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Wed Jul 15 21:46:49 BST 2009

Michelle - 

As you know, the patient's response to pain is highly variable.  The classic
mortality rate quoted for scapular fractures is about 30%.

Here's some recent data to muddy the waters - 

*****CRITICAL CARE MEDICINE*****

(REFERENCE 1 OF 2)

PMID- 16625122

Brasel KJ,  Guse CE,  Layde P,  Weigelt JA  
Rib fractures: relationship with pneumonia and mortality.

In: Crit Care Med (2006 Jun) 34(6):1642-6

ISSN: 0090-3493

OBJECTIVE: In single-institution studies, age is a risk factor for
  mortality after rib fracture. Sample size has limited the assessment
  of other risk factors. We used a national database to analyze
  suspected risk factors contributing to pneumonia and mortality in
  patients sustaining rib fractures. DESIGN:: Database analysis.
  PATIENTS: All patients with rib fractures discharged from hospitals
  submitting information to the Nationwide Inpatient Sample database.
  INTERVENTIONS: The 1999 Nationwide Inpatient Sample was queried for
  all patients with rib fracture. Age, gender, number of rib fractures,
  Injury Severity Score, comorbidities, pneumonia, and mortality were
  abstracted from the database. Comorbidities were scored according to
  Elixhauser. Multivariate analysis identified independent risk factors
  for mortality and pneumonia. MEASUREMENTS AND MAIN RESULTS: We
  identified 23,426 patients; 17,308 patients had a primary diagnosis
  of trauma and were included in the analysis. Mean age was 56. Mean
  Injury Severity Score was 13.1. The number of comorbidities ranged
  from 0 to 9. Overall mortality was 4%. Six percent of patients had
  pneumonia. In a multivariate model, age and Injury Severity Score
  were significantly associated with both mortality and pneumonia.
  Comorbidity score was associated with pneumonia and mortality only in
  patients with isolated thoracic trauma. Pneumonia was associated with
  mortality only in patients with isolated thoracic trauma.
  CONCLUSIONS: In a model controlling for multiple known risk factors,
  age and Injury Severity Score were the only important predictors of
  mortality in patients with rib fractures and multiple-system injury.
  Pneumonia was significantly associated with mortality only in
  patients with isolated thoracic trauma.

Comment in:  Crit Care Med. 2006 Jun;34(6):1828-9

Institutional address: 
     Department of Surgery
     Injury Research Center
     Medical College of Wisconsin
     USA.

*****JOURNAL OF TRAUMA*****

(REFERENCE 2 OF 2)

PMID- 18404055

Livingston DH,  Shogan B,  John P,  Lavery RF  
CT diagnosis of Rib fractures and the prediction of acute respiratory
  failure.

In: J Trauma (2008 Apr) 64(4):905-11

ISSN: 1529-8809

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Institutional address: 
     Division of Trauma
     Department of Surgery
     New Jersey Medical School
     Newark
     New Jersey
     USA. livingst at umdnj.edu

Errington C. Thompson, MD, FACS, FCCM
Trauma/Critical Care
Talk Show Host - WPEK 880 AM
www.whereistheoutrage.net

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Michelle Bailey
Sent: Monday, July 13, 2009 1:57 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Non invasive Ventilation with Flail Chest

Hi
looking for articles related to Rib fractures and when to admit for
observation. Had a 49 yo patient in the ED with 5 rib fractures (2-6 ) and a
scapular fracture - plus atelectasis appearing on CT. I tend to be
conservative and would have admitted him for observation. Looking for any
evidence regarding rib fractures and delayed complications (pneumo/hemo)

thanks
Michelle Bailey PA-C
Trauma Coordinator

On Mon, Jul 13, 2009 at 10:48 AM, Gross, Ronald <
Ronald.Gross at baystatehealth.org> wrote:

> A mind is a terrible thing to waste!!  I do remember that, but missed your
> inuendo!  Oh well.  we are still working on putting that study together -
> will let you know when it comes to be!
> be well,
> Ron
> ________________________________________
> From: trauma-list-bounces at trauma.org [trauma-list-bounces at trauma.org] On
> Behalf Of Dr Timothy Hardcastle [dr.tchardcastle at absamail.co.za]
> Sent: Friday, July 10, 2009 8:49 AM
> To: Trauma-List [TRAUMA.ORG <http://trauma.org/>]
> Subject: RE: Non invasive Ventilation with Flail Chest
>
> Ron
>
> That was said with tongue firmly in cheek - from our previous mails you
> would recall I would participate in such a study.
>
> I don't believe in using metal plates - the absorbable ones work just as
> well and they give no long-term issues. Having said that I think that the
> real role is for the flail or "stove-in" chest without significant
> contusion who would simply require mechanical stability, the cases with
> real contusion usually require tube and vent - then when they come off the
> pump after about 7 - 10 days the ribs are usually reletively stable
> already.
>
> Tim
>
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Lecturer University of KwaZulu-Natal Dept Surgery
> Deputy Director - IALCH Trauma Service
> Durban - South Africa
> > Tim,
> > Trunkey, Mayberry and others (including yours truly) would disagree
> > (respectfully, of course).  Would you be interested in participating in
a
> > study using this technology?
> > Ron
> >
> > None
> >
> > I think it is still a procedure looking for a pathology!
> >
> > Tim
> >> Dear Dr. Hardcastle,
> >>
> >> Your experience with blunt chest injuries is impressive. May I ask how
> >> many
> >> of these flails were surgically repaired with metal plates, etc.?
>
>
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