Journal of Trauma and Injury

Original Article

Validation of chest trauma scoring systems in polytrauma: a retrospective study with 1,038 patients in Korea: Hongrye Kim, Mou Seop Lee, Su Young Yoon, Jonghee Han, Jin Young Lee, Junepill Seok; J Trauma Inj. 2024;37(2):114-123. Published online May 9, 2024; DOI: https://doi.org/10.20408/jti.2023.0087

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Purpose
Appropriate scoring systems can help classify and treat polytrauma patients. This study aimed to validate chest trauma scoring systems in polytrauma patients.
Methods
Data from 1,038 polytrauma patients were analyzed. The primary outcomes were one or more complications: pneumonia, chest complications requiring surgery, and mortality. The Thoracic Trauma Severity Score (TTSS), Chest Trauma Score, Rib Fracture Score, and RibScore were compared using receiver operating characteristic (ROC) analysis in patients with or without head trauma.
Results
In total, 1,038 patients were divided into two groups: those with complications (822 patients, 79.2%) and those with no complications (216 patients, 20.8%). Sex and body mass index did not significantly differ between the groups. However, age was higher in the complications group (64.1±17.5 years vs. 54.9±17.6 years, P<0.001). The proportion of head trauma patients was higher (58.3% vs. 24.6%, P<0.001) and the Glasgow Coma Scale score was worse (median [interquartile range], 12 [6.5–15] vs. 15 [14–15]; P<0.001) in the complications group. The number of rib fractures, the degree of rib fracture displacement, and the severity of pulmonary contusions were also higher in the complications group. In the area under the ROC curve analysis, the TTSS showed the highest predictive value for the entire group (0.731), head trauma group (0.715), and no head trauma group (0.730), while RibScore had the poorest performance (0.643, 0.622, and 0.622, respectively)
Conclusions
Early injury severity detection and grading are crucial for patients with blunt chest trauma. The chest trauma scoring systems introduced to date, including the TTSS, are not acceptable for clinical use, especially in polytrauma patients with traumatic brain injury. Therefore, further revisions and analyses of chest trauma scoring systems are recommended.

Summary

Citations

Citations to this article as recorded by

Clinical prediction models for the management of blunt chest trauma in the emergency department: a systematic review
Ceri Battle, Elaine Cole, Kym Carter, Edward Baker
BMC Emergency Medicine.2024;[Epub] CrossRef

Case Report

An unstable patient with a large sucking chest wound managed with gauze packing for preventing tension and bleeding control before surgery in Korea: a case report: Chang-Sin Lee, Min-Jeong Cho, Tae-Wook Noh, Nak-Jun Choi, Jun-Min Cho; J Trauma Inj. 2024;37(2):147-150. Published online February 23, 2024; DOI: https://doi.org/10.20408/jti.2023.0066

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Abstract PDF: This case report describes the management of a 51-year-old female patient who arrived at the emergency room with a stab wound to the upper right chest. Immediate medical interventions were undertaken, including blood transfusions and endotracheal intubation. To prevent tension and control bleeding, gauze packing was applied directly through the large open wound. Further surgical exploration identified a laceration in the lung, necessitating a right upper lobe resection. Postoperatively, the patient’s vital signs stabilized, and she was subsequently discharged without complications. This case highlights the decision-making process in selecting between an emergency department thoracotomy and an operating room thoracotomy for patients with penetrating chest trauma. It also illustrates the role of gauze packing in managing tension and hemorrhage. In summary, gauze packing can be an effective interim measure for stabilizing patients with traumatic injuries, unstable vital signs, and large open chest wounds, particularly when a chest tube is already in place, to prevent tension and facilitate bleeding control prior to surgical intervention.; Summary

Original Article

Chest wall injury fracture patterns are associated with different mechanisms of injury: a retrospective review study in the United States: Jennifer M. Brewer, Owen P. Karsmarski, Jeremy Fridling, T. Russell Hill, Chasen J Greig, Sarah Posillico, Carol McGuiness, Erin McLaughlin, Stephanie C. Montgomery, Manuel Moutinho, Ronald Gross, Evert A. Eriksson, Andrew R. Doben; J Trauma Inj. 2024;37(1):48-59. Published online February 23, 2024; DOI: https://doi.org/10.20408/jti.2023.0065

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Abstract PDF

Purpose
Research on rib fracture management has exponentially increased. Predicting fracture patterns based on the mechanism of injury (MOI) and other possible correlations may improve resource allocation and injury prevention strategies. The Chest Injury International Database (CIID) is the largest prospective repository of the operative and nonoperative management of patients with severe chest wall trauma. The purpose of this study was to determine whether the MOI is associated with the resulting rib fracture patterns. We hypothesized that specific MOIs would be associated with distinct rib fracture patterns.
Methods
The CIID was queried to analyze fracture patterns based on the MOI. Patients were stratified by MOI: falls, motor vehicle collisions (MVCs), motorcycle collisions (MCCs), automobile-pedestrian collisions, and bicycle collisions. Fracture locations, associated injuries, and patient-specific variables were recorded. Heat maps were created to display the fracture incidence by rib location.
Results
The study cohort consisted of 1,121 patients with a median RibScore of 2 (0–3) and 9,353 fractures. The average age was 57±20 years, and 64% of patients were male. By MOI, the number of patients and fractures were as follows: falls (474 patients, 3,360 fractures), MVCs (353 patients, 3,268 fractures), MCCs (165 patients, 1,505 fractures), automobile-pedestrian collisions (70 patients, 713 fractures), and bicycle collisions (59 patients, 507 fractures). The most commonly injured rib was the sixth rib, and the most common fracture location was lateral. Statistically significant differences in the location and patterns of fractures were identified comparing each MOI, except for MCCs versus bicycle collisions.
Conclusions
Different mechanisms of injury result in distinct rib fracture patterns. These different patterns should be considered in the workup and management of patients with thoracic injuries. Given these significant differences, future studies should account for both fracture location and the MOI to better define what populations benefit from surgical versus nonoperative management.

Summary

Citations

Citations to this article as recorded by

Non-Completely Displaced Traumatic Rib Fractures: Potentially Less Crucial for Pulmonary Adverse Outcomes, Regardless of Classification
Hongrye Kim, Su Young Yoon, Jonghee Han, Junepill Seok, Wu Seong Kang
Medicina.2025; 61(1): 81. CrossRef
Radiological insights into costal margin rupture injuries: patterns of associated rib and costal cartilage fractures
K. Mattam, P. Wijerathne, J. N. Rao, S. Tenconi, L. Ventura, J. G. Edwards
European Journal of Trauma and Emergency Surgery.2025;[Epub] CrossRef
Epidemiology of Symptomatic Non-Union/Malunion Rib Fractures
Daniel Akyeampong, Alexander Hoey, Ronald Gross, Evert A. Eriksson
Surgeries.2025; 6(2): 32. CrossRef

Case Reports

A rare and unique experience of a blunt intrathoracic traumatic injury of the trachea and its management in South Africa: a case report: Rudo Mutsa Vanessa Pswarayi, Anna Katariina Kerola; J Trauma Inj. 2023;36(4):416-420. Published online November 30, 2023; DOI: https://doi.org/10.20408/jti.2023.0036

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Abstract PDF: Blunt intrathoracic tracheal injuries are rare, even among blunt chest trauma patients. An early diagnosis based on a high index of suspicion allows for timely surgical management of potentially fatal airway trauma, thereby improving overall outcomes. Diagnosing these injuries can be difficult due to their nonspecific clinical features and the occasional difficulty in radiologic diagnosis. If a patient exhibits respiratory compromise with difficult ventilation and poor lung expansion, despite the insertion and management of an intercostal drain following high-energy blunt trauma, there should be a heightened suspicion of potential airway trauma. The aim of primary repair is to restore airway integrity and to minimize the loss of pulmonary parenchyma function. This case report discusses the rare clinical presentation of a patient with blunt trauma to the intrathoracic airway, the surgical management thereof, and his overall outcome. Although blunt traumatic injuries of the trachea are extremely rare and often fatal, early surgical intervention can potentially reduce the risk of mortality.; Summary

Penetrating chest trauma from a “less lethal” bean bag in the United States: a case report: Gloria Sanin, Gabriel Cambronero, Megan E. Lundy, William T. Terzian, Martin D. Avery, Samuel P. Carmichael II, Maggie Bosley; J Trauma Inj. 2023;36(4):421-424. Published online September 5, 2023; DOI: https://doi.org/10.20408/jti.2023.0021

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Abstract PDF: This case report presents the case of a 49-year-old man who presented to our level I trauma center after sustaining injuries in an altercation with local law enforcement in which he was shot with a less lethal bean bag and tased. In a primary survey, a penetrating left supraclavicular wound was noted in addition to a taser dart lodged in his flank. No other traumatic findings were noted in a secondary survey. Given hemodynamic stability, completion imaging was obtained, revealing a foreign body in the left lung, a left open clavicle fracture, a C5 tubercle fracture, a possible grade I left vertebral injury, and a left first rib fracture. Soft tissue gas was seen around the left subclavian and axillary arteries, although no definitive arterial injury was identified. The bean bag projectile was embedded in the parenchyma of the left lung on cross-sectional imaging. The patient underwent thoracotomy for removal of the projectile and hemostasis. A thoracotomy was chosen as the operative approach due to concerns about significant bleeding upon foreign body removal. A chest tube was placed and subsequently removed on postoperative day 5. The patient was discharged on postoperative day 7. At a 2-week outpatient follow-up visit, the patient was doing well. This case report is the first to describe this outcome for a drag-stabilized bean bag. Although law enforcement officers utilize bean bag projectiles as a “less lethal” means of crowd control and protection, these ballistics pose significant risk and can result in serious injury.; Summary

Traumatic Tricuspid Regurgitation Cause by Chordal Rupture: A Case Report: Min Ae Keum, Hyo Keun No, Byung Joo Sun, Suk Kyung Hong; J Trauma Inj. 2015;28(2):67-70. Published online June 30, 2015; DOI: https://doi.org/10.20408/jti.2015.28.2.67

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Abstract PDF: Traumatic tricuspid regurgitation is a rare complication of blunt chest trauma caused by chordal rupture, anterior papillary muscle rupture and anterior leaflet tear. Since clinical symptoms are vague, early diagnosis is difficult and some patient exhibit symptoms of right heart failure. Right heart failure has been the traditional indication for surgical treatment, such as tricuspid valve replacement. Recently, early detection using transthoracic echocardiography and surgical treatment, like valve repair, prior to overt right heart failure have been shown to better prognosis. We report a case of traumatic tricuspid regurgitation with chordal rupture in patient due to traffic accident.; Summary

Original Article

Evaluation of Lung Injury Score as a Prognostic Factor of Critical Care Management in Multiple Trauma Patients with Chest Injury: Kook Nam Han, Seok Ho Choi, Yeong Cheol Kim, Kyoung Hak Lee, Soo Eon Lee, Ki Young Jeong, Gil Joon Suh; J Korean Soc Traumatol. 2011;24(2):105-110.

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Abstract PDF: PURPOSE
Chest injuries in multiple trauma patients are major predisposing factor for increased length of stay in intensive care unit, prolonged mechanical ventilator, and respiratory complications such as pneumonia. The aim of this study is the evaluation of lung injury score as a risk factor for prolonged management in intensive care unit (ICU).
METHODS
Between June to August in 2011, 46 patients admitted to shock and trauma center in our hospital and 24 patients had associated chest damage without traumatic brain injury. Retrospectively, we calculated injury severity score (ISS), lung injury score, and the number of fractured ribs and performed nonparametric correlation analysis with length of stay in ICU and mechanical ventilator support.
RESULTS
Calculated lung injury score(<48 hours) was median 1(0-3) and ISS was median 30(8-38) in study population. They had median 2(0-14) fractured ribs. There were 2 bilateral fractures and 2 flail chest. Ventilator support was needed in 11(45.8%) of them for median 39 hours(6-166). The ISS of ventilator support group was median 34(24-34) and lung injury score was median 1.7(1.3-2.5). Tracheostomy was performed in one patient and it was only complicated case and ICU stay days was median 9(4-16). In correlation analysis, Lung injury score and ISS were significant with the length of stay in ICU but the number of fractured ribs and lung injury score were predicting factors for prolonged mechanical ventilator support.
CONCLUSION
Lung injury score could be a possible prognostic factor for the prediction of increased length of stay in ICU and need for mechanical ventilator support.; Summary

Case Reports

A Case of Cardiac Laceration due to Anterior Thoracic Stab Injury: Won Gi Woo, Ji Young Jang, Seung Hwan Lee, Chang Young Lee, Jae Gil Lee; J Trauma Inj. 2014;27(3):71-74.

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Abstract PDF: Among chest trauma patients, cardiac laceration is a rare, but severe, condition requiring prompt management. Depending on the patient's hemodynamic status, early detection rate of a cardiac laceration may or may not be occur. If a possibility of cardiac laceration exists, an emergent thoracotomy should be performed. Furthermore, patients who experience a cardiac laceration also experience different kinds of complications. Therefore, close follow-up and monitoring are required. Herein, we report a 41-year-old man with a left atrium and a left ventricle laceration caused by a thoracic stab injury.; Summary

Traumatic Asphyxia due to Blunt Chest Trauma with External Auditory Canal Bleeding: Je Ho Lee, Kyu Hyouck Kyoung, Jeong Won Kim, Hui Jun Yang, Eun Seog Hong; J Trauma Inj. 2013;26(4):297-299.

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Abstract PDF: Traumatic asphyxia, also called 'Perthes syndrome', is characterized by subconjunctival hemorrhage, cervicofacialpetechiae and cyanosis resulting from venous hypertension caused by an abrupt, severe, compressive force to the thoracoabdominal region. A 37-year-old male patient who was transferred to the emergency room due to chest trauma by overturning of a forkcrane. His head, neck, and shoulders showed severe ecchymosis, and his upper chest was cyanotic. There was bilateral subconjunctival hemorrhage and bilateral ear bleeding without tympanic rupture. Perthes syndrome is a rare condition and we treated a patient with typical and atypical symptoms; thus we report this case of Perthes syndrome.; Summary

Clinical Analysis of Ventilator-associated Pneumonia (VAP) in Blunt-chest-trauma Patients: Joong Hwan Oh, Il Hwan Park, Chun Sung Byun, Geum Suk Bae; J Trauma Inj. 2013;26(4):291-296.

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Abstract PDF: PURPOSE
Prolonged ventilation leads to a higher incidence of ventilator-associated pneumonia (VAP), resulting in weaning failure and increased medical costs. The aim of this study was to analyze clinical results and prognostic factors of VAP in patients with blunt chest trauma.
METHODS
From 2007 to 2011, one hundred patients undergoing mechanical ventilation for more than 48 hours were divided into two groups: a VAP-negative group, (32 patients, mean age; 53 years, M:F=25:7) and a VAP-positive group, (68 patients, mean age; 60 years, M:F=56:12). VAP was diagnosed using clinical symptoms, radiologic findings and microorganisms. The injury severity score (ISS), shock, combined injuries, computerized tomographic pulmonary findings, transfusion, chronic obstructive lung disease (COPD), ventilation time, stay in intensive care unit (ICU) and hospital stays, complications such as sepsis or disseminated intravascular coagulation (DIC) and microorganisms were analyzed. Chi square, t-test, Mann-Whitney U test and logistic regression analysies were used with SPSS 18 software.
RESULTS
Age, sex, ISS, shock and combined injuries showed no differences between the VAP - negative group and - positive group (p>0.05), but ventilation time, ICU and hospital stays, blood transfusion and complications such as sepsis or DIC showed significant differencies (p<0.05). Four patients(13%) showed no clinical symptoms eventhough blood cultures were positive. Regardless of VAP, mortality-related factors were shock (p=0.036), transfusion (p=0.042), COPD (p=0.029), mechanical ventilation time (p=0.011), ICU stay (p=0.032), and sepsis (p=0.000). Microorgnisms were MRSA(43%), pseudomonas(24%), acinetobacter(16%), streptococcus(9%), klebsiela(4%), staphillococus aureus(4%). However there was no difference in mortality between the two groups.
CONCLUSION
VAP itself was not related with mortality. Consideration of mortality-related factors for VAP and its aggressive treatment play important roles in improving patient outcomes.; Summary

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