Patterns of serial rib fractures after blunt chest trauma: An analysis of 380 cases

Christian Liebsch, Tina Seiffert, Markus Vlcek, Meinrad Beer, Markus Huber-Lang, Hans-Joachim Wilke, Christian Liebsch, Tina Seiffert, Markus Vlcek, Meinrad Beer, Markus Huber-Lang, Hans-Joachim Wilke

Abstract

Rib fractures represent the most common bone fracture, occurring in 10-20% of all blunt trauma patients and leading to concomitant injuries of the inner organs in severe cases. The purpose of this study was to identify specific serial rib fracture patterns after blunt chest trauma. 380 serial rib fracture cases were investigated. Fractures were assigned to five different locations within the transverse plane. Rib level, fracture type, and dislocation grades were recorded and related to the cause of accident. In total, 3735 rib fractures were identified (9.8 per patient). 54% of the rib fractures were detected on the left thorax. Rib fracture distribution exhibited a hotspot at rib levels 4 to 7 in the lateral and posterolateral segments. On average, most rib fractures occurred in crush/burying injuries (15.8, n = 13) and pedestrian accidents (12.8, n = 13), least in car/truck accidents (8.9, n = 75). In the car/truck accident group, 47% of all rib fractures were in the lateral segment, in case of frontal collision (n = 24) even 60%. Fall injuries (n = 141) entailed mostly posterolateral rib fractures (35%). In case of falls >3 m (n = 45), 48% more rib fractures were detected on the left thorax. In cardiopulmonary resuscitation related serial rib fractures (n = 33), 70% of all rib fractures were located anterolaterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all rib fractures were dislocated (15% ≥ rib width). Serial rib fractures showed distinct fracture patterns depending on the cause of accident. When developing a serial rib fracture classification system, data regarding patterns, fracture types, dislocation grades, and associated fractures should be included.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Exemplary illustration of the rib…
Fig 1. Exemplary illustration of the rib fracture localization using the method of Ritchie et al. (2006).
Fig 2. Heat maps illustrating the rib…
Fig 2. Heat maps illustrating the rib fracture distributions on the rib cage in frontal view for the overall collective and the cardiopulmonary resuscitation group.
R/L = right/left side of the rib cage, RL = rib level, P = posterior, PL = posterolateral, LA = lateral, AL = anterolateral, A = anterior.
Fig 3. Heat maps illustrating the rib…
Fig 3. Heat maps illustrating the rib fracture distributions on the rib cage in frontal view for the car/truck accident group and its subgroup of frontal collisions as well as the fall groups including falls from low height and falls from great height.
R/L = right/left side of the rib cage, RL = rib level, P = posterior, PL = posterolateral, L = lateral, AL = anterolateral, A = anterolateral.
Fig 4. Heat maps illustrating the fracture…
Fig 4. Heat maps illustrating the fracture distribution on the rib cage in frontal view for patients with and without flail chest.
R/L = right/left side of the rib cage, RL = rib level, P = posterior, PL = posterolateral, L = lateral, AL = anterolateral, A = anterolateral.
Fig 5. Possible fracture mechanisms causing the…
Fig 5. Possible fracture mechanisms causing the detected specific fracture patterns in cases of cardiopulmonary resuscitations (~70% anterolateral rib fractures), frontal collisions (~60% lateral rib fractures), and falls (~40% posterolateral rib fractures).

References

    1. Shorr R, Crittenden M, Indeck M, Hartunian S, Rodriguez A. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg. 1987; 206: 200–205. 10.1097/00000658-198708000-00013
    1. Narayanan R, Kumar S, Gupta A, Bansal V, Sagar S, Singhal M, et al. An Analysis of Presentation, Pattern and Outcome of Chest Trauma Patients at an Urban Level 1 Trauma Center. Indian J Surg. 2018; 80: 36–41. 10.1007/s12262-016-1554-2
    1. Ziegler D, Agarwal N. The morbidity and mortality of rib fractures. J Trauma. 1994; 37: 975–979. 10.1097/00005373-199412000-00018
    1. Amponsah G, Gorleku P. Bony injuries in trauma patients diagnosed by radiological examination. Ghana Med J. 2015; 49: 97–101. 10.4314/gmj.v49i2.6
    1. Flagel B, Luchette F, Reed R, Esposito T, Davis K, Santaniello J, et al. Half-a-dozen ribs: The breakpoint for mortality. Surgery. 2005; 138: 717–723. 10.1016/j.surg.2005.07.022
    1. Shelat V, Eileen S, John L, Teo L, Vijayan A, Chiu M. Chronic pain and its impact on quality of life following a traumatic rib fracture. Eur J Trauma Emerg Surg. 2012; 38: 451–455. 10.1007/s00068-012-0186-x
    1. Rabiou S, Ouadnouni Y, Lakranbi M, Traibi A, Antoini F, Smahi M. Chronic chest pain after rib fracture: It can cause a disability? Rev Pneumol Clin. 2018; 74: 89–95. 10.1016/j.pneumo.2017.08.001
    1. Caragounis E, Fagevik Olsen M, Pazooki D, Granhed H. Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study. World J Emerg Surg. 2016; 11:27 10.1186/s13017-016-0085-2
    1. Karadayi S, Nadir A, Sahin E, Celik B, Arslan S, Kaptanoglu M. An analysis of 214 cases of rib fractures. Clinics. 2011; 66: 449–451. 10.1590/S1807-59322011000300015
    1. Nirula R, Diaz JJ, Trunkey D, Mayberry J. Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009; 33: 14–22. 10.1007/s00268-008-9770-y
    1. Sirmali M, Türüt H, Topçu S, Gülhan E, Yazici U, Kaya S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003; 24: 133–138. 10.1016/s1010-7940(03)00256-2
    1. Dunham C, Hileman B, Ransom K, Malik R. Trauma patient adverse outcomes are independently associated with rib cage fracture burden and severity of lung, head, and abdominal injuries. Int J Burns Trauma. 2015; 5: 46–55.
    1. Shweiki E, Klena J, Wood G, Indeck M. Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients. J Trauma. 2001; 50: 684–688. 10.1097/00005373-200104000-00015
    1. Al-Hassani A, Abdulrahman H, Afifi I, Almadani A, Al-Den A, Al-Kuwari A, et al. Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury. Am Surg. 2010; 76: 888–891.
    1. Van Vledder M, Kwakernaak V, Hagenaars T, Van Lieshout E, Verhofstad M. Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study. Eur J Trauma Emerg Surg. 2019; 45: 575–583. 10.1007/s00068-018-0969-9
    1. Kralj E, Podbregar M, Kejzar N, Balazic J. Frequency and number of resuscitation related rib and sternum fractures are higher than generally considered. Resuscitation. 2015; 93: 136–141. 10.1016/j.resuscitation.2015.02.034
    1. Olds K, Byard R, Langlois N. Injuries associated with resuscitation—An overview. J Forensic Leg Med. 2015; 33: 39–43. 10.1016/j.jflm.2015.04.003
    1. Koga Y, Fujita M, Yagi T, Nakahara T, Miyauchi T, Kaneda K, et al. Effects of mechanical chest compression device with a load-distributing band on post-resuscitation injuries identified by post-mortem computed tomography. Resuscitation. 2015; 96: 226–231. 10.1016/j.resuscitation.2015.08.013
    1. Lardi C, Egger C, Larribau R, Niquille M, Mangin P, Fracasso T. Traumatic injuries after mechanical cardiopulmonary resuscitation (LUCAS2): a forensic autopsy study. Int J Legal Med. 2015; 129: 1035–1042. 10.1007/s00414-015-1146-x
    1. Viano D, Lau I, Asbury C, King A, Begeman P. Biomechanics of the human chest, abdomen, and pelvis in lateral impact. Accid Anal Prev. 1989; 21: 553–574. 10.1016/0001-4575(89)90070-5
    1. Asbun H, Irani H, Roe E, Bloch J. Intra-abdominal seatbelt injury. J Trauma. 1990; 30: 189–193.
    1. Crandall J, Kent R, Patrie J, Fertile J, Martin P. Rib fracture patterns and radiologic detection—a restraint-based comparison. Annu Proc Assoc Adv Automot Med. 2002; 44: 235–259.
    1. Wallis L, Greaves I. Injuries associated with airbag deployment. Emerg Med J. 2002; 19: 490–493. 10.1136/emj.19.6.490
    1. Lee E, Craig M, Scarboro M. Real-world rib fracture patterns in frontal crashes in different restraint conditions. Traffic Inj Prev. 2015; 16 Suppl 2: S115–S123.
    1. Ritchie N, Wang S, Sochor M, Schneider L. A method for documenting locations of rib fractures for occupants in real-world crashes using medical computed tomography (CT) scans. SAE Technical Paper. 2006; 2006-01-0250.
    1. Kindig M, Kent R. Characterization of the centroidal geometry of human ribs. J Biomech Eng. 2013; 135: 111007–1-9. 10.1115/1.4025329
    1. Pinto D, Haden-Pinneri K, Love J. Manual and automated cardiopulmonary resuscitation (CPR): a comparison of associated injury patterns. J Forensic Sci. 2013; 58: 904–909. 10.1111/1556-4029.12146
    1. Dunham G, Perez-Girbes A, Bolster F, Sheehan K, Linnau K. Use of whole body CT to detect patterns of CPR-related injuries after sudden cardiac arrest. Eur Radiol. 2018; 28: 4122–4127. 10.1007/s00330-017-5117-0
    1. Kim MJ, Park YS, Kim S, Yoon Y, Lee K, Lim T, et al. Chest injury following cardiopulmonary resuscitation: A prospective computed tomography evaluation. Resuscitation. 2013; 84: 361–364. 10.1016/j.resuscitation.2012.07.011
    1. Yang K, Lynch M, O'Donnell C. "Buckle" rib fracture: An artifact following cardio-pulmonary resuscitation detected on postmortem CT. Leg Med. 2011; 13: 233–239.
    1. Casali M, Battistini A, Blandino A, Cattaneo C. The injury pattern in fatal suicidal falls from a height: An examination of 307 cases. Forensic Sci Int. 2014; 244: 57–62. 10.1016/j.forsciint.2014.08.004
    1. Isbister E, Roberts J. Autokabalesis: a study of intentional vertical deceleration injuries. Injury. 1992; 23: 119–122. 10.1016/0020-1383(92)90046-u
    1. Atanasijevic T, Popovic V, Nikolic S. Characteristics of chest injury in falls from heights. Leg Med. 2009; 11 Suppl 1: S315–S317.
    1. Daegling D, Warren M, Hotzman J, Self C. Structural analysis of human rib fracture and implications for forensic interpretation. J Forensic Sci. 2008; 53: 1301–1307. 10.1111/j.1556-4029.2008.00876.x
    1. Holcomb J, McMullin N, Kozar R, Lygas M, Moore F. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003; 196: 549–555. 10.1016/S1072-7515(02)01894-X
    1. Lin F, Li R, Tung Y, Jeng K, Tsai S. Morbidity, mortality, associated injuries, and management of traumatic rib fractures. J Chin Med Assoc. 2016; 79: 329–334. 10.1016/j.jcma.2016.01.006
    1. Lee R, Bass S, Morris J, MacKenzie E. Three or more rib fractures as an indicator for transfer to a Level I trauma center: A population-based study. J Trauma. 1990; 30: 689–694. 10.1097/00005373-199006000-00006
    1. Baker C, Oppenheimer L, Stephens B, Lewis F, Trunkey D. Epidemiology of trauma deaths. Am J Surg. 1980; 140: 144–150. 10.1016/0002-9610(80)90431-6

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