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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.

Background: Rib fractures are common in trauma patients, often leading to complications such as pneumonia and prolonged hospitalization. Surgical Stabilization of Rib Fractures (SSRF) has become increasingly prevalent in treating severe cases. However, traditional approaches, like posterolateral thoracotomy, are invasive and cause significant muscle damage. Recently, muscle-sparing minimally invasive techniques have been introduced, yet they still require advanced reduction and fixation techniques to avoid complications. This study presents an "ultra" minimally invasive SSRF (uMI-SSRF) technique designed to minimize surgical wounds and soft tissue damage while maintaining the benefits of rib fixation. Methods: This study involved 76 patients with multiple rib fractures treated using the uMI-SSRF technique between August 2021 and December 2023. Preoperative chest tomography with 3D reconstruction was used for surgical planning. The technique employed small incisions (3–5 cm), muscle-sparing approaches, and advanced fixation techniques. Data on patient demographics, intraoperative details, and postoperative outcomes were collected. Results: The mean patient age was 58 years, with 66% being male. On average, patients had 6.4 fractured ribs, and 3.5 ribs with 3.88 plates were fixed per surgery, achieving a fixation/fracture ratio of 59%. The average wound length was 4.2 cm, with a mean operation time of 122 min. Most patients required only one incision (74%). The median hospital length of stay was 7 days, with a pneumonia rate of 5%. No wound infections or implant-related complications were observed. Conclusions: The uMI-SSRF technique effectively reduces wound size and soft tissue damage in rib fracture stabilization while maintaining high fixation quality. This method shows promise for improving patient outcomes, reducing recovery time, and minimizing complications. Further studies with larger sample sizes and comparisons with other methods are warranted to verify the advantages of uMI-SSRF. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of the titanium mesh on flail chest and bone healing from clinical and animal experiments. Methods: Clinical experiment: 24 patients with flail chests in our hospital from January 2020 to January 2023 were prospectively selected and divided into control and titanium mesh groups according to different treatment plans and basic data‐matching principles, with 12 cases in each group. The control group was treated with conservative external fixation, and the titanium mesh group was treated with titanium mesh fixation. The clinical efficacy index, visual analog scale and blood gas indexes and hemodynamic indexes of the two groups of patients were recorded. Chest CT and pulmonary function and life quality were examined after operation. Animal experiment: The flail chest sheep were treated conservatively with a titanium mesh, and the expression of bone‐healing‐related proteins was detected. Results: The mechanical ventilation time, drain indwelling time, ICU observation time, and hospital time in the titanium mesh group were significantly shorter than those in the control group (p < 0.05). The PaO2, CVP, FVC, FEV1, MVV, and life quality of the titanium mesh group were significantly better than those of the control group after operation, and the visual analog scale, PaCO2, CI, ELWI, and the proportions of atelectasis, thoracocyllosis, and consolidation tardive after operation were significantly lower than those of the control group (p < 0.05). The expressions of BMP2, IGF‐1, VEGF, and PDGFD in the rib tissue of titanium mesh sheep were higher than those of control sheep at 4 weeks after operation (p < 0.05). Conclusion: Titanium mesh is a safe and effective treatment for flail chest, which can improve pain, blood gas, hemodynamic indexes, and pulmonary function and promote fracture healing. [ABSTRACT FROM AUTHOR]

Background: According to previous studies, a prolonged hospital stay, along with the patient's clinical features, can lead to the onset of disability. Objectives: This study aimed to identify predictive factors of moderate-to-severe disability following hospital discharge in rib fracture patients. Methods: We conducted a retrospective study with hospitalized adult patients with rib fractures who received conservative treatment. Patients' clinical profiles and characteristics were collected from their clinical histories and healthcare professional records. Results: Overall, patients exhibited a 44% rate of moderate-to-severe disability after a six-day hospital stay. The incidence of patients with a prolonged hospital stay who showed disabilities was associated with male sex (HR 0.73, p < 0.001), presence of first rib fracture (HR 1.78, p = 0.047), presence of flail chest (HR 1.29, p = 0.046), severity of lung injury (HR 1.65, p < 0.001), and functional status (HR 1.37, p < 0.001). Conclusions: Moderate-to-severe disability in patients with rib fractures may depend on factors such as sex, functionality, severity of lung injury, and presence of first rib fracture and flail chest during a prolonged hospital stay. [ABSTRACT FROM AUTHOR]

Abstract Background Rib fractures are common in trauma patients, often leading to complications such as pneumonia and prolonged hospitalization. Surgical Stabilization of Rib Fractures (SSRF) has become increasingly prevalent in treating severe cases. However, traditional approaches, like posterolateral thoracotomy, are invasive and cause significant muscle damage. Recently, muscle-sparing minimally invasive techniques have been introduced, yet they still require advanced reduction and fixation techniques to avoid complications. This study presents an “ultra” minimally invasive SSRF (uMI-SSRF) technique designed to minimize surgical wounds and soft tissue damage while maintaining the benefits of rib fixation. Methods This study involved 76 patients with multiple rib fractures treated using the uMI-SSRF technique between August 2021 and December 2023. Preoperative chest tomography with 3D reconstruction was used for surgical planning. The technique employed small incisions (3–5 cm), muscle-sparing approaches, and advanced fixation techniques. Data on patient demographics, intraoperative details, and postoperative outcomes were collected. Results The mean patient age was 58 years, with 66% being male. On average, patients had 6.4 fractured ribs, and 3.5 ribs with 3.88 plates were fixed per surgery, achieving a fixation/fracture ratio of 59%. The average wound length was 4.2 cm, with a mean operation time of 122 min. Most patients required only one incision (74%). The median hospital length of stay was 7 days, with a pneumonia rate of 5%. No wound infections or implant-related complications were observed. Conclusions The uMI-SSRF technique effectively reduces wound size and soft tissue damage in rib fracture stabilization while maintaining high fixation quality. This method shows promise for improving patient outcomes, reducing recovery time, and minimizing complications. Further studies with larger sample sizes and comparisons with other methods are warranted to verify the advantages of uMI-SSRF.

Abstract 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.

Abstract Background Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. Methods A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. Results From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I 2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P

Introduction: Rib fractures commonly occur in trauma patients with varying presentations. Though the literature in recent years has moved toward favoring more early intervention of acute rib fractures, little has been reported on the matter of surgical fixation for symptomatic rib fracture nonunions. Materials and methods: We performed a review of PubMed and Cochrane databases for articles published since 2000. Inclusion criteria were studies with greater than six months of follow-up, while case studies were excluded. A thorough analysis was performed on patient outcomes, complications reported, operative techniques utilized, and fixation systems used, among other parameters reported by the articles. Results: One hundred and thirty-nine studies resulted from our review, and a total of nine studies met our inclusion criteria with a combined total of 182 patients who underwent open reduction and internal fixation for symptomatic rib fracture nonunions. All studies reported a significant reduction of pain with increased satisfaction in the majority of patients. There were a total of 71 postoperative complications, the most common of which included surgical site infections, hardware failure, and hematoma. The most serious complications were insulting injury to the lung parenchyma or pleura; however, these were extremely rare based off the current literature. The use of bone grafting was common with eight of the nine studies mentioning the benefits of grafting. Conclusion: Surgical stabilization of rib fracture nonunions appears to be an appropriate treatment alternative, and various techniques and approaches may be used with similar success. Further studies with higher level of evidence are recommended on the subject. [ABSTRACT FROM AUTHOR]

Background: Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures. Methods: A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research. Results: From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence. Conclusion: Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients. Systematic review registration: UMIN Clinical Trials Registry UMIN000049365. [ABSTRACT FROM AUTHOR]

Copyright of Die Unfallchirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Die Unfallchirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Background Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries. Methods Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes. Results Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility. Conclusions The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes.

Flail chest (FC) after blunt trauma is associated with significant morbidity and prolonged hospitalizations. The goal of this study was to examine the relationship between timing of rib fixation (ORIF) and pulmonary morbidity and mortality in patients with FC. FC patients were identified from the Trauma Quality Improvement Program database over 3-year, ending 2019. Demographics, severity of injury and shock, time to ORIF, pulmonary morbidity, and mortality were recorded. Youden's index identified optimal time to ORIF. Patients were compared based on undergoing ORIF versus nonoperative management, then for patients undergoing ORIF based on time from admission to operation, utilizing Youden's index to determine the preferred time for fixation. Multivariable logistic regression determined predictors of pulmonary morbidity and mortality. 20,457 patients were identified: 3347 (16.4%) underwent ORIF. The majority were male (73%) with median age and injury severity score of 58 and 22, respectively. Patients undergoing ORIF were clinically similar to those managed nonoperatively but had increased pulmonary morbidity (27.6 versus 15.2%, P < 0.0001) and reduced mortality (2.9 versus 11.7%, P < 0.0001). Multivariable logistic regression identified ORIF as the only modifiable risk factor significantly associated with reduced mortality (odds ratio: 0.26; 95% CI:0.21-0.32, P < 0.0001). Youden's index identified the inflection point for time to ORIF as 4 d postinjury: EARLY (≤4 d) and LATE (>4 d). EARLY fixation was associated with a significant decrease in ventilator days, intensive care unit and hospital length of stay, and pulmonary morbidity. Patients undergoing ORIF for FC experienced increased pulmonary morbidity; however, had an associated reduced mortality benefit compared to the nonoperative cohort. EARLY ORIF was associated with a reduction in pulmonary morbidity, without impacting the mortality benefit found with ORIF. Thus, for patients with FC, ORIF performed within 4 d postinjury may help reduce pulmonary morbidity, length of stay, and mortality. [ABSTRACT FROM AUTHOR]

Background: Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries. Methods: Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes. Results: Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility. Conclusions: The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes. Highlights: Current metal prosthesis surgical fixation requires division of intercostal muscles, which may lead to neurovascular injuries and chronic pain. Metal plate stabilization from the inward facing side of the rib avoids muscle division, and only needs a cut through a thin layer of periosteum to expose the bones. A flexible soft shaft extension screwdriver can be bent, twisted, rotated, and turned into narrow space and dead end. It can be used with VATS in surgical rib fixation. [ABSTRACT FROM AUTHOR]

Purpose: Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. Methods: Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. Results: Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD − 4.34, 95% CI – 6.98, − 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI − 13.51, 4.84); length of intensive care unit stay (WMD − 4.62, 95% CI − 7.19, − 2.05; p < 0.01; I2 = 78%; GRADE: low; PI − 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD − 5.39, 95% CI − 11.38, − 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI − 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. Conclusions: Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures. [ABSTRACT FROM AUTHOR]

PurposeThe proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18-64 years old) undergoing SSRF.MethodsThe Trauma Quality Improvement Program (2010-2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.ResultsFrom 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p

Abstract Background One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. Methodology A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. Results The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49–16613.52), 6.86 (2.86–16.49), and 1.19 (1.09–1.30), respectively]. Conclusion The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients.

Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65–0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43–0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49–0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46–0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries. [ABSTRACT FROM AUTHOR]

We report a case of chest wall resection for painful chest wall nonunion, 5 years after traumatic flail chest and a first attempt at surgical treatment. The decision was made to perform surgery again after 2 years of unsuccessful well-conducted analgesic treatment. During surgery, we found the same sites of pseudarthrosis and decided to perform parietectomy of the fifth, sixth, and seventh ribs. A Gore-Tex patch was used to bridge the gap created by the resection. In immediate postoperative care, the patient’s pain was quickly and sufficiently eased by stage 1 and 2 pain killers. The results of bone samples taken from the pseudarthrosis sites all found Propionibacterium acnes. Five months after surgery, the patient had considerable improvement in pain sensations. Computed tomography showed healing of ribs, the plate in place, and no sign of complications.

Background: Multiple rib fractures are common in blunt chest trauma. Until recently, most surgical rib fixations for multiple rib fractures were performed via open thoracotomy. However, due to the invasive nature of tissue dissection and the resulting large wound, an alternative endoscopic approach has emerged that minimizes the postoperative complications caused by the manipulation of injured tissue and lung during an open thoracotomy. Methods: Our study concentrated on patients with multiple rib fractures who underwent surgical stabilization of rib fractures (SSRF) between June 2018 and May 2020. We found 27 patients who underwent SSRF using video-assisted thoracoscopic surgery. The study design was a retrospective review of the patients’ charts and surgical records. Results: No intraoperative events or procedure-related deaths occurred. Implant-related irritation occurred in 4 patients, and 1 death resulted from concomitant trauma. The average hospital stay was 30.2±20.1 days, and ventilators were used for 12 of the 22 patients admitted to the intensive care unit. None of the patients experienced major pulmonary complications such as pneumonia or acute respiratory distress syndrome. Conclusion: Minimally invasive rib stabilization surgery with the assistance of a thoracoscope is expected to become more widely used in patients with multiple rib fractures. This method will also assist patients in a quick recovery.

BackgroundFlail chest is a common and serious traumatic condition in thoracic surgery. The treatment of flail chest often includes open reduction and internal fixation, which is relatively traumatic, complicated, and expensive. As three-dimensional (3D) printing technology is widely used in the clinical field, the application of 3D-printed products to chest trauma will become a new treatment option. To date, the use of 3D-printed external fixation guides for flail chests has not been reported. Thus, we aimed to assess the short-term efficacy of a new technology that treated flail chests with an individualized 3D-printed external fixation guide combined with video-assisted thoracoscopic surgery (VATS).Patients and methodsA retrospective analysis was performed on patients with flail chest treated with this new technique at our center from January 2020 to December 2022. The following parameters were included: operative time, thoracic tube extraction time, intensive care unit time, thoracic volume recovery rate, visual analog scale score 1 month postoperatively, and postoperative complication rate. All patients were followed up for at least 3 months.ResultsFive patients (mean age: 45.7 years) were enrolled; they successfully underwent surgery without chest wall deformity and quickly returned to daily life. The average number of rib fractures was 8.4; all patients had lung contusion, hemopneumothorax, and anomalous respiration. The abnormal breathing of all patients was completely corrected on postoperative day 1, and the chest wall was stable. One case experienced mild loosening of the 3D-printed guide postoperatively; however, the overall stability was not affected. The other four cases did not experience such loosening because we replaced the ordinary silk wire with a steel wire. All cases were discharged from the hospital 2 weeks postoperatively and returned to normal life 1 month after the removal of the 3D-printed guide on average. Only one case developed a superficial wound infection postoperatively, and no perioperative death occurred.ConclusionsThe 3D-printed external fixation guide combined with video-assisted thoracoscopic surgery is a novel technique in the treatment of flail chest and is safe, effective, feasible, and minimally invasive, with satisfactory clinical efficacy.

Purpose: The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies. Methods: All adult (≥ 18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed. Results: A total of 223 patients were admitted with concurrent ipsilateral rib and scapula fractures. A total of 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only, and seven patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax and revision surgery) between groups. Conclusion: Injury severity resulted in different treatment modalities. As a result, different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible; however, the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies. [ABSTRACT FROM AUTHOR]

Background: One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. Methodology: A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. Results: The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49–16613.52), 6.86 (2.86–16.49), and 1.19 (1.09–1.30), respectively]. Conclusion: The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients. [ABSTRACT FROM AUTHOR]

Objective: Anterior flail chest frequency represents a significant case of ventilator insufficiency. Surgical stabilization of acute phase of trauma is considered to effectively shorten the period of ventilation compared to conservative treatment using mechanical ventilation. We have applied minimally invasive surgery to stabilize the injured chest wall. Methods: Surgical stabilization of predominantly anterior flail chest segments was performed using one or two bars as per the Nuss procedure, during the acute phase of chest trauma. Data from all patients were examined. Results: Ten patients received surgical stabilization using the Nuss method between 1999 and 2021. All patients had already been mechanically ventilated prior to surgery. The mean period from trauma to surgery was 4.2 days (range, 1–8 days). The number of bars used was one for 7 patients, and two for 3 patients. The mean operation time was 60 min (range, 25–107 min). All patients were extubated from artificial respiration without surgical complications or mortality. Mean total ventilation period was 6.5 days (range, 2–15 days). All bars were removed in a subsequent surgery. No collapses or fracture recurrences were observed. Conclusion: This method is simple and effective for fixed anterior dominant frail segment. [ABSTRACT FROM AUTHOR]

• There is no consensus regarding surgical method when operating on chest wall injuries. • A retrospective study was conducted where an invasive procedure with thoracotomy was compared to a minimally invasive method. • The minimally invasive procedure was superior regarding time in ventilator, intensive care and in hospital. • Patients with minimally invasive surgery had a lower incidence of pneumonia and fewer required tracheostomy. Surgical management of chest wall injuries is a common procedure. However, operative techniques are diverse, and no universal guidelines exist. There is a lack of studies comparing the outcome with different operative techniques for chest wall surgery. The aim of this study was to compare hospital outcomes between patients operated for chest wall injuries with a conventional method with large incisions and often a thoracotomy or a minimally invasive, muscle sparing method. A retrospective study was carried out including patients ≥18 years operated for chest wall injuries 2010–2020. Patients were divided into two groups based on the surgery performed: conventional surgery (C-group) and minimally invasive surgery (M-group). Data on demographics, trauma, surgery, and outcomes were extracted from patient records. Primary outcome was length of stay on mechanical ventilator (MV-LOS). Secondary outcomes were length of stay in intensive care (ICU-LOS) and in hospital (H-LOS), and complications such as re-operation, incidence of empyema, tracheostomy, pneumonia, and mortality. Of 311 included patients, 220 were in the C-group and 91 in the M-group. The groups were similar in demographics and injury pattern. MV-LOS was 0 (0–65) in the C-group vs 0 (0–34) in the M-group (p < 0.001). ICU-LOS and H-LOS were significantly shorter in the M-group as compared to the C-group (p < 0.001), however with a large overlap. Tracheostomy was performed in 22.3% of patients in the C-group vs 5.4% in the M-group (p < 0.001). Pneumonia was diagnosed in 32.3% of patients in the C-group vs 16.1% in the M-group (p = 0.004). In-hospital mortality was lower in the M-group compared to the C-group but there was no difference in mortality within 30 days or a year. Our study indicates that a minimally invasive technique was favorable regarding clinical outcomes for patients operated for chest wall injuries. [ABSTRACT FROM AUTHOR]

PurposeThe proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18-64 years old) undergoing SSRF.MethodsThe Trauma Quality Improvement Program (2010-2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.ResultsFrom 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p

Abstract Background The development of titanium claw plates has made rib osteosynthesis easy to achieve and led to a renewed interest for this surgery. We report the management of patients referred to the intensive care unit (ICU) of a referral center for surgical rib fracture fixation (SRFF) after chest trauma. Methods We performed a retrospective observational cohort study describing the patients’ characteristics and analyzing the determinants of postoperative complications. Results From November 2013 to December 2016, 42 patients were referred to our center for SRFF: 12 patients (29%) had acute respiratory failure, 6 of whom received invasive mechanical ventilation. The Thoracic Trauma Severity Score (TTSS) was 11.0 [9–12], with 7 [5–9] broken ribs and a flail chest in 92% of cases. A postoperative complication occurred in 18 patients (43%). Five patients developed ARDS (12%). Postoperative pneumonia occurred in 11 patients (26%). Two patients died in the ICU. In multivariable analysis, the Thoracic Trauma Severity Score (TTSS) (OR = 1.89; CI 95% 1.12–3.17; p = 0.016) and the Simplified Acute Physiology Score II without age (OR = 1.17; CI 95% 1.02–1.34; p = 0.024) were independently associated with the occurrence of a postoperative complication. Conclusion The TTSS score appears to be accurate for determining thoracic trauma severity. Short and long-term benefit of Surgical Rib Fracture Fixation should be assessed, particularly in non-mechanically ventilated patients.

Abstract A flail chest is one of the possible medical conditions suffered by individuals who were injured in traffic accidents, caused by multiple fractures of the ribs and sternum. Which often results in paradoxical chest movements. The consequence may be respiratory failure and need for long-term mechanical ventilation. Such treatment require Intensive Care Unit and may be associated with the possibility of numerous complications. Modified Nuss procedure was performed in 79-year-old man, a victim of a car crash to obtain stabilization of the flail chest. After compensation of paradoxical movements on the third day it was possible to end mechanical ventilation. A quick procedure dedicated to the congenital deformation of the chest made it possible to avoid long, expensive intensive therapy with possible respiratory complications. The NUSS procedure enables the effective and safe treatment of a flail chest in a selected group of patients.

Rib fractures occur in almost half of blunt chest wall trauma victims in Australia. They are associated with a high rate of pulmonary complications, and consequently, with increased discomfort, disability, morbidity, and mortality. This article summarises thoracic cage anatomy and physiology, and chest wall trauma pathophysiology. Institutional clinical strategies and clinical pathway "bundles of care" are usually available to reduce mortality and morbidity in patients with chest wall injury. This article analyses multimodal clinical pathways and intervention strategies that include surgical stabilisation of rib fractures (SSRF) in thoracic cage trauma patients with severe rib fractures, including flail chest and simple multiple rib fractures. The management of thoracic cage injury should include a multidisciplinary team approach with proper consideration of all potential avenues and treatment modalities (including SSRF) to obtain the best patient outcomes. There is good evidence for the positive prognostic role of SSRF as part of a "bundle of care" in the setting of severe rib fractures such as ventilator-dependent patients and patients with flail chest. However, the use of SSRF in flail chest treatment is uncommon worldwide, although early SSRF is standard practice at our hospital for patients presenting with multiple rib fractures, flail chest, and/or severe sternal fractures. Several studies report that SSRF in patients with multiple simple rib fractures lead to positive patient outcomes, but these studies are mostly retrospective studies or small case–control trials. Therefore, prospective studies and well-designed RCTs are needed to confirm the benefits of SSRF in patients with multiple simple rib fractures, as well as in elderly chest trauma patients where there is scant evidence for the clinical outcomes of SSRF intervention. When initial interventions for severe chest trauma are unsatisfactory, SSRF must be considered taking into account the patient's individual circumstances, clinical background, and prognostic projections. [ABSTRACT FROM AUTHOR]

Thoracic traumas are common in trauma patients and mainly include pulmonary contusion, pulmonary laceration, pneumothorax, hemothorax, rib and sternum fractures and diaphragmatic hernia. The main causes are car accidents, falls and bites. Tachypnea or dyspnea are possible clinical signs, associated with hypovolemic shock and gastrointestinal signs. Thoracic injuries may be overlooked when distracting injuries, such as limb fractures, are present. Thus, thorough clinical examination is mandatory and animals with respiratory failure may require stabilization and emergency surgery. Considering the importance of thoracic trauma in clinical practice, the manuscript aimed to report the case of spurious thoracic hernia associated with traumatic laceration of the caudal lung lobe in a bitch with severe dyspnea after car trauma. After an emergency evaluation and radiographic examinations, a flail chest, rib fractures, pulmonary contusion and severe pneumothorax were diagnosed. After clinical stabilization, surgical treatment was performed to stabilize the flail chest. During surgery, herniation and laceration of the left caudal lobe of the lung were observed, and sutures were performed to correct the pulmonary laceration and stabilize the rib cage, in addition to thoracostomy to control the pneumothorax. In cases of flail chest and lobar entrapment, surgical treatment is essential, as in this case, with the aim of repairing and repositioning the pulmonary lobe and stabilizing the flail chest. Traumatic pulmonary herniation is a possible differential diagnosis in post-traumatic flail chest, as well as repairing the lobe and stabilizing the ribs using sutures are effective surgical treatment techniques. [ABSTRACT FROM AUTHOR]

Introduction: Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. Methods: The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. Results: 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P =.006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P <.001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR.591, P =.005). Conclusion: Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients. [ABSTRACT FROM AUTHOR]

Background: Traumatic flail chest results in respiratory distress and prolonged hospital stay. Timely surgical fixation of the flail chest reduces respiratory complications, decreases ventilator dependence, and shortens hospital stays. Concomitant head injury is not unusual in these patients and can postpone surgical timing due to the need to monitor the status of intracranial injuries. Reducing pulmonary sequelae also assists in the recovery from traumatic brain injury and improves outcomes. No previous evidence supports that early rib fixation can improve the outcome of patients with concomitant flail chest and traumatic brain injury. Research Question: Can early rib fixation improve the outcome of patients with concomitant flail chest and traumatic brain injury? Study Design and Methods: Adult patients with blunt injuries from the Trauma Quality Improvement Project between 2017 and 2019 were eligible for inclusion. Patients were divided into two treatment groups: operative and nonoperative. Inverse probability treatment weighting was used to identify the predictors of mortality and adverse hospital events. Results: Patients in the operative group had a higher intubation rate [odds ratio (OR), 2.336; 95% CI, 1.644-3.318; p < 0.001), a longer length of stay (coefficient ß, 4.664; SE, 0.789; p < 0.001), longer ventilator days (coefficient ß, 2.020; SE, 0.528; p < 0.001), and lower mortality rate (OR], 0.247; 95% CI, 0.135-0.454; p < 0.001). Interpretation: Timely rib fixation can improve the mortality rate of patients with flail chest and a concomitant mild-to-moderate head injury. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to assess trends in management of flail chest injuries over time and to determine impact on patient outcomes. Methods: A retrospective review of data from a prospectively collated database of all trauma patients admitted to a level 1 trauma service in Victoria was conducted. All trauma patients admitted to the hospital between July 2008 and June 2020 with an Abbreviated Injury Scale (AIS) code for flail chest injury were included. Results: Our study included 720 patients, mean age was 59.5 ± 17.3 years old, and 76.5% of patients were male. Length of ICU stay decreased on average by 9 h each year. Regional anaesthesia use increased by 15% per year (0% in 2009 to 36% in 2020) (p < 0.001). Surgical stabilisation of rib fractures increased by 16% per year (2.9% in 2009 to 22.3% in 2020) (p = 0.006). The use of invasive ventilation decreased by 14% per year (70% in 2008 to 27% in 2020) (p < 0.001), and invasive ventilation time decreased by 8 h per year (p = 0.007). Conclusion: Over the past decade, we have seen increasing rates of regional anaesthesia and surgical rib fixation in the management of flail chest. This has resulted in lower requirements for and duration of invasive mechanical ventilation and intensive care unit stay but has not impacted mortality in this patient cohort. [ABSTRACT FROM AUTHOR]

No abstract is available.

IntroductionMost studies about rib fractures focus on mortality and morbidity. Literature is scarce on long term and quality of life (QoL) outcomes. Therefore, we report QoL and long-term outcomes after rib fixation in flail chest patients.MethodsA prospective cohort study of clinical flail chest patients admitted to six level 1 trauma centres in the Netherlands and Switzerland between January 2018 and March 2021. Outcomes included in-hospital outcomes and long-term outcomes, such as QoL measurements 12 months after hospitalization using the EuroQoL five dimensions (EQ-5D) questionnaire.ResultsSixty-one operatively treated flail chest patients were included. Median hospital length of stay was 15 days and intensive care length of stay was 8 days. Sixteen (26%) patients developed pneumonia and two (3%) died. One year after hospitalization the mean EQ5D score was 0.78. Complication rates were low and included hemothorax (6%) pleural effusion (5%) and two revisions of the implant (3%). Implant related irritation was commonly reported by patients (n = 15, 25%).ConclusionsRib fixation for flail chest injuries can be considered a safe procedure and with low mortality rates. Future studies should focus on quality of life rather than solely short-term outcomes.Trial registration: Registered in the Netherlands Trial Register NTR6833 on 13/11/2017 and the Swiss Ethics Committees Registration Number 2019-00668

Background: Spinal ankylosing disorders (SADs) refer to a group of conditions resulting in spontaneous or postsurgical ossification and fusion of the spinal segments. The spine becomes increasingly susceptible to injury over time such that even low-energy trauma can cause a spinal injury. We report two cases of SADs, associated with massive thoracic hemorrhage. Case presentation: The first patient was an 85-year-old male, who suffered from a vehicular crash. He was diagnosed with a fracture of the first lumbar vertebra, accompanied by SADs. Intubation was required, and thoracic drainage tubes were inserted. The patient underwent a massive transfusion and thoracotomy with packing. Despite prompt treatment, the hemorrhage from the vertebral fracture was uncontrolled, and the patient died 180 min after the injury. The second case features an 88-year-old male who fell from a height. He was diagnosed with flail chest, hemothorax, pneumothorax, and a fracture of the eighth thoracic vertebra with SADs. After intubation, four thoracic drainage tubes were placed, and a massive transfusion was conducted. He died after 3 days due to hypoxemia secondary to persistent bleeding of the vertebral fracture for 24 h. Conclusions: The patients died of persistent thoracic hemorrhage, and the sources of bleeding were the fracture site of the spine fractures. Controlling spinal hemorrhage is difficult due to the absence of a bleeding artery, which is managed via trans-arterial embolization. This report emphasized that fracture of SADs could be a fatal disease that requires prompt intervention. [ABSTRACT FROM AUTHOR]

Objective To explore the optimal set of trauma activation criteria predicting paediatric patients' need for acute care following multi-trauma, with particular attention to Glasgow Coma Scale (GCS) cut-off value. Methods A retrospective cohort study of paediatric multi-trauma patients aged 0 to 16 years, performed at a Level 1 paediatric trauma centre. Trauma activation criteria and GCS levels were examined with respect to patients' need for acute care, defined as: direct to operating room disposition, intensive care unit admission, need for acute interventions in the trauma room, or in-hospital death. Results We enrolled 436 patients (median age 8.0 years). The following predicted need for acute care: GCS <14 (adjusted odds ratio [aOR] 23.0, 95% confidence interval [CI]: 11.5 to 45.9, P < 0.001), hemodynamic instability: (aOR 3.7, 95% CI: 1.2-8.1, P = 0.01), open pneumothorax/flail chest (aOR: 20.0, 95% CI: 4.0 to 98.7, P < 0.001), spinal cord injury (aOR 15.4, 95% CI; 2.4 to 97.1, P = 0.003), blood transfusion at the referring hospital (aOR: 7.7, 95% CI: 1.3 to 44.2, P = 0.02) and GSW to the chest, abdomen, neck, or proximal extremities (aOR 11.0, 95% CI; 1.7 to 70.8, P = 0.01). Using these activation criteria would have decreased over- triage by 10.7%, from 49.1% to 37.2% and under-triage by 1.3%, from 4.7% to 3.5%, in our cohort of patients. Conclusions Using GCS<14, hemodynamic instability, open pneumothorax/flail chest, spinal cord injury, blood transfusion at the referring hospital, and GSW to the chest, abdomen, neck of proximal extremities, as T1 activation criteria could decrease over- and under-triage rates. Prospective studies are needed to validate the optimal set of activation criteria in paediatric patients. [ABSTRACT FROM AUTHOR]