Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer

INTRODUCTION

Rib plating is becoming increasingly common as a method for stabilizing a flail chest resulting from multiple rib fractures. Recent guidelines recommend surgical stabilization of a flail chest based on consistent evidence of its efficacy and lack of major safety concerns. But complications of this procedure can occur and are wide ranging.

PRESENTATION OF CASE

We report an interesting case of a 58-year-old male patient that worked as a long-distance truck driver and had a flail chest from multiple bilateral rib fractures that occurred when his vehicle was blown over in a wind storm. He underwent open reduction with internal fixation (ORIF) of the bilateral rib fractures and they successfully healed. However, he had permanent long thoracic nerve injury on the side with the most severe trauma. This resulted in symptomatic scapular winging that impeded him from long-distance truck driving. The scapular winging was surgically corrected nearly two years later with a pectoralis major transfer augmented with fascia lata graft. The patient had an excellent final result.

DISCUSSION

We report this case to alert surgeons who perform rib fracture ORIF that long thoracic nerve injury is a potential iatrogenic complication of that procedure or might be a result of the chest wall trauma.

CONCLUSION

Although the specific cause of the long thoracic nerve injury could not be determined in our patient, it was associated with chest wall trauma in the setting of rib fracture ORIF. The scapular winging was surgically corrected with a pectoralis major transfer.     

Pulmonary contusions in patients with rib fractures: The need to better classify a common injury

BackgroundPulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion.MethodsWe identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality.ResultsAmong 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16–33%], respiratory failure 40% [95%CI: 31–50%], and intubation 46% [95%CI: 33–61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications.ConclusionsThere is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.     

The significance of first rib fractures in children

Purpose

The purpose of the study was to determine if first rib fractures are associated with an increased incidence of thoracic vascular injury in pediatric patients.

Methods

The medical records of all children diagnosed with a first rib fracture or a central vascular injury after blunt trauma treated at a state-designated level 1 pediatric trauma center from 2000 to 2009 were reviewed.

Results

Thirty-three children (0.27% of patients; mean age, 10.9 ± 0.9 years) were identified with either a first rib fracture or thoracic vascular injury owing to blunt trauma. Thirty-two children had a first rib fracture, and only 1 child (3%) had significant thoracic vascular injury. Mediastinal abnormalities (indistinct aortic knob) were identified in 3 children, 2 with first rib fracture on initial chest radiograph. Despite a normal cardiovascular examination result, 25 (74%) children with a normal mediastinum on screening chest radiograph underwent computed tomography. No child with a normal mediastinum on initial chest radiograph was found to have associated intrathoracic injuries requiring further intervention. In children with first rib fractures and a normal mediastinum by screening chest x-ray, the negative predictive value for thoracic vascular injury was 100%.

Conclusions

Children with first rib fractures without mediastinal abnormality on chest radiograph require no further workup for thoracic vascular injury.     

快速康复理念在创伤性肋骨骨折手术中的应用

目的探讨快速康复理念在创伤性肋骨骨折手术中的应用。 方法搜集2017年8月至2018年1月西安市红会医院胸外科收治的64例创伤性肋骨骨折患者的临床资料。按治疗方式的不同分为快速康复组(n＝36)和常规治疗组(n＝28)。比较两组患者的手术切口长度、手术时间、术中出血量、术后第1天视觉模拟评分(VAS评分)、拔除胸腔闭式引流管时间、术后第3天最大自由通气量(MVV)、胃肠道功能恢复时间、平均住院时间及住院费用。 结果快速康复组手术切口长度短于常规治疗组,术中出血量少于常规治疗组,差异均有统计学意义(P<0.05);但两组间手术时间比较,差异无统计学意义(P>0.05)。快速康复组术后第1天VAS评分低于常规治疗组,拔除胸腔闭式引流管时间短于常规治疗组,术后第3天MVV值大于常规治疗组,胃肠道恢复时间短于常规治疗组,平均住院时间短于常规治疗组,差异均有统计学意义(P<0.05);但两组间住院费用比较差异无统计学意义(P>0.05)。 结论快速康复理念应用于创伤性肋骨骨折手术中具有明显优势,应在临床中广泛推广。     

对乙酰氨基酚联合酮咯酸氨丁三醇对腹腔镜胆囊切除术后镇痛的影响

目的 探讨对乙酰氨基酚联合酮咯酸氨丁三醇在腹腔镜胆囊切除术(LC)患者术后早期疼痛管理中的有效性及安全性。方法 选择择期在全麻下行LC患者90例,男42例,女48例,年龄18～78岁,BMI 18～28 kg/m²,ASAⅠ或Ⅱ级。采用随机数字表法分为两组：对乙酰氨基酚联合酮咯酸氨丁三醇组(AK组)和纳布啡组(NA组),每组45例。麻醉诱导前15 min, AK组静脉泵注对乙酰氨基酚500 mg(稀释至50 ml)后缓慢推注酮咯酸氨丁三醇30 mg(稀释至10 ml);NA组于相同时点静脉泵注生理盐水50 ml后缓慢推注纳布啡0.2 mg/kg(稀释至10 ml)。记录术后0.5、3、6、12、24 h的VAS疼痛评分(非劣效性界值Δ=1.0分),手术当晚睡眠质量评分,术后24 h内补救镇痛例数,术后0.5、3、6 h的Ramsay镇静评分,术后24 h内恶心呕吐等不良反应的发生情况,以及患者总体满意度。结果 与NA组比较,术后0.5 h AK组VAS疼痛评分明显降低(P<0.05),且两组VAS疼痛评分差值的95%CI上限低于非劣效性界值(P<0.0...     

牵引治疗脊柱胸腰段不稳定性骨折合并肋骨骨折

脊柱胸腰段不稳定性骨折、不全截瘫合并多发性肋骨骨折致反常呼吸、血气胸是较严重的创伤,临床处理困难。自1999-2003年以双侧股骨髁上牵引和肋骨牵引法治疗该病7例,效果满意,报告如下。1临床资料本组7例,男6例,女1例;年龄20～43岁,平均31.4岁。均为矿石或其他巨大重物砸于背部     

The expedited discharge of patients with multiple traumatic rib fractures is cost-effective

Introduction: Rib fractures are a cause of significant morbidity and mortality in trauma patients. It is well documented that optimizing pain control, mobilization, and respiratory care decreases complications. However, the impact of these interventions on hospital costs and length of stay is not well defined. We hypothesized patients with multiple rib fractures can be discharged within three hospital days resulting in decreased hospital costs.Methods: A retrospective review of adult patients (≥18yrs) admitted to our Level 1 trauma center (2011–2013) with ≥2 rib fractures was performed. Patients were excluded if they were intubated, admitted to the ICU, required chest tube placement, or sustained significant multi-system trauma. (n?=?202) Demographics, clinical characteristics, hospital costs, and outcome data were analyzed. Patients discharged within three hospital days of admission were considered to have achieved expedited discharge (ED). Univariate and multivariate analyses determined predictors of failure to achieve ED. A p value of <0.05 was considered significant.Results: Study patients (n?=?202) were 60 (SD?=?19) years of age with an injury severity score (ISS) of 10 (SD?=?5), and 4 (SD?=?2) rib fractures. Of 202 patients, 127 (63%) achieved ED while 75 (37%) did not. No differences in chest AIS, ISS, smoking status or history of pulmonary disease were identified between the two groups (all p?>?0.05). Average LOS (2 (SD?=?1) vs. 7 (SD?=?4) days; p?<?0.001) and hospital costs ($2865 (SD?=?1200) vs. $6085 (SD?=?3033)); p?<?0.001). were lower in the ED group A lower percentage of ED patients required placement in rehabilitation facilities (6% vs. 48%; p?<?0.001). There were no readmissions within 30 days in either group. After controlling for potential confounding variables, multiple variable logistic regression analysis revealed that advancing age (OR 1.05 per year, 1.02–1.07) independently predicted failure to achieve ED.Conclusion: The majority of patients admitted to the hospital with multiple rib fractures can be discharged within three days. This expedited discharge results in significant cost savings to the hospital. Early identification of patients who cannot meet the goal of expedited discharge can facilitate improvement in management strategies.     

Clinical management of rib fractures and methods for prevention of pulmonary complications: A review

Rib fractures are common injuries associated with significant morbidity and mortality, largely due to pulmonary complications. Despite equivocal effectiveness data, incentive spirometers are widely utilized to reduce pulmonary complications in the postoperative setting. Few studies have evaluated the effectiveness of incentive spirometry after rib fracture. Multiple investigations have demonstrated incentive spirometry to be an important screening tool to identify high-risk rib fracture patients who could benefit from aggressive, multidisciplinary pulmonary complication prevention strategies. This review evaluates the epidemiology of rib fractures, their associated pulmonary complications, along with the evidence for optimizing their clinical management through the use of incentive spirometry, multimodal analgesia, and surgical fixation.     

A double-blind placebo-controlled comparison of a novel formulation of intravenous diclofenac and ketorolac for postoperative third molar extraction pain

Dyloject is a novel formulation of diclofenac intended for intravenous (IV) administration. This formulation employs the solubilizing agent hydroxypropyl-β-cyclodextrin to permit bolus IV administration. The efficacy and safety of 5 dose levels of IV diclofenac were compared with IV ketorolac and placebo following third molar extraction. This was a single-dose, randomized, double-blind, placebo- and comparator-controlled, parallel-group study. A total of 353 subjects with moderate to severe pain received placebo; ketorolac 30 mg; or IV diclofenac 3.75, 9.4, 18.75, 37.5, or 75 mg (N = 51 for all groups, except N = 47 for ketorolac). The primary endpoint was total pain relief over 6 hours (TOTPAR6) as measured by the visual analog scale (VAS). Secondary endpoints included multiple measures of pain intensity and relief; patient global evaluation; and times to pain relief and rescue medication. Dropouts and adverse effects (AEs) were also monitored. IV diclofenac was superior to placebo as measured by TOTPAR6 (P < .0001 for all doses except 3.75 mg, for which P = .0341). IV diclofenac 3.75 mg was statistically superior to placebo for TOTPAR2 and TOTPAR4. IV diclofenac at both 37.5 and 75 mg was superior to placebo (P < .05) at the earliest (5 minute) assessments of pain intensity and pain relief, but ketorolac was not. The proportion of patients reporting 30% or greater pain relief at 5 minutes was significantly greater after IV diclofenac 37.5 and 75 mg than after ketorolac 30 mg or placebo. Secondary endpoints confirmed the primary findings. Treatment-related AEs were generally mild to moderate and were typical for nonsteroidal anti-inflammatory drugs (NSAIDs). The more rapid onset of action of IV diclofenac compared with the reference injectable NSAID ketorolac suggests additional clinical benefit. If confirmed in larger series, these findings may improve the safety and efficacy of postoperative NSAID analgesia.     

Impact of rib fixation on quality of life after major trauma with multiple rib fractures

Introduction

Multiple rib fractures have been shown to reduce quality of life both in the short and long term. Treatment of rib fractures with operative fixation reduces ventilator requirements, intensive care unit stay, and pulmonary complications in flail chest patients but has not been shown to improve quality of life in comparative studies to date. We therefore wanted to analyse a large cohort of multiple fractured rib trauma patients to see if rib fixation improved their quality of life.

肋骨骨折内固定的分析与体会

目的分析肋骨骨折内固定的手术适应证。方法回顾性分析103例肋骨骨折的临床资料,按治疗方法分成内固定组（n=49）与保守组（n=54）,比较两组的治疗效果。结果在住院时间、VAS疼痛评分及骨折愈合时间方面,内固定组明显低于保守组,内固定组显著降低了肺部感染、胸廓畸形及迟发性血胸的发病率。结论肋骨骨折内固定术有极大的优越性,对有适应证的患者应积极采取内固定治疗以提高治疗效果。     

手术干预与传统方法治疗多发性肋骨骨折随机对照研究的系统评价与Meta分析

目的对手术和传统方法治疗多发性肋骨骨折进行系统评价,对比其疗效。方法计算机检索中国期刊全文数据库(CNKI)、万方数据库(Wanfang)、维普期刊数据库(VIP)、PubMed、OVID、EMbase、The Cochrane Library、Thieme及Springer Link数据库。收集有关手术和传统方法治疗多发性肋骨骨折的随机对照研究(RCT),检索时限为各数据库建库至2019年7月。对文献进行筛选、质量评价及数据提取。Meta分析采用RevMan 5.3软件。结果共纳入文献12篇,患者1039例。其中手术组512例,传统组527例。Meta分析显示:两组在肺部感染发生率[RR=0.41,99%CI(0.29,0.58),P<0.00001]、肺不张发生率[RR=0.24,99%CI(0.06,0.94),P=0.007]、呼吸机支持时间[SMD=-2.64,99%CI(-4.38,-0.91),P<0.0001]、住ICU时间[SMD=-1.33,99%CI(-2.26,-0.40),P=0.0002]、总体住院时间[SMD=-2.25,99%CI(-3.30,-1.19),P<0.00001]、胸壁畸形发生率[RR=0.08,99%CI(0.04,0.17),P<0.00001]等方面差异有统计学意义。在住院死亡率[RR=0.75,99%CI(0.23,2.46),P=0.53]、气管切开率[RR=0.69,99%CI(0.39,1.21),P=0.09]、呼吸机支持率[RR=0.65,99%CI(0.41,1.05),P=0.02]、胸腔引流时间[SMD=-2.58,99%CI(-6.41,1.25),P=0.08]等方面差异无统计学意义。结论手术治疗多发性肋骨骨折能够减少肺部并发症、缩短住院时间、降低胸壁畸形发生率,有利于患者快速康复和改善生活质量。     

Multiple rib fractures and head injury—an indication for intercostal catheterisation and infusion of local anaesthetics

A case is presented which demonstrates the advantages of continuous intercostal analgesia in a patient with a head injury and multiple rib fractures.     

预成型肋骨锁定钛板联合超声引导下胸椎旁神经阻滞治疗老年多发性肋骨骨折

目的:探讨预成型肋骨锁定钛板内固定手术与超声引导下胸椎旁神经阻滞联合应用对于老年多发性肋骨骨折患者的疗效。方法:回顾性分析2016年2月至2020年11月收治的221例老年多发性肋骨骨折患者,根据是否手术治疗,分为预成型肋骨锁定钛板联合超声引导下胸椎旁神经阻滞组(手术组)102例,保守治疗组(非手术组)119 例。手术组中男58 例,女44 例;年龄60~85(67.2±3.6)岁;肋骨骨折3~12(5.3±2.1)处。非手术组中男66 例,女53 例;年龄60~84 (66.8±3.2)岁;肋骨骨折2~11 (6.1±2.3)处。比较分析两组患者的临床资料、治疗效果及并发症情况。结果:两组患者术前临床资料比较,差异无统计学意义(P>0.05),所有患者顺利出院。手术组患者肺部感染(P=0.028),肺不张(P=0.032),呼吸衰竭(P=0.026),主动下床时间(P=0.040),骨折愈合时间(P=0.035),住院时间(P=0.043),治疗后3 d疼痛视觉模拟评分(visual analogue scale,VAS)(P=0.028),治疗后5 d VAS (P=0.032),治疗后7 d VAS (P=0.019),术后3个月最大自主通气量(maximal voluntary ventilation,MVV)(P=0.042),1 s用力呼气容积(forced expiratory volume in one second,FEV1)(P=0.035)以及术后6个月MVV(P=0.021),FEV1(P=0.026)均优于非手术治疗组。结论:对于老年严重多发肋骨骨折的患者,预成型肋骨锁定钛板与超声引导下胸椎旁神经阻滞的联合应用与非手术治疗相比较,能够及时有效镇痛,恢复胸廓稳定性,缩短住院时间,减少肺部感染及急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS) 等并发症的发生率。预成型肋骨锁定钛板治疗老年多发性肋骨骨折具有较好的临床效果。     

Hepatocellular carcinoma associated with hemorrhaging from iatrogenic rupture of a rib metastasis

Detecting a rib metastasis as a first manifestation before identifying hepatocellular carcinoma (HCC) is rare. We report an HCC with massive bleeding from the biopsied rib tumor. A 68-year-old man was referred for right chest pain. Computed tomography showed a mass in the rib and two small masses in the liver. The biopsied rib continued to bleed, so we removed the entire tumor, including the rib. We histologically confirmed the diagnosis as rib metastasis from the HCC. The patient died 3 months after the onset. We caution against performing an incisional biopsy without due consideration.     

Fracture Risk Associated with Use of Nonsteroidal Anti-Inflammatory Drugs, Acetylsalicylic Acid, and Acetaminophen and the Effects of Rheumatoid Arthritis and Osteoarthritis

We studied the effects of various nonmorphine pain medications as well as rheumatoid arthritis and osteoarthritis on fracture risk in a nationwide case-control study. Cases were all subjects with any fracture sustained during the year 2000 (n = 124,655) in Denmark. For each case, three controls (n = 373,962) matched on age and gender were randomly drawn from the background population. The primary exposure variables were use of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or acetylsalicylic acid (ASA). Adjustments were made for several confounders. The effect of dose was examined by stratifying for cumulated dose (defined daily dose, DDD). For acetaminophen, a small increase in overall fracture risk was observed with use within the last year (odds ratio [OR] = 1.45, 95% confidence interval [CI] 1.41–1.49). For ASA, no increase in overall fracture risk was present with recent use. Significant heterogeneity was present for the NSAIDs; e.g., ibuprofen was associated with an increased overall fracture risk (OR = 2.09, 95% CI 2.00–2.18 for <20 DDD), while celecoxib was not (OR = 0.76, 95% CI 0.51–1.13 for <20 DDD, 2P < 0.01 for comparison). Osteoarthritis was associated with a decreased risk of any fracture if the diagnosis had been made more than 1 year ago (OR = 0.70, 95% CI 0.67–0.72). Rheumatoid arthritis was associated with an increase in overall fracture risk if the diagnosis had been made within the last year (OR = 1.86, 95% CI 1.68–2.07). Weak analgesics may be associated with fracture risk in a varying way. The effects in most cases were small. Falls may be one reason for the increase in fracture risk with some NSAIDs.