[Bony injuries of the thoracic cage in multiple trauma : Incidence, concomitant injuries, course and outcome]

[Complications after conservative vs. operative treatment of severe thoracic trauma]

BACKGROUND

Thoracic trauma is a frequent injury in the routine treatment of injured patients. Due to the increasing demographic changes a further increase is to be expected, especially after low-energy trauma.

OBJECTIVE

Expected complications after conservative vs. operative treatment of various injury patterns of thoracic trauma.

MATERIAL AND METHODS

Evaluation of a selective literature search regarding possible complications after thoracic trauma and formulation of instructions for action as expert recommendations.

CONCLUSION

Both conservative and operative treatment of thoracic trauma have their specific complications, which have to be known to the treating physician. Lung contusions are often underestimated in the initial radiological diagnostics but often lead to relevant problems during the further course of treatment. After conservative treatment of rib fractures persistent pain, functional limitations or even relevant deformities due to secondary dislocation, can remain. There is a significant risk of overlooking or underestimating relevant injuries during the initial diagnostics which then leads to secondary complications. By far the most frequent risk of surgical treatment is an incorrect positioning of chest tubes. Overall, postoperative infections after chest trauma are relatively rare.

[Treatment strategy for severe implosion injuries of the lateral chest wall]

In the majority of cases implosion injuries to the thoracic wall are caused by blunt, massive force acting on the thorax. Basically, different regions and directions of the acting energy have to be taken into account. In common usage, the term implosion injury has become established, especially for the sequelae of lateral energy impact. Particular attention should be paid to the stability of the shoulder girdle, the underlying hemithorax and its intrathoracic organs.

[Bilateral thoracic trauma-"double the trouble"?]

BACKGROUND

Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma.

OBJECTIVE

The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two.

MATERIAL AND METHODS

In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome.

RESULTS

A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors.

CONCLUSION

Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

Surgical strategy for treating multiple symptomatic rib fracture malunions with bridging heterotopic ossifications: A case report

Rib fractures are common and serious injuries, which can negatively impact long-term quality of life. Here we present a woman in her early twenties who was referred to our trauma surgery outpatient clinic five years after a motor vehicle collision in which she sustained upper extremity injury and multiple displaced rib fractures. The rib fractures were initially managed non-operatively. At the time of the outpatient consultation, she endured persistent severe pain located between the left scapula and the thoracic spine. The pain worsened on repetitive motion and deep respiration. A new chest CT revealed left-sided posterior rib fracture malunions of ribs 4 to 8 with heterotopic ossifications (HO) that formed an osseous bridge between these ribs. Surgical excision of the bridging HO and remodeling of the angulated rib malunions resulted in significant alleviation of symptoms, which allowed her to return to work and other activities. Given the dramatic improvement after surgery, we suggest considering surgical remodeling and excision for rib fracture malunions and associated HO that cause local mechanical symptoms.

Biomechanical characteristics of rib fracture fixation systems

BACKGROUND

The primary aim of this study was to determine and compare the biomechanical properties of a fractured or intact rib after implant fixation on an embalmed thorax.

METHODS

Five systems were fixated on the bilateral fractured or intact (randomly allocated) 6th to 10th rib of five post-mortem embalmed human specimens. Each rib underwent a four-point bending test to determine the bending structural stiffness (Newton per m²), load to failure (Newton), failure mode, and the relative difference in bending structural stiffness and load to failure as compared to a non-fixated intact rib.

FINDINGS

As compared to a non-fixated intact rib, the relative difference in stiffness of a fixated intact rib ranged from -0.14 (standard deviation [SD], 0.10) to 0.53 (SD 0.35) and for a fixated fractured rib from -0.88 (SD 0.08) to 0.17 (SD 0.50). The most common failure mode was a new fracture at the most anterior drill hole for the plate and screw systems and a new fracture within the anterior portion of the implant for the clamping systems.

INTERPRETATION

The current fixation systems differ in their design, mode of action, and biomechanical properties. Differences in biomechanical properties such as stiffness and load to failure especially apply to fractured ribs. Insight in the differences between the systems might guide more specific implant selection and increase the surgeon's awareness for localizing hardware complaints or failure.

[Pathophysiology, Diagnostics and Therapy of Pulmonary Contusion - Recommendations of the Interdisciplinary Group on Thoracic Trauma of the Section NIS of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT)]

Pulmonary contusion usually occurs in combination with other injuries and is indicative of a high level of force. Especially in multiply injured patients, pulmonary contusions are frequently detected. The injury is characterised by dynamic development, which might result in difficulties in recognising the actual extent of the injury at an early stage. Subsequently, correct classification of the extent of injury and appropriate initiation of therapeutic steps are essential to achieve the best possible outcome. The main goal of all therapeutic measures is to preserve lung function as best as possible and to avoid associated complications such as the development of pneumonia or Acute Respiratory Distress Syndrome (ARDS).The present report from the interdisciplinary working group "Chest Trauma" of the German Society for Trauma Surgery (DGU) and the German Society for Thoracic Surgery (DGT) includes an extensive literature review on the background, diagnosis and treatment of pulmonary contusion. Without exception, papers with a low level of evidence were included due to the lack of studies with large cohorts of patients or randomised controlled studies. Thus, the recommendations given in the present article correspond to a consensus of the aforementioned interdisciplinary working group.Computed tomography (CT) of the chest is recommended for initial diagnosis; the extent of pulmonary contusion correlates with the incidence and severity of complications. A conventional chest X-ray may initially underestimate the injury, but is useful during short-term follow-up.Therapy for pulmonary contusion is multimodal and symptom-based. In particular, intensive care therapy with lung-protective ventilation and patient positioning are key factors of treatment. In addition to invasive ventilation, non-invasive ventilation should be considered if the patient's comorbidities and compliance allows this. Furthermore, depending on the extent of the lung injury and the general patient's condition, ECMO therapy may be considered as an ultima ratio. In particular, this should only be performed at specialised hospitals, which is why patient assignment or anticipation of early transfer of the patient should be anticipated at an early time during the course.

[Treatment of Persistent Parenchymal Lung Injuries in Thoracic Trauma: Lung Laceration, Pleural Fistula and Pneumothorax]

Thoracic trauma is a frequent injury pattern with high patient morbidity and mortality. Preclinical and clinical emergency treatment is consented in a national S3-guideline. Following emergency therapy one third of patients may develop lung lacerations, pleural fistulation and persisting pneumothorax. An interdisciplinary working group of the German Society for Thoracic Surgery and the German Society for Traumatology reviewed the published medical literature on treatment of those injuries and assessed the existing evidence according to consensus recommendations. An inconsistent classification of those subsequent lung injuries was found. Evidence for diagnostic and therapeutic recommendations is small.

Is it Necessary to Stabilize Every Fracture in Patients with Serial Rib Fractures in Blunt Force Trauma?

Introduction

Management of traumatic rib fractures is subject of controversial discussions. Rib fractures are common, especially after traffic accidents and falls. There is no consensus on whether and how many rib fractures need reconstruction. Not every rib fracture needs to be stabilized, but conservative treatment by internal splinting and analgesia is not effective for all patients. Deformities of the chest wall with reduced thoracic volume and restrictive ventilation disorders must be avoided. Intraoperative assessment of fractures and chest stability plays a central role.

Material and methods

From 07/2016 to 07/2021, a total of 121 chest wall stabilizations were performed (m:f = 2:1, age 65 ± 14.5 a). Indications for surgery were the following criteria: (1) palpatory instability of the chest wall, (2) dislocated fracture endings, (3) concomitant injuries, (4) uncontrollable pain symptoms. In all patients, a computed tomography scan of the thorax was performed before the osteosynthetic treatment to assess dislocation of the fracture endings and possible concomitant injuries of intrathoracic organs.

Results

Video-assisted thoracoscopy was performed in all patients. Hemothorax and concomitant injuries of the lung, diaphragm and mediastinum could be assessed. This was followed by an intraoperative assessment of the rib fractures, in particular penetration of fracture endings and resulting instability and deformity. Relevant fractures could be identified and subsequent incisions for rib osteosynthesis precisely defined. 6.3 (±2.7) rib fractures were detected, but 2.4 (±1.2) ribs treated osteosynthetically. Bilateral rib fractures were present in 26 patients (21.5%). Post-operative bleeding occurred in seven patients (5.8%), a breakage of the osteosynthetic material in two patients (1.7%).

Discussion

Intraoperative assessment of relevant fractures and dislocation is the decisive criterium for osteosynthesis. Thoracoscopy is mandatory for this purpose - also to identify accompanying injuries. Not every fracture has to be approached osteosynthetically. Even with serial rib fractures or multiple fractures in a single rib, the thoracic contour can be restored by stabilizing only relevant fractures. Intraoperative palpation can adequately assess the stability and thus the result of the osteosynthesis. Even after surgical treatment of thoracic trauma, adequate analgesia and respiratory therapy are important to the healing process.

Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®

Purpose

In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay.

Methods

Data from the TraumaRegister DGU^® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability.

Results

In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h.

Conclusions

In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.

Outcome after surgical stabilization of symptomatic rib fracture nonunion: a multicenter retrospective case series

Purpose

This study aimed to determine the long-term level of pain after surgical treatment of one or more symptomatic rib fracture nonunions. Secondary aims were to evaluate the occurrence of adverse events, satisfaction, and activity resumption. The final aim was to assess the association between pain and the presence of bridging callus at the nonunified fracture. Hypothesized was that thoracic pain would diminish after surgery.

Methods

This retrospective case series included adults who underwent surgery for a symptomatic rib fracture nonunion from three hospitals. Symptomatic nonunion was defined as persistent pain associated with nonbridging callus of ≥1 rib fractures on a chest CT scan at ≥3 months after the initial injury. Patients completed questionnaires about pain, satisfaction, and activity resumption ≥3 months postoperatively.

Results

Thirty-six patients (26 men, 10 women), with a median age of 55 (P₂₅–P₇₅ 49–62) years and 169 acute rib fractures were included. Nonunion occurred in 98 (58%) fractures of which 70 (71%) were treated surgically. After a median of 11 months (P₂₅–P₇₅ 7–21), 13 (36%) patients reported severe pain, in contrast to 26 (72%) preoperatively. Patients who underwent intercostal neurectomy or neurolysis in addition to surgical stabilization less often reported pain reduction. Twenty-six (72%) had postoperative complications, for which 12 (33%) underwent additional surgery, mostly for persistent pain. The majority (n = 27; 75%) was satisfied with their functional recovery. Of patients who had paid work pre-trauma, 65% had resumed working.

Conclusion

Most patients reported less pain and better daily functioning after surgical stabilization of symptomatic rib fracture nonunions, although causality cannot be proven with this retrospective case series. Additional intercostal nerve treatment was not associated with pain relief. Despite surgery-related complications being common, patient satisfaction was high.

Level of evidence: Level V.

Study type: Therapeutic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01867-x.

Long-term pulmonary function, thoracic pain, and quality of life in patients with one or more rib fractures

BACKGROUND

Long-term outcomes after rib fractures and the effect of treatment modality or chest wall injury severity on these outcomes remains uncertain. This retrospective cohort study evaluated the long-term pulmonary function, thoracic pain, and quality of life in patients admitted with rib fractures.

METHODS

Patients admitted with rib fractures between January 1, 2012, and December 1, 2019, were included. Data on long-term outcomes were collected during one follow-up visit. Patients were stratified by chest wall injury severity (one or two rib fractures, ≥3 rib fractures, or a flail chest) and treatment modality (surgical stabilization of rib fractures [SSRF] or nonoperative management). Multivariable analysis was performed to compare outcomes after SSRF with nonoperative treatment in patients with three or more rib fractures.

RESULTS

In total, 300 patients were included. The median follow-up was 39 months (P25-P75, 18-65 months). At follow-up, the corrected forced vital capacity returned to 84.7% (P25-P75, 74.3-93.7) and the forced expiratory volume in 1 second to 86.3% (P25-P75, 75.3-97.0) of the predicted reference values. Quality of life was determined using the Short Form-12 version 2 and EuroQoL-5D-5L. The Short Form-12 version 2 physical and mental component summary were 45 (P25-P75, 38-54) and 53 (P25-P75, 43-60), respectively. The EuroQoL-5D-5L utility score was 0.82 (P25-P75 0.66-0.92) and visual analog scale score 75 (P25-P75 70-85). This indicated a quality of life within normal population ranges. Moderate to severe thoracic pain was reported by 64 (21.3%) patients. Long-term outcomes returned to values within population ranges and were similar across chest wall injury severity and for patients treated with SSRF or nonoperatively.

CONCLUSION

While long-term pulmonary function and quality of life recover to values considered normal, subjective thoracic complaints, such as pain and dyspnea, remain frequently present following rib fractures. No effect of chest wall injury severity or treatment modality on long-term outcomes was demonstrated.

LEVEL OF EVIDENCE

Therapeutic, level III.

Influence of surgical stabilization of clavicle fractures in multiply-injured patients with thoracic trauma

Thoracic trauma has decisive influence on the outcome of multiply-injured patients and is often associated with clavicle fractures. The affected patients are prone to lung dysfunction and multiple organ failure. A multi-center, retrospective analysis of patient records documented in the TraumaRegister DGU was performed to assess the influence of surgical stabilization of clavicle fractures in patients with thoracic trauma. A total of 3,209 patients were included in the analysis. In 1362 patients (42%) the clavicle fracture was treated operatively after 7.1 ± 5.3 days. Surgically treated patients had a significant reduction in lung failure (p = 0.013, OR = 0.74), multiple organ failure (p = 0.001, OR = 0.64), intubation time (p = 0.004; -1.81 days) and length of hospital stay (p = 0.014; -1.51 days) compared to non-operative treatment. Moreover, surgical fixation of the clavicle within five days following hospital admission significantly reduced the rates of lung failure (p = 0.01, OR = 0.62), multiple organ failure (p = 0.01, OR = 0.59) and length of hospital stay (p = 0.01; -2.1 days). Based on our results, multiply-injured patients with thoracic trauma and concomitant clavicle fracture may benefit significantly from surgical stabilization of a clavicle fracture, especially when surgery is performed within the first five days after hospital admission.

Surgical Site Infection after Surgical Stabilization of Rib Fractures: Rare But Morbid

Background: Although surgical stabilization for rib fractures (SSRF) has been adopted widely over the past decade, little information is available regarding the prevalence and outcomes of post-operative surgical site infection (SSI). We hypothesized that SSI after SSRF is uncommon but morbid. Patients and Methods: Patients undergoing SSRF at a level 1 trauma center from 2010-2020 were reviewed. The primary outcome was the prevalence of SSI, documented by clinical examination, radiography, systemic markers of infection, and microbiology. Results: Of 228 patients undergoing SSRF, 167 (73.2%) were male, the median age was 53 years (P₂₅-P₇₅; 41-63 years), injury severity score (ISS) was 19 (P₂₅-P_75, 13-26), with a median of eight fractured ribs (P₂₅-P_75, 6-11). All stabilization plates were titanium. SSRF was typically performed on post-injury day one (P₂₅-P_75, 0-2 days) after trauma. All patients received antibiotic agents within 30 minutes of incision, and a median of four ribs (P₂₅-P_75, 3-6) were repaired. Four (1.8%) patients developed an SSI and all underwent implant removal. Two patients required implant removal within 30 days (on post-operative day seven and 17) and two for chronic infection at seven and 17 months after SSRF. The causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) bacteria in all patients. After implant removal, three patients received intravenous and oral antibiotic agents, ranging from two to six weeks, without recurrent infection. No patient required additional SSRF. Conclusions: Surgical site infection after SSRF is rare but morbid and can become symptomatic within one week to 17 months. Implant removal results in complete recovery.

What is the optimal timing to perform surgical stabilization of rib fractures?

The practice of surgical stabilization of rib fractures (SSRF) for severe chest wall injury has exponentially increased over the last decade due to improved outcomes as compared to nonoperative management. However, regarding in-hospital outcomes, the ideal time from injury to SSRF remains a matter of debate. This review aims to evaluate and summarize currently available literature related to timing of SSRF. Nine studies on the effect of time to SSRF were identified. All were retrospective comparative studies with no detailed information on why patients underwent early or later SSRF. Patients underwent SSRF most often for a flail chest or ≥3 displaced rib fractures. Early SSRF (≤48-72 hours after admission) was associated with shorter hospital and intensive care unit length of stay (HLOS and ICU-LOS, respectively), duration of mechanical ventilation (DMV), and lower rates of pneumonia, and tracheostomy as well as lower hospitalization costs. No difference between early or late SSRF was demonstrated for mortality rate. As compared to nonoperative management, late SSRF (>3 days after admission), was associated with similar or worse in-hospital outcomes. The optimal time to perform SSRF in patients with severe chest wall injury is early (≤48-72 hours after admission) and associated with improved in-hospital outcomes as compared to either late salvage or nonoperative management. These data must however be cautiously interpreted due the retrospective nature of the studies and potential selection and attrition bias. Future research should focus on both factors and pathways that allow patients to undergo early SSRF.

Abdominal flank bulge following intercostal neurectomy for symptomatic rib fracture nonunion

The gold standard for rib fracture nonunion management remains a matter of debate. Operative treatment of rib fracture nonunion has become increasingly popular. A 69-year-old man was operatively treated with intercostal neurectomy of the left eighth rib to resolve chronic thoracic pain following a rib fracture nonunion. After the intervention, the patient developed a flank bulge which was most likely due to the intercostal neurectomy, causing partial denervation of the abdominal musculature. Although the pain at the nonunion site decreased after the operative intervention, the patient still experienced severe pain during daily activities and reported poor quality of life due to the flank bulge. Physiotherapy and an abdominal belt did not improve this flank bulge. When considering operative neurectomy of the intercostal nerves of ribs 7-12 to resolve chronic pain due to rib fracture nonunion, the treating surgeon should be aware of this debilitating complication.

Epidemiology of combined clavicle and rib fractures: a systematic review

Purpose

The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries.

Methods

A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14^th of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant–Murley score, union and complications.

Results

Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56–60.6% versus 29% in patients without clavicle fractures. Vice versa, 14–18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days).

Conclusion

Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01701-4.

Morphology of direct and indirect rib fractures

Rib fractures are a common finding in legal medicine and information on the impact mechanism is relevant for trauma reconstruction. This study focuses on morphological characteristics of rib fractures resulting from direct or indirect force. Fresh human ribs (n = 312) were divided into two groups and broken through local force (direct) and bending (indirect) in anterolateral areas. The ribs were macerated, visually investigated and the results statistically analysed. The indirect fractures showed a significant larger lateral offset of the internal and external fracture ends while the fracture ends of the direct fractures were more often straight, in line. Also, the morphology of the inner and outer fracture edges was significantly related to fracture type. Direct fractures mostly had rough and jagged inner edges (tension side) and straight, smooth outer edges (compression side), whereas indirect fractures more often showed the characteristics vice versa. The results were more convincing in combination and in ribs from persons aged ≤ 75 years at death. In summary, the direct and indirect rib fractures showed significantly different characteristics regarding orientation and offset of the fracture lines and roughness of the inner and outer fracture edges, which can be helpful to distinguish the traumatizing impact mechanisms in forensic autopsy routine.

Demographic, Clinical Features and Outcome Determinants of Thoracic Trauma in Sri Lanka: A Multicentre Prospective Cohort Study

Prognostic determinants in thoracic trauma are of major public health interest. We intended to describe patterns of thoracic trauma, demographic factors, clinical course, and predictors of outcome in selected tertiary care hospitals in Sri Lanka. A multicentre prospective cohort study was conducted in five leading teaching hospitals from June to September 2017. Patients with thoracic trauma were followed up during the hospital stay. A logistic regression analysis was conducted using in-hospital morbidity as the dichotomous outcome variable. One hundred seventy-one patients were included in the study yielding 1450 (median = 8.5) person-days of observation. Of them, 71.9% (n = 123) were males. The mean age was 45.8 ± 17.9 years. Majority (39.2%, n = 67) were recruited from the National Hospital of Sri Lanka. Automobile accidents were the commonest (62.6%, n = 107), followed by falls (26.9%, n = 46), assaults (8.8%, n = 15), and animal attacks (1.8%, n = 3). The ratio of blunt to penetrating trauma was 5.6 : 1. Injury patterns were rib fractures (80.7%, n = 138), haemothorax (44.4%, n = 76), pneumothorax (44.4%, n = 76), lung contusion (22.8%, n = 39), flail segment (15.8%, n = 27), tracheobronchial trauma (7.0%, n = 12), diaphragmatic injury (2.3%, n = 4), vascular injury (2.3%, n = 4), cardiac contusions (1.1%, n = 2), and oesophageal injury (0.6%, n = 1). Ninety nine (57.9%) had extrathoracic injuries. Majority (63.2%, n = 108) underwent operative management including intercostal tube insertion (60.8%, n = 104), wound exploration (6.4%, n = 11), thoracotomy (4.1%, n = 7), rib reconstruction (4.1%, n = 7), and video-assisted thoracoscopic surgery (2.9%, n = 5). Pneumonia (10.5%, n = 8), bronchopleural fistulae (2.3%, n = 4), tracheaoesophageal fistulae (1.8%, n = 3), empyema (1.2%, n = 2), and myocardial infarction (1.2%, n = 2) were the commonest postoperative complications. The mean hospital stay was 15.6 ± 18.0 days. The in-hospital mortality was 11 (6.4%). The binary logistic regression analysis with five predictors (age, gender, mechanism of injury (automobile/fall/assault), type of trauma (blunt/penetrating), and the presence of extrathoracic injuries) was statistically significant to predict in-hospital morbidity (X ² (6, n = 168) = 13.1; p=0.041), explaining between 7.5% (Cox and Snell R ²) and 14.5% (Nagelkerke R ²) of variance. The automobile accidents (OR: 2.3, 95% CI = 0.2-26.2) and being males (OR: 2.3, 95% CI = 0.6-9.0) were the strongest predictors of morbidity.

A case of severe flail chest with several dislocated sterno-chondral fractures

•

Surgical stabilization of flail chest lead to fast weaning from mechanical ventilation.

•

Plates can be used for stabilization of sterno-costal dehiscence.

•

Cartilage reconstruction of a CT scan can reveal the true severity of the trauma.

Introduction

Flail chest is diagnosed clinically by the presence of paradox movement of a segment of the thoracic wall during spontaneous breathing. Radiographic finding confirming a clinical flail chest are fractures of three or more consecutive ribs or costal cartilages in two or more places. Surgical stabilization is associated with a reduced length of hospital stay, time with mechanical ventilation and risk of respiratory complications.

Presentation of case

A trauma patient had a Computed Tomography (CT) scan showing multiple costa fractures, sternal fracture, manubrium fracture, sternal displacement and dehiscence of the sternal-costal attachment. The severity of the trauma was visualized after performing a cartilage reconstruction of the trauma CT scan. The patient underwent surgery, using fixation plates to stabilize the thoracic cage, and was then weaned quickly from mechanical ventilation.

Discussion

This case indicates, that if a patient has a severe flail chest recognized clinically, but not radiologically, a reconstruction of cartilage can reveal the true severity of the trauma. Indeed, the patient in this case experienced a positive outcome from surgery. However, such a procedure demands correct timing and experience in surgical stabilization of the thoracic wall. Furthermore, the injury required accurate planning with the involved personal before surgery.

Conclusion

Surgical stabilization of advanced flail chest with concomitant sternal fracture, seems to be a safe procedure, that might reduce the need of mechanical ventilation and the length of stay at the Intensive Care Unit (ICU). Furthermore, cartilage reconstruction of the trauma CT scan can potentially identify a severe flail chest, that might be missed on regular 3D bone reconstruction.

[Anesthesia, ventilation and pain treatment in thoracic trauma]

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

[Injuries of the posterior and lateral chest wall-importance of an additional clavicular fracture]

BACKGROUND

Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show a high incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to a loss of function of the shoulder and a pronounced deformation of the chest wall.

OBJECTIVE

This article shows the origin and clinical importance of FCI. What importance does a concomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively?

MATERIAL AND METHODS

After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in a corpse study and then put into practice.

RESULTS AND CONCLUSION

This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the 2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and a marked deformation of the thoracic wall are present. Remaining misalignments are associated with a simultaneous loss of function of the chest wall and shoulder.

[Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]

BACKGROUND

Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed.

OBJECTIVE

A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options.

MATERIAL AND METHODS

Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed.

RESULTS AND DISCUSSION

Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.

Osteosynthesis of sternal fractures with double locking compression plate fixation: a retrospective cohort study

PURPOSE

Sternal fractures are rare injuries and mostly treated non-operatively. In selected cases, internal fixation becomes necessary. No standard operative approach has been determined yet among experts. The aim of this study is to describe our treatment algorithm and results after operative stabilisation of sternal fractures with locking compression plates (LCP), mainly focusing on the functional outcome.

METHODS

A retrospective cohort study was conducted. We included all patients after operative stabilisation of a sternal fracture between 2008 and 2016. Endpoints were the functional outcome using the Activities of Daily Living (ADL) score, pain analysed by the numeric rating scale (NRS), breathing ability, complications and implant removal.

RESULTS

Eighteen out of 153 (12%) patients with a sternal fracture underwent operation. Three patients were lost to follow-up. Eleven out of 15 (73%) patients were treated with double straight LCP 3.5 mm implants and 4 (27%) patients with pre-countered LCP 3.5 mm implants. Mean follow-up was 57 months. The median ADL score was 1 (1-4), the median NRS was 0 (0-9), and respiratory complaints scored a median of 1 (1-4). No non-union, hardware failure or implant-related complication occurred. Post-operative complications were pneumonia (20%) and respiratory insufficiency (20%). Implants were removed in 4/15 (27%) patients; three times due to implant-related irritation, once on patient's request.

CONCLUSION

Operative stabilisation of sternal fractures with double LCP 3.5 mm provides excellent long-term functional results and seems to be an appropriate option for internal fixation. The rate of post-operative complications is low; however, 27% had a second operation for implant removal.

Efficacy of nickel-titanium memory alloy in the treatment of multiple rib fracture combined with sternal fracture

Clinical efficacy and complications of nickel-titanium memory alloy in the treatment of multiple rib fractures combined with sternal fractures was investigated. A retrospective analysis of 123 patients with multiple rib fractures combined with sternal fractures admitted to First People's Hospital of Fuzhou from January 2013 to December 2015 was performed, including study group (treated with internal fixation by the nickel-titanium memory alloy, n=68) and control group (treated with internal fixation by partial pressure bandage, n=55). Μean arterial pressure (MAP), heart rate (HR), and visual analogue pain score (VAS) of the two groups before and after treatment were compared and analyzed. No significant difference in MAP, HR and VAS scores between groups was detected before treatment (P>0.05). After treatment, MAP score of study group was significantly higher, and HR and VAS scores were significantly lower (P<0.05). Μethod of internal fixation by the nickel-titanium memory alloy, with better efficacy than the traditional method of internal fixation by partial pressure bandage and less postoperative complications in the treatment of flail chest caused by multiple rib fractures combined with sternal fractures, is worthy of clinical application and promotion.

Limited Influence of Flail Chest in Patients With Blunt Thoracic Trauma - A Matched-pair Analysis

BACKGROUND

Flail chest is considered as one of the most severe forms of blunt thoracic trauma. However, its actual influence on post-traumatic morbidity and mortality is debatable.

MATERIALS AND METHODS

A retrospective cohort analysis was performed of multiply injured patients (injury severity score ≥16) at a level I trauma center. Flail chest was defined as segment fracture of at least three consecutive ribs on at least one side. Propensity score matching was performed.

RESULTS

A total of 600 patients were included, with a mean age of 44.1±19.1 years and a mean injury severity score of 31.6±10.4. Overall, 367 patients (61.2%) had a serial rib fracture. Forty-five patients (7.5%) presented with flail chest. Patients with flail chest more often had lung contusions (70 vs. 50%, p=0.04) and pneumo-/hematothorax (93 vs. 71%, p=0.005). There were no differences in post-traumatic morbidity and mortality.

CONCLUSION

Flail chest had no independent influence in addition to injury severity on post-traumatic morbidity and mortality in multiply injured patients with blunt thoracic trauma.

[Lesions of the anterior chest wall-significance of additional fractures of the spine]

BACKGROUND

Fractures of the anterior chest wall are rare among the total number of fractures. They include sternal fractures (SF) and the adjacent cartilaginous structures of the ribs. The accident mechanism can allow conclusions to be drawn about which further accompanying injuries may be present, e.g. rib and spinal fractures.

OBJECTIVE

The present work is intended to give an overview of injuries of the anterior chest wall. It includes clinical aspects as well as imaging and popular literature.

MATERIAL AND METHODS

Included are injury constellations of the anterolateral chest wall, in particular of the sternum in combination with injuries of the spinal column in the sense of a sternovertebral injury (SVI). Possible treatment strategies were reviewed and the corresponding advantages and disadvantages are presented.

RESULTS

In symptomatic fractures of the anterior chest wall, their operative stabilization should be considered in order to restore the stability of the trunk. In addition, rib fractures in direct trauma and spinal injuries in indirect trauma are often included in the treatment.

CONCLUSION

In the case of injuries of the thoracic trunk, this must always be regarded as a unit and must therefore be clarified in the context of the clinical examination and diagnostic apparatus. The possible accident mechanism can allow conclusions to be drawn about possible injury patterns, e.g. in the sense of SVIs.

[Chest trauma from a surgical perspective]

Patients with multiple injuries in particular frequently also suffer from chest trauma. During the initial phase the identification and treatment of life-threatening injuries is essential and tension pneumothorax is of particular importance during this phase. The Advanced Trauma Life Support (ATLS) algorithm should be followed for structured treatment. In most cases treatment by insertion of a chest tube is sufficient but for some injuries an emergency thoracotomy is unavoidable as a life-saving intervention. In the further treatment especially a flail chest and retained hemothorax are responsible for complications, such as acute lung failure and thoracic empyema. Early operative interventions in the sense of rib fracture stabilization and thoracoscopy-assisted evacuation of hematomas can help to prevent such complications.

[Single-port VATS-assisted internal fixation of serial rib fractures]

This article describes the operative stabilization of a flail chest due to traumatic serial rib fractures with extensive chest wall deformation and respiratory insufficiency. Initial conservative treatment including systemic and regional pain management and non-invasive positive pressure ventilation did not improve the pain or ventilation. Therefore, a single-port video-assisted thoracoscopic surgery (VATS) assisted internal fixation of the ribs was performed. The thoracoscopy enabled easy repositioning of the ribs and additionally an estimation of intrathoracic injuries.

Fractures of the manubrium sterni: treatment options and a possible classification of different types of fractures

Background

Sternum fractures are mostly located on the sternal corpus, seldom on the manubrium. Fractures of the sternal manubrium are, however, more frequently associated with severe concomitant injuries of thoracic organs, and therefore deserve special attention. In addition, in its function as a capstone in between the anterior chest wall and the shoulder girdle, it is exposed to a multiplicity of forces. Therefore the questions arise what types of fractures are observed in today's clinical practice, how to classify them and which treatment options are available. This study reports on different types of fractures which involve the manubrium sterni.

Methods

Between January 2012 and October 2014, data was collected from all severely injured patients (ISS ≥16), which received a CT scan of the thorax in our Level-I-Trauma Center and retrospectively analyzed concerning sternal fractures. Fracture type, collateral injuries, age, and information about the circumstances of the accident were noted.

Results

Of 890 evaluable patients, 154 (17.3%) had a fracture of the sternum and 23 (2.6%) of the manubrium. Fractures of the manubrium appeared in following types: A-type-transverse fracture (n=11) in 1st intercostal space by direct blunt trauma or flexion of the torso with sagittal instability; B-type-oblique fracture (n=9) by seat belt injury with rotatory instability; C-type-combined, more fragmentary fracture (n=3) by direct blunt trauma with simultaneous flexion of the torso and multi directional instability. Fractures only little dislocation were treated conservatively, and unstable fractures were surgically stabilized (n=10).

Conclusions

In summary, three main types of fractures could be found. A-type fractures were stabilized with a longitudinal plate osteosynthesis and B-type fractures with transverse positioned plates. To treat complex C-type fractures, plates with a T- or H-form could be a good solution. Level of evidence: Level III retrospective prognostic cohort study.

[Frequency and age distribution of combined sternovertebral injuries : Analysis of routine data from German hospitals 2005-2012]

BACKGROUND

Combinations of sternal and spinal fractures often occur due to high velocity accidents and are associated with a high incidence of concomitant injuries. The anterior thoracic wall is described as the fourth column of torso stability, which is why sternovertebral injuries (SVI) present a high risk of sagittal deformation of the trunk, in particular injuries of the thoracic spine. To date, no studies have been published on the frequency distribution of the involved vertebral bodies in large patient groups.

OBJECTIVES

This study was intended to elaborate a frequency distribution of vertebral fractures accompanying sternal fractures (SF) and examine the risk of a vertebral fracture accompanying a SF.

MATERIAL AND METHODS

A total of 48,193 cases with the main or secondary diagnosis of a SF and 897,963 cases with vertebral fractures based on routine data of German hospitals from the years 2005-2012 were evaluated. A concomitant injury to the spinal column was examined for each vertebral body and then evaluated statistically.

RESULTS AND CONCLUSIONS

Of all patients with a SF 30.96% also suffered from a vertebral fracture. Of these 3.11% were SF as the main diagnosis and 60.89% the secondary diagnosis. While vertebral fractures generally occurred most frequently in the region of the thoracolumbar transition and the second cervical vertebral body, the SVI showed a further frequency peak in the range from the lower cervical spine to the middle thoracic spine. The present study was able to show a frequency distribution of accompanying vertebral body injuries in a large and representative collective in the case of SF for the first time.

Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries?

BACKGROUND

Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants.

METHODS

11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred.

RESULTS

Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years..

CONCLUSIONS

A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.