Download - CT THORAX FOR SUSPECTED TRAUMATIC RIB FRACTURES · trauma were excluded. Referral criteria as below. CT reports and electronic discharge summaries were reviewed. Binary logistic modelling

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

[email protected]