Whylookintothis?Ribfracturesareassociatedwithsignificantmorbidityandmortality.Oftentheyareunder-recognisedandunder-treated,leadingtosubsequentcomplicationssuchaspneumonia.Giventhatthechestradiographhasbeenproventobeaninsensitivemethod,lowdose,unenhancedCTThoraxmayhelpwithearlydiagnosisandpotentiallychangeoutcomes.WetrialledearlyCTforribfracturesatourinstitutionoverthelastyearandsoughttoanswersomequestions:(1) Howmanyscansarewedoing?(2) Whoarewescanning?(3) Whatarewedoingaboutthesefractures,ifanything?e.g.open
reductionandinternalfixation,nerveblocks(4) Howlongarethesepatientsstayinginhospitalfor?
MethodsRetrospectiveanalysisofallemergencydepartment(ED)CTThoraxreferralsover12months(Aug2017–Aug2018)forsuspectedtraumaticribfracturesafterminortrauma.Patientspresentingwithmajortraumawereexcluded.Referralcriteriaasbelow.CTreportsandelectronicdischargesummarieswerereviewed.Binarylogisticmodellingwasusedtodeterminepredictorsofribfracture,admissionoroperativefixation.
CTTHORAXFORSUSPECTEDTRAUMATICRIBFRACTURES1yearretrospectivestudyof373scansatamajortraumacentre
JPJen1,RGeevarghese2,MChristie-Large2
ReferralprotocolAge<60- Lowimpact,1-2ribstender,goodA/Eandgoodinspiration–Noimaging- LowimpactandunilateralreducedA/E–CXRfor?pneumothoraxAge>60- Severebruising-CT- Tendernessover3moremoreribs-CT- Painlimitinginspiration-CT2orfewerribfractures:Clinicallyassessiffitfordischarge3moremoreribfracture:Refercardiothoracics
n=373
Nofracture166(45%)
Positive207(55%)
Management
Conservative187(91%)
ORIF9(4%)
Nerveblock11(5%)
Pathway
Admitted157(75%)
Cardiothoracics64(41%)
Medics49(31%)
ED35(22%)
Others9(6%)
Discharged51(25%)
*SubgroupanalysisConservative NerveBlock ORIF
Patients(n) 187 11 9Age(average) 75.7 78.5 69.7Ribfractures(average) 2.5 4 5.6Degreeofdisplacement(mode) Mild Moderate ModeratePulmonarycomplications 15.6% 45% 22%Flailsegment 9.6% 45% 55%Othertraumaticinjuries 14.5% 45% 66%Lengthofstay(days) 5.4 10.1 10.8
Results• 373CTswereidentified:45%werenormal.
91%ofthosewithfracturesreceivedconservativemanagement.
• Averageagewas74.3andagewasasignificantpredictorofribfracture(p<0.01).
• Significantradiologicalpredictorsofadmissionandoperativefixation
were:(i)numberoffracturesand(ii)degreeoffracturedisplacement(p<0.01)
• Surgicallymanagedpatientshadmorefractures,displacement,flail
segments,haemo/pneumothorices,andlongerlengthofstay*.
Discussion• Wedemonstrateahighincidenceofribfracturesinmainlyelderlypatients
presentingtoEDwithminortrauma.Aroundthree-quartersrequiredadmission,likelyalsorelatingtoothercomplexmedicalandsocialproblemsrelatedtofalling.
• Thevastmajorityofribfracturesweremanagedconservatively,althoughwhenpresent,thetotalnumberandseverityofdisplacementwerethemostsignificantradiologicalfeaturesassociatedwithadmissionandsurgicalfixation.
• Thisstudydoesnotchallenge,butinsteadreinforcescurrentdogmathat
suspectedribfracturesafterminortraumadonotnecessarilyrequireurgentimagingin,oroutofhours.IfthepurposeofCTistotriagepatientsintothecorrectadmissionpathwayortofacilitateearlydischarge,itwouldnotseemunwisetotreatsuchpatientsempiricallyandaggressivelywithanalgesiaandoxygensupport,thecorrectmanagementover90%ofthetime.
• Itispatientswithrefractorypain,respiratorydistressorthosewhoarepoorhistoriansthatshouldbeconsideredforearlyCT.Thismayprovetheoptimumstrategyinbalancingclinicalneedandradiologicalservicecapacity.
(1) UniversityHospitalsBirmingham,MindelsohnWay,Birmingham,B152TH
(2) UniversityHospitalCoventryandWarwickshire,CliffordBridgeRoad,Coventry,CV22DX