Quality of life after major trauma with multiple rib fractures

Injury, Int. J. Care Injured 46 (2015) 61–65

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Quality of life after major trauma with multiple rib fractures Silvana Marasco a,*, Geraldine Lee a, Robyn Summerhayes a, Mark Fitzgerald b, Michael Bailey c a

CJOB Cardiothoracic Surgery Department, The Alfred Hospital, Australia Trauma Service, The Alfred Hospital, Australia c Department of Epidemiology & Preventive Medicine, Monash University, Australia b

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 13 June 2014

Introduction: Rib fractures are a common injury presenting to major trauma centres and community hospitals. Aside from the acute impact of rib fracture injury, longer-term morbidity of pain, disability and deformity have been described. Despite this, the mainstay of management for the vast majority of rib fracture injuries remains supportive only with analgesia and where required respiratory support. This study aimed to document the long-term quality of life in a cohort of major trauma patients with rib fracture injury over 24 months. Methods: Retrospective review (July 2006–July 2011) of 397 major trauma patients admitted to The Alfred Hospital with rib fractures and not treated with operative rib fixation. The main outcome measures were quality of life over 24 months post injury assessed using the Glasgow Outcome Scale Extended and SF12 health assessment forms and a pain questionnaire. Results: Assessment over 24 months of major trauma patients with multiple rib fractures demonstrated significantly lower quality of life compared with published Australian norms at all time points measured. Return to work rates were poor with only 71% of those who were working prior to their accident, returning to any work. Conclusions: This study demonstrates a significant reduction in quality of life for rib fracture patients requiring admission to hospital, which does not return to the level of Australian norms for at least two years. Crown Copyright ß 2014 Published by Elsevier Ltd. All rights reserved.

Keywords: Rib fracture Quality of life Flail chest

Background Rib fractures are a common injury presenting to both major trauma centres and community hospitals. Rib fracture injuries extend across a broad spectrum of severity from a single fractured rib which may be sustained in a fall or sporting injury, to multiple fractured ribs resulting in a flail chest with paradoxical chest wall movement and respiratory failure. Fractured ribs are present in approximately 21% of patients admitted to trauma centres with blunt chest trauma [1]. Mortality rates of up to 33% have been reported for flail chest injury reflecting the high impact nature of the injury as well as associated life threatening injuries such as

* Corresponding author at: CJOB Cardiothoracic Department, The Alfred Hospital, Commercial Road, Prahran 3181, Australia. Tel.: +61 390762558. E-mail addresses: [email protected] (S. Marasco), [email protected] (G. Lee), [email protected] (R. Summerhayes), m.fi[email protected] (M. Fitzgerald), [email protected] (M. Bailey). http://dx.doi.org/10.1016/j.injury.2014.06.014 0020–1383/Crown Copyright ß 2014 Published by Elsevier Ltd. All rights reserved.

splenic or liver lacerations [2]. Aside from the acute impact of rib fracture injury, longer-term morbidity of pain, disability and deformity have been described [3,4]. Despite this, the mainstay of management for the vast majority of rib fracture injuries remains supportive only with analgesia and where required respiratory support. However, in many patients this acute management does not address the potential longer-term morbidity of such injuries. The aim of this study was to examine the long-term morbidity and quality of life outcomes in a single centre cohort of rib fracture patients over 24 months post injury.

Methods Morbidity and quality of life data were collected from a consecutive cohort of patients from The Alfred Hospital, Australia. The Alfred Hospital is one of two adult major trauma services in the state of Victoria, Australia. Approximately 1200 major trauma patients are treated at The Alfred each year with an overall mortality of 8%. Approximately 600 major chest trauma patients

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are treated each year with a mortality of approximately 5%. The Alfred Hospital data were collected from Traumanet – a prospective database on all trauma patients admitted to the hospital. All the patients admitted to the hospital between July 2006 and July 2011 with major thoracic trauma and a diagnosis of multiple fractured ribs were considered for inclusion in this cohort. Patients not classified as major trauma, or with a single fractured rib or who were treated for fractured ribs in the emergency department without being admitted to the hospital were not included in this group. Patients who underwent operative fixation of their fractured ribs were excluded. Follow-up data were collected on the enrolled patients by the Victorian State Trauma Registry (VSTR). Institutional ethics approval was granted and the requirement for individual patient consent was waived. Data are prospectively collected into the VSTR and Traumanet databases with a retrospective opt out consent process in place. VSTR has ethics approval from all trauma receiving hospitals in the state and Alfred Hospital institutional ethics approval has been given for the collection of data in the Traumanet database. Thus major trauma patients received by other regional hospitals and transferred to The Alfred were also included in this cohort. VSTR data are collected by telephone interview with either the patient or by proxy. VSTR collects data about all major trauma patients in the state with major trauma being defined as any of: 1) death after injury; 2) an Injury Severity Score (ISS) > 15; 3) an intensive care unit (ICU) stay > 24 h, requiring mechanical ventilation for at least part of their ICU stay; 4) urgent surgery for intrathoracic, intracranial, intra-abdominal procedures, or fixation of pelvic or spinal fractures [5]. The instruments used are the Glasgow Outcome Scale Extended (GOS-E), the twelve-item short form (SF-12) health survey, and a pain questionnaire using a numerical rating scale for pain ranging from 0 (no pain at all) to 10 (worst possible pain). The GOS-E provides a global measure of function taking into account domains such as social and leisure activities, relationships, return to work, self care and mobility in the community, and is rated on a scale of 1 (death) to 8 (upper good recovery) (Table 1) [6]. Follow-up rates in the database have been reported as 86%, 83% and 82% for 6 months, 12 months and 24 months, respectively [5]. The Abbreviated Injury Score 2008 version (AIS08) has been used in this dataset. 446 consecutive major trauma patients who were admitted to The Alfred Hospital with multiple fractured ribs over the five-year review period were identified. VSTR collects data on major trauma patients only, and so only major trauma patients are included in

this analysis. Furthermore, the fractured ribs may not necessarily have been the primary diagnosis. Twenty-six patients underwent rib fixation over the time period of this review as part of a pilot study and a randomised controlled trial and have been excluded from this analysis [7,8]. Follow-up data were missing or incomplete on 23 patients leaving 397 patients in the analysis. To separate out those patients in whom other injuries may have dictated their outcomes, the cohort of 397 patients was divided into those in whom the thoracic injury was the primary diagnosis (coded as a thoracic AIS08 3 out of 5 without a score 3 in any other body region) (‘‘Thoracic group’’). The remainder of the patients had a thoracic AIS08 score 3 but also had an AIS08 score 3 in another body region (‘‘Multi-trauma group’’). A flail segment was defined as three or more consecutive ribs fractured in more than one place leading to a floating segment of chest wall. The diagnosis was primarily made on radiological evidence. However, the clinical finding of paradoxical chest wall motion in the setting of multiple fractured ribs was also recorded as a flail chest. Statistical analysis Univariate analysis was conducted using continuity adjusted chi-square tests for equal proportion, Student’s t-tests or nonparametric tests where appropriate with results presented as numbers (percentages), mean (standard deviation) or median (interquartile range) respectively. Multivariate analysis was performed using generalised linear modelling with a compound symmetric error structure (PROC MIXED procedure in SAS) adjusting for age, gender, and time. Results have been reported as least square means (standard errors). To determine if changes over time differed significantly between covariates, interaction terms with time were fitted; however no significant interaction terms were found to exist. All the analyses were performed using SAS version 9.3 (SAS Institute Inc., Cary, NC, USA) and a two-sided p-value of 0.05 was used to indicate statistical significance. Results Demographic data on the 397 consecutive major trauma patients admitted to The Alfred Hospital with multiple fractured ribs are presented in Table 2. Division of the entire cohort into a predominant thoracic injury group (n = 216) and a multi-trauma group (n = 181) showed a significant difference in ISS between the two groups (p < 0.0001) with a higher ISS in the multi-trauma group (Table 3). Over the same time period, 855 patients were seen in the emergency departments of The Alfred and the affiliated Sandringham community hospital who did not require admission

Table 1 Glasgow Outcome Scale-Extended [6]. 1 2 3 4

5

6

7 8

Dead Vegetative State Lower Severe Disability (carer required for all activities of daily living) Upper Severe Disability (able to look after themselves for up to 8 h per day but unable to perform tasks out of the house such as shopping without assistance) Lower Moderate Disability (able to shop, drive or use public transport without assistance but unable to work or study, and rarely participates in social or leisure activities) Upper Moderate Disability (able to shop, drive or use public transport without assistance and able to work or study but at a reduced capacity. Extensive restriction to social or leisure activities) Lower Good Recovery (returned to preinjury work or study capacity but still reporting some disruption to social and leisure activities) Upper Good Recovery (essentially no problems relating to their injury that affect daily life)

Table 2 Demographics entire cohort. Variable

N = 397

Age years [mean (SD)] Sex (M/F) Mechanism of injury Motor vehicle driver Motor vehicle passenger Motorcycle Bicycle Pedestrian struck by car Fall from height Struck by or collision with person or object Other Flail segment ISS (AIS08) [mean (SD)]

53.9 (18.8) 298/99 118 43 54 27 38 72 19 26 211 22.5 (11.8)

S. Marasco et al. / Injury, Int. J. Care Injured 46 (2015) 61–65 Table 3 Injury comparison between thoracic and multi-trauma subgroups.

ISS (AIS08) [mean (SD)] AIS08 highest count (median IQR) Head Neck Face Spine Thorax Abdominal Upper extremity Lower extremity

Thoracic group (n = 216)

Multitrauma group (n = 181)

p value

16.0 (7.3) 3 (2–4) 1 (0–1) 0 (0–1) 0 (0–0) 0 (0–2) 3 (3–3) 0 (0–0) 0 (0–2) 0 (0–1)

30.1 (11.6) 4 (3–5) 2 (0–3) 0 (0–1) 0 (0–1) 2 (0–3) 3 (3–4) 0 (0–2) 1 (0–2) 1 (0–3)

<0.001 <0.001 <0.001 0.35 <0.001 <0.001 0.7 <0.001 0.1 <0.001

to hospital and were discharged home, representing an overall admission rate of 33% (420/1275). Outcome data are shown in Table 4. The multi-trauma group demonstrated a significantly higher mortality, longer hospital length of stay and a higher proportion needing to go to rehabilitation from hospital rather than straight to home. Follow-up pain scores and quality of life data at 6, 12 and 24 months are shown in Table 4. Follow-up rates at 6 months for both groups for pain and SF12 data was 64%; at 12 months follow-up rates were 64% in the multitrauma group and 60% in the thoracic group; at 24 months the follow-up rate was 50% in the thoracic group and 54% in the multitrauma group. Follow-up data for GOS-E were higher at all time points in both the thoracic and multitrauma cohorts; 76% versus 92% at 6 months; 70% versus 88% at 12 months

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and 57% versus 76% at 24 months. The GOS-E data were dichotomised to represent good recovery (categories 7 and 8) versus less than good recovery (categories <7). There were significant differences over time in the SF12 physical component score, pain score and GOS-E rate with improvements seen from 6 to 24 months (Table 5). For the purposes of demonstrating change over time, the GOS-E rate was analysed as a continuous variable in Table 5. Comparison between the SF12 results and published Australian norms showed significant differences at all time points when comparing the physical component scores [Australian 2013 published norm 48.9  10.2 (mean  SD); p < 0.0001] and mental component scores [Australian 2013 published norm 52.4  8.8 (mean  SD); p < 0.0001], with the Australian norms being significantly higher than our study population [9]. Multivariable analysis was performed to examine the impact of demographic data on the quality of life outcomes (Table 5). Male patients did significantly better in terms of GOSErate, pain scores and SF12 MCS. Older patients (over 55 years) had a significantly better SF12 MCS score but the other quality of life tools showed no difference between age groups. Flail chest was also analysed in the multivariable model but showed no significant differences in outcomes. Pain at each time point reduced over the follow-up period (Table 5). Of those patients with a pain score 5/10, 16% patients identified the main site of their pain as thoracic at six months, 21% at 12 months and 20% at 24 months. The next most commonly identified sites of most pain were lower back and shoulder girdle. Of the entire cohort of patients, 189 of the survivors reported working either full time (86%) or part time (12%) prior to their accident. At six months, 181 of those patients were able to be contacted and 106 of those had returned to work (59%), 94% of

Table 4 Outcome data.

Mortality Hospital length of stay [days] (median[IQR]) Discharge destination Home Rehabilitation Other facility Pain 6 months Pain 12 months Pain 24 months SF-12 PCS 6 months SF-12 PCS 12 months SF-12 PCS 24 months SF-12 MCS 6 months SF-12 MCS 12 months SF-12 MCS 24 months GOSErate 6 months (%categories 7 and 8) GOSErate 12 months (%categories 7 and 8) GOSErate 24 months (%categories 7 and 8)

Thoracic group (n = 216)

Multi-trauma group (n = 181)

p value

15 (6.8%) 8 (4–13)

26 (14%) 14 (8–26)

0.02 <0.001

124 (57%) 75 (35%) 2 (1%) 2 (0–5) 0 (0–5) 1 (0–4) 39.7 (12.6) 41.4 (12.4) 42.5 (12.2) 49.2 (12.4) 49.2 (11.1) 49.7 (11.2) 61/110 (35.7%) 53/102 (34.2%) 57/73 (43.8%)

39 (22%) 106 (59%) 10 (6%) 2 (0–5) 2 (0–5) 0 (0–5) 37.3 (12.3) 39.4 (13.8) 39.2 (14.0) 48.3 (14.4) 49.2 (12.8) 47.9 (12.5) 38/131 (22.5%) 45/117 (27.8%) 43/101 (29.8%)

<0.001 <0.001 0.02 0.35 0.09 0.50 0.14 0.26 0.11 0.61 0.99 0.32 <0.001 0.06 <0.001

GOSErate recorded as number of patients in categories 7 and 8 (good recovery)/number of patients in categories 1–6 (less than good recovery) and percentage of patients in categories 7 and 8.

Table 5 Follow-up survey data with multivariable analysis (entire cohort). Parameter

GOSErate

p value

Pain score

p value

SF12 PCS

p value

SF12 MCS

p value

Female Male Age over 55 Age under 55 6 month follow-up 12 month follow-up 24 month follow-up

5.6 6.1 5.9 5.8 5.7 5.8 6.0

0.03

3.5 2.2 2.8 2.9 3.1 2.9 2.6

0.002

49.1 48.8 37.9 38.3 36.9 38.6 38.9

0.84

35.0 41.2 50.9 47.1 48.8 49.3 48.9

<0.001

(0.2) (0.1) (0.1) (0.1) (0.1) (0.1) (0.1)

0.61 0.001

(0.3) (0.2) (0.2) (0.2) (0.2) (0.2) (0.2)

0.75 0.03

(1.4) (0.8) (1.1) (1.1) (0.9) (0.9) (1.0)

0.81 0.01

(1.5) (0.8) (1.1) (1.0) (0.9) (0.9) (1.0)

Data presented as least square means (standard error) with p-values to indicated statistically significant differences between gender, age and time.

0.01 0.86

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those returning to the same type of work they had been doing before the accident. Comparison of the six-month return to work rates between the multi-trauma group n = 47 (51%) and thoracic group n = 59 (63%) were not significantly different (p = 0.16). At 12 and 24 months, the return to work figures were the same. At 24 months, of the 110 patients who returned to work, 52 (46%) were manual labourers and the remainder were a combination of professionals and skilled non-manual workers. Discussion There is ample evidence that rib fractures are painful and cause significant interruption to quality of life in the early post injury phase [3,4]. However, there is little published follow-up data of what happens to these patients longer term at 12 and 24 months post injury. Data from the United States has demonstrated that 77% of patients with rib fractures are not admitted to hospital [10], which correlates with the data from our own hospital. The prevalence of this injury has significant ramifications on society in terms of productivity as rib fracture pain and disability can be a serious impediment to returning to work. In this study, only 59% of patients who could be contacted had returned to work by six months. This represents only 55% of the entire cohort. If we just look at those patients who were able to be contacted at 6 months, only 55% reported being able to return to the work they had done prior to their accident. Interestingly, the rate of return to work did not improve much at all between 6 months and 24 months post injury. Thus, in this cohort, failure to return to work by 6 months predicted failure to return to work for the next 18 months as well. A previous study of rib fracture pain and disability demonstrated an average of 70 days of work/usual activity lost per patient in the post injury phase [3]. Interestingly, patient appraisal of injury severity has been found to be more predictive of time off work than objective measures of severity [11]. In addressing pain and disability outcomes, assessment of a minimal clinically important difference is an important aspect in verifying the clinical relevance of the results. In this study, there were significant improvements between the 6-month and 24month assessment in pain, and disability as assessed by the GOS-E rate and SF12 physical component scores. However, it seems unlikely that these differences would be clinically relevant to the patients. In a study designed to assess the MCID in patients undergoing spinal surgery, the MCID threshold values for pain varied between 2.0 and 3.2 points and for SF12 PCS varied between 3.2 and 6.1 points [12]. In the current study, improvements of this magnitude were not seen between the 6-month and 24-month assessments. It is possible, and probable that a more clinically significant improvement was seen in the first six months post injury in these patients. Thus again, the recovery and quality of life, seen at 6 months in this cohort of patients, seem to predict their quality of life at 24 months without clinically significant improvements seen between 6 and 24 months in the measures analysed. In contrast, the statistically significant differences seen between our study cohort and the Australian norms in SF12 PCS were well above the MCID threshold levels reported above, again supporting the fact that our study cohort do have a clinically significant reduction in quality of life out to 24 months post injury. Interestingly, we saw very similar pain and quality of life results as assessed by the SF-12 questionnaire between the thoracic trauma and the multitrauma groups, indicating the significant impact that thoracic trauma has on quality of life in these patients. Furthermore, less than half the thoracic trauma group had returned to a good level of functioning (as determined by the GOS-E scale of categories 7 and 8) by 24 months. This leaves a substantial number of patients with significant reduction in

function even at this late stage after their injury. Our multivariate analysis indicated that female patients tended to have worse quality of life outcomes compared to males. There did not appear to be an effect of age in our study although older patients scored better in their mental component score indicating that perhaps they are able to accept their limitations better than younger patients. A previous study looking at all blunt trauma patients enrolled in the VSTR database between October 2006 and June 2009 (and thus overlapping our patient cohort in terms of era and patient population), examined the predictors of functional outcome as assessed by the GOSE rating [13]. Multivariable regression modelling showed that women, older age groups, patients with lower education, and associated head or spinal injury all demonstrated lower odds of experiencing better functional outcome at 12 months post injury. Functional outcomes of intentional injury or assault were also worse than unintentional injury and compensable patients experienced worse functional recovery than non-compensable patients [13]. In that study 35% of patients experienced a ‘good’ recovery at 12 months which correlates very closely with the 34.2% noted in our thoracic trauma group. Previous studies of rib fracture patients have identified significant pain and disability at 30 days [3] and 60 days [4] follow-up. However, there are little published data following these patients out to one and two years. Trauma patients are a notoriously mobile population and follow-up data can be very difficult to achieve. Although the natural history of any rib fracture is a process of callus formation and healing by bony union, there are many reports of malunion, pseudarthrosis formation, residual deformity, clicking and movement and of course pain which fails to resolve over the expected 8–12 week timeframe for complete healing after injury [14,15]. A recent prospective study of rib fracture patients found that pain and disability at 8 weeks post injury could be predicted by the pain intensity within the first few days after injury [4]. Interestingly, the number of fractures and the bilaterality of fractures were not predictive in that study. However, there is mounting evidence that a patient’s perception of pain in that early post injury period is associated with chronic pain development [16]. Most thoracic and trauma surgeons will have seen patients with severe disabling chronic pain from old rib fractures. The management of these patients is extremely difficult and despite requests from the patients to operate, there is no level 1 evidence that operative intervention at this chronic stage has any role. Despite case reports of successful surgical intervention in these patients [17,18], the inherent bias of publishing positive reports would indicate that there are many operative failures that never make it to publication. It is possible that more aggressive pain management in the acute phase could impact on longer-term pain and functional outcomes. Although different studies have shown benefits of various analgesic regimens in the acute phase (such as intravenous ibuprofen, intercostal nerve blocks, lidocaine topical patch), none of them have followed the patients to monitor whether there is any difference in longer term pain syndromes [19–21]. A meta-analysis of epidural analgesia in patients with traumatic rib fractures showed no significant benefit on mortality, ICU or hospital length of stay [22]. Further, epidural catheter placement is often contraindicated in multi trauma patients. Operative rib fixation may provide both short- and long-term pain relief in these patients. However, the only prospective randomised trials performed so far looking at operative fixation of fractured ribs have focussed on ventilator dependent flail chest patients with primary outcomes of ventilator times and hospital length of stay [8,23,24]. Although the earliest of those studies found reduced pain reported in the operative group at 6 months

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[23], the most recent study found no difference in quality of life at 6 months as assessed by the short form-36 questionnaire [8]. A retrospective study in a small number of patients found that operative rib fixation reduced analgesic requirements compared to pre-operatively but did not show any difference in analgesic requirements with a matched control group [25]. This is an area that needs further study. Although reducing ventilation times and hospital stay certainly has its associated benefits, what matters most to patients is ongoing pain and disability and these are the two important aspects that have not yet been definitively proven to be impacted on by operative rib fixation. Conclusion To our knowledge, this is the largest cohort study of rib fracture patients with quality of life follow-up to 24 months. This study indicates that a clinically significant reduction in quality of life in these patients remains even at 24 months post injury. At six months, return to work rates remains poor confirming the significant personal and societal impact of these injuries. No intervention to improve quality of life has been assessed in this study. Patients who had their ribs fixed were excluded as this was a very small number in the time frame studied. However, this study will form a useful basis for a prospective study of operative fixation of fractured ribs, focussing on pain and quality of life outcomes. Given that 20% of patients identified their main site of pain as thoracic, even at 24 months post injury, and that 60% of patients still reported significant functional reduction at 24 months post injury, this is an area that is in need of better and more effective intervention. Conflicts of interest No conflicts of interest to declare. Acknowledgements The Victorian State Trauma Registry (VSTR) is a Department of Health, State Government of Victoria and Transport Accident Commission funded project. References [1] Cameron P, Dziukas L, Hadj A, Clark P, Hooper S. Rib fractures in major trauma. Aust N Z J Surg 1996;66:530–4. [2] Ciraulo DI, Elliott D, Mitchell KA, Rodriguez A. Flail chest as a marker for significant injuries. J Am Coll Surg 1994;178:466–70. [3] Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? J Trauma 2003;54:1058–64.

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