A rare case of blunt thoracoabdominal trauma with small bowel perforation from air bags

Vehicle collisions represent more than 75% of mechanism of blunt abdominal trauma. In spite of the incomparable improvement of car safety devices, recent studies pointed out that the air bags might cause injuries, specially when it is not associated with seatbelt. In fact, some studies pointed out that crash victims using air bags alone have increased injury severity, hospitalisations, thoracoabdominal procedure, and rehabilitation. Some of the most frequently injured organs reported from air bag deployment are the liver (38%), the spleen (23%) and digestive system (17%). Injury of the hollow viscera are far less common. In particular, blunt abdominal trauma resulting in small bowel perforation is an infrequent lesion. These injuries are difficult to diagnose because specific signs are poor and a delay in treatment increases mortality and morbidity of the patients. We describe a case of thoracoabdominal trauma that occurred during a head-on collision after an air bag deployment without seatbelt use.

Rib cage strain pattern as a function of chest loading configuration

Rib fractures are the most frequent types of AIS3+ chest injuries and constitute a good indication of severity. However, the behavior of the rib cage is not well documented, and though chest external measurements are often provided in the literature, the strains of the ribs themselves during a crash remain unknown. In order to address this issue, a test protocol was developed, where the ribs of 8 PMHS were equipped with up to 96 strain gauges. In a first series of 3 tests, the subjects were seated upright and their chests were loaded by a 23.4 kg impactor propelled at 4.3 m/s in 0 degrees (pure frontal), 60 degrees (oblique) and 90 degrees (pure lateral) directions. In a second series of 3 tests, the subjects were loaded by the deployment of an unfolded airbag in the same 3 directions. Finally, a third series of 2 tests was performed with airbags at different distances from the subjects, in a pure lateral direction. This paper presents the results of the tests and an analysis of the strain patterns. The differences between a pure frontal, a pure lateral and an oblique loading are explored. The airbag loading is compared to impactor loading and the severity effect is described. Finally, the time and location of the rib fractures are analyzed as a function of the test configuration.

A rare reason for the end of a career in competitive tennis

Stress fractures are reported in adolescents taking part in high standard sports and they are associated with specific sites for stress fractures. The first rib is also affected in rowers and ball throwing sports. This report describes the complications of such a case in a competitive tennis player at international level practicing 5 times a week with far-reaching consequences. Due to constant load dependent pain in the region of the right shoulder, standard diagnosis, X-ray, magnetic resonance imaging (MRI) and a computed tomography (CT) scan with 3-D reconstruction were done, showing a pseudoarthrosis of the first rib. Therefore, further treatment was conservative without pain relieve. At follow-up 5 years after onset of symptoms the patient did not play tennis, he did not complain pain, but control imaging still showed a pseudoarthrosis of the first rib. Our case shows that it is important, when treating shoulder pain in the overhead athlete, to think of the possibility of a stress fracture.

[Blunt injuries of the lungs, pleura and chest bone structures: computed tomography contribution]

INTRODUCTION

The most frequent incidences of blunt chest injuries occur due to motorvehicle accidents, falls and work-related traumas. Chest computed tomography is usually associated with examination of the subsequent regions with the aim to enable a more efficient diagnostic procedure. The purpose of this research study is to define the contribution of the chest CT in blunt injury patients.

MATERIAL AND METHODS

This retrospective study encompasses the results of CT examination of 36 patients with one or more injuries of the thoracic wall, pleura, lungs and spinal column suspected to suffer chest organs traumas. Chest CT survey was performed in 30 patients, while thoracic spine CT survey was performed in 11 patients.

RESULTS AND DISCUSSION

The most frequent incidences of injuries were due to motor vehicle accidents (22 patients--61.11%). Falls were the reason of injuries in 11 patients--17.46%. Chest injuries are usually associated with injuries of the surrounding regions, but occurred in isolated form, too (27.78%). Rib fractures and lungs parenchyma traumas were evidenced by CT examination in more than 60% of the patients. Thoracic spine fractures were most frequently reported at the 10-th, 11-th and 12-th vertebra and made more than 70% of the thoracic spine fractures.

CONCLUSION

The findings of this study coincide to a great extent with the findings presented in world literature.

The biomechanics of human ribs: material and structural properties from dynamic tension and bending tests

The purpose of this study was to quantify both the tensile material properties and structural response of human ribs in order to determine which variables contribute to regional variation in the strength of human ribs. This was done by performing 94 matched tests on human rib specimens; 46 tension coupon tests, 48 three-point bending tests. Contralateral matched specimens were dissected from anterior and lateral regions of ribs 4 through 7 of six male fresh frozen post mortem human subjects ranging from 42 to 81 years of age. Tension coupons were taken from one side of the thorax, while three-point bending specimens were taken from the opposite side as the tension coupons at corresponding anatomical locations. The results of the tension coupon testing showed that there were no significant differences with respect to region or rib level: ultimate stress (p=0.90; p=0.53), ultimate strain (p=0.49; p=0.86), or modulus (p=0.72; p=0.81). In contrast, lateral three-point bending specimens were found to have a significantly higher peak bending moment (p<0.01), peak strain (p=0.03), modulus (p=0.05), and stiffness (p<0.01) than anterior specimens. The lateral three-point bending specimens also had a significantly larger area moment of inertia (p<0.01), larger distance to the neutral axis (p<0.01), smaller ratio of distance to the neutral axis to area moment of inertia (p<0.01), larger cortical bone area (p<0.01), and larger radius of gyration (p<0.01) than the anterior specimens. In addition, the peak moment (Ant p=0.20; Lat p=0.02), peak strain (Ant p=0.05; Lat p=0.15), and stiffness (Ant p<0.01; Lat p<0.01) were found to vary significantly with respect to rib level. Similar to anatomical region, the changes in the structural response with respect to rib level were also accompanied by significant changes in geometry. For anterior specimens, distance to the neutral axis (p<0.01), ratio of the distance to the neutral axis to area moment of inertia (p=0.02) and radius of gyration (p=0.04) were found to be significantly different with respect to rib level. For lateral specimens, the area moment of inertia (p<0.01), distance to the neutral axis (p<0.01), ratio of the distance to the neutral axis to area moment of inertia (p<0.01), the cortical bone area (p=0.01), and radius of gyration (p=0.03) were found to be significantly different with respect to rib level. These results clearly illustrate that there is variation in the structural response of human ribs with respect to anatomical region and rib level and this variation is due to changes in local geometry of each rib while the material properties remain constant.

Traumatic heart perforation by a D5 osteophyte: a case report

Osteophytes are bony outgrowths usually found in the context of osteoarthritis and diffuse idiopathic skeletal hyperostosis (DISH). Even if they are usually asymptomatic, they may present with complications such as spinal stenosis, myelopathy and radiculopathy. We here present the case of a 56-year-old woman found dead from a homicidal traumatic heart perforation by a D5 osteophyte.

Morphologic, experimental–comparative investigation as an identification of the injuring instrument method

Aiming to identify the injuring tool characteristics and the tool itself morphologic, experimental-comparative investigations of the skin wound, rib and cartilage injuries taken during the autopsy are performed. During 1995-2004, 489 investigations were performed for this purpose. In 418 cases, knives were submitted for identification of the specific injuring tool (in total-835 knives). In 205 cases the investigation included not only skin wounds, but also the injured rib cartilages. Identification investigations were performed by investigating both the skin wounds morphologic characteristics and dynamic traces-trails in the rib cartilage tissue left by the micro relief of the knife blade edge. In the case of the investigated and experimental skin wounds characteristics coincidence the experimental and comparative dynamic traces investigation was performed when the traces were suitable for the tool identification purposes. In the case of the investigated and experimental skin wounds, dynamic traces coincidence, the totality of the coincided characteristics was considered individual. In those cases, the conclusion included the fact that the injury had been made by a particular knife. According to our data during 1995-2004 in 23 cases-15.9% (5.5% out of the total investigated cases), the knife identification was based on the skin wound characteristics and dynamic traces in the rib cartilage tissue. In our opinion, the dynamic traces in the rib cartilage tissue investigations supplement the identification field and are valuable in the tool identification. In 11 (2.6% out of the total investigated cases) cases knives were identified only by the skin wounds morphologic characteristics, the ribs being not injured or dynamic traces being not suitable for the tool identification.

[Successful management of severe unremitting chylothorax after thoraci trauma]

Post-traumatic chylothorax needs surgical approach when conservative treatment is not successful to reduce chyle leakage. Thoracic duct ligation requires thoracoscopic or thoracotomic access. The authors report on a surgical thoracotomic approach to a severe and unremitting thoracic duct lesion after IX and X ribs and vertebral fractures.

Tuberculosis in the New World: a study of ribs from the Schild Mississippian population, West-Central Illinois

Vertebral lesions have been the main evidence for infection by the Mycobacterium tuberculosis complex (MTC) in paleopathology. Skeletal involvement is expected in a small percentage of infected individuals. Recently, several authors report a correlation between rib lesions and tuberculosis (TB) complex infection. This study tests the hypothesis that rib lesions can serve as a useful marker for MTC infection within the Mississippian Schild skeletal collection from West-Central Illinois. Ribs from 221 adults and juveniles were examined, and affected individuals were tested for TB complex infection. DNA from rib samples of affected individuals was amplified with primers targeting the IS6110 insertion element, which is common to all members of the TB complex. Although it cannot allow discrimination between different species of TB, IS6110 is present in many copies within their genomes, and its presence is thus an indication of MTC infection. The results support the use of rib lesions as a marker for TB infection. Additionally, we demonstrate that MTC DNA can be recovered from ribs that lack lesions in individuals who have lesions of other bones. We recommend that an examination of ribs be incorporated into investigations for TB.

Sensitivity of autopsy and radiological examination in detecting bone fractures in an animal model: Implications for the assessment of fatal child physical abuse

Skeletal injuries are often strong indicators of child abuse and their detection is therefore crucial. The aim of this study was to compare the sensitivity of three diagnostic approaches, namely autopsy, traditional (conventional) radiology, and computed tomography on "battered" piglets, in order to verify the sensitivity of each method, with respect to the true number of bone fractures assessed once the piglet was skeletonised (osteological control). Four newborn cadaver piglets who had died from natural causes were severely beaten post-mortem in every district of the body. Traditional radiography, computed tomography (CT) and autopsy were performed. The piglet was then macerated until skeletonised and the number of all fractures present recorded (osteological control). On the cranium, traditional radiology revealed only 35% circa of actual fractures, autopsy detected only 31% (P<0.01 for both comparisons versus osteological control), whereas CT imaging detected all fractures actually present. For ribs, radiology detected only 47% of all fractures present, and autopsy 65% circa (P>0.05 for both comparisons versus osteological control), while CT scans detected 34% (P<0.01). In suspected cases of fatal child abuse, we suggest that the bones of specific districts be directly analysed either at autopsy or by collecting specific diagnostic sites, such as parts of the rib cage, and subjecting them to maceration. The removed areas could be replaced with artificial material for cosmetic purposes. The authors stress the importance of combined radiological, CT scan, autopsy and osteological survey in the detection of perimortem bone fractures.

Wrestling and sports medicine

The coverage of wrestling events from the perspective of medical personnel is reviewed here. Considerations are made regarding the role of medical personnel, the supplies that are important for wrestling event coverage, and the injuries that are frequently encountered in wrestling. Attention is given to treatment of injuries and conditions that are largely specific to wrestling.

Rib impingement in first class cricketers: case reports of two patients who underwent rib resection

Two first class cricket bowlers presented with costoiliac pain secondary to rib impingement. In both patients, conservative management of the injury had failed to improve symptoms. Surgical resection of the affected rib was undertaken. At follow up, both patients had made a good recovery and had returned to competitive cricket.

Repair of long intercalated rib defects using porous beta-tricalcium phosphate cylinders containing recombinant human bone morphogenetic protein-2 in dogs

A new method to repair rib defects with biomaterials containing recombinant human bone morphogenetic protein-2 (rhBMP-2) is presented in this report. We had reported previously the successful regeneration of bony rib defects by placing a short chain of small beta-tricalcium phosphate (beta-TCP) cylinders on the intact periosteum. The multi-cylinder implants were ineffective in promoting rib repair when the periosteum was absent. By adding rhBMP-2 to the beta-TCP cylinders, we were able to promote rib bone regeneration in the presence or absence of the periosteum. The osteogenic capacity of the rhBMP-2/beta-TCP composite implant and the time required to complete regeneration were evaluated in a canine model. An 8cm long section of rib bone, including the periosteum, was removed and replaced with a chain of the rhBMP-2/beta-TCP cylinders. At 6 weeks after implantation, the ribs were restored to their original configuration and mechanical strength. The multi-cylinder beta-TCP implants were degraded and replaced by new bone in 12 weeks. This new degradable bone-inducing implant material has significant clinical potential for rib repair.

Resuscitation injuries complicating the interpretation of premortem trauma and natural disease in children

Minor soft tissues injuries are common in both adults and children who have had cardiopulmonary resuscitation (CPR). Potentially life-threatening injuries are rare. The pre-arrest history in a resuscitated adult often assists the pathologist to interpret autopsy findings. In contrast, an infant or child may not have a reliable history. In this situation, it may be difficult if not impossible to distinguish resuscitation injuries from pre-existing accidental or inflicted trauma. I describe two children who had significant autopsy-documented injuries initially attributed to abuse. The State filed murder charges against the caretaker in each case. However, further history and review of the medical records suggested that resuscitation rather than pre-arrest trauma caused almost all of the injuries. The State dismissed the charges in the first case. A jury returned a "not guilty" verdict in the second. It is essential to consider the entire history and not just autopsy findings when performing a death investigation.

Post-traumatic fibro-osseous lesion of the ribs: a relatively under-recognised entity

AIM

To report the description of a rare benign osseous lesion affecting the ribs entitled post-traumatic fibro-osseous lesion (PTFOL).

METHODS

Seven cases of PTFOLs were retrieved from the archives of the University Hospital of Lille. Histological slides were reviewed and lesions were classified according to the histological patterns described by McDermott et al. Clinical and follow-up data were obtained from the patients' charts.

RESULTS

PTFOLs occurred principally in men (mean age 31.8 years) with a known or suspected previous chest injury for four of them. No previous cancer was noted. Radiologically, PTFOLs readily presented as an isolated expansive lucency with a sclerotic rim located on the last five ribs. A constant increased uptake of radionucleotide was noted on bone scan. Microscopically, two fibro-osseous, four xanthomatous and one mixed pattern were individualised. Lesions were characterised by a network of anastomosing bone trabeculae without osteoblast lining within a fibrous stroma. A zonal maturation from woven to peripheral lamellar bone was characterised. Central sheets of lipid-laden histiocytes were conspicuous in the xanthomatous type. For each patient, clinical follow-up was excellent, without any recurrence.

CONCLUSIONS

This is the second largest series of PTFOLs, which is considered to be a dysplastic healing process after trauma. It may be symptomatic or shown by imaging studies realised for unrelated reason. PTFOL is regularly misdiagnosed with other more common lesions of the ribs, such as fibro-osseous dysplasia, osteoma osteoid and benign fibrous histiocytoma. Its recognition is of importance because no follow-up is needed after resection.

Acquired Deformities of the Anterior Chest Wall

BACKGROUND

Acquired chest wall deformities are difficult to describe and to classify. We propose the following classification and treatment options.

METHODS

We observed 11 patients with acquired deformities (AD) that required surgical correction.

RESULTS

AD of the chest can be classified into 4 groups: (1) AD resulting from a pathological process within the thorax (heart enlargement, mediastinal tumors), (2) AD resulting from chest wall disease (rib osteomyelitis or tumors), (3) iatrogenic deformities (following rib graft harvesting, acquired Jeune's syndrome), and (4) post-traumatic deformities. Group 1 requires treatment of the pathological process. Group 2 is guided by oncological or infectious disease principles. Groups 3 and 4 require chest wall reconstruction. Iatrogenic AD usually occur after pectus excavatum repair with rib cartilage extirpation in young patients, which results in a reduced, restricted thorax. Post-traumatic AD often have pathological chest wall mobility owing to pseudo-articulation of injured ribs.

CONCLUSIONS

To prevent AD formation and to protect thoracic growth and mobility, costosternal and costochondral junctions should be preserved during cartilage resection. Substernal suturing of the perichondrium should be avoided.

Upper Extremity Stress Fractures

Although less common than lower-extremity stress fractures, upper-extremity stress fractures are becoming recognized much more frequently. A majority of these fractures are caused by overuse and fatigue of the surrounding musculature and, as a result, may be prevented by appropriate training and conditioning. Diagnosis is made by history and physical examination with the aid of plain radiographs, bone scans, and MRI. Most of these fractures heal with a period of relative rest followed by a structured rehabilitation program. A small percentage of these fractures, however, may require surgical fixation. The present article reviews the different types of upper extremity and torso stress fractures seen in athletes, starting with the sternum and extending outward to the fingers. The presentation, diagnosis, mechanism of injury, treatment, prevention, and prognosis for each of these injuries will be discussed.

Fracture toughness of manatee rib and bovine femur using a chevron-notched beam test

Bone is an anisotropic material with a hierarchical structure consisting of organic matrix, minerals and water. Fracture toughness (K(C)) has been shown to be a good index to assess the mechanical performance of bone. A chevron-notched (CN) beam test, a standard fracture mechanics test successfully applied to many other materials, was used to determine the transverse-direction fracture toughness in manatee rib and bovine femur cortical bone. Although human and bovine bone has been well studied, there is virtually no information on the toughness of manatee rib bone. As a biological material, manatee rib is interesting for study in that it is a highly mineralized bone. Three major advantages of the CN specimen test are: (1) it is easier to reach plane strain condition; (2) there is no fatigue-precracking needed; and (3) it is relatively easy to produce stable crack propagation before catastrophic fracture. The fracture toughness values of manatee rib and bovine femur were measured to be 4.5 +/- 0.5 MPa m(1/2) and 5.8 +/- 0.5 MPa m(1/2), respectively. Based on the microstructures shown in SEM images, two features that contributed to the greater fracture toughness of bovine femur were identified as greater osteon density and lesser porosity.

Ewing sarcoma of the rib with normal blood flow and blood pool imagings on a 3-phase bone scan

Ewing sarcoma is the second most common pediatric malignant bone tumor. It usually presents as a hot spot on a 3-phase bone scan as a result of increased vascularity of the tumor and new bone formation. However, aggressive Ewing sarcoma can also appear as a cold lesion. We present the features of a Ewing sarcoma of the rib on a 3-phase bone scan in a child who was being investigated for rib fracture after trauma.