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Background: Surgical stabilization of rib fractures (SSRF) is a viable treatment option for rib fracture patients. Polyetheretherketone (PEEK) plates have become available for SSRF. The objective of this pilot study was to examine the use of PEEK plates for SSRF., Methods: A prospective, observational, multi-center study of patients undergoing SSRF with PEEK plates from 4/23 through 2/24. Standard indications for SSRF were followed and the decision to use PEEK plates was left to the discretion of the treating surgeon. Basic demographics were obtained. Outcomes included the number of rib fractures stabilized with PEEK plates, complications related to SSRF, and 6-month follow-up with chest computed tomography (CT) to assess healing of PEEK repaired fracture sites, identified as complete or incomplete union. Patients also answered a five-question quality-of-life survey regarding mobility, self-care, usual activities, chest pain/discomfort, and anxiety/depression. Answers were scaled 1 to 5 (1=worse condition possible; 5=best possible condition). Patients rated their health on a scale of 0 to 100 (100=closet to their health preinjury). All data was reported as descriptive., Results: Forty-six patients were included. Average age was 57(±16) years; 82.6 % were male. Median ISS was 18 (IQR 14,29) and median chest-AIS was 4 (IQR 3,4). 219 rib fractures were stabilized with PEEK plates. Sixteen (34.8 %) had a combination (PEEK + titanium) procedure. Three patients had a complication: one required a second surgery for additional SSRF, and two patients were readmitted. Twenty-seven patients were surveyed at 6 months, and 19 agreed to CT scan. Eighty PEEK repaired rib fractures were assessed for healing. 80 % of fractures had complete union and no hardware failure. Quality-of-life survey averaged >4.5/category and mean overall health was 89., Conclusion: PEEK plates for SSRF are safe and effective, allowing for adequate rib fracture healing and are associated with positive patient reported outcomes., Competing Interests: Declaration of competing interest Dr. Zachary Bauman is a paid educational consultant for KLS-Martin, Zimmer-Biomet, Atricure, and Smith&Nephew. Dr. Thomas White is a paid educational consultant for DePuy Synthes and KLS-Martin. No other authors have any conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF., Methods: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements., Results: A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection., Conclusion: This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research., (© 2024. The Author(s).)

Background: Rib fracture pain is a major issue but likely underappreciated, given that patients avoid activity due to the pain. Pain is one criterion used to determine if someone is a candidate for surgical stabilization of rib fractures (SSRF). The purpose of this study was to assess pain for rib fracture patients, hypothesizing pain from rib fractures is underappreciated in current practice., Methods: A prospective study analyzing patients with one or more rib fractures admitted to our Level I trauma center from March 2023 through February 2024. Exclusion criteria included refusal to participate, ventilator dependent, younger than 18 years, moderate/severe traumatic brain injury, spinal cord injury, pregnancy, or incarceration. Basic demographics were obtained. Participants rated their pain on an 11-point Numerical Rating Scale while resting in bed and performing a series of movements (0, no pain; 10, worst pain imaginable). Movements included incentive spirometer, flexion, extension, bilateral side bending, bilateral rotation, and holding a 5-pound dumbbell. Patients undergoing SSRF were surveyed pre- and postoperatively. Outcomes included the difference between pain scores at rest versus performing all movements, difference between pain scores pre- and post-SSRF, and incentive spirometry pre- and postoperatively. Nonparametric analysis was completed with the Wilcoxon signed-rank test with statistical significance set at p < 0.05., Results: One-hundred two patients were enrolled. The mean age was 60 ± 15 years; 57.8% were male. The median pain score at rest was 3 (interquartile range [IQR], 2-5.5). Pain scores significantly increased to >5 for all movements. Thirty-one patients underwent SSRF. Resting pain prior to SSRF was 3 (IQR, 1-6) and postoperatively was 2 (IQR, 1.5-3) (p = 0.446). For all movements, median Numerical Rating Scale score was significantly less after SSRF (p < 0.001). The median incentive spirometry was 1,100 mL (IQR, 625-1,600 mL) preoperatively and 2,000 mL (IQR, 1,475-2,250 mL) postoperatively., Conclusion: Traditional assessment of pain in patients with rib fractures significantly underappreciates true pain severity caused by movements involving the chest wall and should be considered when evaluating for SSRF., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical stabilization of rib fractures (SSRF) has shown benefits for rib fracture patients. However, the incidence of SSRF performed remains low. We compare our institution's rib fracture patients meeting criteria for SSRF versus those actually receiving the operation, hypothesizing a significant portion are not undergoing SSRF., Methods: A retrospective review of rib fracture patients presenting to our Level 1 trauma center from 1/2016 to 4/2023. Patients were categorized as those who met SSRF inclusion criteria versus those who didn't based on the 2023 Chest Wall Injury Society (CWIS) SSRF Guidelines. Basic demographics were obtained. Patients meeting SSRF criteria were divided into those who received SSRF versus those who didn't. Outcomes of interest included type and frequency of SSRF indications and frequency of absolute/relative contraindications. Descriptive statistics were used. Median test and t-test were used for statistical analysis. Statistical significance was set at p < 0.05., Results: A total of 3,432 patients presented with ≥1 rib fracture(s). Of those, 1,573(45.8 %) met SSRF inclusion criteria. These patients were predominantly male, with mean age of 57.4(±18.5) and a similar Injury Severity Score but significantly higher chest-Abbreviated Injury Score of 3 (Interquartile range 3,4)(p = 0.048). Only 458(29.1 %) patients underwent SSRF, leaving 1,115(70.9 %) managed non-operatively, of which 215(19.3 %) were ventilated and "failure to wean from the ventilator" was the most common (81.4 %) indication for SSRF. Of the 900(80.7 %) non-ventilated patients managed non-operatively, 659 (69.9 %) had ≥two indications for SSRF, 382(34.3 %) had zero relative contraindications and 394(35.3 %) had one relative contraindication for SSRF. Lastly, 52.6 % of patients in this cohort had reported "clicking/popping" of their fractures., Conclusion: Only 29.1 % of patients meeting criteria for SSRF had the operation based on data from our institution. There may be additional opportunity to benefit this cohort of patients meeting SSRF criteria but not undergoing surgery., Competing Interests: Declaration of competing interest Dr. Zachary Bauman is a paid educational consultant for KLS-Martin, Zimmer-Biomet and Atricure, and Smith&Nephew. Jonathan Nguyen is a paid educational consultant for Zimmer-Biomet, Prytime, and Teleflex. All other authors declare no conflicts of interest. All authors agree to publication of this article in its current form. No funding for this project., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Surgical stabilization of rib fractures (SSRF) continues to gain acceptance. Controversary exists around the number of rib fractures needing stabilization. We sought to analyze chest wall stability (CWS) after SSRF using finite element analysis (FEA) modeling in various rib fracture patterns, hypothesizing not stabilizing all fractures leaves the chest wall unstable., Methods: FEA thoracic model development was described previously. Two fracture patterns with three case scenarios each were defined for right ribs 4 to 9. Fracture Pattern 1; Case 1-all 6 ribs with lateral fractures and no stabilization; Case 2-all six fractures stabilized; Case 3-only fractures 5 to 7 were stabilized. Fracture Pattern 2; Case 4-all six ribs fractured in a flail pattern (anterior-lateral and posterior-lateral) and no stabilization; Case 5-all 12 fractures stabilized; Case 6-only six anterior-lateral fractures were stabilized. Three assessment criteria were used to quantify thoracic motion: normalized mean absolute error (NMAE), normalized root mean square error (NRMSE), and normalized interfragmentary motion (NIFM)., Results: Fracture Pattern 1: Case 1-NMAE and NRMSE analysis demonstrated significant loss of CWS up to 50% with left axial rotation; Case 2-CWS almost completely returned to nonfractured state; Case 3-CWS loss up to 37%. Fracture Pattern 2: Case 4-up to 49% of CWS lost with right axial rotation; Case 5-less than 3% CWS lost; Case 6-over 40% CWS lost. For both fracture patterns, when stabilizing all fractures, NIFM decreased by 95%. In Case 3, NIFM decreased by 56% and in Case 6, NIFM increased by 1% at the non-stabilized fracture line., Conclusion: Stabilizing all rib fractures significantly improves CWS. Not stabilizing both fractures of a flail segment worsens motion at the non-stabilized fractures., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Rib fractures are associated with significant pain and morbidity. Intercostal nerve cryoablation (INCA) offers targeted, prolonged pain relief for these patients. Over the last decade, more patients have undergone surgical stabilization of rib fractures (SSRF) after injury. However, data on INCA use in SSRF patients are limited. This study aimed to identify the relationship of INCA in blunt trauma patients (BTPs) undergoing SSRF, hypothesizing INCA coupled with SSRF would decrease hospital length of stay (LOS)., Methods: The Trauma Quality Improvement Program database (2017-2021) was queried for BTPs ≥18 y old who underwent SSRF. Patients who received INCA ((+)INCA) were compared to patients who did not ((-)INCA). The primary outcome was LOS. Secondary outcomes included intensive care unit (ICU) LOS and in-hospital complications. A subgroup analysis of only flail chest patients was performed., Results: From 15,784 BTPs, 750 (4.8%) received INCA. Hospital LOS was similar between groups (12 versus 12 d, P = 0.10); however, the (+)INCA patients had decreased ICU LOS (6 versus 7 d, P < 0.001). The (+)INCA cohort also had decreased hospital complications (20.4% versus 24.4%, P = 0.01), including pulmonary embolism (0.7% versus 1.8%, P = 0.02) and ventilator-associated pneumonia (2.1% versus 3.8%, P = 0.02). On subgroup analysis of flail chest patients, decreased ICU LOS in the (+)INCA patients remained a significant outcome (7 versus 8 d, P = 0.02)., Conclusions: Nearly 5% of SSRF patients received INCA. While overall LOS was similar, the (+)INCA cohort had decreased ICU LOS and in-hospital complications. Future studies are needed to corroborate these findings and evaluate any long-term complications associated with INCA before widespread adoption., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

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., (© 2024 The Authors. World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This research was presented via podium presentation during the 36th Annual Eastern Association for the Surgery of Trauma Annual Scientific Assembly, Lake Buena Vista, FL on January 17th-21st. Dr Zachary Bauman is a paid educational consultant for KLS-Martin, Zimmer-Biomet, Smith & Nephew, and Atricure.

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., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

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., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J Nguyen receives honoraria from Teleflex, Zimmer Biomet, and Pry-time Medical for educational lectures. Z Bauman receives honoraria from Biomet, AtriCure, and KLS for educational lectures.

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., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Serpa et al.)

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., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Bauman et al.)

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., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: Declaration of competing interest None of the authors have any conflicts of interest at this time., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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., Competing Interests: Declaration of competing interest ZMB is a paid educational consultant for Zimmer-Biomet and KLS-Martin for areas unrelated to the current study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Purpose: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients., Methods: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern., Results: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034)., Conclusion: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery., (© 2022. The Author(s).)

Introduction: Surgical stabilization of rib fractures (SSRF) has been gaining popularity for the treatment of rib fractures. Limited literature exists regarding the long-term effects of SSRF versus non-operative (NO) intervention. The goal of this study is to better understand these long-term effects, hypothesizing SSRF patients have better outcomes., Methods: IRB approved survey study at our Level I trauma center. Patients suffering rib fractures from 1/2017 through 1/2019 were surveyed via phone call and asked five questions. Basic demographics obtained. The five survey questions asked: "Are you still experiencing pain from your rib fractures?"; "If yes, how would you rate your pain 1-10?"; "Are you back to your baseline activity level?"; "If no, is this related to your rib fractures?"; "Do you feel your rib fractures moving/clicking?" Paired t test, Chi square, and median tests were utilized. Significance was set at p < 0.05., Results: 527 patients were called with 228 unsuccessfully reached. 47 refused to participate. 252 patients (47.8%) participated in the survey; 78 SSRF and 174 NO. Age and gender were similar between cohorts. Majority of patients suffered blunt trauma. No significant difference between ISS; 15 SSRF vs 14 NO. SSRF patients had worse chest trauma with median chest AIS of 3 (IQR 3-4) vs 3 (IQR 3-3) for NO (p < 0.001). Response to survey questions revealed similar incidences of pain between SSRF and NO cohorts (28.2% vs 27.6%; p = 0.939), however decreased pain scores for SSRF group (2 vs 4; p = 0.006). Return to baseline activity was better for the SSRF group (75.6% vs 56.3%; p = 0.143) and the incidence of rib fractures being the reason for patients not returning to baseline was decreased (26.3% vs 44.7%; p = 0.380). Lastly, SSRF resulted in significantly less movement of rib fractures (3.8% vs 13.8%; p = 0.031)., Conclusion: Patients who undergo SSRF show significant long-term improvements in pain scores and better return to baseline function with less overall issues from their rib fractures compared to those managed non-operatively., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Trauma patient care is complex. Clustering these patients within the hospital seems intuitive. This study's purpose was to explore the benefits of trauma patient clustering, hypothesizing these patients will have decreased costs and better outcomes., Methods: This was an analysis of all adult (18-99 years) trauma patients admitted from 1/2017-1/2019 without an intensive care unit stay. Patients were grouped into those admitted to the trauma unit (TU) versus non-trauma units (NTU). Outcomes evaluated between groups were baseline demographics, direct costs, complication rates (using our TQIP registry), and discharge location. T-test, median test, and chi squared test were used. Linear regression was performed. Significance was set at p < 0.05., Results: 1481 patients (684 TU and 797 NTU) were analyzed. TU patients were younger. Injury Severity Score, mortality, and hospital length of stay were similar between groups. Direct hospital costs were decreased for TU patients ($4941(±$4740) versus $5639(±$4897), p = 0.006). Fewer TU patients experienced inpatient complications (7.8% versus 13.5%, p < 0.001). More TU patients were discharged to home (78.9% versus 73.8%, p = 0.02). Linear regression analysis demonstrated admission to NTUs predicted a direct cost increase of $766.35 (p < 0.001)., Conclusions: Clustering minorly injured trauma patients on a dedicated unit resulted in reduced costs, decreased complications, and higher likelihood for discharge to home., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The ideal device for hemodynamic monitoring of critically ill patients in the intensive care unit (ICU) or the operating room has not yet been developed. This would need to be affordable, consistent, have a very low margin of error (<30%), be minimally or noninvasive, and allow the clinician to make a reasonable therapeutic decision that consistently led to better outcomes. Such a device does not yet exist. This article will describe the distinct options we, as critical care physicians, currently possess for this Herculean endeavor., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Sternal fractures are debilitating due to intractable pain, constant fracture movement and limited range of motion (ROM) of the upper extremities (UE). Traditional treatment comprises mainly of pain control, delaying return to daily activities. Recently, sternal fixation has gained popularity. There is, however, a lack of literature demonstrating efficacy. We report our experience of traumatically fractured sternal fixation., Methods: Following IRB approval, a retrospective chart review was completed for all patients undergoing sternal fixation by a single trauma surgeon at our Level I trauma center. Basic demographics were obtained. Primary outcomes included average cumulative pain scores, total cumulative narcotic amounts and total number of pain medication agents utilized prior to and after sternal fixation. Secondary outcome included physical therapy UE ROM before and after surgery. Paired t tests were used for comparison; significance set at p < 0.05., Results: Thirteen patients underwent sternal fixation from 8/2016 to 2/2018. Average age was 54.4 ± 20.8 years; 54% were female. All patients experienced blunt trauma; average injury severity score was 15.8 ± 10.9 and abbreviated chest injury score was 2.5 ± 0.51. Average intensive care unit/hospital length of stay was 2.3/10.2 days. Average pain scores significantly improved by a score of 3.5 postoperatively (preoperative = 7.08 ± 2.3, postoperative = 3.54 ± 2.5; p = 0.001). Total pain medications required by sternal fixation patients significantly decreased by 1 medication postoperatively (preoperative = 4.2 medications, postoperative = 3.2 medications; p = 0.002). Average narcotic requirements significantly decreased by 7.59 morphine milligram milliequivalents (MME) after sternal fixation (preoperative amount = 71.78 MME, postoperative amount = 64.19 MME; p = 0.041). Every patient had limited UE ROM preoperatively; however, all but one patient resumed full UE ROM postoperatively (p < 0.001). There were no postoperative complications., Conclusions: Sternal fixation is a safe and effective procedure resulting in improved pain, decreased narcotic requirements, and faster recovery., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Rib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time., Methods: Retrospective review of all RF patients from 2016-2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1-2, 3-6, 7-10, 11-12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002., Results: 78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13-27) with Chest Abbreviated Injury Score of 3 (IQR, 3-4). Median time between CT1 and CT2 was 6 days (IQR, 3-12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11-12 in all planes (p < 0.002)., Conclusion: RF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Chest computed tomography (CT) scans are important for the management of rib fracture patients, especially when determining indications for surgical stabilization of rib fractures (SSRFs). Chest CTs describe the number, patterns, and severity of rib fracture displacement, driving patient management and SSRF indications. Literature is scarce comparing radiologist versus surgeon rib fracture description. We hypothesize there is significant discrepancy between how radiologists and surgeons describe rib fractures., Methods: This was an institutional review board-approved, retrospective study conducted at a Level I academic center from December 2016 to December 2017. Adult patients (≥18 years of age) suffering rib fractures with a CT chest where included. Basic demographics were obtained. Outcomes included the difference between radiologist versus surgeon description of rib fractures and differences in the number of fractures identified. Rib fracture description was based on current literature: 1, nondisplaced; 2, minimally displaced (<50% rib width); 3, severely displaced (≥50% rib width); 4, bicortically displaced; 5, other. Descriptive analysis was used for demographics and paired t test for statistical analysis. Significance was set at p = 0.05., Results: Four hundred and ten patients and 2,337 rib fractures were analyzed. Average age was 55.6(±20.6); 70.5% were male; median Injury Severity Score was 16 (interquartile range, 9-22) and chest Abbreviated Injury Scale score was 3 (interquartile range, 3-3). For all descriptive categories, radiologists consistently underappreciated the severity of rib fracture displacement compared with surgeon assessment and severity of displacement was not mentioned for 35% of rib fractures. The mean score provided by the radiologist was 1.58 (±0.63) versus 1.78 (±0.51) by the surgeon (p < 0.001). Radiologists missed 138 (5.9%) rib fractures on initial CT. The sensitivity of the radiologist to identify a severely displaced rib fracture was 54.9% with specificity of 79.9%., Conclusion: Discrepancy exists between radiologist and surgeon regarding rib fracture description on chest CT as radiologists routinely underappreciate fracture severity. Surgeons need to evaluate CT scans themselves to appropriately decide management strategies and SSRF indications., Level of Evidence: Prognostic/Diagnostic Test, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The traditional treatment of traumatic hemothorax (HTX) has been an insertion of a large-bore 36- to 40-Fr chest tube. Our previous single-center randomized controlled trial (RCT) had shown that 14-Fr percutaneous catheters (PCs) (pigtail) were equally as effective as chest tube. We performed a multicenter RCT, hypothesizing that PCs are as equally effective as chest tubes in the management of patients with traumatic HTX (NCT03546764)., Methods: We performed a multi-institution prospective RCT comparing 14-Fr PCs with 28- to 32-Fr chest tubes in the management of patients with traumatic HTX from July 2015 to September 2020. We excluded patients who were in extremis and required emergent tube placement and those who refused to participate. The primary outcome was failure rate, defined as a retained HTX requiring a second intervention. Secondary outcomes included daily drainage output, tube days, intensive care unit and hospital length of stay, and insertion perception experience (IPE) score on a scale of 1 to 5 (1, tolerable experience; 5, worst experience). Unpaired Student's t test, χ2, and Wilcoxon rank sum test were used with significance set at p < 0.05., Results: After exclusion, 119 patients participated in the trial, 56 randomized to PCs and 63 to chest tubes. Baseline characteristics between the two groups were similar. The primary outcome, failure rate, was similar between the two groups (11% PCs vs. 13% chest tubes, p = 0.74). All other secondary outcomes were also similar, except PC patients reported lower IPE scores (median, 1: "I can tolerate it"; interquartile range, 1-2) than chest tube patients (median, 3: "It was a bad experience"; interquartile range, 2-5; p < 0.001)., Conclusion: Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated., Level of Evidence: Therapeutic, level II., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jtd-21-1198). JD Forrester reports unrestricted research funding from Varian. ZM Bauman is the educational consultant for Zimmer-Biomet and KLS-Martin. AR Doben is the educational consultant for Zimmer-Biomet. E Eriksson is the speaker for Synthes.

Background: Intercostal nerve cryoablation (INCA) coupled with surgical stabilization of rib fractures (SSRF) has been shown to reduce post-operative pain scores but at what monetary cost. We hypothesize that in-hospital outcomes improve with the addition of INCA to SSRF and potential increased hospital charges are justified by patient benefits., Methods: Multi-institutional, retrospective review of patients undergoing SSRF with and without INCA over an 8-year period. Institutions involved were Level II or higher trauma centers. Basic demographics were obtained. Patients were included if SSRF was performed during the index hospitalization. Primary outcomes included total hospital length of stay (HLOS) and HLOS after SSRF, total hospital charges (HC), HC the day of surgery and HC after surgery. Secondary outcome included total narcotic consumption in morphine milliequivalents (MME) after SSRF. Mann-Whitney U test was used for analysis. Statistical significance p < 0.05., Results: 136 patients analyzed; 92 underwent SSRF only and 44 underwent SSRF with INCA. Demographics were similar between groups. Number of ribs stabilized was comparable; 4.78 ± 1.64 SSRF only and 4.73 ± 1.66 SSRF with INCA (p = 0.463). Median ISS [16 (IQR 11.5-16) SSRF only and 14 (IQR 9-18.75) SSRF with INCA (p = 0.463)] was not statistically different. The INCA group showed a decrease in the median total HLOS, 9 versus 10 days (U = 1517.5, p = 0.026) and HLOS after SSRF, 4 versus 6 days (U = 1217.5, p < 0.001). HC the day of surgery were higher for the INCA group, $93,932 versus $71,143 (U = 1106, p < 0.001). However, total HC were similar between groups and total HC after SSRF was significantly less for the INCA group, $10,556 versus $20,269 (U = 1327, p = 0.001). Total median narcotic use after SSRF was significantly less for the INCA group, 88.6 vs 113.7 MME (U = 1544.5, p = 0.026)., Conclusion: SSRF with INCA is safe and does not increase overall HC with the added benefit of decreased HLOS post-operatively and decreased narcotic consumption., Competing Interests: Declaration of Competing Interest Dr. Bauman is a paid educating faculty for Zimmer-Biomet and KLS-Martin. Dr. Kaye is a paid educating faculty for Zimmer-Biomet and Atricure. All other authors have no additional conflicts of interest. All authors contributed substantially to this research project. All authors were fully involved in this research project and collectively designed, conducted and interpreted the data. Furthermore, all authors reviewed and approved the decision to submit this manuscript for publication in its current form. The institutions providing the patient population and data collected were the University of Nebraska Medical Center and Overland Park Regional Medical Center., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32-40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX., Methods: Prospective RCT comparing 14Fr PCs to 28-32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1-5 (1 = tolerable experience, 5 = worst experience). Unpaired Student's t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05., Results: Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375-1087; for PCs vs. 400 ml; IR, 240-700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, "I can tolerate it"; IR, 1-2) than CT patients (median, 3, "It was a bad experience"; IR, 3-4, P = 0.001)., Conclusion: In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28-32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience. www.ClinicalTrials.gov Registration ID: NCT02553434.

Background: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI., Methods: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI., Results: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034)., Conclusion: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI., Level of Evidence: Therapeutic, level IV., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The left ventricle assist device (LVAD) patient population is rapidly expanding. Unique characteristics of these patients complicate the management of noncardiac surgical problems. Emergent general surgery (EGS) intervention is often warranted but remains poorly described. We reviewed EGS consultations in LVAD patients to better understand these patients., Methods: During a 12-year period, 301 LVAD patients were reviewed. Demographics, comorbidities, reason for EGS consultation, operative intervention, transplantation, and mortality were analyzed. Wilcoxon, Fisher's exact, and chi-square tests were used for analysis. Statistical significance was P < .05., Results: A total of 139 (46.2%) patients required EGS consultation. EGS consultations were older (63 vs 57 years; P = .002), primarily Caucasian (86%), and male (83%) with average preimplant cardiac index of 1.84. Comorbidities were similar between those with and without EGS consultation. Gastrointestinal (GI) bleeding was the most common reason for consultation (53%), followed by abdominal pain (22%) and bowel ischemia/obstruction (19%). Of EGS consultations, 77% were on warfarin and 60% on aspirin. Procedures were not withheld: 46% required esophagogastroduodenoscopy (EGD) and 30% required colonoscopy. Surgical intervention was performed in 28% of EGS consults-49% emergent (within 24 hours) and 44% urgent (during hospitalization). Mean time to surgery was 48 days after LVAD placement. EGS intervention precluded 7 (18%) patients from heart transplantation and 10 (26%) patients suffered perioperative mortality. Elevated lactic acid was associated with increased mortality., Conclusion: EGS consultation is necessary in almost half of all LVAD patients, most commonly for GI bleed. EGD/colonoscopy can be safely used to manage the majority of these consultations; one-third will require surgery. High lactic acid is associated with higher mortality. Additional analysis of this population is required for improving surgical management.

Background: Historically, youth violence prevention strategies used deterrence-based programming with limited success. We developed a youth violence prevention program, Dusk to Dawn (D2D), intended to improve youths' recognition of high-risk situations and teach new skills in conflict resolution. The aim of this study was to evaluate the effect of D2D on youths' perceptions of personal risk factors and high-risk situations., Methods: Youth ages 12 years to 18 years were referred to D2D by community-based organizations, probation, or youth detention center. The youth completed a self-report survey before and after participating in D2D., Results: One hundred eight youth participated in D2D. Pretest and posttest results for self-reported personal risk factors and high-risk situations for violence are presented. For personal risk factors, a statistically significant increase in the perception that family (p < 0.01) and other issues (p < 0.05), and a decrease in the perception that school problems (<0.05) were seen as important personal risk factors. For high-risk situations, increases in the perception that peer violence and substance use as high-risk situations were seen as significant at the trend level (p < 0.10). Of the 60% of participants who answered questions regarding satisfaction with D2D, 83.3% agreed or strongly agreed that D2D helped them to better understand violence and 83.3% would recommend D2D to others., Conclusion: Youth violence prevention programming including an explicit discussion of how violence is learned and the role of family, friends, school, and a community in shaping youths' attitudes toward violence can effectively raise awareness of one's own risk factors. Risk factors for youth violence are often preventable or modifiable, making awareness of one's own risk factors a realistic target for youth violence prevention programs., Level of Evidence: Therapeutic/Care Management, Level III.

Purpose: The American College of Surgeons' Rural Trauma Team Development Course (RTTDC) was designed to help rural hospitals optimize a team approach to trauma management recognizing the need for early transfer. Little literature exists on the success of RTTDC achieving its objectives. The purpose of this study was to determine the impact of RTTDC on rural trauma team members., Methods: RTTDC was hosted at seven rural hospitals. A pre-course 30-question Likert survey gauging confidence managing trauma patients was administered to participants. Four weeks following, participants received a post-course survey with corresponding Likert questions and 11 trauma knowledge-based questions. Chi-square, Fisher's exact tests and general linear models were utilized. Statistical significance is set as p < 0.05., Results: 111 participants completed the pre-course survey; 53 (48%) completed the post-course survey. Results presented on a 5-point Likert scale with 1 = "not at all comfortable" to 5 = "extremely comfortable." Participants knowing their role in the trauma team improved by 16% (p = 0.02). Familiarity with the roles of other trauma team members was significantly improved (3.4 vs. 4.15; p < 0.01). Participants comfort with resuscitating trauma patients and managing traumatic brain injury significantly improved (3.29 vs. 3.69; p = 0.01 and 2.62 vs. 3.14; p = 0.004, respectively). Comfortability communicating with the regional trauma center improved significantly (3.64 vs. 4.19; p = 0.004). Participant decision to transfer trauma patients within 15 min of arrival improved by 3.2%. Participants answered 82% of the knowledge-based questions correctly., Conclusion: RTTDC instills confidence in providers at rural hospitals. The information taught is well retained, allowing for quality care and timely patient transfer to the nearest trauma center.

Background: Surgical stabilization of rib fractures (SSRF) is increasingly used for severe rib fractures/flail chest. There are no reports discussing mechanisms of failure of implanted hardware, its clinical presentation, or consequences. The purpose of this study was to evaluate the incidence, presenting signs, and clinical sequela of hardware failure after SSRF., Methods: A multicenter, retrospective study was performed by a group of surgeons with a large SSRF case volume. All cases with known hardware failure from January 1, 2010, to December 31, 2017, were included. The surgeon's experience at the time of hardware implantation, specific implant used, number of failures the surgeon had experienced with the same system, and time from implantation to hardware failure were recorded. Additionally, patient demographics, including age, comorbid conditions, and number and location of rib fractures were recorded. Symptomatology associated with hardware failure and need for explant and/or reimplantation of hardware was also recorded. Nonparametric statistical tests were used to compare cohorts., Results: Of 1,224 patients who underwent SSRF, 38 patients with 233 rib fractures and 279 fracture segments experienced hardware failure and were enrolled in the study. Twelve patients presented more than 3 months following injury. Median age was 54 years old and 34% were active smokers. One hundred forty-four plates were implanted with a median of four plates per patient. Median number of SSRF cases by each surgeon was 100 (range, 1-280). Fractures and hardware failure were most frequent in the anterolateral/lateral region. Hardware failure was mostly due to screw migration and plate fracture. Hardware failure was asymptomatic in 40% and presented as pain in 42% of cases. Fifty-five percent of the cases required explantation of hardware, and only 10% required SSRF again. There was no difference between the acute and chronic fracture cohorts., Conclusion: Hardware failure after SSRF is rare and often asymptomatic. When present, it rarely requires redo SSRF., Level of Evidence: Therapeutic, level V.

Background: The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization. Discussion: This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.

Intestinal volvulus, regardless of location, is a rare disease process, but one that requires high suspicion and timely diagnosis given the increased incidence of intestinal necrosis and potential mortality. Most patients with intestinal volvulus require some form of surgical intervention. However, over the last few decades, the work-up and management of intestinal volvulus has changed given constant advancements in technology and patient care. Most importantly, however, is recognizing the need for emergent versus more elective surgery because this influences the morbidity and mortality for the individual patient., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs., Methods: Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P < 0.05., Results: During the 7-year period, 496 trauma patients required chest drainage for traumatic HTX/HPTX: 307 by CTs and 189 by PCs. PC patients were older (52 ± 21 vs. 42 ± 19, P < 0.001), demonstrated a significantly higher occurrence of blunt trauma (86 vs. 55%, P ≤ 0.001), and had tubes placed in a non-emergent fashion (Day 1 [interquartile range (IQR) 1-3 days] for PC placement vs. Day 0 [IQR 0-1 days] for CT placement, P < 0.001). All primary outcomes of interest were similar, except that the initial drainage output for PCs was higher (425 mL [IQR 200-800 mL] vs. 300 mL [IQR 150-500], P < 0.001). Findings for subgroup analysis among emergent and non-emergent PC placement were also similar to CT placement., Conclusion: PCs had similar outcomes to CTs in terms of failure rate and tube insertion-related complications, and the initial drainage output from PCs was not inferior to that of CTs. The usage of PCs was, however, selective. A future multi-center study is needed to provide additional support and information for PC usage in traumatic HTX/HPTX.