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Schulz-Drost S, Spering C. [Treatment strategy for severe implosion injuries of the lateral chest wall]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:188-196. [PMID: 38273139 DOI: 10.1007/s00113-023-01406-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
- Stefan Schulz-Drost
- Zentrum für Bewegungs- und Altersmedizin, Helios Kliniken Schwerin, Wismarsche Str. 397, 19055, Schwerin, Deutschland.
- Klinik für Unfallchirurgie, orthopädische Chirurgie, Universitätsklinikum, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland.
| | - Christopher Spering
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
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Rehme-Röhrl J, Sicklinger K, Brand A, Fürmetz J, Neuerburg C, Stuby F, von Rüden C. Early Internal Fixation of Concomitant Clavicle Fractures in Severe Thoracic Trauma Prevents Posttraumatic Pneumonia. J Clin Med 2023; 12:4878. [PMID: 37568281 PMCID: PMC10420208 DOI: 10.3390/jcm12154878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Severe thoracic trauma can lead to pulmonary restriction, loss of lung volume, and difficulty with ventilation. In recent years, there has been increasing evidence of better clinical outcomes following surgical stabilization of clavicle fractures in the setting of this combination of injuries. The aim of this study was to evaluate surgical versus non-surgical treatment of clavicle fractures in severe thoracic trauma in terms of clinical and radiological outcomes in order to make a generalized treatment recommendation based on the results of a large patient cohort. PATIENTS AND METHODS This retrospective study included 181 patients (42 women, 139 men) from a European level I trauma centre with a median of 49.3 years in between 2005 and 2021. In 116 cases, the clavicle fracture was stabilized with locking plate or hook plate fixation (group 1), and in 65 cases, it was treated non-surgically (group 2). Long-term functional outcomes at least one year postoperatively using the disabilities of the arm, shoulder and hand (DASH) questionnaire and the Nottingham Clavicle Score (NCS) as well as radiological outcomes were collected in addition to parameters such as hospital days, intensive care days, and complication rates. RESULTS The Injury Severity Score (ISS) was 17.8 ± 9.8 in group 1 and 19.9 ± 14.4 in group 2 (mean ± SEM; p = 0.93), the time in hospital was 21.5 ± 27.2 days in group 1 versus 16 ± 29.3 days in group 2 (p = 0.04). Forty-seven patients in group 1 and eleven patients in the group 2 were treated in the ICU. Regarding the duration of ventilation (group 1: 9.1 ± 8.9 days, group 2: 8.1 ± 7.7 days; p = 0.64), the functional outcome (DASH group 1: 11 ± 18 points, group 2: 13.7 ± 18. 4 points, p = 0.51; NCS group 1: 17.9 ± 8.1 points, group 2: 19.4 ± 10.3 points, p = 0.79) and the radiological results, no significant differences were found between the treatment groups. With an overall similar complication rate, pneumonia was found in 2% of patients in group 1 and in 14% of patients in group 2 (p = 0.001). DISCUSSION This study could demonstrate that surgical locking plate fixation of clavicle fractures in combination with CWI significantly reducing the development of posttraumatic pneumonia in a large patient collection and, therefore, can be recommended as standard therapeutic approach for severe thoracic trauma.
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Affiliation(s)
- Julia Rehme-Röhrl
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Korbinian Sicklinger
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, Ludwig-Maximilians University Munich, 81377 Munich, Germany
| | - Andreas Brand
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Institute for Biomechanics, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Julian Fürmetz
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, Ludwig-Maximilians University Munich, 81377 Munich, Germany
| | - Carl Neuerburg
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich, Ludwig-Maximilians University Munich, 81377 Munich, Germany
| | - Fabian Stuby
- Department of Trauma Surgery, BG Unfallklinik Murnau, 82418 Murnau, Germany
| | - Christian von Rüden
- Institute for Biomechanics, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Trauma Surgery, Orthopaedics and Hand Surgery, Weiden Medical Center, 92637 Weiden, Germany
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Influence of surgical stabilization of clavicle fractures in multiply-injured patients with thoracic trauma. Sci Rep 2021; 11:23263. [PMID: 34853398 PMCID: PMC8636561 DOI: 10.1038/s41598-021-02771-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 11/22/2021] [Indexed: 12/13/2022] Open
Abstract
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.
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Bakir MS, Langenbach A, Pinther M, Lefering R, Krinner S, Grosso M, Ekkernkamp A, Schulz-Drost S. The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU ®. Eur J Trauma Emerg Surg 2021; 48:3623-3634. [PMID: 34739544 PMCID: PMC9532310 DOI: 10.1007/s00068-021-01819-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022]
Abstract
Purpose Isolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax. Methods A retrospective analysis of the TraumaRegister DGU® (project 2017-10) was carried out involving the years 2009–2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF. Results 73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF. Conclusion Due to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.
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Affiliation(s)
- Mustafa Sinan Bakir
- Department of Trauma and Reconstructive Surgery and Rehabilitative Medicine, Medical University Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany. .,Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.
| | - Andreas Langenbach
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.,Department of Orthopaedics and Trauma Surgery, Klinikum Forchheim, Krankenhausstraße 10, 91301, Forchheim, Germany
| | - Melina Pinther
- Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany
| | - Rolf Lefering
- Department of Medicine, Institute for Research in Operative Medicine (IFOM), Faculty of Health, Universität Witten-Herdecke, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Sebastian Krinner
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Marco Grosso
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Axel Ekkernkamp
- Department of Trauma and Reconstructive Surgery and Rehabilitative Medicine, Medical University Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany.,Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany
| | - Stefan Schulz-Drost
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.,Department for Trauma Surgery and Orthopaedics, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Germany.,Department for Trauma Surgery, Helios Hospital Schwerin, Wismarsche Strasse 393-397, 19049, Schwerin, Germany
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Sweet AAR, Beks RB, IJpma FFA, de Jong MB, Beeres FJP, Leenen LPH, Houwert RM, van Baal MCPM. Epidemiology of combined clavicle and rib fractures: a systematic review. Eur J Trauma Emerg Surg 2021; 48:3513-3520. [PMID: 34075434 PMCID: PMC9532289 DOI: 10.1007/s00068-021-01701-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
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 14th 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.
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Affiliation(s)
- Arthur A R Sweet
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands.
| | - Reinier B Beks
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Frank F A IJpma
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Frank J P Beeres
- Department of Orthopedics and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
| | - Mark C P M van Baal
- Department of Surgery, University Medical Center Utrecht, 85500, 3508 GA, Utrecht, The Netherlands
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Schulz-Drost S, Ekkernkamp A, Stengel D. [Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]. Unfallchirurg 2019; 121:605-614. [PMID: 30073550 DOI: 10.1007/s00113-018-0532-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- S Schulz-Drost
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland.
| | - A Ekkernkamp
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
| | - D Stengel
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
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