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.     

Role of the trauma-room chest x-ray film in assessing the patient with severe blunt traumatic injury

Objectives

To examine the accuracy of standard trauma-room chest x-ray films in assessing blunt abdominal trauma and to determine the significance of missed injuries under these circumstances.

Design

A retrospective review.

Setting

A regional trauma unit in a tertiary-care institution.

Patients

Multiply injured trauma patients admitted between January 1988 and December 1990 who died within 24 hours of injury and in whom an autopsy was done.

Intervention

Standard radiography of the chest.

Main Outcome Measures

Chest injuries diagnosed and recorded by the trauma room team from standard anteroposterior x-ray films compared with the findings at autopsy and with review of the films by a staff radiologist initially having no knowledge of the injuries and later, if injuries remained undetected, having knowledge of the autopsy findings.

Results

Thirty-seven patients met the study criteria, and their cases were reviewed. In 11 cases, significant injuries were noted at autopsy and not by the trauma-room team, and in 7 cases these injuries were also missed by the reviewing radiologist. Injuries missed by the team were: multiple rib fractures (11 cases), sternal fractures (3 cases), diaphragmatic tear (2 cases) and intimal aortic tear (1 case). In five cases, chest tubes were not inserted despite the presence (undiagnosed) of multiple rib fractures and need for intubation and positive-pressure ventilation.

Conclusions

Significant blunt abdominal trauma, potentially requiring operative management or chest-tube insertion, may be missed on the initial anteroposterior chest x-ray film. Caution must therefore be exercised in interpreting these films in the trauma resuscitation room.     

Prevalence of brachial plexus injuries in patients with scapular fractures: A National Trauma Data Bank review

BACKGROUND:

Studies investigating the prevalence of brachial plexus injuries associated with scapular fractures are sparse, and are frequently limited by small sample sizes and often restricted to single-centre experience.

OBJECTIVE:

To determine the prevalence of brachial plexus injuries associated with scapular fractures; to determine how the prevalence varies with the region of the scapula injured; and to assess which specific nerves of the brachial plexus were involved.

METHODS:

The present study was a retrospective review of data from the National Trauma Data Bank over a five-year period (2007 to 2011).

RESULTS:

Of 68,118 patients with scapular fractures, brachial plexus injury was present in 1173 (1.72%). In patients with multiple scapular fractures, the prevalence of brachial plexus injury was 3.12%, and ranged from 1.52% to 2.22% in patients with single scapular fractures depending on the specific anatomical location of the fracture. Of the 426 injuries with detailed information on nerve injury, 208 (49%) involved the radial nerve, 113 (26.5%) the ulnar nerve, 65 (15%) the median nerve, 36 (8.5%) the axillary nerve and four (1%) the musculocutaneous nerve.

CONCLUSION:

The prevalence of brachial plexus injuries in patients with scapular fractures was 1.72%. The prevalence was similar across anatomical regions for single scapular fracture and was higher with multiple fractures. The largest percentage of nerve injuries were to the radial nerve.     

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.

Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment

Background

Serial rib fractures and flail chest injury can be treated by positive-pressure ventilation. Operative techniques reduce intensive care unit (ICU) stay, overall costs, mortality and morbidity, as well as pain. The aim of this study was to evaluate the benefit of surgical rib stabilisation in comparison to non-operative treatment in patients with severe trauma of the chest wall.

Materials and methods

From 2006 to 2011, the data of 44 patients with flail chest and serial rib fractures were collected retrospectively. A surgical group and an intensive care group with only intensive care therapy were formed. Rib and sternal fractures, flail chest, injury severity, thoracic injuries, mechanical ventilation, time in the ICU, overall hospital stay and mortality were evaluated.

Results

No postoperative surgical complications had been observed. The time under mechanical ventilation in the surgical group was 10.6 ± 10.2 days, whereas in the non-surgical group, it was 13.7 ± 13.7 days. Mechanical ventilation time after surgery was 6.9 ± 6.5 days. Time in the ICU for the surgical group was 16.4 ± 13.6 days, compared to the non-surgical group with 20.1 ± 16.2 days. Postoperative time in the ICU was 11.7 ± 10.3 days. The mortality in the surgical group was 10 % and in the non-surgical group it was 17 %.

Conclusions

Operative rib stabilisation with plates is a safe therapy option for severe trauma of the chest wall. Provided that the duration of preoperative mechanical ventilation and time spent in the ICU is minimised due to early operation, our data suggest that the stabilisation of serial rib fractures and flail chest may lead to a reduced time of mechanical ventilation, time in the ICU and mortality.     

Efficacy of different fixation devices in maintaining an initial reduction for surgically managed distal radius fractures

Background

Fracture of the distal radius is a common injury. Many treatment options exist for the surgical management of extra-articular and intra-articular distal radius fractures. The best method of treatment for these fractures remains controversial. We sought to examine radiographic outcomes of patients treated with non-spanning external fixator (NSEF), open reduction and internal fixation (ORIF) with locking plates and screws or closed reduction and percutaneous pinning (CRPP) and compare their ability to maintain radiographic parameters over the initial 6-week postoperative period.

Methods

We performed a retrospective review of radiographs showing 211 distal radius fractures treated with NSEF, ORIF or CRPP. We examined the images for a variety of radiological parameters. Measurements were taken immediately postoperatively and at 6-week follow-up to determine whether there was any loss of reduction.

Results

Of the 211 fractures, 104 (49.3%) were type-A fractures, 12 (5.7%) were type-B fractures and 95 (45.0%) were type-C fractures. The 3 treatments maintained the reduction obtained at surgery until healing. The CRPP and ORIF treatments failed to maintain correction in ulnar variance for the 6-week period; however, only ORIF actually changed the ulnar variance from presurgical values.

Conclusion

Treatment with ORIF for comminuted, intra-articular distal radius fractures produces good radiographic results with maintenance of surgical radiographic parameters, whereas NSEFand CRPP of less complex fractures also provide good results. This suggests that fracture-specific fixation with CRPP or NSEF are sufficient for certain distal radius fractures.     

Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: Long-term results in 50 cases

Background  

Long thoracic nerve injury leading to scapular winging is common, often caused by closed trauma through compression, stretching, traction, direct extrinsic force, penetrating injury, or neuritides such as Parsonage-Turner syndrome. We undertook the largest series of long thoracic nerve decompression and neurolysis yet reported to demonstrate the usefulness of long thoracic nerve decompression.     

Stabilization of multiple rib fractures in a canine model

Background

Operative stabilization is frequently used in the clinical treatment of multiple rib fractures (MRF); however, no ideal material exists for use in this fixation. This study investigates a newly developed biodegradable plate system for the stabilization of MRF.

Methods

Silk fiber-reinforced polycaprolactone (SF/PCL) plates were developed for rib fracture stabilization and studied using a canine flail chest model. Adult mongrel dogs were divided into three groups: one group received the SF/PCL plates, one group received standard clinical steel plates, and the final group did not undergo operative fracture stabilization (n = 6 for each group). Radiographic, mechanical, and histologic examination was performed to evaluate the effectiveness of the biodegradable material for the stabilization of the rib fractures.

Results

No nonunion and no infections were found when using SF-PCL plates. The fracture sites collapsed in the untreated control group, leading to obvious chest wall deformity not encountered in the two groups that underwent operative stabilization.

Conclusions

Our experimental study shows that the SF/PCL plate has the biocompatibility and mechanical strength suitable for fixation of MRF and is potentially ideal for the treatment of these injuries.     

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome

Background

Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course.

Methods

We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview.

Results

From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB^® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49–63] with a median ISS of 21 [IQR 16–29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12–68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred.

Conclusions

In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule.Trial registration number KEK BASEC Nr. 2016-01679.

     

Minimally displaced clavicle fracture after high-energy injury: Are they likely to displace?

Background

Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture.

Methods

We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded.

Results

Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission.

Conclusion

Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury.     

Clinical value of total white blood cells and neutrophil counts in patients with suspected appendicitis: retrospective study

Background

Severe chest wall injuries are potentially life-threatening injuries which require a standardized multidisciplinary management strategy for prevention of posttraumatic complications and adverse outcome.

Case presentation

We report the successful management of a 55-year old man who sustained a complete ??bony disruption?? of the thoracic cage secondary to an ??all-terrain vehicle?? roll-over accident. The injury pattern consisted of a bilateral ??flail chest?? with serial segmental rib fractures, bilateral hemo-pneumothoraces and pulmonary contusions, bilateral midshaft clavicle fractures, a displaced transverse sternum fracture with significant diastasis, and an unstable T9 hyperextension injury. After initial life-saving procedures, the chest wall injuries were sequentially stabilized by surgical fixation of bilateral clavicle fractures, locked plating of the displaced sternal fracture, and a two-level anterior spine fixation of the T9 hyperextension injury. The patient had an excellent radiological and physiological outcome at 6?months post injury.

Conclusion

Severe chest wall trauma with a complete ??bony disruption?? of the thoracic cage represents a rare, but detrimental injury pattern. Multidisciplinary management with a staged timing for addressing each of the critical injuries, represents the ideal approach for an excellent long-term outcome.     

Acetabular fractures before and after the introduction of seatbelt legislation

Objectives

To compare the incidence and severity of acetabular fractures and associated injuries before and after seatbelt legislation.

Design

A retrospective study.

Setting

Two major trauma centres, which are teaching hospitals.

Patients

Three hundred and ninety-three patients who sustained acetabular fractures during the 5 years before and 5 years after seatbelt legislation was enacted. Of these, the fractures in 198 patients (50.4%) resulted from a motor vehicle accident.

Main Outcome Measures

The number and severity of acetabular fractures and associated injuries.

Results

There has been a significant reduction in the number of acetabular fractures (p = 0.005) since seatbelt use became mandatory, and the complexity of the fractures has decreased. There has also been a marked reduction in associated injuries, such as fractures of other bones, and head, chest and abdominal injuries (p < 0.001).

Conclusion

The seatbelt law has been a useful preventive measure, resulting in a reduction in the incidence of acetabular fractures and associated injuries.     

Rib stabilization: lessons learned

Introduction

The management of rib fractures and flail chest has changed considerably over the past century, and recently there has been a renewed interest in operative rib stabilization for these injuries. Despite numerous reports suggesting improved outcomes with rib stabilization, there are not well-defined indications and the approach remains somewhat controversial.

Materials and methods

The authors reflect on their experience of performing rib stabilization in over 100 patients with rib fractures and flail chest.

Conclusion

The authors offer their opinions on this operation with respect to rationale, indications, timing, technique, and postoperative care.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.     

Traumatic oesophageal perforation due to haematoma

INTRODUCTION

Traumatic oesophageal perforation is a rare, life-threatening emergency that requires early recognition and prompt surgical management.

PRESENTATION OF CASE

We present an unusual case of a patient on warfarin treatment developed an intramural oesophageal haematoma following blunt thoracic trauma leading to perforation on the 18th day.

DISCUSSION

In treatment of oesophageal haematoma in patients on vitamin-K antagonists, strict control of the International Normalized Ratio (INR) is essential along with total parenteral nutrition therapy and refrainment through nasogastric tubes. Three explanations postulated to be the cause for late perforation which might be due to esophageal wall ischemia from pressure built up between the hematoma, azygos vein and the lower part of thoracic trachea; or could be an immediate rupture walled-off until the patient became symptomatic; or the intramural hematoma gradually lysed and causing late perforation.

CONCLUSION

Although extremely rare, an oesophageal haematoma and late complications must be considered in patients on anti-coagulant therapy following blunt thoracic trauma and complaining only of chest pain.     

Pectoralis major transfer for serratus anterior paralysis

Serratus anterior paralysis can result in winging of the scapula and weakness of arm elevation. The etiology of the condition is injury to the long thoracic nerve. There are many proposed causes of long thoracic nerve injury including acute trauma, Parsonage-Turner syndrome, or viral illness. The long length of the long thoracic nerve makes it prone to compression injury along the chest wall. Most patients recover nerve function with conservative treatment. In those in whom nerve function fails to recover, surgical treatment involving pectoralis major transfer may be beneficial. In this study 9 patients underwent pectoralis major transfer with a fascia lata extension graft. The symptoms of most were improved, with correction of the winging and improved movement in the affected shoulder.     

Economic analysis of open approach versus conventional methods of zygoma fracture repair

BACKGROUND:

As resource allocations in health care are being increasingly guided by cost containment issues, surgical professionals must consider the costs associated with various procedures. The present study identifies the financial costs attributed to the two principal treatment options available for zygoma fractures: the Gillie’s method and open reduction and internal fixation (ORIF).

METHODS:

Patients were included if they sustained an isolated zygoma fracture and were treated within 10 days of injury using either ORIF or the Gillie’s method. Those who suffered concomitant injuries or required orbital floor exploration and repair were excluded. The end point, which consisted of the total cost required to bring a patient to preinjury facial appearance and function, incorporated the cost of primary treatment and that of any secondary procedures required to correct unfavourable outcomes.

RESULTS:

In total, 45 patients were included: 25 were treated with Gillie’s method and 20 were treated with ORIF. The cost associated with the primary treatment of zygoma fractures was found to be higher for ORIF than Gillie’s method, amounting to $1,811 and $715, respectively. However, when taking into account potential repair of unsatisfactory results, the final sum totalled $1,930 and $3,725, respectively. This difference was statistically significant.

CONCLUSION:

To the authors’ knowledge, this is the first study to objectively examine the cost of the Gillie’s method and ORIF in the repair of zygoma fractures. Although the initial cost of ORIF is higher, the final cost of the Gillie’s method is greater. Thus, surgeons should not allow higher initial costs to deter them from using more extensive and accurate techniques.     

Scapular Bracing is Effective in Some Patients but Symptoms Persist in Many Despite Bracing

Background

A scapular-protecting brace is one option for treating patients with a winging scapula in isolated serratus palsy. However, outcomes after brace treatment have been reported in only a few studies, and to our knowledge, none has results reported at long-term beyond 10 years.

Questions/purpose

We asked: (1) What was the average length of time patients wore the brace? (2) Did scapular winging and ROM improve with brace treatment? (3) Was pain decreased? (4) Did the duration of symptoms before brace treatment influence the outcome?

Patients and Methods

Between 1980 and 1999, we treated 110 patients with a scapular-protecting brace. General indications for this treatment included electroneuromyography-verified isolated serratus palsy, 3 cm or greater scapular winging, and limited ROM. For patients with scapular winging less than 3 cm we used observation and avoidance of all heavy work or lifting. Of the patients treated with a brace, 55 (50%) were available at a minimum followup of 10 years (mean, 22 years; range, 10–28 years). Mean patient age was 30 years at the onset of symptoms (range, 15–52 years). Brace use was based on patient self-report, and we determined the degree of scapular winging and ROM clinically and level of pain by chart review before and after treatment.

Results

The brace was applied a mean 6 months (median, 5 months) after onset of symptoms. Mean duration of brace use was 10 months for 12 hours per day. Winging of the scapula, measured in 90° flexion without resistance, disappeared in 35 patients (64%) with brace use. Flexion averaged 153° and abduction 168°. Ten patients (18%) were pain-free during exertion and 18 (33%) at rest. Pain at rest was present in 37 patients (67%); of those, it was present only seldom in 15 (27%), sometimes present in 21 (38%), and one patient (2%) experienced continuous pain at rest despite brace treatment. With the number of patients available, there were no differences between patients who started brace treatment early (within 6 months of onset of symptoms) and those who started later (more than 6 months after symptom onset) in terms of improvement of scapular winging in flexion at 90° with resistance (mean, 1.2 ± 2.0 cm vs 1.7 ± 2.3 cm; p = 0.415; 95% CI, −1.6 to 0.7), better flexion (mean, 156° ± 17° flexion vs 149° ± 28° flexion; p < 0.253; 95% CI, −5 to 19), or improvement in other parameters that we measured.

Conclusions

Compliance was high for scapular-protecting brace treatment in patients with serratus palsy but recovery was incomplete for many patients, most of whom still had some pain and a large proportion still had some degree of scapular winging. We continue to use scapular bracing for treating patients who have 3 cm or more scapular winging and limited ROM, and whose work or hobbies demand motions causing winging, although we counsel our patients that recovery is likely to be incomplete.

Level of Evidence

Level IV, therapeutic study.