric M, Agarwal Suresh, Doben Andrew, Shiroff Adam, Lottenberg Larwence, Whitbeck Sarah Ann, White Thomas W
Denver Health Medical Center, Denver, CO, USA.
Duke University School of Medicine, Durham, NC, USA.
Int Orthop. 2018 Feb;42(2):401-408. doi: 10.1007/s00264-017-3612-1. Epub 2017 Aug 29.
There are currently no evidence-based indications for surgical stabilization of rib fractures (SSRF) in patients without flail chest. The purpose of this survey was to identify patients for whom there is relative equipoise (operative vs. non-operative) in order to assist in designing a randomized clinical trial.
Members of the Chest Wall Injury Society were sent an online survey, in which 18 patient scenarios were presented. The baseline patient had ≥ three displaced, contiguous fractures and had no other contraindications for surgery. This default scenario was then varied based upon patient age, degree of traumatic brain injury (TBI), fracture series location, and number of abnormal pulmonary physiologic variables (oxygen requirement, respiratory rate, incentive spirometry ability, cough, and numeric pain score).
Thirty respondents provided a total of 540 answers. Overall, the majority of responses were in favor of SSRF (n = 413, 84.1%). Furthermore, the vast majority of responses indicated that some degree of pulmonary compromise was necessary to recommend SSRF (n = 44, 90.4%), with ≥ two abnormal parameters being the most common threshold (n = 156, 31.8%). Decision to recommend SSRF varied significantly by number of abnormal clinical variables, age, and degree of TBI, but not by fracture series location. Patients aged 85 years old and those with moderate TBI were the least likely to be recommended for SSRF, regardless of abnormal pulmonary physiologic variables. The most appropriate cutoff for equipoise appeared to be a patient aged 21-79 years old, with no or mild TBI, ≥ two abnormal pulmonary parameters, and regardless of fracture location (44.8% consensus for SSRF).
SSRF was recommended for most patients with non-flail, displaced rib fractures. However, this recommendation was contingent upon patient age, degree of TBI, and pulmonary clinical status. Results of this survey may be used to inform inclusion criteria for a future randomized, clinical trial.
目前对于无连枷胸的肋骨骨折患者，尚无基于证据的手术固定指征。本调查的目的是确定存在相对平衡（手术与非手术）的患者，以协助设计一项随机临床试验。
向胸壁损伤协会成员发送了一份在线调查问卷，其中呈现了18种患者情况。基线患者有≥3处移位的连续性骨折，且无其他手术禁忌证。然后根据患者年龄、创伤性脑损伤（TBI）程度、骨折序列位置以及异常肺生理变量（吸氧需求、呼吸频率、激励肺活量测定能力、咳嗽和数字疼痛评分）的数量对该默认情况进行改变。
30名受访者共提供了540份答案。总体而言，大多数回答支持肋骨骨折手术固定（n = 413，84.1%）。此外，绝大多数回答表明，推荐肋骨骨折手术固定需要一定程度的肺功能受损（n = 44，90.4%），≥2个异常参数是最常见的阈值（n = 156，31.8%）。推荐肋骨骨折手术固定的决定因异常临床变量的数量、年龄和TBI程度而有显著差异，但不因骨折序列位置而有差异。无论肺生理变量是否异常，85岁及以上患者和中度TBI患者最不可能被推荐进行肋骨骨折手术固定。平衡的最合适界限似乎是年龄在21 - 79岁之间、无或轻度TBI、≥2个异常肺参数且无论骨折位置的患者（44.8%的人一致认为应进行肋骨骨折手术固定）。
对于大多数无连枷胸、移位肋骨骨折的患者，推荐进行肋骨骨折手术固定。然而，这一推荐取决于患者年龄、TBI程度和肺部临床状况。本次调查结果可用于为未来的随机临床试验制定纳入标准提供参考。
