Sternal fixation for traumatic sternal fractures demonstrates better long-term quality of life outcomes than nonoperative management: A survey analysis.

INTRODUCTION: Sternal fractures are rare, causing significant pain, respiratory compromise, and decreased upper extremity range of motion. Sternal fixation (SF) is a viable treatment option; however, there remains a paucity of literature demonstrating long-term benefits. This study examined long-term outcomes of SF, hypothesizing they have better long-term quality of life (QoL) than patients managed nonoperatively (NOM). METHODS: This was a survey study at our level 1 academic hospital. All patients diagnosed with a sternal fracture were included from January 2016 to July 2021. Patients were grouped whether they received SF or NOM. Basic demographics were obtained. Three survey phone call attempts were conducted. The time from injury to survey was recorded. Outcomes included responses to the QoL survey, which included mobility, self-care, usual activities, chest pain/discomfort, and anxiety/depression. The survey scale is 1-5 (1 = worst condition possible; 5 = best possible condition). Patients were asked to rate their current health on a scale of 0-100 (100 being the best possible health imaginable). Chi square and t-tests were used. Significance was set at p < 0.05. RESULTS: Three hundred eighty four patients were surveyed. Sixty nine underwent SF and 315 were NOM. Thirty-eight (55.1%) SF patients and 126 (40%) NOM patients participated in the survey. Basic demographics were similar. Average days from sternal fracture to survey was 1198 (±492) for the SF group and 1454 (±567) for the NOM group. The SF cohort demonstrated statistically significant better QoL than the NOM cohort for all categories except anxiety/depression. CONCLUSION: SF provides better long-term QoL and better overall health scores compared to NOM.

Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: The Joint Commission reports at least half of communication breakdowns occur during handovers or transitions of care. There is no consensus on how best to approach the transfer of care within Acute Care Surgery (ACS). We conduct a systematic review and meta-analysis of the current data on handoffs and transitions of care in ACS patients and evaluate the impact of standardization and formalized communication processes. METHODS: Clinically relevant questions regarding handoffs and transitions of care with clearly defined patient Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes (PICO) were determined. These centered around specific transitions of care within the setting of ACS - specifically perioperative interactions, EMS and trauma team interactions, and intra/inter floor and ICU interactions. A systematic literature review and meta-analysis was conducted utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS: A total of 10 studies were identified for analysis. These included 5,113 patients in the standardized handoff group and 5,293 in the current process group. Standardized handoffs reduced handover errors for perioperative interactions and preventable adverse events for intra/inter floor and ICU interactions. There was insufficient data to evaluate outcomes of clinical complications and medical errors. CONCLUSION: We conditionally recommend a standardized handoff in in the field of ACS, including perioperative interactions, EMS and trauma team interactions, as well as intra-inter floor and ICU interactions. LEVEL OF EVIDENCE: Guideline; Systematic review/meta-analysis, Level III.

Rural Trauma Team Development Course Positively Impacts its Desired Objectives.

BACKGROUND: The Rural Trauma Team Development Course (RTTDC) is designed to help rural hospitals better organize and manage trauma patients with limited resources. Although RTTDC is well-established, limited literature exists regarding improvement in the overall objectives for which the course was designed. The aim of this study was to analyze the goals of RTTDC, hypothesizing improvements in course objectives after course completion. METHODS: This was a prospective, observational study from 2015 through 2021. All hospitals completing the RTTDC led by our Level 1, academic trauma hospital were included. Our institutional database was queried for individual patient data. Cohorts were delineated before and after RTTDC was provided to the rural hospital. Basic demographics were obtained. Outcomes of interest included: Emergency Department (ED) dwell time, decision time to transfer, number of total images/computed tomography scans obtained, and mortality. Chi square and non-parametric median test were used. Significance was set at P < .05. RESULTS: Sixteen rural hospitals were included with a total of 472 patients transferred (240 before and 232 after). Patient demographics were similar before and after RTTDC. ED dwell time was significantly reduced by 64 min (P = .003) and decision to transfer time was cut by 62 min (P = .004) after RTTDC. Mean total radiographic images and CT scans were significantly reduced (P < .001 and P = .002, respectively) after RTTDC. Mortality was unaffected by RTTDC completion (P = .941). CONCLUSION: The RTTDC demonstrates decreased ED dwell time, decision time to transfer, and number of radiographic images obtained prior to transfer. More rural hospitals should be offered this course.

Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience.

INTRODUCTION: The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries. METHODS: A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series. RESULTS: 6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge. CONCLUSIONS: This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

A Contemporary Study of Pre-hospital Traumatic Cardiac Arrest: Distinguishing Exsanguination From Non-exsanguination Arrest With a Review of Current Literature.

Background Traumatic cardiac arrest (TCA) remains a challenging problem in terms of diagnosis and management. This is due to difficulty distinguishing the TCA cause and therefore understanding the pathophysiology. The goal of this study was to analyze a contemporary series of TCA patients and classify the causes of TCA into exsanguination (EX) arrest and non-exsanguination (non-EX) arrest. Methods This was a retrospective review of patients suffering TCA during 2019 at a level I trauma center. We excluded patients whose arrests were from medical causes such as ventricular fibrillation, ventricular tachycardia, pulmonary embolus, etc., hanging, drowning, thermal injury, outside transfer, and pediatric patients (age <13 as this is our institutional definition for pediatric trauma patients). We reviewed pre-hospital run-sheets, hospital charts including autopsy findings, and classified patients into EX and non-EX TCA. We defined a witnessed arrest (WA) using the traditional outside hospital cardiac (non-trauma) arrest definition. Outcomes included the incidence of EX arrest, survival to discharge, and hospital costs. Descriptive statistics were used. Significance was set at p < 0.05. Results After exclusion, 54 patients suffered TCA with a mean age of 45.9 (±19.8) years. Eighty-three percent of patients were male. The average cost per TCA was ~$16,000. Of the 54 TCAs, 26 (48%) were WA, with one (1.85%) survivor (no non-WA TCA patients survived). Twenty-two (41%) patients died from EX-arrest; 59% penetrating vs. 28% blunt (p = 0.03). The one EX-arrest survivor was a 19-year-old gunshot wound to the leg whose arrest was witnessed, with a short downtime, and the cause of arrest (bleeding leg wound) was quickly reversible. Conclusion We classified 41% of TCAs to have died from EX-arrest with only a 1.85% survival rate. This study calls for a TCA pre-hospital registry with accurate and consistent data definitions and collection. The registry should capture the cause of arrest for future research, management decision-making, and prognostication.

Anatomy of the anterior ribs and the composition of the costal margin: A cadaver study.

BACKGROUND: Traditional rib anatomy and costal margin teaching contends that the costal margin consists of a combined costal cartilage made up of ribs 7 to 10. Variations in 9th and 10th rib anatomy have been observed. We sought to evaluate the variability of interchondral joints and the make-up of the costal margin. METHODS: Cadaveric dissections were performed to evaluate the anatomy of the anterior ribs and the composition of the costal margin. Experienced chest wall surgeons evaluated this anatomy through a standardized dissection and assessment. Dissection videos were performed to allow for further review/assessment. RESULTS: Bilateral chest wall anatomy of 30 cadavers was evaluated (15 male, 15 female). The average age was 78 ± 12 years, and all patients were Caucasian. In all patients, the first rib attached to the manubrium, the second rib attached to the manubriosternal junction, and ribs 3 to 6 attached directly to the sternum. Interchondral joints were present between ribs 4/5-3%, 5/6-68%, 6/7-83%, 7/8-72%. Ribs combining to form a common costal cartilage via cartilaginous unions were observed between 6/7-3%, 7/8-45%, 8/9-30%, and 9/10-20%.The 8th rib attached directly to the sternum without joining the 7th rib in 10% of cadavers. The 8th and 9th ribs had free tips in 45% and 60% of evaluations, respectively. The 10th rib was found to have a hooked tip in 25% of cases and was a floating rib without attachment to the 9th rib 52% of the time. Rib tip mobility was noted in ribs 8, 9, and 10 in 52%, 70%, and 90%, respectively. CONCLUSION: Interchondral joints are common between ribs 5 and 8. Significant variability exists in the chest wall and costal margin compared with traditional teaching. It is important for chest wall surgeons treating diseases of the costal margin to appreciate this anatomic variability.

Better late than never-a single-center review of delayed rib fixation for symptomatic rib fractures and nonunions.

BACKGROUND: Surgical stabilization of rib fractures (SSRFs) has become an emerging therapy for treatment of patients with rib fractures. More commonly, it is used in the acute setting; however, delayed SSRF can be utilized for symptomatic rib fracture nonunions. Here, we describe our institution's experience with delayed SSRF, hypothesizing it is safe and resolves patient symptoms. METHODS: This is a retrospective review of patients presenting to our Level I trauma center to undergo delayed SSRF for symptomatic nonunions from January 2017 to September 2022. Delayed SSRF was defined as SSRF over 2 weeks in the outpatient setting. Basic demographics were obtained. Outcomes of interest included mean pain score (preoperatively and postoperatively), intensive care unit (ICU) and hospital length of stay (LOS), and resolution of preoperative symptoms, specifically chest wall instability, with return to activities of daily living (ADLs). RESULTS: Forty-four patients met inclusion criteria with a total of 156 symptomatic nonunion rib fractures that received delayed SSRF. The average age was 59.2 ± 11.9 years and median number of days from injury to SSRF was 172.5 (interquartile range, 27.5-200). The average number rib fractures plated per patient 3.5 ± 1.8. Only three patients required ICU admission postoperatively for no longer than 2 days. Median hospital LOS was 2 days (interquartile range 1-3 days). Average preoperative and postoperative pain score was 6.8 ± 1.9 and 2.02 ± 1.5, respectively ( p < 0.001). Chest wall instability and preoperative symptoms resolved in 93.2% of patients postoperatively ( p < 0.001). Two patients (4.5%) had postoperative complications that resolved after additional surgical intervention. Rib fracture healing was demonstrated on radiographic imaging during postoperative follow-up. CONCLUSION: Delayed SSRF is safe and demonstrates significant resolution of preoperative symptoms by decreasing pain, improving chest wall stability, and allowing patients to return to activities of daily living. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Surgical stabilization of rib fractures is associated with better return on investment for a health care institution than nonoperative management.

BACKGROUND: Surgical stabilization of rib fractures (SSRFs) continues to gain popularity due to patient benefits. However, little has been produced regarding the economic benefits of SSRF and its impact on hospital metrics such as Vizient. The aim of this study was to explore these benefits hypothesizing SSRF will demonstrate positive return on investment (ROI) for a health care institution. METHODS: This is a retrospective review of all rib fracture patients over 5 years at our Level I trauma center. Patients were grouped into SSRF versus nonoperative management. Basic demographics were obtained including case mix index (CMI). Outcomes included narcotic requirements in morphine milliequivalents prior to discharge, mortality, and discharge disposition. Furthermore, actual hospital length of stay (ALOS) versus Vizient expected length of stay were compared between cohorts. Contribution margin (CM) was also calculated. Independent t-test, paired t-test, and linear regression analysis were performed, and significance set at p < 0.05. RESULTS: A total of 1,639 patients were included; 230 (14%) underwent SSRF. Age, gender, and Injury Severity Score were similar. Surgical stabilization of rib fracture patients had more ribs fractured (7 vs. 4; p < 0.001) and more patients with flail chest (43.5% vs. 6.7%; p < 0.001). Surgical stabilization of rib fracture patients also had a significantly higher CMI (4.33 vs. 2.78; p = 0.001). Narcotic requirements and mortality were less in the SSRF cohort; 155 versus 246 morphine milliequivalents ( p < 0.001) and 1.7% versus 7.1% ( p = 0.003), respectively. Surgical stabilization of rib fracture patients were more likely to be discharged home (70.4% vs. 63.7%; p = 0.006). Surgical stabilization of rib fracture patients demonstrated shorter ALOS where nonoperative management patients demonstrated longer ALOS compared with Vizient expected length of stay. Contribution margins for SSRF patients were significantly higher and linear regression analysis showed a CM $1,128.14 higher per patient undergoing SSRF ( p < 0.001). CONCLUSION: Patients undergoing SSRF demonstrate a significant ROI for a health care organization. Despite SSRF patients having a higher CMI, they were able to be discharged sooner than expected by Vizient calculations resulting in better a CM. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma.

BACKGROUND: Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists. METHODS: The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation. RESULTS: No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection. CONCLUSION: This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1).

PURPOSE: Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions. METHODS: A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis. RESULTS: Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001). CONCLUSION: Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.

Increase in Alcohol Use Among the Geriatric Trauma Population During the COVID-19 Pandemic.

The COVID-19 pandemic has had profound effects on the everyday behaviors of all patients. At the same time, the United States population is aging, and an increasing portion of traumatically injured patients are geriatric. Our study aims to examine the effects of the COVID-19 pandemic on the geriatric trauma population. We performed a retrospective review of the trauma database from our single institution level I trauma center examining pandemics impact on geriatric trauma demographics, mechanism of injury, injury severity, hospitalization characteristics, and alcohol use. Data during the pandemic was compared to the prior 3 years and controlled for seasonality. Statistical analysis demonstrated an increase in duration of mechanical ventilation and alcohol use during the pandemic while other factors remained stable. This shows the need for targeted alcohol assessment in the geriatric trauma population during periods of social isolation and additional research into the effects of the COVID-19 on trauma patients.

Hardware Infection From Surgical Stabilization of Rib Fractures Is Lower Than Previously Reported.

Introduction Surgical stabilization of rib fractures (SSRF) is an emerging therapy for the treatment of patients with traumatic rib fractures. Despite the demonstrated benefits of SSRF, there remains a paucity of literature regarding the complications from SSRF, especially those related to hardware infection. Currently, literature quotes hardware infection rates as high as 4%. We hypothesize that the hardware infection rate is much lower than currently published. Methods This is an IRB-approved, four-year multicenter descriptive review of prospectively collected data from January 2016 to June 2022. All patients undergoing SSRF were included in the study. Exclusion criteria included those patients less that 18 years of age. Basic demographics were obtained: age, gender, Injury Severity Score (ISS), Abbreviate Injury Scale-chest (AIS-chest), flail chest (yes/no), delayed SSRF more than two weeks (yes/no), number of patients with a pre-SSRF chest tube, and number of ribs fixated. Primary outcome was hardware infection. Secondary outcomes included mortality rate and hospital length of stay (HLOS). Basic descriptive statistics were utilized for analysis. Results A total of 453 patients met criteria for inclusion in the study. Mean age was 63 ± 15.2 years and 71% were male. Mean ISS was 17.3 ± 8.5 with a mean AIS-chest of 3.2 ± 0.5. Flail chest (three consecutive ribs with two or more fractures on each rib) accounted for 32% of patients. Forty-two patients (9.3%) underwent delayed SSRF. The average number of ribs stabilized was 4.75 ± 0.71. When analyzing the primary outcome, only two patients (0.4%) developed a hardware infection requiring reoperation to remove the plates. Overall HLOS was 10.5 ± 6.8 days. Five patients suffered a mortality (1.1%), all five with ISS scores higher than 15 suggesting significant polytrauma. Conclusion This is the largest case series to date examining SSRF hardware infection. The incidence of SSRF hardware infection is very low (<0.5%), much less than quoted in current literature. Overall, SSRF is a safe procedure with low morbidity and mortality.

Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.

BACKGROUND: Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS: Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS: Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION: We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level IV.

Impact of sternal fixation on patient outcomes: A case matched review.

INTRODUCTION: Sternal fractures are debilitating injuries often resulting in severe pain and respiratory compromise. Surgical fixation of sternal fractures is gaining popularity as a treatment modality for sternal fractures. Unfortunately, little literature exists on this topic. This study looks to further examine the benefits of sternal fixation (SF), hypothesizing SF results in improved pain, improved respiratory function, and decreased opioid use. METHODS: Retrospective review was performed between patients with sternal fractures who underwent nonoperative management (NOM) versus operative SF. Case matching was used to construct an artificial control group matched on age and Injury Severity Score using a 1:1 ratio of treatment to control. Exclusion criteria were age younger than 18 years. Outcomes of interest included mean pain score, total opioid requirements (in morphine milliequivalents) within 24 hours of discharge, intensive care unit and hospital length of stay (LOS), and incentive spirometry percent predicted value at discharge. Dependent variables were analyzed using t test, and Injury Severity Score was analyzed using the sign test. Statistical significance was set at p < 0.05. RESULTS: Fifty-eight patients from the SF cohort were matched with 58 patients from the NOM cohort. The average age was 59.8 years for the SF group and 62.2 years for the NOM group. Injury Severity Score was matched at 9 for both cohorts. Although pain scores were similar for both cohorts, the SF group required significantly less opioids at discharge (62.1 vs. 92.2 morphine milliequivalents; p = 0.007). In addition, the SF cohort demonstrated significantly improved respiratory function per incentive spirometry percent predicted value at discharge (75.5% vs. 59.9%; p < 0.001). Intensive care unit LOS and hospital LOS were similar between cohorts. CONCLUSION: Despite similarities in pain scores, intensive care unit LOS, and hospital LOS, SF was associated with decreased opioid requirements and improved respiratory function at discharge in this study. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Focusing in on gallbladder disease. Do current imaging modalities accurately depict the severity of final pathology?

BACKGROUND: Accuracy of imaging modalities for gallbladder disease(GBD) remains questionable. We hypothesize ultrasonography(US), computed tomography(CT), and magnetic resonance imaging(MRI) poorly correlate with final pathologic analysis. METHODS: This was a retrospective review of all patients who underwent cholecystectomy at our institution. Primary outcome was agreement between US, CT, and MRI, and final pathology report of the gallbladder. Cohen's Kappa statistic was used to describe the level of agreement (0 = agreement equivalent to chance, 0.1-0.2 = slight agreement, 0.21-0.40 = minimal/fair agreement, 0.41-0.60 = moderate agreement, 0.61-0.80 = substantial agreement, 0.81-0.99 = near perfect agreement, 1 = perfect agreement). Significance was set at p < 0.05. RESULTS: 1107 patients were enrolled. Average age was 48.6(±17.6); 64.2% were female. There was minimal agreement between the three imaging modalities and final pathology (US = 0.363; CT = 0.223; MRI = 0.351;p < 0.001). CONCLUSION: Poor agreement exists between imaging modalities and final pathology report for GBD. Urgent surgical intervention for patients presenting with symptoms of GBD should be considered, despite imaging results.

Finite element analysis for better evaluation of rib fractures: A pilot study.

INTRODUCTION: Modeling rib fracture stability is challenging. Computer-generated finite element analysis (FEA) is an option for assessment of chest wall stability (CWS). The objective is to explore FEA as a means to assess CWS, hypothesizing it is a reliable approach to better understand rib fracture pathophysiology. METHODS: Thoracic anatomy was generated from standardized skeletal models with internal/external organs, soft tissue and muscles using Digital Imaging and Communications in Medicine data. Material properties were assigned to bone, cartilage, skin and viscera. Simulation was performed using ANSYS Workbench (2020 R2, Canonsburg, PA). Meshing the model was completed identifying 1.3 and 2.1 million elements and nodes. An implicit solver was used for a linear/static FEA with all bony contacts identified and applied. All material behavior was modeled as isotropic/linear elastic. Six load cases were evaluated from a musculoskeletal AnyBody model; forward flexion, right/left lateral bending, right/left axial rotation and 5-kg weight arm lifting. Standard application points, directions of muscle forces, and joint positions were applied. Ten fracture cases (unilateral and bilateral) were defined and 66 model variations were simulated. Forty-three points were applied to each rib in the mid/anterior axillary lines to assess thoracic stability. Three assessment criteria were used to quantify thoracic motion: normalized mean absolute error, normalized root mean square error, and normalized interfragmentary motion. RESULTS: All three analyses demonstrated similar findings that rib fracture deformation and loss of CWS was highest for left/right axial rotation. Increased number of ribs fracture demonstrated more fracture deformation and more loss of CWS compared with a flail chest segment involving less ribs. A single rib fracture is associated with ~3% loss of CWS. Normalized interfragmentary motion deformation can increases by 230%. Chest wall stability can decrease by over 50% depending on fracture patterns. CONCLUSION: Finite element analysis is a promising technology for analyzing CWS. Future studies need to focus on clinical relevance and application of this technology. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Redefining the costal margin: A pilot study.

BACKGROUND: Classical teaching of rib anatomy contends that the false ribs (7th to 10th) fuse anteriorly to form the costal margin of the chest. Slipped rib syndrome consists of false rib subluxation into the thorax with symptomatic impingement of the intercostal nerve. We sought to determine the incidence of this anatomic finding through anatomic study of the costal margin. METHODS: Cadavers were evaluated for mobility and attachment of the ninth and tenth ribs. Experienced anatomists and chest wall surgeons conducted a standardized dissection and assessed rib tip mobility using predefined criteria. Videos of dissections were submitted to a single investigator who reviewed the findings. RESULTS: Costal margins of 40 cadavers (45% male) were evaluated bilaterally. The average age was 83 years ± 11 years. The ninth rib was found to be attached to the eighth rib 100% of the time by an interchondral cartilaginous attachment along the body of the eighth and ninth ribs. Internal subluxation was noted in 19% (15 of 80), and the tip of the rib was mobile in 86% (69 of 80) evaluations. The tenth rib was attached to the ninth rib in 18%(14/80). A "floating" 10th rib was noted in 59% (47 of 80) of specimens. Subluxation was noted in 33% (26 of 60). Half of the ribs that subluxed moved medially to the ninth rib and half moved externally. An upwardly hooked tip was noted in 10% (8 of 80). Ribs with a hooked tip subluxed in 63% (5 of 8), and all of these ribs (5 of 5) moved to the interior of the chest ( p = 0.020). CONCLUSION: The ninth rib is commonly attached to the eighth rib, but the tenth rib is often not attached to the ninth rib. Most commonly, the tenth rib is a "floating" rib. Internal subluxation of the tenth rib as well as the presence of a hooked tip may predispose individuals to the development of "slipped rib syndrome." LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level III.

Severity of Illness Impacts Outcomes More than Admitting Service for Isolated Hip Fracture Patients.

INTRODUCTION: Isolated hip fractures (IHF) are common injuries in the elderly. Controversy exists about which hospital service is best suited to manage these patients. We hypothesize that baseline patient severity of illness (SOI) score drives patient outcomes, not the hospital service managing these patients. METHODS: Retrospective review of all IHF patients from 2014 to 2018 at our Level 1 trauma center. Basic demographics were obtained. Patients were divided into service line they were admitted; surgical vs non-surgical. Primary outcomes included hospital length of stay (HLOS), time to OR, time to VTE prophylaxis, complication rate (defined by the Trauma Quality Improvement Program), 30-day mortality, and readmissions. SOI score (which is DRG-based) was controlled to see if any differences in primary outcomes occurred between cohorts. Chi-square was used for categorical variables and regression analysis for continuous variables. Significance was p < 0.05. RESULTS: A total of 366 total patients were analyzed with the same ISS. A total of 102 were admitted to a surgical service and 264 to a non-surgical service. Average overall age was 80 year, 66.9% were female, and 86% were Caucasian. There was no statistical difference between outcomes when comparing admitting services. Controlling for SOI score, there was no difference between admitting service for outcomes as well. SOI score was a significant predictor for increased HLOS and complication occurrence (p < 0.001) via regression analysis, with a 6.06-fold increase in complication rate from mild to moderate SOI score (p = 0.001). CONCLUSION: There is no difference in outcomes based on admitting service and process measures. However, the SOI score is perhaps a better predictor of outcomes for isolated hip fracture patients.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.