Top

European Journal of Trauma and Emergency Surgery

Published in:

01-02-2022 | Thoracic Trauma | Original Article

Iatrogenic rib fractures and the associated risks of mortality

Authors: Max R. Coffey, Katelynn C. Bachman, Vanessa P. Ho, Stephanie G. Worrell, Matthew L. Moorman, Philip A. Linden, Christopher W. Towe

Published in: European Journal of Trauma and Emergency Surgery | Issue 1/2022

Abstract

Purpose

Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures.

Methods

Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression.

Results

34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings.

Conclusion

IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity.

Available only for authorised users

Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma Inj Infect Crit Care. 1994;37:975–9. https://doi.org/10.1097/00005373-199412000-00018.CrossRef

Liman S, Kuzucu A, Tastepe A, Ulasan G, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003;23:374–8. https://doi.org/10.1016/s1010-7940(02)00813-8.CrossRefPubMed

Sirmali M, Trürüt H, Topçu S, Gülhan E, Yazici Ü, Kaya S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24:133–8. https://doi.org/10.1016/S1010-7940(03)00256-2.CrossRefPubMed

Shweiki E, Klena J, Wood GC, Indeck M. Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients. J Trauma Inj Infect Crit Care. 2001;50:684–8. https://doi.org/10.1097/00005373-200104000-00015.CrossRef

Tran H-V, Charles M, Garrett RC, Kempe PW, Howard CA, Khorgami Z. Ten-year trends in traumatic cardiac injury and outcomes: a trauma registry analysis. Ann Thorac Surg. 2020. https://doi.org/10.1016/j.athoracsur.2019.12.038.CrossRefPubMed

Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138:717–25. https://doi.org/10.1016/j.surg.2005.07.022.CrossRefPubMed

Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation. 2014;85:724–31. https://doi.org/10.1016/j.resuscitation.2014.01.028.CrossRefPubMedPubMedCentral

Olds K, Byard RW, Langlois NEI. Injuries associated with resuscitation—an overview. J Forensic Leg Med. 2015;33:39–43. https://doi.org/10.1016/j.jflm.2015.04.003.CrossRefPubMed

Setälä P, Hellevuo H, Huhtala H, Kämäräinen A, Tirkkonen J, Hoppu S. Risk factors for cardiopulmonary resuscitation-related injuries sustained during out-of-hospital cardiac arrests. Acta Anaesthesiol Scand. 2018;62:1290–6. https://doi.org/10.1111/aas.13155.CrossRefPubMed

10.

Thompson M, Langlois NEI, Byard RW. Flail chest following failed cardiopulmonary resuscitation. J Forensic Sci. 2017;62:1220–2. https://doi.org/10.1111/1556-4029.13411.CrossRefPubMed

11.

Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski MF, et al. Part 5: adult basic life support: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S685-705. https://doi.org/10.1161/circulationaha.110.970939.CrossRefPubMed

12.

Beom JH, You JS, Kim MJ, Seung MK, Park YS, Chung HS, et al. Investigation of complications secondary to chest compressions before and after the 2010 cardiopulmonary resuscitation guideline changes by using multi-detector computed tomography: a retrospective study. Scand J Trauma Resusc Emerg Med. 2017;25:8. https://doi.org/10.1186/s13049-017-0352-6.CrossRefPubMedPubMedCentral

13.

National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2012.

14.

Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8–27. https://doi.org/10.1097/00005650-199801000-00004.CrossRefPubMed

15.

Chu Y-T, Ng Y-Y, Wu S-C. Comparison of different comorbidity measures for use with administrative data in predicting short- and long-term mortality. BMC Health Serv Res. 2010;10:140. https://doi.org/10.1186/1472-6963-10-140.CrossRefPubMedPubMedCentral

16.

Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med. 1991;324:370–6. https://doi.org/10.1056/NEJM199102073240604.CrossRefPubMed

17.

Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200. https://doi.org/10.1001/jama.279.15.1200.CrossRefPubMed

18.

Haines KL, Zens T, Warner-Hilliard C, DeSouza E, Jung HS, Agarwal S. Rib fracture location should be evaluated when predicting morbidity and mortality in trauma patients. Am Surg. 2018;84:1462–5. https://doi.org/10.1177/000313481808400950.CrossRefPubMed

19.

Zehr M, Klar N, Malthaner RA. Risk score for predicting mortality in flail chest. Ann Thorac Surg. 2015;100:223–8. https://doi.org/10.1016/j.athoracsur.2015.03.090.CrossRefPubMed

20.

Enarson DA, Didier EP, Gracey DR. Flail chest as a complication of cardiopulmonary resuscitation. Heart Lung. 1977;6:1020–2.PubMed

21.

Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB. Rib fracture fixation in the 65 years and older population. J Trauma Acute Care Surg. 2017;82:524–7. https://doi.org/10.1097/TA.0000000000001330.CrossRefPubMed

22.

Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma Inj Infect Crit Care. 2000;48:1040–7. https://doi.org/10.1097/00005373-200006000-00007.CrossRef

23.

Gumbs RV, Peniston RL, Nabhani HA, Henry LJ. Rib fractures complicating median sternotomy. Ann Thorac Surg. 1991;51:952–5. https://doi.org/10.1016/0003-4975(91)91012-K.CrossRefPubMed

24.

Tirone L, LaRusca I, Ciccarelli F. Rib fracture as a complication of tissue expansion in breast reconstruction. Plast Reconstr Surg. 2010;126:2290–1. https://doi.org/10.1097/PRS.0b013e3181f61b56.CrossRefPubMed

25.

Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, et al. Deeper chest compression—more complications for cardiac arrest patients? Resuscitation. 2013;84:760–5. https://doi.org/10.1016/j.resuscitation.2013.02.015.CrossRefPubMed

26.

Baubin M, Kollmitzer J, Pomaroli A, Kraincuk P, Kranzl A, Sumann G, et al. Force distribution across the heel of the hand during simulated manual chest compression. Resuscitation. 1997;35:259–63. https://doi.org/10.1016/S0300-9572(97)00040-3.CrossRefPubMed

27.

Oschatz E, Wunderbaldinger P, Sterz F, Holzer M, Kofler J, Slatin H, et al. Cardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography. Anesth Analg. 2001;93:128–33. https://doi.org/10.1097/00000539-200107000-00027.CrossRefPubMed

28.

Seung MK, You JS, Lee HS, Park YS, Chung SP, Park I. Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest. Resuscitation. 2016;98:64–72. https://doi.org/10.1016/j.resuscitation.2015.11.004.CrossRefPubMed

29.

Smith G, Beger S, Vadeboncoeur T, Chikani V, Walter F, Spaite DW, et al. Trends in overdose-related out-of-hospital cardiac arrest in Arizona. Resuscitation. 2019;134:122–6. https://doi.org/10.1016/j.resuscitation.2018.10.019.CrossRefPubMed

30.

May T, Gagnon D, Seder DB, West B, Lerwick P, Sholl M, et al. Opioid-related cardiac arrest incidence and epidemiology in Maine. Circulation. 2019;140:A230.CrossRef

31.

Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma. J Trauma Acute Care Surg. 2017;82:618–26. https://doi.org/10.1097/TA.0000000000001350.CrossRefPubMed

32.

Pieracci FM, Leasia K, Bauman Z, Eriksson EA, Lottenberg L, Majercik S, et al. A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma Acute Care Surg. 2020;88:249–57. https://doi.org/10.1097/TA.0000000000002559.CrossRefPubMed

33.

Schulz-Drostl S, Grupp S, Pachowsky M, Oppel P, Krinner S, Mauerer A, Hennig FF, Langenback A. Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability. Eur J Trauma Emerg Surg. 2017;43:169–78. https://doi.org/10.1007/s00068-016-0664-7.CrossRef

34.

Prins JT, Van Lieshout EM, Eriksson EA, Wijffels MM. Surgical stabilization of rib fractures in adults with multiple rib fractures after cardiopulmonary resuscitation (CPR); a Chest Wall Injury Society multicenter retrospective matched case-control study (CWIS-CPR). Chest Wall Injury Society. 2020.

Title: Iatrogenic rib fractures and the associated risks of mortality
Authors: Max R. Coffey
Katelynn C. Bachman
Vanessa P. Ho
Stephanie G. Worrell
Matthew L. Moorman
Philip A. Linden
Christopher W. Towe
Publication date: 01-02-2022
Publisher: Springer Berlin Heidelberg
Keywords: Thoracic Trauma
Intoxication
Rib Fracture
Thoracic Trauma
Tracheostomy
Cardiopulmonary Resuscitation
Published in: European Journal of Trauma and Emergency Surgery / Issue 1/2022
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-020-01598-5

At a glance: The STEP trials

Springer Medicine

Iatrogenic rib fractures and the associated risks of mortality

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2022

Thoracoabdominal injuries after a bomb explosion: blast injuries and their clinical effects

Survey of trauma patients injured by falling or flying objects in Japan based on the Japan Trauma Data Bank

The role of bed-side laparoscopy in the management of acute mesenteric ischemia of recent onset in post-cardiac surgery patients admitted to ICU

Avascular necrosis of the femoral head after traumatic posterior hip dislocation with and without acetabular fracture

β1-Blocker improves survival and ventricular remodelling in rats with lethal crush injury

Characteristics of pediatric thoracic trauma: in view of before and after the establishment of a regional trauma center