title: Trauma patient adverse outcomes are independently associated with rib cage fracture burden and severity of lung, head, and abdominal injuries.
abstract: OBJECTIVE
  We hypothesized that lung injury and rib cage fracture quantification would be associated with adverse outcomes.
  
  
  METHODS
  Consecutive admissions to a trauma center with Injury Severity Score ≥ 9, age 18-75, and blunt trauma. CT scans were reviewed to score rib and sternal fractures and lung infiltrates. Sternum and each anterior, lateral, and posterior rib fracture was scored 1 = non-displaced and 2 = displaced. Rib cage fracture score (RCFS) = total rib fracture score + sternal fracture score + thoracic spine Abbreviated Injury Score (AIS). Four lung regions (right upper/middle, right lower, left upper, and left lower lobes) were each scored for % of infiltrate: 0% = 0; ≤ 20% = 1, ≤ 50% = 2, > 50% = 3; total of 4 scores = lung infiltrate score (LIS).
  
  
  RESULTS
  Of 599 patients, 193 (32%) had 854 rib fractures. Rib fracture patients had more abdominal injuries (p < 0.001), hemo/pneumothorax (p < 0.001), lung infiltrates (p < 0.001), thoracic spine injuries (p = 0.001), sternal fractures (p = 0.0028) and death or need for mechanical ventilation ≥ 3 days (Death/Vdays ≥ 3) (p < 0.001). Death/Vdays ≥ 3 was independently associated with RCFS (p < 0.001), LIS (p < 0.001), head AIS (p < 0.001) and abdominal AIS (p < 0.001). Of the 193 rib fracture patients, Glasgow Coma Score 3-12 or head AIS ≥ 2 occurred in 43%. A lung infiltrate or hemo/pneumothorax occurred in 55%. Thoracic spine injury occurred in 23%. RCFS was 6.3 ± 4.4 and Death/Vdays ≥ 3 occurred in 31%. Death/Vdays ≥ 3 rates correlated with RCFS values: 19% for 1-3; 24% for 4-6; 42% for 7-12 and 65% for ≥ 13 (p < 0.001). Death/Vdays ≥ 3 was independently associated with RCFS (p = 0.02), LIS (p = 0.001), head AIS (p < 0.001) and abdominal AIS (p < 0.001). Death/Vdays ≥ 3 association was better for RCFS (p = 0.005) than rib fracture score (p = 0.08) or number of fractured ribs (p = 0.80).
  
  
  CONCLUSIONS
  Rib fracture patients have increased risk for truncal injuries and adverse outcomes. Adverse outcomes are independently associated with rib cage fracture burden. Severity of head, abdominal, and lung injuries also influence rib fracture outcomes.
authors.affiliation: Trauma/Critical Care Services, St. Elizabeth Health Center 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
authors.forename: C Michael
authors.initials: CM
authors.lastname: Dunham
authors.affiliation: Trauma/Critical Care Services, St. Elizabeth Health Center 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
authors.forename: Barbara M
authors.initials: BM
authors.lastname: Hileman
authors.affiliation: Trauma/Critical Care Services, St. Elizabeth Health Center 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Ransom
authors.affiliation: Trauma/Critical Care Services, St. Elizabeth Health Center 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
authors.forename: Rema J
authors.initials: RJ
authors.lastname: Malik
keywords: CT imaging; Rib fractures; abdominal injuries; head injuries; hospital mortality; intensive care; lung injury; mechanical ventilation; pneumonia