From the Department of Surgery (L.S., Y.B., M.B., A.C., T.E., M.M., J.N., J.Y., R.N.), University of Utah, Salt Lake City, Utah; Department of Surgery (S.D.), Hackensack University Medical Center Hackensack, New Jersey; Division of Acute Care Surgery, Department of Surgery (K.M.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (R.N., S.P.), Hennepin County Medical Center, Minneapolis, Minnesota; Division of Trauma and General Surgery (G.B., J.S.), University of Pittsburgh Medical Center Pittsburgh, Pennsylvania; Department of General Surgery (E.E., S.M.L.), Medical University of South Carolina, Charleston, South Carolina; Division of Burns, Trauma and Surgical Critical Care, Department of Surgery (T.K., P.S.), Maricopa Medical Center, Phoenix, Arizona; Department of General Surgery (A.K.), NYU Lutheran, Brooklyn, New York; and Department of Surgery (F.M., A.T.), Chandler Regional Medical Center, Chandler, Arizona.
J Trauma Acute Care Surg. 2020 Oct;89(4):658-664. doi: 10.1097/TA.0000000000002848.
Current evaluation of rib fractures focuses almost exclusively on flail chest with little attention on bicortically displaced fractures. Chest trauma that is severe enough to cause fractures leads to worse outcomes. An association between bicortically displaced rib fractures and pulmonary outcomes would potentially change patient care in the setting of trauma. We tested the hypothesis that bicortically displaced fractures were an important clinical marker for pulmonary outcomes in patients with nonflail rib fractures.
This nine-center American Association for the Surgery of Trauma multi-institutional study analyzed adults with two or more rib fractures. Admission computerized tomography scans were independently reviewed. The location, degree of rib fractures, and pulmonary contusions were categorized. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia, acute respiratory distress syndrome (ARDS), and tracheostomy. Analyses were performed in nonflail patients and also while controlling for flail chest to determine if bicortically displaced fractures were independently associated with outcomes.
Of the 1,110 patients, 103 (9.3%) developed pneumonia, 78 (7.0%) required tracheostomy, and 30 (2.7%) developed ARDS. Bicortically displaced fractures were present in 277 (25%) of patients and in 206 (20.3%) of patients without flail chest. After adjusting for patient demographics, injury, and admission physiology, negative pulmonary outcomes occurred over twice as frequently in those with bicortically displaced fractures without flail chest (n = 206) when compared with those without bicortically displaced fractures-pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.6), ARDS (OR, 2.6; 95% CI, 1.0-6.8), and tracheostomy (OR, 2.7; 95% CI, 1.4-5.2). When adjusting for the presence of flail chest, bicortically displaced fractures remained an independent predictor of pneumonia, tracheostomy, and ARDS.
Patients with bicortically displaced rib fractures are more likely to develop pneumonia, ARDS, and need for tracheostomy even when controlling for flail chest. Future studies should investigate the utility of flail chest management algorithms in patients with bicortically displaced fractures.
Prognostic and epidemiological study, level III.
目前对肋骨骨折的评估几乎完全集中在连枷胸上，而对双皮质移位骨折关注甚少。导致骨折的严重胸部创伤会导致更糟糕的结果。双皮质移位肋骨骨折与肺部结果之间的关联可能会改变创伤患者的治疗方式。我们测试了这样一个假设，即双皮质移位骨折是无连枷胸肋骨骨折患者肺部结果的重要临床标志物。
这项由美国创伤外科学会进行的 9 中心多机构研究纳入了两名或更多肋骨骨折的成年患者。对入院计算机断层扫描进行独立评估。对肋骨骨折的位置、程度和肺挫伤进行分类。使用单变量和多变量逻辑回归分析来确定肺炎、急性呼吸窘迫综合征（ARDS）和气管切开术的独立预测因素。在非连枷胸患者中进行分析，并同时控制连枷胸，以确定双皮质移位骨折是否与结果独立相关。
在 1110 名患者中，有 103 名（9.3%）发生肺炎，78 名（7.0%）需要气管切开术，30 名（2.7%）发生 ARDS。277 名（25%）患者和 206 名（20.3%）无连枷胸患者存在双皮质移位骨折。在调整患者人口统计学、损伤和入院生理状况后，与无双皮质移位骨折的患者相比，无连枷胸的双皮质移位骨折患者发生负性肺部结局的频率要高两倍以上，包括肺炎（比值比 [OR]，2.0；95%置信区间 [CI]，1.1-3.6）、ARDS（OR，2.6；95%CI，1.0-6.8）和气管切开术（OR，2.7；95%CI，1.4-5.2）。当调整连枷胸的存在时，双皮质移位骨折仍然是肺炎、气管切开术和 ARDS 的独立预测因素。
即使在控制连枷胸的情况下，存在双皮质移位肋骨骨折的患者更有可能发生肺炎、ARDS 和需要气管切开术。未来的研究应探讨在双皮质移位骨折患者中使用连枷胸管理算法的效果。
预后和流行病学研究，III 级。
