Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study

The presence of major chest wall injury is an indication for transfer to a Level I trauma center. We hypothesized that the presence of three or more rib fractures on initial chest X-ray would identify a small subgroup of patients with a high probability of requiring trauma center care. All trauma discharges in Maryland between 1984 and 1986 (N = 105,683) were reviewed. Patients were divided by the presence of rib fractures (no rib fractures, 1-2 fractures, 3+ fractures) and age in years (0-13, 14-64, 65+). Results: The presence of three or more rib fractures in the pediatric age group was rare and precluded further evaluation. When comparing patients with 1-2 rib fractures versus 3 or more rib fractures, significant differences were found in mortality, mean Injury Severity Score, mean hospital stay and mean number of ICU days (p less than 0.001). The significant differences occurred in all age groups 14 years old and older. The presence of three or more rib fractures increased the relative risk of splenic injury (6.2) and liver injury (3.6) but did not predict the presence of aortic injury. Conclusion: The presence of 3 or more rib fractures identifies a small subgroup of patients (2.4%) likely to require tertiary care. This triage tool is useful in all patients over the age of 14 years.     

The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children

BACKGROUND: Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT. METHODS: We reviewed the medical records and imaging of all children with rib fractures over a 6-year period. NAT was determined by the Child Advocacy and Protection team. RESULTS: In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures. CONCLUSION: In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.     

Use of traction in cervical spine fractures during interhospital transfer by aircraft

Despite significant improvement in the organization and function of the nation's emergency medical services and the increasing sophistication of initial providers of critical care, there has apparently been no reduction in the incidence of neurological deficits suffered by patients with unstable cervical spine injuries during management prior to intervention by the spine surgeon. In analyzing the techniques used to stabilize patients with suspected unstable cervical spine injuries during this phase, we conclude that present standard techniques are either insufficient or potentially destabilizing. We have developed a system that will permit the use of cervical traction, applied with a halter or the standard Gardner-Wells tongs, during the prehospital phase of management of patients with cervical spine injuries. Based on our experience with the system, we recommend that patients with such injuries be stabilized with skeletal traction when transferred between hospitals by air ambulance. Logic permits consideration of the concept even earlier in the prehospital phase of management and in ground ambulances.     

Preparation of the critically ill for interhospital transfer

Changes in monitoring and therapy during the preparation of 100 critically ill patients for interhospital transfer by a specialist team were documented prospectively with the aim of providing guidelines for nonspecialists. Severity of illness scores were recorded before and after preparation. Median duration of preparation for ambulance journeys was 50 min and for aeroplane journeys was 82 min. During preparation, a portable electrocardiogram and pulse oximeter were attached to 21 and 76 patients respectively and intra-arterial pressure monitoring was continued or instituted in 88 patients. Supplemental oxygen and intravenous fluids were the therapies most commonly increased or instituted by the transport team; mechanical ventilation, positive end-expiratory pressure and inotropic drugs were increased or instituted less frequently. Median therapeutic intervention scores before and after preparation were 21 and 23 respectively, highlighting the need to increase rather than withdraw support for transfer.     

Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures

Background

Intramedullary fixation of rib fractures with generic Kirschner wires has been practiced for over 50 years. However, this technique has not been advanced to address reported complications of wire migration and cut-out. This biomechanical study evaluated a novel rib splint designed to replicate the less-invasive fixation approach of Kirschner wires while mitigating their associated complications.

Methods

The durability, strength, and failure mode of rib fracture fixation with intramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs were loaded to failure to determine their strength and to induce realistic rib fractures. Subsequently, fractures were stabilised with a novel rib splint made of titanium alloy with a rectangular cross-section that was secured with a locking screw. All fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load magnitude to determine their durability. Finally, constructs were loaded to failure to determine their residual strength and failure modes.

Results

Native ribs had a strength of 9.7 ± 5.0 N m, with a range of 3.5-19.6 N m. Fracture fixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out. Dynamic loading caused no significant decrease in construct stiffness (p = 0.85) and construct subsidence remained on average below 0.5 mm. The residual strength of splint constructs after dynamic loading was 1.1 ± 0.24 N m. Constructs failed by splint bending in 44% of specimens and by developing fracture lines along the superior and inferior cortices in 56% of specimens. Regardless of the failure mode, all rib splint constructs recoiled elastically after failure and retained functional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex.

Conclusions

Rib splints can provide sufficient stability to support respiratory loading throughout the healing phase, but they cannot restore the full strength of native ribs. Most importantly, rib splints mitigated the complications reported for rib fracture fixation with generic Kirschner wires, namely implant cut-out and migration through the lateral cortex. Therefore, rib splints may provide an advanced alternative to the original Kirschner wire technique for less-invasive fixation of rib fractures.     

距下关节镜联合后侧小切口在跟骨骨折手术中的应用

目的通过比较距下关节镜联合后侧小切口与跗骨窦切口治疗跟骨骨折的疗效,观察距下关节镜联合后侧小切口治疗跟骨骨折的可行性。方法回顾性分析广州市正骨医院足踝外科2017年1月至2017年6月收治的85例跟骨骨折患者资料。患者男43例,女42例;年龄32~58岁,平均46.0岁。根据治疗方法不同分为距下关节镜联合后侧小切口手术治疗(关节镜组,40例)和经跗骨窦切口治疗(跗骨窦组,45例)。记录并比较两组患者的手术时间、骨折愈合时间、切口并发症发生率,以及美国足踝外科协会(AOFAS)的踝-后足评分。结果两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。所有患者术后获6~12个月(平均8个月)随访。关节镜组和跗骨窦组的骨折愈合时间分别为(8.6±2.4)周和(8.9±1.8)周,末次随访时的AOFOS的踝-后足评分分别为(82.5±5.6)分和(85.1±4.0)分,差异无统计学意义(P>0.05);关节镜组手术时间[(43.6±5.4)min]少于跗骨窦组[(56.5±6.4)min],关节镜组的切口并发症发生率2.5%(1/40)低于跗骨窦组15.6%(7/45),差异均有统计学意义(P<0.05)。结论距下关节镜联合后侧小切口治疗跟骨骨折可以一定程度上降低切口并发症的发生率,可以作为治疗跟骨骨折的一种可行的手术方法。     

Quality of life three years or more after esophagectomy for cancer.

The quality of life and alimentary comfort of 17 patients with esophageal cancer who were disease free more than 3 years after an esophageal resection were evaluated by analyzing responses to a follow-up questionnaire. Fourteen patients had subtotal esophagectomy and gastric pull-up to the neck. Three patients underwent a total esophagopharyngolaryngectomy, the digestive continuity being restored by means of an isoperistaltic colon segment interposed between the base of the tongue and the stomach. Current body weight, when compared with that existing postoperatively, was increased in 13 patients and unchanged in four. The number of meals per day was an average of 2.8, but 12 patients took additional snacks between main meals (2.3 as a mean). The major long-term complaints were a sensation of early fullness during eating in 11 patients, dysphagia in three, diarrhea in two, cough-induced vomiting in two, and postprandial sweating in two. Ratings given by self-evaluation of current alimentary comfort in comparison with that predating the initial esophageal symptoms ranged from 3 of 10 to 10 of 10 (mean 7.1/10). Thirteen patients led active lives, seven at home and six employed outside the home. The present survey suggests that most disease-free patients may obtain a satisfactory quality of life after esophagectomy and gastric or colonic pull-up; long-term alimentary comfort is conditioned mainly by the small capacity of the esophageal substitute.     

Frailty as a predictor of negative outcomes in trauma patients with rib fractures

BackgroundIn patients with rib fractures, adverse outcomes are associated with number of rib fractures; however, studies suggest an association with frailty. We assessed whether frailty, measured using the Canadian Study of Health and Aging clinical frailty scale, was associated with adverse outcomes in this population.MethodsPatients ≥50 years admitted for rib fractures from July 2015 to June 2020 were retrospectively scored for frailty. Demographics, comorbidities, injury information, hospital course, and complications were collected. Univariate analyses were performed to assess significant differences between the fit, prefrail, and frail groups. The association between number of rib fractures and frailty with outcomes was determined.ResultsControlling for age, sex, Injury Severity Score, preadmission anticoagulant, injury mechanism, and comorbidities and nonchest Abbreviated Injury Scores showing significant differences, the number of rib fractures was associated with developing pneumonia (odds ratio = 1.197 [1.076–1.332]; P = .001), hospital length of stay (odds ratio = 1.066 [1.033–1.100], P < .001), mortality (odds ratio = 1.157 [1.048–1.278], P = .004), and discharge to long-term acute care facilities (odds ratio = 1.295 [1.084–1.546], P = .004). Frailty was associated with hospital length of stay (odds ratio = 1.659 [1.059–2.598], P = .027) and discharge to skilled nursing facilities (odds ratio = 5.282 [1.567–17.802], P = .007).ConclusionIn our population, the number of rib fractures was associated with respiratory complications and mortality. Frailty was associated with longer hospitalization and discharge to higher level of care.     

Vital capacity as a predictor of outcome in elderly patients with rib fractures

BACKGROUND: This study tests the relationships between early bedside vital capacity (VC) measurement and morbidity, mortality, and resource consumption in geriatric blunt chest trauma patients with rib fractures. METHODS: This was a retrospective study examining all patients > or = 65 years old with rib fractures who had a VC measured within 48 hours of their emergency department evaluation. Outcome variables included pulmonary complications, death from pulmonary complications, hospital length of stay (LOS), intensive care unit length of stay (ICU LOS), and discharge disposition. RESULTS: Thirty-eight patients met the study criteria. The mean age was 80.2 (+/-7.4) years, the mean number of rib fractures was 3.6 (+/-1.6), and the mean ISS was 6.9 (+/-4.7). VC and the percentage of the predicted vital capacity (pVC) were both inversely correlated with LOS (p = 0.0076 and p = 0.0172, respectively). Linear regression analysis suggested that patients with a VC < 1.4 L or < 55% of their pVC had a LOS > 3 days. Mean VC was 36% higher in patients who were discharged home versus those discharged to an extended care facility (ECF; p = 0.025). There was a trend toward significance when comparing VC to ICU LOS (p = 0.079), but none in predicting pulmonary complications (p = 0.3299). No correlations between VC and mortality can be drawn given the single death in the cohort. CONCLUSIONS: Bedside VC is a simple measurement which could predict LOS in elderly patients with rib fractures and may identify those patients requiring ECF upon discharge. Further prospective study may highlight the utility of emergency room VC in determining the disposition of these patients.     

Embolization of wide-necked aneurysms with using three or more microcatheters

Summary Background. A new and relatively simple endovascular technique, in which more than three microcatheters are used for endovascular treatment of cerebral aneurysms for the first time, is described. Method. Eight patients with wide necked aneurysms were successfully treated with detachable coils using the multiple microcatheter technique. Three patients presented with subarachnoid haemorrhage and five were unruptured. The aneurysm locations were superior hypophyseal artery (2), posterior communicating artery (2), middle cerebral artery bifurcation (1), distal anterior cerebral artery (1), basilar artery (1) and vertebral artery (1). The average neck size was 7.4 ± 2.8 mm (3.5–12 mm), average width of the aneurysms was 10.6 ± 5.7 mm (6.2–23 mm) and depth was 8.9 ± 5.8 mm (3–22 mm). Three microcatheters (7 patients) and four microcatheters (1 patient) were introduced and used for coil delivery. Three or four coils were deployed and intermingled to stabilize the whole coil mass as well as to occupy the aneurysmal sac. When a relatively stable coil frame was formed, one coil was detached and subsequent coils were inserted. After the coil mass became more stable, other coils were also detached and all microcatheters were used for subsequent coil deployment. Findings. All aneurysms were successfully treated without complications. Postemboilzation angiograms showed no contrast filling in 5 cases (100% occlusion) and a very small residual neck in 3 cases. There was no procedure related complication. Conclusion. The multiple microcatheter technique can be one technical option for the endovascular treatment of wide necked aneurysms.     

Diagnostic peritoneal lavage as an indicator for therapeutic surgery

Diagnostic peritoneal lavage (DPL) has been reported to be extremely accurate in identifying intra-abdominal injury. Many studies, however, fail to indicate clearly if the procedure is helpful in determining which patients require truly therapeutic surgical intervention, because not all injuries need such surgery. In this study the authors reviewed the charts of 174 patients with blunt abdominal trauma and, by applying strict criteria to define a therapeutic laparotomy, sought to determine, retrospectively, whether DPL was useful for indicating the need for therapeutic surgery. Although 94% of patients with positive findings from DPL underwent a laparotomy, only 65% underwent one that was clearly of therapeutic value. Although other factors may have partially contributed to the discrepancy between these results and those generally referred to in the trauma literature, this study suggests that criteria providing a strict definition of a therapeutic laparotomy must be universally applied when analysing the value of DPL.