Available online 13 April 2024, 111562

Author links open overlay panel, , , , , , , AbstractBackground

Optimal treatment of patients with rib fractures requires identification of those patients at risk of pulmonary complications. It is also important to determine which patients would benefit from Surgical Stabilisation of Rib Fractures (SSRF). This study aims to validate two scoring systems (RibScore and SCARF score) in predicting complications and association with SSRF in an Australian trauma population. Clinical observation suggests that complications and criteria for SSRF is associated with anatomical and physiological factors. Therefore it is hypothesized that utilisation of an anatomical (RibScore) and physiological (SCARF) in conjunction will have improved predictive ability.

Method

Retrospective cohort study of rib fracture patients admitted to an Australian Level I trauma centre from Jan 2017 to Jan 2021. RibScore and SCARF score were calculated. Multivariate logistic regression was performed to determine risk factors associated with complications and SSRF, as well the scoring systems’ ability via ROC AUC.

Results

1157 patients were included. Higher median RibScore (1vs0; p<0.001) and SCARF score (3vs1, p<0.001) was associated with development of complications. Similarly for SSRF, RibScore (3vs0; p<0.001), SCARF score (3vs1; p<0.001) were higher. On multivariate analysis, increasing RibScore and SCARF score were associated with an increased risk of respiratory failure, pneumonia, death, and SSRF. The sensitivity for a patient with a high risk score in either RibScore or SCARF increased to 96.3% in identifying pulmonary complications (from 66.7% in RibScore and 88% in SCARF, when used individually) and 91.9% in identifying association with SSRF (from 86.5% in RibScore and 70.3% in SCARF).

Conclusion

RibScore and SCARF score demonstrate predictive ability for complications and SSRF in an Australian trauma rib fracture population. Combining a radiological score with a clinical scoring system demonstrates improved sensitivity over each score individually for identifying patients at risk of complications from rib fractures, those who may require SSRF, and those who are low risk.

Study type

: Retrospective Cohort Study

Level of evidence

: Level III

Section snippetsIntroduction/Background

Rib fractures are present in approximately 10-40% of all trauma cases and severe chest wall injury as defined by 3 or more rib fractures, is associated with a high risk of significant morbidity.[1], [2], [3] The sequalae of these injuries include pain and splinting leading to atelectasis and impaired clearance of secretions, which in turn results in pneumonia and respiratory compromise.[3] Additional complications of rib fractures include pneumothorax, haemothorax and pulmonary contusions.[2]

Methods

This retrospective cohort study examined data from a Level 1 Trauma Centre in Australia between 1st January 2017 to 31st January 2021. Patients aged 16 or above, diagnosed with rib fractures and a chest wall abbreviated injury scale (AIS) ≥3 were identified from the trauma registry. Exclusion criteria included patients with severe brain injury (defined as head injury AIS ≥ 3) and those with penetrating chest trauma. Approval was granted as a part of quality improvement project by the Western

RESULTS

A total of 1157 patients met inclusion criteria. One hundred and seventy nine patients were excluded due to unavailable electronic records, incorrect diagnosis, delayed presentation, incomplete care period (transferred to other facility, transfer of care to another specialty before day 3 or discharge against medical advice) or missing RibScore / SCARF (exclusions not necessarily mutually exclusive). After mentioned exclusions, 978 patients remained for data analysis.

Patient characteristics and

DISCUSSION

In this retrospective cohort study, we assessed the predictive capability of two scoring systems, RibScore and SCARF, in its association with SSRF and pulmonary complications. Optimal RibScore and SCARF cut-off's in our population were determined and compared to original cut-off's. In addition, we examined if both scores could be utilised concurrently to improve accuracy and clinical decision making in rib fracture patients.

Our analysis demonstrates that both RibScore and SCARF are sensitive to

Conclusion

In conclusion the RibScore and SCARF have good capability in predicting complications and SSRF in rib fracture patients. The utilisation of the two scores together increases the sensitivity of predicting complications and SSRF even further. RibScore and SCARF have the potential to be incorporated into assessment of rib fracture patients early in admission to determine prognostic and disposition decisions. We recommend that these scores be incorporated into future studies or trials in rib

Presentations

Findings of this study has been presented at the 2022 Chest Wall Injury Society (CWIS) Summit in Utah, USA, the 2022 Royal Australian College of Surgeons (RACS) Annual Scientific Congress in Brisbane, Australia, and 2021 SA/NT training committee registrar paper day

Funding

The authors declare that they have no financial disclosures.

Supplemental Digital Content

Supplemental Digital Content (SDC) contains STROBE and TRIPOD checklists, as well as conflict of interest disclosure statements.

Supplemental Figure 1. SROBE and TRIPOD checklist

CRediT authorship contribution statement

Kabytto Chen: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Data curation. Bayan Minasian: Writing – review & editing, Data curation, Conceptualization. Evangeline Woodford: Methodology, Investigation, Formal analysis, Conceptualization. Pranav Shivashankar: Investigation, Data curation. Kah Ann Ho: Writing – review & editing, Investigation, Conceptualization. Saimurooban Muralidaran: Writing – review & editing, Methodology. James

Declaration of competing interest

JH has an ongoing consultancy/education agreement with Acumed, Hillsboro, OR USA and Depuy Synthes, Raynham, MA USA

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