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PubMed2005

[Ultrasound diagnosis in blunt thoracic trauma].

AIM: Aim of the study was to determine the rate of injuries detectable by ultrasonography in patients suffering from blunt thoracic trauma. PATIENTS AND METHODS: Ultrasonography of the thorax was prospectively performed in patients with blunt chest trauma additionally to the routine radiological diagnostic procedures. A comparison between ultrasonography and chest x-ray findings referring to the rate of detection of fractures and pleural effusions was performed. RESULTS: 100 patients were enrolled in the study. 23 of them were examined within 24 hours after the trauma, the remaining 77 were examined with a delay of more than 24 hours. The findings detectable by ultrasonography were the following: fractured rib 65%, fracture of sternum 7%, fracture of clavicle 1%, rib fracture with callus 3%, haematoma of the chest wall 11%, pleural effusion 37%, pneumothorax 1%, atelectasis 8%, pneumonia 1%, lung contusion 18%, splenic rupture 3%. Rib fractures were detected in 36% of the patients and pleural effusions were detected in 11%, respectively, by chest x-ray. CONCLUSION: Rib fractures and pleural effusions are commonly diagnosed by ultrasonography in patients with blunt thoracic trauma. Concerning the diagnosis of rib fractures (65% versus 36%) and pleural effusions (37% versus 11%), ultrasonography is superior to chest-x-ray. A new and remarkable result is that subpleural infiltrates which are supposed to be lung contusions are also detectable by ultrasonography.

Clavicle↗
PubMed2004

A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury.

OBJECTIVE: Diagnosing inflicted traumatic brain injury (TBI) in young children is difficult in practice. Comparisons of children with inflicted and noninflicted TBI may help to identify markers of inflicted TBI. The objective of this study was to compare inflicted and noninflicted TBI in terms of presenting complaints, clinical features, and hospital outcomes. METHODS: The presenting complaint, clinical finding, hospital course, and outcome of all children who were aged 2 years or younger in North Carolina and were admitted to a pediatric intensive care unit or died with a TBI in 2000 and 2001 were reviewed. Clinical presentation and injury types were compared between children with inflicted and noninflicted TBI. Risk ratios were used to compare clinical and outcome characteristics between the 2 groups. Among survivors, multivariate binomial regression was used to examine the adjusted risk of a poor outcome dependent on injury type. RESULTS: A total of 80 (52.6%) children had inflicted and 72 (47.3%) children had noninflicted TBI. Children with noninflicted TBI (not in a motor vehicle crash) were more likely to present to the emergency department asymptomatic (44.8% vs 8.3%) and to have a specific history of trauma than children with inflicted TBI. Retinal hemorrhage, metaphyseal fracture, rib fracture, and subdural hemorrhage were more commonly found in children with inflicted compared with noninflicted TBI. Skeletal survey and ophthalmologic examination combined would have missed 8 (10.0%) inflicted TBI cases. CONCLUSIONS: Manner of presentation and injury types are helpful in distinguishing inflicted TBI. Clinicians should not rule out inflicted TBI on the basis of skeletal survey and ophthalmoscopy alone but should proceed to computed tomography and/or magnetic resonance imaging.

Accidental Falls↗
PubMed1975

Blunt liver trauma: an analysis of 75 treated patients.

The surgical management of 75 consecutive blunt liver injuries seen at the Albany Medical Center between 1969 and 1973 is reviewed and analyzed. The most common associated injury was right lower rib fractures which were found in one out of three patients. The spleen was the intra-abdominal organ most commonly injured (one out of four patients). The symptoms and signs of blunt liver injury may be misleading, since in one out of five cases there was no clinical evidence of intra-abdominal injury. The findings of fractured ribs on the right side associated with hypotension and a positive peritoneal tap demand immediate abdominal exploration. In patients with large amounts of disrupted hepatic tissue, a wedge resection was preferred over either simple debridement or hepatic lobectomy. A simple technique for limited hepatic resection provided fast, safe control of massive hemorrhage. The overall mortality was 33.3%. In six patients death was ascribed directly to the liver injury. The results of the present study suggest that death from liver injury per se can generally be prevented by prompt adequate surgical control of hemorrhage. When mortality occurs in these patients it is a result of injury to other organ systems.

Drainage↗
PubMed2002

Aetiology of rib stress fractures in rowers.

Rib stress fractures are a common and significant problem in the rowing population. They occur in approximately 6.1 to 12% of rowers and account for the most time lost from on-water training and competition. This review discusses possible causative factors for rib stress fractures in rowers. Central to the establishment of causative factors is the identification that each rib forms part of a closed ring of bone that is completed anteriorly by the sternum and posteriorly by the thoracic vertebrae. Because of the shared sternum anteriorly each ring of bone is mechanically connected. Subsequently, during rowing individual ribs are not loaded in isolation, rather the rib cage is loaded as a complete unit. Incorporating this functioning as a complete unit a possible mechanism by which different factors contribute to rib stress fracture can be developed. In rowing, muscle factors generate loading of the rib cage. The characteristics of this loading stimulus are influenced by equipment, technique and joint factors. Rib-cage loading generates bone strain in individual ribs with the response of each rib depending upon site-specific skeletal factors. Depending on the characteristics of the bone strain in terms of the magnitude and rate of strain, microdamage may develop. The bone response to this microdamage is reparative remodelling. Whether this response is capable of repairing the damage to prevent progression to a stress fracture is dependent upon training and gender factors. Identification of these factors will generate a better understanding of the aetiology of this injury, which is required for improved prevention and treatment strategies.

Athletic Injuries↗
PubMed1984

Cough fracture of the ribs.

A case of multiple rib fractures induced by a paroxysm of coughing in an elderly women is presented. The cough mechanism and theories of the mechanism of injury are reviewed, as well as the complications and treatment of the injury. The disorder may be underdiagnosed and should be considered in any patient with an acute onset of chest pain following coughing or sneezing.

Age Factors↗
PubMed2001

Fracture of the first rib as a consequence of pertussis infection.

We report the first described case of a first rib fracture secondary to pertussis infection. An 11-year-old boy presented with sudden onset of severe right-sided pleuritic chest pain on a background of a 6 week history of a coughing illness and considerable weight loss. Pertussis was clinically suspected and proven on serology. A cause for the severe pain was initially difficult to confirm, causing some concern regarding possible underlying pathology, but was later demonstrated to be due to a first rib fracture. The anatomy of the first rib, and the biomechanical forces placed upon it that are exacerbated during a coughing illness are described.

Child↗
PubMed2003

Chest wall disruption with and without acute lung injury: effects of continuous positive airway pressure therapy on ventilation and perfusion relationships.

OBJECTIVE: We investigated the evolution of lung injury in an animal model with multiple rib fractures, both with and without acute lung injury, and the influence of spontaneous breathing with continuous positive airway pressure (CPAP) therapy on the relative distributions of alveolar ventilation ([OV0312]a) and perfusion ([OV0422]). DESIGN: Prospective, randomized laboratory investigation using an established porcine model with instrumentation for measurement of ventilation/perfusion distribution, pulmonary mechanics and gas exchange, and cardiovascular variables. SETTING: University experimental research laboratory. SUBJECTS: Twenty-nine domestic swine. INTERVENTIONS: Anesthetized pigs were assigned randomly to undergo chest wall dissection alone or chest wall dissection and bilateral fractures of ribs with or without oleic acid-induced acute lung injury. MEASUREMENTS AND MAIN RESULTS: Gas exchange was evaluated by blood gas analysis and multiple inert gas elimination technique. After baseline data were collected, subsequent data were collected at 60 and 120 mins after experimental injuries, and at 180 mins, which was 60 mins after titration of CPAP therapy. The range of CPAP was 4-22 cm H2O. Shunt ([OV0312]a/[OV0422] < 0.005), venous admixture [OV0312]a/[OV0422] < 0.1), and functional deadspace ([OV0312]a/[OV0422] > 10) before injury were similar among all animals and ranged from 3.4% to 4.5%, 4.2% to 5.0%, and 54.4% to 56.5%, respectively. There were no changes, throughout the study, in lung regions with low [OV0312]a/[OV0422] (0.005 < [OV0312]a/[OV0422] </= 0.1) in any group of animals. Shunt of control animals increased to 10.5 +/- 8.8% (p <.05) at 60 mins but demonstrated no further changes in [OV0312]a/[OV0422] at subsequent measurements. Shunt also increased after animals underwent bilateral rib fractures without (12.7%, p <.05) and with (19.9%, p <.05) acute lung injury; however, it decreased in both groups after the application of CPAP (4.6% and 6.6%, respectively, p <.05). All changes in venous admixture directly reflected the change in shunt at all intervals. Functional deadspace was unaffected by chest wall dissection, rib fractures, or subsequent lung injury but decreased after CPAP therapy in all animals. CONCLUSIONS: Acute lung injury exacerbated the right-to-left intrapulmonary shunt seen within the first hour after disruption of the chest wall. Application of CPAP decreased shunt, improved matching of [OV0312]a/[OV0422], and reduced the requirement for supplemental oxygen, without any significant impairment in cardiovascular function.

Analysis of Variance↗
PubMed1995

The influence of age on injury severity of restrained front seat occupants in head-on collisions.

This excerpt is part of a large-scale retrospective study on the interrelationship between accident severity and injury severity. A multivariate analysis of 319 cases of restrained front seat occupants involved in car-to-car head-on collisions showed the significant influence of the energy equivalent speed (EES) and age of the occupants on the number of rib fractures and sternum fractures. Three hundred occupants sustained no rib fractures, nine occupants one to 16 rib fractures, and ten occupants 17 to 32 rib fractures. In these three groups the EES increased from 35 km/h (no rib fractures) to 55 km/h (one to 16 rib fractures) and to then to 67 km/h (17 to 32 rib fractures). The average age in these groups was 34, 55 and 57 years respectively. Twenty-four occupants sustained sternum fractures. The average values of the EES and the average age were: in the group with sternum fractures: 56 km/h; 50 years old; in the group without sternum fractures: 35 km/h; 34 years old. The probability of sustaining fatal injuries in a head-on collision depended on the EES as well as the age of the occupant. At an EES of 60 km/h the probability of fatal injuries was 0.05% in the group < 30 years and 35% in the group > 59 years. Fifty-eight per cent of the occupants with sternal fractures had rib fractures as well; 46% of the occupants with rib fractures also had sternal fractures. The results were compared to the results of 185 post-mortem simulations of head-on collisions from the year 1973 to 1978. In post-mortem simulations the number of rib fractures and sternum fractures was influenced by vehicle decelerations and the age of the test subjects. The number of rib fractures increased at higher collision speeds, higher decelerations and increased age; the number of sternum fractures increased at higher deceleration and increased age of the test subjects. Seventy-two per cent of the test subjects with sternal fractures had rib fractures; 91% of the subjects with rib fractures had sternal fractures.

Accidents, Traffic↗
PubMed2005

High-resolution sonography of the rib: can fracture and metastasis be differentiated?

OBJECTIVE: Our aim was to evaluate whether high-resolution sonography can provide additional information concerning rib lesions compared with radiography or bone scintigraphy. MATERIALS AND METHODS: Fifty-eight patients with high-uptake rib lesions seen on bone scintigraphy were selected. Radiography and rib high-resolution sonography were performed on these patients. High-resolution sonography was performed using a linear 5-12 MHz transducer. By means of clinical history, histopathologic examination, and follow-up observation, these patients were classified into rib fracture (n = 37), rib metastasis (n = 18), or unknown (n = 3) groups. High-resolution sonography images of the 55 proven cases were reviewed for the presence of five representative findings: cortical disruption, callus formation, cortical deformity, mass, or bone destruction. The frequencies of these findings were compared between the groups with fracture and metastasis. RESULTS: Rib lesions were matched by bone scintigraphy and high-resolution sonography in 53 (96%) of 55 patients and by bone scintigraphy and plain radiography in 23 (42%) of 55 patients. High-resolution sonography revealed 17 (94%) of 18 patients with metastasis and 36 (97%) of 37 patients with rib fractures. Metastatic lesions were seen as mass formation (n = 13) and irregular bone destruction (n = 7) on high-resolution sonography. Fracture was seen as cortical disruption with or without hematoma (n = 17), callus formation (n = 9), or cortical deformity, such as angling or stepping (n = 12). CONCLUSION: High-resolution sonography of the ribs is a useful method of characterizing rib lesions in patients who have hot-uptake lesions on bone scintigraphy.

Adult↗
PubMed1982

Brachial plexus injury following median sternotomy. Part II.

Brachial plexus injury may be a consequence of median sternotomy. In a previous study, we documented that median sternotomy can cause first rib fractures and that the first rib fractures may be associated with brachial plexus injury. In the current study, two groups of patients were compared for the incidence of brachial plexus injury and first rib fracture. In Group A, an Ankeney retractor was used with the crossbar placed caudal to the incision: in Group C, a Cooley sternal retractor was used with the crossbar placed cephalad to the incision. The major effective difference between these two retractors was the more caudal placement of the retractor blades with the Cooley retractor than with the Ankeney retractor. Our previous study showed that first rib fractures were caused by high placement of the sternal retractor and that they could be avoided by placing the retractor at a lower position. In the present study, 33% in Group A and 14% in Group C sustained first rib fractures (p = 0.024). Signs of brachial plexus injury occurred in 18% of Group A and 12% of Group C (p = 0.52). We found no correlation between the presence of rib fracture and the presence of neurologic symptoms, but all patients who had both neurologic symptoms and a rib fracture had the symptoms only on the same side as the rib fracture. We also found that standard chest x-ray films identified only 15% of the rib fractures seen on special first rib views. The study demonstrates that the incidence of first rib fractures following median sternotomy is reduced when the sternal retractor is placed at a lower position and that the incidence of brachial plexus injury may also thereby be reduced.

Age Factors↗
PubMed2005

Half-a-dozen ribs: the breakpoint for mortality.

BACKGROUND: We hypothesized that the number of rib fractures independently impacted patient pulmonary morbidity and mortality. METHODS: The National Trauma Data Bank (NTDB, v. 3.0 American College of Surgeons, Chicago, IL) was queried for patients sustaining 1 or more rib fractures. Data abstracted included the number of rib fractures by International Classification of Diseases-9 code, Injury Severity Score, the occurrence of pneumonia, acute respiratory distress syndrome, pulmonary embolus, pneumothorax, aspiration pneumonia, empyema, and associated injuries by abbreviated injury score, the need for mechanical ventilation, number of ventilator days, intensive care unit (ICU) length of stay (LOS), hospital LOS, mortality, and use of epidural analgesia. Statistical analysis was performed using the Student t test and linear regression analysis. Statistical significance was defined as a P value of less than .05. RESULTS: The NTDB included 731,823 patients. Of these, 64,750 (9%) had a diagnosis of 1 or more fractured ribs. Thirteen percent (n = 8,473) of those with rib fractures developed 13,086 complications, of which 6,292 (48%) were related to a chest-wall injury. Mechanical ventilation was required in 60% of patients for an average of 13 days. Hospital LOS averaged 7 days and ICU LOS averaged 4 days. The overall mortality rate for patients with rib fractures was 10%. The mortality rate increased (P < .02) for each additional rib fracture. The same pattern was seen for the following morbidities: pneumonia (P < .01), acute respiratory distress syndrome (P < .01), pneumothorax (P < .01), aspiration pneumonia (P < .01), empyema (P < .04), ICU LOS (P < .01), and hospital LOS for up to 7 rib fractures (P < .01). An association between increasing hospital LOS and number of rib fractures was not shown (P = .19). Pulmonary embolism also was not related to the number of rib fractures (P = .06). Epidural analgesia was used in 2.2% (n = 1,295) of patients with rib fractures. A reduction in mortality with epidural analgesia was shown at 2, 4, and 6 through 8 rib fractures. The use of epidural analgesia had no impact on the frequency of pulmonary complications. When stratifying data by Injury Severity Score and the presence or absence of rib fractures the mortality rates were similar. CONCLUSIONS: Increasing the number of rib fractures correlated directly with increasing pulmonary morbidity and mortality. Patients sustaining fractures of 6 or more ribs are at significant risk for death from causes unrelated to the rib fractures. Epidural analgesia was associated with a reduction in mortality for all patients sustaining rib fractures, particularly those with more than 4 fractures, but this modality of treatment appears to be underused.

Anesthesia, Epidural↗