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A case with severe haemoptysis nearly three weeks after a chest trauma is presented. Aortography revealed rupture of the aorta below the origin of the left subclavian artery. The rupture was caused by a fractured rib which also caused a tear in the lower lobe of the left lung. Aortic haemorrhage had dissected into the lung, causing a haematoma and finally resulting in a severe haemoptysis.
Superior mesenteric artery (SMA) syndrome is a rare disease in which the third portion of the duodenum is compressed by SMA. There are many causes leading to the SMA syndrome, however it's extremely rare that aortic aneurysm causes a SMA syndrome. We report a case of a successfully treated SMA syndrome due to an abdominal aortic aneurysm in a renal transplant recipient. The patient was a 52-yr-old woman with a thin stature (weight 40 kg, height 164 cm). She received a renal transplant 8 yr before, and had hypertension and abdominal aortic aneurysm. Her SMA syndrome developed in a prolonged supine position for the accidental rib fractures and was diagnosed by clinical and radiological findings. After a surgical correction (resection of an aneurysm and aortobiiliac bypass with an inverted Y graft), her symptoms relieved without deterioration of the graft function.
The biomechanical behavior of 4-point seat belt systems was investigated through MADYMO modeling, dummy tests and post mortem human subject tests. This study was conducted to assess the effect of 4-point seat belts on the risk of thoracic injury in frontal impacts, to evaluate the ability to prevent submarining under the lap belt using 4-point seat belts, and to examine whether 4-point belts may induce injuries not typically observed with 3-point seat belts. The performance of two types of 4-point seat belts was compared with that of a pretensioned, load-limited, 3-point seat belt. A 3-point belt with an extra shoulder belt that "crisscrossed" the chest (X4) appeared to add constraint to the torso and increased chest deflection and injury risk. Harness style shoulder belts (V4) loaded the body in a different biomechanical manner than 3-point and X4 belts. The V4 belt appeared to shift load to the clavicles and pelvis and to reduce traction of the shoulder belt across the chest, resulting in a reduction in chest deflection by a factor of two. This is associated with a 5 to 500-fold reduction in thoracic injury risk, depending on whether one assumes 4-point belts apply concentrated or distributed load. In four of six post mortem human subjects restrained by V4 belts during 40 km/h sled tests, chest compression was zero or negative and rib fractures were nearly eliminated. Submarining was not observed in any test with post mortem human subjects. Though lumbar, sacral and pelvic injuries were noted, they are believed to be due to the artificial restraint environment (no knee bolsters, instrument panels, steering systems or airbags). While they show significant potential to reduce thoracic injury risk, there are still many issues to be resolved before 4-point belts can be considered for production vehicles. These issues include, among others, potential effects on hard and soft neck tissues, of interaction with inboard shoulder belts in farside impacts and potential effects on the fetus of latch/buckle junctions at the centerline of pregnant occupants. Work continues at Ford Motor Company to resolve these issues.
The human body undergoes a variety of changes as it ages through adulthood. These include both morphological (structural) changes (e.g., increased thoracic kyphosis) and material changes (e.g., osteoporosis). The purpose of this study is to evaluate structural changes that occur in the aging bony thorax and to assess the importance of these changes relative to the well-established material changes. The study involved two primary components. First, full-thorax computed tomography (CT) scans of 161 patients, age 18 to 89 years, were analyzed to quantify the angle of the ribs in the sagittal plane. A significant association between the angle of the ribs and age was identified, with the ribs becoming more perpendicular to the spine as age increased (0.08 degrees/year, p=0.012). Next, a finite element model of the thorax was used to evaluate the importance of this rib angle change relative to other factors associated with aging. A three-factor, two-level factorial design was used to assess the relative importance of rib cage morphology ("young" and "old" rib angle), thickness of the cortical shell (thick = "young" and thin = "old"), and the bone material properties ("young" and "old") on the force-deflection response and injury tolerance of the thorax. The simulations showed that the structural and material changes played approximately equal roles in modulating the force-deflection response of the thorax. Changing the rib angle to be more perpendicular to the spine increased the effective thoracic stiffness, while the "old" material properties and the thin cortical shell decreased the effective stiffness. The offsetting effects of these traits resulted in similar effective thoracic stiffness for the "elderly" and baseline thoracic models, which is consistent with cadaver data available in the literature. All three effects tended to decrease chest deflection tolerance for rib fractures, though the material changes dominated (a four- to six-fold increase in elements eliminated using a maximum strain criterion). The primary conclusion, therefore, is that an older person's thorax, relative to a younger, does not necessarily deform more in response to an applied force. The tolerable sternal deflection level is, however, much less.
Several three-dimensional (3D) finite element (FE) models of the human body have been developed to elucidate injury mechanisms due to automotive crashes. However, these models are mainly focused on 50(th) percentile male. As a first step towards a better understanding of injury biomechanics in the small female, a 3D FE model of a 5(th) percentile female human chest (FEM-5F) has been developed and validated against experimental data obtained from two sets of frontal impact, one set of lateral impact, two sets of oblique impact and a series of ballistic impacts. Two previous FE models, a small female Total HUman Model for Safety (THUMS-AF05) occupant version 1.0Beta (Kimpara et al. 2002) and the Wayne State University Human Thoracic Model (WSUHTM, Wang 1995 and Shah et al. 2001) were integrated and modified for this model development. The model incorporated not only geometrical gender differences, such as location of the internal organs and structure of the bony skeleton, but also the biomechanical differences of the ribs due to gender. It includes a detailed description of the sternum, ribs, costal cartilage, thoracic spine, skin, superficial muscles, intercostal muscles, heart, lung, diaphragm, major blood vessels and simplified abdominal internal organs and has been validated against a series of six cadaveric experiments on the small female reported by Nahum et al. (1970), Kroell et al. (1974), Viano (1989), Talantikite et al. (1998) and Wilhelm (2003). Results predicted by the model were well-matched to these experimental data for a range of impact speeds and impactor masses. More research is needed in order to increase the accuracy of predicting rib fractures so that the mechanisms responsible for small female injury can be more clearly defined.
The purpose of this paper is to compare the biofidelity rating schemes of ISO/TR9790 and the NHTSA Bio Rank System. This paper describes the development of new impact response corridors being proposed for ISO/TR9790 from the results of a recent series of side-impact sled tests. The response data were analyzed by methods consistent with ISO/TR9790, including normalization by impulse-momentum analysis and the elimination of subjects that sustained six or more rib fractures. Unlike ISO/TR9790, this paper proposes the elimination of the data from tests in which the timing and the sequence of loading of the individual impact plates were inconsistent compared to other tests conducted with the same impact wall configuration. As a result of differences in the analysis methods, data selection criteria, and the method of corridor construction, the impact response corridors proposed here are different from those developed by NHTSA, despite the fact that both sets of corridors were developed from the same series of sled tests. Responses of the ES-2 and ES-2re side impact dummies are compared to both sets of corridors. The response corridors developed in this paper are proposed as an addition to and not a replacement for those given in the 1999 revision of ISO/TR9790.
The U.S. Navy Asbestos Medical Surveillance Program is a comprehensive effort to decrease exposure to asbestos, a known health hazard. This study was part of a programmatic review of the Asbestos Medical Surveillance Program database, which included 233,353 radiographic examinations from 1990 to 1999. The initial review focused on incidental findings recorded by B-readers for 23,460 radiographs. Abnormalities reported included bullae (0.68%), cancer (0.56%), cardiac size/ shape abnormalities (1.36%), emphysema (0.74%), subpleural fat (2.62%), fractured ribs (1.24%), hilar adenopathy (0.13%), ill-defined diaphragm (0.46%), ill-defined heart border (0.29%), Kerley lines (0.06%), pleural thickening (2.35%), and tuberculosis (0.27%). The rates by age cohort for pleural abnormalities decreased significantly (30-39 years, chi2 for trend = 23.49, df = 1; 40-49 years, chi2 for trend = 176.21; 50-59 years, chi2 for trend = 401.87), but findings were not significantly different for those > or =60 years of age. This suggests that sequential age cohorts in the program are developing fewer pleural abnormalities; pleural abnormalities have historically been associated with asbestos exposure.
Nine bottlenose dolphin (Tursiops truncatus) calves that stranded in Virginia in 1996 and 1997 died of severe blunt-force trauma. Injuries were concentrated on the head and chest and multiple rib fractures, lung lacerations, and soft tissue contusions were prominent. Skeletal and/or soft tissue trauma occurred bilaterally in all of the calves. One had a bite wound across the left mandible that exhibited deep punctures consistent with the tooth placement in an adult bottlenose dolphin. The lesions were not compatible with predation, boat strike, fisheries interactions, rough-surf injury, or blast injury. However, they were similar to traumatic injuries described in stranded bottlenose dolphin calves and harbor porpoises (Phocoena phocoena) in Great Britain attributed to violent dolphin interactions. The evidence suggests that violent dolphin behavior was the cause of the trauma in the nine calves reported here and that infanticide occurs in bottlenose dolphins of the western North Atlantic.
New applications of the video-assisted technique for the management of intrathoracic diseases continue to be developed, including major lung resections for cancer. The differences in the techniques proposed from various centers reflect the fact that the procedure is not accurately standardized yet and that prospective randomized trials with long-term follow-up data are needed. The authors report the results of their preliminary experience with a mini-invasive modern approach for video-assisted anatomic lobectomy: an utility muscle-sparing minithoracotomy through the auscultatory triangle. Eight patients successfully undergone this surgical procedure (7 for non-small cell lung cancer in early stage, 1 for benign disease). No mortality, nor complications (including minor morbidity: i.e. rib fractures) were recorded. Medium hospital stay time was 9.25 days (range 7-16) and chest drainage time 6 days (range 4-11). This operation proved to be technically feasible, although an accurate selection of patients and an adequate training in thoracoscopic procedures are mandatory. According to the more recent literature no significant differences are noted in operation's time, postoperative pain, chest drainage time, hospital stay compared to the standard posterolateral thoracotomy incisions. Otherwise the approach described enables to perform a truly "conservative" operation in conformity with the philosophy of the minimal invasive surgery and the patient's comfort and functional recover 2-3 weeks after surgery seems to be improved.
Twenty-eight patients with severe chest injuries were classified into 3 groups: fractures of rib, hemopneumothorax and lung injured. Their respiratory rate (RR), SpO2 and blood gas were analysed. The results showed that SpO2 and PaO2 in lung-injured group were the lowest and RR was the highest in the 3 groups. After HFJV, there was a significant rise in PaO2 and SpO2 (P < 0.05) and a gradual recovery of respiratory and pulse rates in lung-injured group. The results suggest that respiratory monitoring is important for patients with chest injuries and HFJV may be used as an effective ventilation method for treating patients with severe chest injuries.
Rupture of the thoracic aorta following blunt trauma is increasing in incidence and remains a highly lethal injury. Blunt traumatic rupture and acute dissection of the thoracic aorta is very rare. A 50-year-old man involved in a motor vehicle accident on March 3, 1998 was admitted to our hospital one and a half hours following the accident. On admission, he was alert and his hemodynamics were stable. Chest roentgenogram demonstrated a widened mediastinum and multiple left-sided rib fractures. Enhanced chest CT revealed a periaortic hematoma just distal to the isthmus, dissection of the descending thoracic aorta and mediastinal hematoma. With the diagnosis of thoracic aortic rupture and acute DeBakey type IIIB dissection, an emergency operation was performed. Intraoperative transesophageal echocardiogram showed a mobile intimal flap and diminished caliber of the proximal descending aorta. Disruption and dissection of the descending thoracic aorta were found. Prosthetic graft interposition was accomplished with the aid of left atrium-left femoral artery bypass using a centrifugal pump and heparin-coated circuits and a blood collection device for blood conservation. The weak dissected aortic wall was glued and reapproximated with Gelatine-Resorcine-Formol glue. The postoperative course was uneventful.
We experienced a case of tracheoesophageal fistula successfully cured by surgical therapy after blunt trauma received 38 years ago. A 71-year-old man was injured blunt trauma at right chest by traffic accident in 1960, and was treated for pneumothorax and ribs fracture. In April, 1998, the patient came to the hospital for hemoptysis. Tracheoesophageal fistula at membranous wall 3 cm upper from the carina was diagnosed and operation was performed. Severe adhesion at 3 cm upper from carina was thought to be fistula. Incision was made at lateral esophageal wall and the fistula was confirmed at the esophageal anterior wall and the esophagus was cut in a circle around the fistula. Trachea was closed 1 layer sutures using esophageal all layers and esophagus was closed with 2 layer sutures. A pedicled 4th intercostal muscle was interposed between the tracheal and esophageal suture lines. Prevention of tracheal stenosis was possible without resection of fistula and closure of trachea using esophageal all layers. This operation was seemed to be effective. This case is supposed to be the longest delay between time of injury and its repair in the world.
OBJECTIVE: There is a lack of data on the etiology and outcome of pneumothorax among the Pakistani population. Our aim was to review the etiology, clinical course, management and outcome of patients presenting with pneumothorax. PATIENTS AND METHODS: All adult cases with pneumothorax admitted to a University Teaching Hospital in Karachi, between January 1992 and June 1996, were reviewed and analyzed. RESULTS: A total of 146 patients were reviewed. Their mean age was 46.3 years (SD +/- 17.8 years) with a male to female ratio of 3.7:1. Secondary pneumothorax was the commonest type seen (45%), followed by traumatic (21%), iatrogenic (18%) and primary (16%). Tuberculosis (47%) and COPD (45%) were most common lung diseases associated with secondary pneumothorax. Pneumothorax secondary to TB presented at an earlier age than that with COPD (49.6 vs. 60.1 years). Similarly, patients with primary pneumothorax were significantly younger than patients with secondary pneumothorax (42.3 vs. 51.7 years). Rib fracture was the most common cause of traumatic pneumothorax. Coronary artery bypass grafting, transthoracic fine needle aspiration and neck vein cannulations were the leading iatrogenic causes. The commonest symptoms of pneumothorax were dyspnea (68%) and chest pain (40%). Most cases (81%) were successfully managed by intercostal tube drainage. CONCLUSION: In our study population, secondary pneumothorax was the commonest variety seen. TB was the commonest cause of secondary pneumothorax, closely followed by COPD. Nearly 40% of pneumothorax were either traumatic or iatrogenic. Intercostal tube drainage remains the treatment of choice for pneumothorax.
We report two cases of traumatic-diaphragmatic hernia caused by blunt injury. In case 1, abdominal findings were discovered on the 2nd day after the patient fell on the bottom from a horse, and in case 2, an emergency laparotomy was carried out due to the respiratory dysfunction which appeared immediately after a labor injury. The diaphragmatic ruptures at the left side observed in both cases, were closed directly. The prolapsed organs which shifted into the thoracic cavity were the stomach and colon in case 1, and the spleen and the tail part of the pancreas in case 2. In both cases, the organs were easily repositioned into the abdominal cavity without a hernial sac, but a splenectomy had to be performed because of splenic lacerations. In case 2, right rib fractures and lacerations of the left adrenal gland with retroperitoneal hematoma were observed. In the case of thoraco-abdominal blunt injuries, it is important to perform an early diagnosis and to consider the possibility of diaphragmatic hernia.
Homer's syndrome, which classically presents as ipsilateral ptosis, meiosis, and facial anhydrosis, may present as a consequence of thoracic epidural analgesia. Pain that limits the patient's ability to maintain adequate pulmonary mechanics may optimally be treated with a thoracic epidural. The importance of recognition of a Horner's syndrome in such a patient is critical in preventing unnecessary anxiety for the patient and potentially embarking on an unnecessary diagnostic workup. The following is a case presentation of a patient who sustained multiple rib fractures in an automobile accident. The patient presented with a Horner's syndrome after a thoracic epidural infusion had begun. This article highlights the importance of early recognition of this benign, transient syndrome and discusses the pathways and potential mechanism of this process.
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This paper describes some of the basic pathophysiologic information required for the interpretation of pulmonary perfusion and ventilation scintigraphy, i.e., perfusion reduction associated with hypoxic vasoconstriction due to ventilatory dysfunction, vascular beds in the upper lung as a reserve of perfusion, stripe sign, fissure sign, characteristic MAA distributions in right-to-left shunt, and different tracer distributions in the lung according to tracer sizes. The utility of perfusion and xenon-133 SPECT in the evaluation of cross-sectional lung function in various disorders is also emphasized. Also described are the utility of Tc-99m-DTPA lung scan in the evaluation of alveolar permeability, Ga-67 scan in the diagnosis of sarcoidosis, bone scans in the diagnosis of pulmonary metastatic calcifications and stress rib fractures, lymphoscintigraphy in the diagnosis of chylothorax, and Tc-99m-HSA scan in the detection of bleeding sites.
Assessing elderly patients is like putting together a jigsaw puzzle. In the case described, it's entirely possible that the patient stumbled and fell, bumping his head and bruising his chest. His confusion is probably secondary to dementia, and his vital signs indicate a lack of serious injury. However, it's just as likely that the patient is hypotensive and unable to mount a compensatory tachycardia, has an expanding subdural hematoma, multiple rib fractures with a hemothorax and a ruptured spleen. And it could be worse. His diabetes could be out of control. He could suffer from chronic congestive heart failure, and his living will could be sticking out of his pocket. As the elderly population increases in number, their medical and social issues grow as well. The onus is on us, as healthcare providers, to learn about the aging population and the special problems they present so that we can continue to improve the quality of care we deliver.