Table 1 Characteristics of included studies
Author / year | Risk score | Study type | Study design | Participants | Number | Outcomes | Results |
|---|---|---|---|---|---|---|---|
Aukema 2011 [15] | TTSS | External validation | Single centre, retrospective, trauma database | Patients with a score of 1 + on the AISthorax admitted to ED | 516 | Mortality, pneumonia, second PTX, persistent HTX, ARDS, empyema | AUROC mortality: 0.844. TTSS was significant higher in patients who died of thorax-related complications than in patients who died because of non thorax-related complications (p < 0.001). |
Baker 2020 [16] | OIS & AIS | External validation | Single centre, retrospective, trauma database | Adult patients with rib / sternal #s admitted to ED | 3033 | Mortality, tracheostomy, cardiopulmonary complications, readmissions within 30 days | OIS AUROCs: 0.679 for mortality and 0.667 for tracheostomy. TTSS and CTS outperformed both OIS and AIS for all outcomes except for readmissions. |
Bass 2022 [17] | PIC Score | External validation | Single centre, retrospective, trauma database | Patients with isolated chest wall injuries (excluded AIS > 2 in head or abdomen) | 194 | ICU admission, mechanical ventilation and length of stay. | A cut-off PIC score of ≤ 7 was associated with ICU admission OR: 8.19. 95%CI: 3.39–22.55, p < 0.001 and with ICU admission for > 48 h OR: 26.9 95%CI: 5.5-43.96, p < 0.001. |
Bass 2023 [18] | RCRI | External validation | Multi-centre, retrospective, trauma database | Patients aged ≥ 65 with ≥ 1 rib fracture. Exclusion: managed operatively | 96,750 | In-hospital mortality, myocardial infarction, cardiac arrest with CPR, stroke, ARDS | Compared to RCRI 0, an RCRI score of 1 had a 16% increased risk of in-hospital mortality: adj-IRR: 1.16 95%CI: 1.02–1.32, p = 0.020; RCRI score of 2: adj-IRR: 1.72 95%CI:1.44–2.06, p < 0.001 |
Battle 2014 [19] | STUMBL | Development / External validation | Single centre, retrospective chart review (development study). Multi-centre prospective observational (external validation) | Patients with primary diagnosis of blunt chest-wall trauma. Exclusion: <18 yrs, any immediate life-threatening injury. | 274 237 | Composite outcome: in-hospital mortality, morbidity including all pulmonary complications, ICU admission, or a prolonged LOS 7 + days | Final model reported AUROC of 0.96 (95% confidence intervals: 0.93 to 0.98), sensitivity was 80%, specificity was 96%, positive predictive value was 93% and negative predictive value was 86%. |
Blasius 2023 [20] | T3P-Score | Development / Internal validation | Multi-centre, retrospective, trauma database | Adult patients with multi-trauma and severe thoracic trauma, requiring MV | 1019 | Tracheostomy, multi-organ failure, sepsis | The T3P-Score had high predictive validity for tracheostomy (AUROC: 0.938, 95% CI: 0.920, 0.956; Nagelkerke’s R2 was 0.601). Specificity was 0.68, and the sensitivity was 0.96 |
Buchholz 2022 [21] | RIBS | Development / Internal validation | Single centre, retrospective, trauma database | Patients admitted with at least one rib fracture | 838 | Composite outcome: >7 days ventilated, tracheostomy, pneumonia, upgrade to ICU, unplanned intubation, mortality. | Final model AUROC of 0.858. Sensitivity is 72%, specificity is 84%, positive predictive value is 48.4%, and negative predictive value is 93.5% |
Buchholz 2024 [22] | RIBS, ISS, RFS, CTS, STUMBL | External validation | Single centre, retrospective, chart review | Patients admitted with at least one rib fracture | 1493 | Composite outcome: >7 days ventilated, tracheostomy, pneumonia, upgrade to ICU, unplanned intubation, mortality | The RIBS stood out as best predicting any complication (AUROC = 0.73). Other AUROCs were ISS: 0.73, STUMBL: 0.61, RFS: 0.59, CTS: 0.56. No other statistical parameters reported |
Callisto 2022 [23] | STUMBL | External validation | Single centre, retrospective, chart review | Adult patients with ED diagnosis of blunt chest trauma. Exclusion: any immediate life-threatening injury, ICU admission. | 369 | Lower respiratory tract infection, pulmonary consolidation, empyema, pneumothorax, haemothorax, splenic or hepatic injury and 30-day mortality. | ED clinician decision to admit had a sensitivity of 83.9% and specificity of 86.0% for predicting complications. STUMBL score ≥ 11 had a sensitivity of 79.0% and specificity of 77.9%. AUROC of STUMBL score and ED clinician decision to admit was 0.84 (95% CI 0.78–0.90) and 0.85 (95% CI 0.79–0.91). |
Chapman 2016 [24] | RibScore | Development | Single centre, retrospective, trauma database | Patient with blunt trauma with one or more rib fractures visualized on CT | 385 | Pneumonia, respiratory failure, and tracheostomy | RibScore was linearly associated with pneumonia (p < 0.01), ARF (p < 0.01), tracheostomy (p < 0.01). AUROC for the outcomes were 0.71, 0.71, and 0.75, respectively. |
Chen 2014 [25] | CTS | External validation | Single centre, retrospective, trauma database | Patients with blunt torso trauma | 1361 | Mortality, acute pneumonia and respiratory failure | CTS 5 + had nearly 4-fold increased odds of mortality (OR; 3.99, 95%CI: 1.92–8.31, p = 0.001) compared with CTS < 5. |
Choi 2021 [26] | RRFI | Development / External validation | Multi-centre, retrospective, trauma database. | Geriatric patients admitted with multiple rib fractures | 55,540 77,710 | Mortality, pneumonia, mechanical ventilation, hospital length of stay, discharge disposition | Among external validation cohort, increasing frailty risk was associated with stepwise worsening OR of mortality (1.5 [1.2–1.7], 3.5 [3.0–4.0]), intubation (2.4 [1.5–3.9], 4.7 [3.1–7.5]) |
Cinar 2021 [27] | RTS, ISS and NISS | External validation | Single centre retrospective, chart review | Patients with isolated thoracic trauma. Exclusions: <18 years, major injury, | 683 | Mortality | NISS: AUROC: 0.876 (cut off score: >27), sensitivity: 85.3%, specificity: 80.7%, 95%CI: 0.848–0.899, P = 0.000. |
Cornillon 2021 [28] | ROX Index | External validation | Single centre, retrospective, chart review | All patients admitted to the ICU with AIS thorax. | 171 | Standard oxygen therapy failure | AUROC: 0.88 with a 95% CI [0.80–0.94]. ROX cut-off: 12.8: sensitivity: 81.7, 95%CI 0.7–0.9, specificity: 88.5, 95%CI 0.8–0.9 |
Daurat 2016 [29] | TTSS | External validation | Single centre retrospective, chart review | All blunt thoracic trauma with pulmonary contusion | 329 | Delayed ARDS | AUROC for TTSS for ARDS: 0.82 (95% CI 0.78–0.86). A TTSS of 13–25: risk factor for ARDS (OR 25.8 [95% CI 6.7–99.6] P < 0.001) |
Easter 2001 [30] | RFS | Development | Based on literature only | Not stated | n/a | ICU Length of stay | Not stated |
El-Aziz 2022 [31] | TTSS & TRISS | External validation | Single centre, prospective cohort | Patients with chest trauma either penetrating or blunt trauma | 100 | Hospital mortality, need for oxygenation, ventilator, hospital length of stay | TTSS (cut-off value 4.5): AUROC: 0.88, P > 0.001, sensitivity: 84.6%, specificity: 80.5%, 95%CI: 0.788–0.972. TRISS (cut off value: 24.55): AUROC: 0.892, P > 0.001, sensitivity: 92.3%, specificity: 81.6%, 95%CI: 0.828–0.956. |
Emond 2017 [32] | Quebec Decision Rule | Development / Internal validation | Multi-centre, prospective cohort | Adult patients with a minor thoracic injury | 830 552 | Delayed haemothorax at 7, 14, 30 and 90 days | AUROC: 0.78 (95% CI 0.74–0.82) for the derivation cohort and 0.74 (95% CI 0.67– 0.81) for the validation cohort |
Esme 2007 [33] | RTS, TRISS, ISS, LIS, CWIS | External validation | Single centre, retrospective, chart review | Patients with blunt chest trauma | 152 | Mechanical ventilation, thoracotomy, tube thoracostomy duration, LOS hospital and ICU stay, morbid conditions, mortality | TRISS was a predictor of mortality, LIS was an predictor of morbidity, the need for thoracotomy. CWIS, and LIS were independent predictors of the need for mechanical support. RTS, TRISS, ISS and LIS were predictors of the LOS |
Fokin 2018 [34] | RFS, CTS & RibScore | External validation | Single centre, retrospective, chart review | Patients with radiologically confirmed rib fractures | 1089 | Mortality, hospital and ICU length of stay, mechanical ventilation, pneumonia, tracheostomy, epidural analgesia. | RFS: AUROCs (mortality): all patients: 0.636, non-geriatric: 0.642, geriatric: 0.614. CTS: AUROCs (mortality): all patients: 0.669, non-geriatric: 0.687, geriatric: 0.646. RS: AUROCs (mortality): all patients: 0.654, non-geriatric: 0.656, geriatric: 0.656. |
Giamello 2022 [35] | STUMBL | External validation | Single centre, retrospective, chart review | Adult patients with isolated blunt thoracic trauma. Exclusion: immediately life-threatening lesion. | 745 | Composite outcome: in-hospital mortality, pulmonary complications, need for ICU, hospital length of stay 7 + days | Primary outcome c-index: 0.90 (95% CI 0.88–0.93), and the result of the H-L test was 9.01 (p = 0.34). STUMBL score = 16 has a sensitivity: 0.8 (95% CI 0.75–0.85), specificity: 0.87 (95% CI 0.84–0.90), PPV: 0.7 (95%CI 0.64–0.76), NPV: 0.92 (95% CI 0.90–0.94). |
Gonzalez 2015 [36] | Trauma Scoring System | Development | Single centre, retrospective, chart review | Patients aged ≥ 55 with rib fractures | 400 | Intubation, pneumonia | AUROC: 0.82 (95% confidence interval [95% CI], 0.77–0.88). In cross-validation, sensitivity: mean of 70.43%. Specificity mean of 78.3%, NPV: mean of 93.1%. |
Harde 2019 [37] | CTS | External validation | Single centre, prospective cohort | Adult patients with chest trauma. Exclusion: significant injury. | 30 | Mortality, pneumonia and need for ventilator support | AUROC: 0.75. A CTS score 5.5: maximum sensitivity is 87.5% and specificity is 68% |
Hardin 2019 [38] | SCARF score | Development | Single centre, prospective cohort | Adult patients with rib fractures admitted to the surgical ICU | 100 | Pneumonia, FiO2 requirement > 50%, respiratory failure, empyema, tracheostomy, ICU LOS, ICU re-admission, and mortality. | AUROC: the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. |
Kanake 2022 [39] | TTSS | External validation | Single centre, prospective cohort | All patients chest trauma, with associated minor head injury | 284 | Mortality (hospitalised and non-hospitalised) | AUROC for the TTSS of 7.5: 0.9 |
Kim et al. 2024 [40] | TTSS, CTS, RFS, RibScore | External validation | Single centre, retrospective, chart review | Adult trauma patients with rib fractures (with or without head trauma) | 1038 | One or more complications: pneumonia, chest complications requiring surgery, and mortality | TTSS showed highest predictive value (AUROC: 0.73, sensitivity: 0.71 and specificity: 0.37), while RibScore had the poorest performance (AUROC: 0.64, sensitivity: 0.68, specificity: 0.45). |
Kishawi 2021 [41] | Single rib fracture nomogram | Development / internal validation | Multi-centre, retrospective, trauma database | Adult patients with a single rib fracture associated with blunt trauma | 2398 | Composite outcome: mortality, pneumonia, tracheostomy, and hospital LOS > 12 days | Among the training set, the AUROC: 0.700. When applied to the validation set, the model demonstrated AUROC: 0.672. |
Li 2022 [42] | TIPE score | Development / Internal validation | Multi-centre, retrospective, trauma database | Adult trauma patients | 311,608 312,751 | Pulmonary complications | AUROC for the TIPE score was 0.844 for both the derivation and validation-set |
Martinez-Casas 2016 [43] | TTSS | External validation | Single centre, retrospective, chart review | All patients with thoracic trauma | 238 | Length of hospital and ICU stay; need for mechanical ventilation; admission; complications and mortality | AUROC for TTSS was significant for predicting complications (0.848) and mortality (0.856) values. TTSS with a cut off value of 8: sensitivity: 66%, specificity: 94% to predict complications and 80% sensitivity and 94% specificity for predicting mortality |
Maxwell 2012 [44] | RFS | External validation | Single centre, retrospective, trauma database | Patients aged 50 years or older with rib fracture(s) | 81 | Hospital and ICU length of stay, discharge disposition | Correlation between hospital LOS with the RFS score: 0.29 ( P = 0.010). Correlation between RFS and ICU length of stay: 0.29 (P = 0.009) No association of RFS with discharge disposition |
Mommsen 2012 [45] | PCS, AISchest, TTSS, | External validation | Single centre, retrospective chart review | Adult patients with polytrauma with severe thoracic trauma (AISchest > 3) | 278 | ICU length of stay, mechanical ventilation, mortality | TTSS had the best prediction power for ARDS, MODS, and mortality among the examined thoracic trauma scores. No association between the TTSS and the development of SIRS and sepsis could be observed. |
Moon 2017 [46] | TTSS & TRISS | External validation | Single centre, retrospective, chart review | Patients with severe thoracic injury (ISS > 18) who required ICU | 228 | In-hospital mortality | AUROC: 0.787 for the TRISS. At a cut-off value of 25.9%, the TRISS had a sensitivity of 83.6% and specificity of 73.5% to predict in-hospital mortality. |
Mukerji 2021 [47] | STUMBL | External validation | Multi-centre, retrospective, chart review | Adult patients aged with isolated blunt chest trauma. Exclusion: penetrating chest trauma, immediate life-threatening injuries or multi-trauma | 445 | Composite outcome: in-hospital mortality, morbidity including all pulmonary complications, ICU admission, hospital length of stay 7 + days | AUROC for all complications composite were (0.73, 95% CI 0.68–0.77), mortality (0.92, 95% CI 0.89–0.94), ICU admissions (0.78, 95% CI 0.73–0.81) and prolonged LOS (0.80, 95% CI 0.76–0.83) |
Nelson 2022 [48] | RIG | Development | Single centre, prospective cohort | Adult patients with blunt trauma with at least one rib fracture on CT | 1100 | Readmission, unplanned ICU admission, in-hospital mortality | Predictive capabilities not stated |
Pape 2000 [49] | TTSS | Development / External validation | Single centre, retrospective, chart review (development study). Multi-centre, retrospective database (validation study) | Patients with a thoracic injury admitted to ICU | 1495 | Morbidity and mortality | AUROC demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693) |
Pressley 2012 [50] | CTS | Development | Single centre, retrospective, trauma database | Patients with rib fractures | 649 | Mortality, ICU admission, mechanical ventilation, LOS | Predictive capabilities not stated |
Sayed 2022 [51] | LUS | External validation | Single centre, prospective cohort | Patients with polytrauma with blunt chest trauma admitted to ICU | 50 | ARDS | A LUS of 4 was defined as a cut-off value for predicting ARDS development within 72Â h of trauma with sensitivity and specificity (91.67% and 84.21%), respectively |
Schmoekel 2019 [52] | RibScore, MFi, PaCO2 | External validation | Single centre, retrospective, chart review | Patients aged ≥ 55 with blunt trauma and ≥ 1 rib fracture identified by CT | 263 | Pneumonia, respiratory failure and tracheostomy | AUROCs: RibScore: 0.79 (95% CI 0.69 to 0.89); mFI: 0.83 (95% CI 0.75 to 0.91) and PaCO2: 0.88 (95% CI 0.80 to 0.95). The PaCO2 had the highest discriminative ability of the three models. |
Soek 2019 [53] | AIS, TTSS, RFS, CTS | External validation | Single centre, retrospective, chart review | Adult patients with sustained blunt trauma and isolated rib fractures (AIS < 2 except in the chest area). | 177 | Pulmonary complications | Highest AUROC was TTSS (0.723, 95%CI 0.651–0.788). In patients with pulmonary contusion, TTSS also showed the highest AUROC (0.704, 95% CI 0.613–0.784 and without pulmonary contusion, RFS showed the highest AUROC (0.759, 95% CI 0.630–0.861). |
Ujjaneswari 2023 [54] | CTS | External validation | Single centre, retrospective, chart review | Adult patients with ≥ 1 rib fracture. Exclusion: associated injuries, COPD |  | Morbidity and mortality | There was a highly significant association between CTS score and mortality. (AUROC: 0.905, p-<0.0001) |
Wutzler 2012 [55] | LOFS | Development | Multi-centre, retrospective, trauma database | Adult patients admitted to the ICU with lung contusion/ lacerations | 5892 | Pulmonary organ failure | Predictive capabilities not stated |