Thoracic trauma: Clinical and paleopathological perspectives.

OBJECTIVES: Although trauma is one of the most significant areas of study in paleopathology, most studies focus on fractures of single anatomical elements. Paleopathological research on regional trauma, such as of the thorax, is rare. This paper explores the causes, complications, and consequences of adult thoracic trauma using clinical data in order to inform paleopathological research. MATERIALS AND METHODS: Trends in paleopathological thoracic trauma literature were assessed by evaluating publications from Bioarchaeology International, International Journal of Osteoarchaeology, International Journal of Paleopathology, and American Journal of Biological Anthropology. Clinical publications on thoracic trauma throughout time were also assessed through a PubMed search, and modern prevalence data was found through trauma databases such as the National Trauma Databank. RESULTS: Consideration of thoracic trauma involving concomitant injuries is a recent trend in clinical literature and patient care, but paleopathological research on thoracic trauma has been limited. Since thoracic fractures tend to occur in conjunction with other injuries, assessing them together is critical to the interpretation of trauma in the past. CONCLUSIONS: Clinical research into thoracic fractures and concomitant injuries provides valuable data for paleopathological research. Evaluating the likelihood and consequences of concomitant injury in skeletal remains provides a more robust understanding of trauma in the past and its impact on past lifeways. SIGNIFICANCE: This paper provides a review of current clinical and paleopathological literature on thoracic trauma and demonstrates the importance of moving beyond the analysis of fractures or trauma of single anatomical elements. LIMITATIONS: Thoracic bones are often taphonomically altered and differentially preserved leading to difficulty in identifying and interpreting fractures. SUGGESTIONS FOR FURTHER RESEARCH: Practical application of the data presented here to archaeological samples will help to advance paleopathological understandings of thoracic trauma.

Rib fracture fixation: controversies and technical challenges.

Rib fractures are a common injury affecting more than 350,000 people each year in the United States and are associated with respiratory complications, prolonged hospitalization, prolonged pain, long-term disability, and mortality. The social and economic costs that rib fractures contribute to the health care burden of the United States are therefore significant. But despite this measurable impact on patients' quality of life, current treatment of the majority of patients in the United States with rib fracture syndromes is supportive only. Even the most severe of chest wall injuries have historically been treated non-operatively. Recently, however, several reports from American centers support an increased application of operative fixation. With this resurgent interest of American surgeons in mind, we review the clinical presentations, potential indications, controversies, and technical challenges unique to rib fracture fixation.

Bicycle commuter injury prevention: it is time to focus on the environment.

BACKGROUND: Few data exist on the risk of injury while commuting to work or school by bicycle. The proportion of commuters choosing to travel by bike is increasing in the United States, and information on injury incidence and the influences of rider characteristics and environmental factors may suggest opportunities for prevention actions. METHODS: Bicycle commuters in the Portland, OR, metropolitan area were recruited via the websites and community advertising to participate in a 1-year study. Riders completed an initial online survey along with 12 monthly surveys describing their commutes and injury events from September 2007 to August 2008. A traumatic event was considered a serious traumatic event if medical attention was sought. RESULTS: Nine hundred sixty-two adult bicyclists (52% men and 48% women) with a mean age of 36.7 ± 0.4 years (range, 22-70 years) commuted an average of 135 miles (range, 7-617) per month. There were 225 (23%) beginner, 256 (27%) intermediate, and 481 (50%) advanced riders. Four hundred twenty (44%) had a prior traumatic event. Over the 1-year period, 164 (18%) riders reported 192 traumatic events and 49 (5%) reported 50 serious traumatic events. The incidence rates of traumatic events and serious traumatic events were 15.0 (95% CI, 13.2-17.5) and 3.9 (95% CI, 2.9-5.1) per 100,000 miles commuted. There were no differences in age, gender, safety practices, and experience levels between commuters who experienced a traumatic event and those who did not. CONCLUSIONS: Approximately 20% of bicycle commuters experienced a traumatic event and 5% required medical attention during 1 year of commuting. Traumatic events were not related to rider demographics, safety practices, or experience levels. These results imply that injury prevention should focus on improving the safety of the bicycle commuting environment.

Long-term morbidity, pain, and disability after repair of severe chest wall injuries.

Long-term morbidity after severe chest wall injuries is common. We report our experience with acute chest wall injury repair, focusing on long-term outcomes and comparing our patients' health status with the general population. We performed a retrospective medical record review supplemented with a postal survey of long-term outcomes including the McGill Pain Questionnaire (MPQ) and RAND-36 Health Survey. RAND-36 outcomes were compared with reference values from the Medical Outcomes Study and from the general population. Forty-six patients underwent acute chest wall repair between September 1996 and September 2005. Indications included flail chest with failure to wean from the ventilator (18 patients), acute, intractable pain associated with severely displaced rib fractures (15 patients), acute chest wall defect/deformity (5 patients), acute pulmonary herniation (3 patients), and thoracotomy for other traumatic indications (5 patients). Three patients had a concomitant sternal fracture repair. Fifteen patients with a current mean age of 60.6 years (range 30-91) responded to our surveys a mean of 48.5 +/- 22.3 months (range 19-96) postinjury. Mean long-term MPQ Pain Rating Index was 6.7 +/- 2.1. RAND-36 indices indicated equivalent or better health status compared with references with the exception of role limitations due to physical problems when compared with the general population. The operative repair of severe chest wall injuries is associated with low long-term morbidity and pain, as well as health status nearly equivalent to the general population. Both the MPQ and the RAND-36 surveys were useful tools for determining chest wall pain and disability outcomes.

Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair.

INTRODUCTION: Rib and sternal fracture repair are controversial. The opinion of surgeons regarding those patients who would benefit from repair is unknown. METHODS: Members of the Eastern Association for the Surgery of Trauma, the Orthopedic Trauma Association, and thoracic surgeons (THS) affiliated with teaching hospitals in the United States were recruited to complete an electronic survey regarding rib and sternal fracture repair. RESULTS: Two hundred thirty-eight trauma surgeons (TRS), 97 orthopedic trauma surgeons (OTS), and 70 THS completed the survey. Eighty-two percent of TRS, 66% of OTS, and 71% of THS thought that rib fracture repair was indicated in selected patients. A greater proportion of surgeons thought that sternal fracture repair was indicated in selected patients (89% of TRS, 85% of OTS, and 95% of THS). Chest wall defect/pulmonary hernia (58%) and sternal fracture nonunion (>6 weeks) (68%) were the only two indications accepted by a majority of respondents. Twenty-six percent of surgeons reported that they had performed or assisted on a chest wall fracture repair, whereas 22% of surgeons were familiar with published randomized trials of the surgical repair of flail chest. Of surgeons who thought rib fracture or sternal fracture repair was rarely, if ever, indicated, 91% and 95%, respectively, specified that a randomized trial confirming efficacy would be necessary to change their negative opinion. CONCLUSIONS: A majority of surveyed surgeons reported that rib and sternal fracture repair is indicated in selected patients; however, a much smaller proportion indicated that they had performed the procedures. The published literature on surgical repair is sparse and unfamiliar to most surgeons. Barriers to surgical repair of rib and sternal fracture include a lack of expertise among TRS, lack of research of optimal techniques, and a dearth of randomized trials.

Biomechanical testing of a novel, minimally invasive rib fracture plating system.

BACKGROUND: A novel rib fracture repair plating system was developed to provide durable fixation with a shorter length than standard systems and thus facilitate minimally invasive repair. We hypothesized that U-plate fixation would be at least equivalent in durability to standard anterior fixation. STUDY: Twenty fresh frozen ribs (10 pairs) from two human cadavers were first tested for intact stiffness (force or deformation). A gap of 5 mm was then created in the middle of each rib with a saw. Each rib was reconstructed with either the U-plate (4.6 cm length, Acute Innovations, LLC, Hillsboro, OR) with four screws or a 2.4-mm anterior locking plate (9.5 cm length, Synthes, Paoli, PA) with six screws. The U-plates were placed on one rib and the anterior plates on the contralateral rib of the paired levels. The reconstructed ribs were cycled 50,000 times with a load of +/-2N at 1 Hz in a simulation of the repetitive loading of deep breathing. The stiffness of the construct was measured throughout the test. RESULTS: Stiffness decreased from the intact rib to the transected/plated rib for both types of fixation; however, a significant decrease in stiffness was observed only with the anterior repair (p = 0.03). After 50,000 cycles, the U-plated ribs lost 0.12 +/- 0.03 N/mm (1.9%) stiffness, whereas the anterior-plated ribs lost 0.72 +/- 0.13 N/mm (9.9%) stiffness (p = 0.001). CONCLUSIONS: In this simulation of an unstable rib fracture with a small bony gap, U-plate fixation was more durable than standard anterior fixation. The greatly diminished size of the U-plate compared with the standard may facilitate minimally invasive rib fracture repair.

Blunt carotid artery injury: the futility of aggressive screening and diagnosis.

BACKGROUND: Blunt carotid artery injury (BCI) remains a rare but potentially lethal condition. Recent studies recommend that aggressive screening based on broad criteria (hyperextension-hyperflexion mechanism of injury, basilar skull fracture, cervical spine injury, midface fracture, mandibular fracture, diffuse axonal brain injury, and neck seat-belt sign) increases the rate of diagnosis of BCI by 9-fold. If this recommendation becomes a standard of care, it will require a major consumption of resources and may give rise to liability claims. The benefits of aggressive screening are unclear because the natural history of asymptomatic BCI is unknown and the existing treatments are controversial. HYPOTHESIS: The lack of an aggressive angiographic screening protocol does not result in delayed BCI diagnosis or BCI-related neurologic deficits. METHODS: A 10-year medical record review of patients with BCI was undertaken in 2 level I academic trauma centers. In both centers, urgent screening for BCI was performed in patients with focal neurologic signs or neurologic symptoms unexplainable by results of computed tomography of the brain as well as in selected patients undergoing angiography for another reason. RESULTS: Of 35 212 blunt trauma admissions, 17 patients (0.05%) were diagnosed as having BCI. Six showed no evidence of BCI-related neurologic symptoms during hospitalization or prior to death as a result of associated injuries. Eleven sustained a BCI-related stroke, 9 of whom had it within 2 hours of injury. The remaining 2 had a delayed diagnosis (9 and 12 hours after injury) and received only anticoagulation because the lesions were surgically inaccessible. Just 1 of these 2 patients met the criteria for BCI screening and could have been offered earlier treatment, of uncertain benefit, if we had adopted an aggressive screening policy. CONCLUSIONS: Of the few patients with BCI, most remain asymptomatic or develop neurologic deficits shortly after injury. Although a widely applied, resource-consuming screening program may increase the rate of early diagnosis of BCI, an improvement in outcome is uncertain. A cost-effectiveness analysis should be done before trauma surgeons accept an aggressive screening protocol as the standard of care.

Mechanism of acute ascites formation after trauma resuscitation.

BACKGROUND: Severely injured patients have been observed to acutely develop ascites; however, the pathogenesis of this rare phenomenon is poorly understood. OBJECTIVES: To report the factors common among severely injured patients developing ascites and to formulate a hypothesis regarding its origin. METHODS: Retrospective review of case series. RESULTS: We identified 9 injured patients between January 1, 1993, and December 31, 1998, who acutely developed significant amounts of ascites. The mean +/- SD estimated ascites volume was 2.0 +/- 0.8 L. All 9 patients had severe shock and were mechanically ventilated before abdominal decompression for the abdominal compartment syndrome. The mean +/- SD peak inspiratory pressure was 39.0 +/- 5.8 cm H2O. The mean +/- SD volumes of crystalloid and blood product infusion before decompression were 16.1 +/- 10.2 L and 5.2 +/- 4.8 L, respectively, in a mean +/- SD of 17 +/- 15 hours. In comparison, the mean +/- SD volumes of crystalloid and blood product transfusion among 100 contemporary, randomly selected patients undergoing trauma laparotomy were 5.1 +/- 5.5 L and 1.1 +/- 2.5 L, respectively (P<.001). Eight patients had only extra-abdominal injuries, while 1 patient had a combination of extra- and intra-abdominal injuries. Two patients were found to be cirrhotic by liver biopsy, but the other 7 patients had no known preexisting hepatic disease. Eight patients had absorbable mesh temporary abdominal closure, and 1 patient had primary fascial closure. There was persistent ascitic drainage in 5 patients; however, in all but 1 patient with cirrhosis, the drainage did not persist beyond 3 days. Two patients died, 1 of sepsis and the other of a closed head injury. CONCLUSIONS: Common denominators of posttraumatic ascites include shock, massive fluid resuscitation, and elevated intrathoracic pressure. The rapid onset of ascites in the setting of elevated intrathoracic pressure suggests that the patient's ability to clear ascitic fluid is overwhelmed.

Initial management of the trauma patient.

Critical care specialists should be familiar with the initial management of injured patients. Dividing the evaluation and treatment of the patient into the primary, secondary, and tertiary surveys ensures that the multiply injured patient will be managed expeditiously. The primary survey identifies the acute life-threatening problems that must be managed immediately. The secondary survey identifies the remaining major injuries and sets priorities for definitive management. The tertiary survey identifies occult injuries before they become missed injuries.

Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury.

Blunt thoracic trauma can result in significant morbidity in injured patients. Both chest wall and the intrathoracic visceral injuries can lead to life-threatening complications if not anticipated and treated. Pain control, aggressive pulmonary toilet, and mechanical ventilation when necessary are the mainstays of supportive treatment. The elderly with blunt chest trauma are especially at risk for pulmonary deterioration in the several days postinjury and should be monitored carefully regardless of their initial presentation. Blunt thoracic trauma is also a marker for associated injuries, including severe head and abdominal injuries.

Tracheal stenosis after percutaneous dilational tracheotomy.

OBJECTIVE: In many critical care units percutaneous dilational tracheotomy (PDT) has become an alternative to open tracheotomy. Although significant tracheal stenosis after PDT has been reported, the exact incidence is unknown. We report our findings on endoscopic laryngotracheoscopy for a group of patients who had undergone PDT more than 6 months before their examination. STUDY DESIGN AND SETTING: We did a retrospective review of 108 trauma patients who underwent PDT at least 6 months before enrollment in the study. Twenty-eight patients were either deceased or ineligible. Participation requests were mailed to the last recorded address of 80 patients. Thirty-four of those patients were contacted by phone, and 14 indicated their willingness to participate. Only 10 patients were able to make it to the clinic for examination. After transorally anesthetizing the hypopharynx and larynx with 4% lidocaine, each patient underwent flexible laryngotracheoscopy. Findings were categorized as normal or tracheal stenosis (<25%, 25% to 50%, or >50%). RESULTS: The tracheotomy site was virtually undetectable in 5 patients. In 4 patients, a scar was visible at the tracheotomy site, but there was no decrease in cross-sectional area. In 1 patient there was a 25% to 50% stenosis. All patients were completely asymptomatic with regard to airway and voice quality. CONCLUSION: One out of 10 patients in our series had a significant but asymptomatic stenosis after PDT. The risk of tracheal stenosis in PDT appears to be the same as that of open tracheotomy.

Medical management of abdominal compartment syndrome: case report and a caution.

We report the case of a 55 year old woman who developed abdominal compartment syndrome [ACS] following total gastrectomy for caustic ingestion. Contributing factors for the development of ACS included peritonitis and massive fluid resuscitation for cardiovascular support of septic shock. The adverse cardiovascular and pulmonary effects of intra-abdominal hypertension [IAH] were reversed with pharmacological neuromuscular blockade [NMB]. Surgical decompression of ACS was, therefore, postponed, but the patient required re-operation for intra-abdominal sepsis several days later and subsequently died. Although medical management of ACS with NMB may lower IAH and reverse its negative cardiopulmonary effects, surgical decompression may still be required for definitive treatment.

A Technique of Carotid Endarterectomy and Carotid Shunting.

With the advent of carotid arterial operations, concerns of interruption of cerebral perfusion and ischemic injury loomed as the major deterrent. The physiologic basis for cerebral protection is to diminish its oxygen requirement by chemical or hypothermic means or to continue its adequate arterial perfusion. The first successful carotid reconstruction resecting an internal carotid stenosis with anastomosis of the patent external carotid to the distal internal carotid artery was performed by Carrea of Argentina in 1951. Preoperatively, ascorbic acid and phenobarbital was given but its rationale was not explained.

Lidocaine patches reduce pain in trauma patients with rib fractures.

Rib fracture pain is notoriously difficult to manage. The lidocaine patch is effective in other pain scenarios with an excellent safety profile. This study assesses the efficacy of lidocaine patches for treating rib fracture pain. A prospectively gathered cohort of patients with rib fracture was retrospectively analyzed for use of lidocaine patches. Patients treated with lidocaine patches were matched to control subjects treated without patches. Subjective pain reports and narcotic use before and after patch placement, or equivalent time points for control subjects, were gathered from the chart. All patients underwent long-term follow-up, including a McGill Pain Questionnaire (MPQ). Twenty-nine patients with lidocaine patches (LP) and 29 matched control subjects (C) were analyzed. During the 24 hours before patch placement, pain scores and narcotic use were similar (LP 5.3, C 4.6, P = 0.19 and LP 51, C 32 mg morphine, P = 0.17). In the 24 hours after patch placement, LP patients had a greater decrease in pain scores (LP 1.2, C 0.0, P = 0.01) with no change in narcotic use (LP -8.4, C 0.5-mg change in morphine, P = 0.25). At 60 days, LP patients had a lower MPQ pain score (LP 7.7, C 12.2, P < 0.01), although only one patient was still using a patch. There was no difference in time to return to baseline activity (LP 73, C 105 days, P = 0.16) and no adverse events. Lidocaine patches are a safe, effective adjunct for rib fracture pain. Lidocaine patches resulted in a sustained reduction in pain, outlasting the duration of therapy.

Rib fracture repair: indications, technical issues, and future directions.

Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib's relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

American College of Surgeons Guidelines Program: a process for using existing guidelines to generate best practice recommendations for central venous access.

BACKGROUND: Many professional organizations help their members identify and use quality guidelines. Some of these efforts involve developing new guidelines, and others assess existing guidelines for their clinical usefulness. The American College of Surgeons Guidelines Program attempts to recognize useful surgical guidelines and develop research questions to help clarify existing clinical guidelines. We used existing guidelines about central venous access to develop a set of summary recommendations that could be used by practitioners to establish local best practices. STUDY DESIGN: A comprehensive literature search identified existing clinical guidelines for short-term central venous access. Two reviewers independently rated the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Highly scored guidelines were analyzed for content, and their recommendations were compiled into a summary table. The summary table was reviewed by an independent panel of experts for clinical utility. RESULTS: Thirty-two guidelines were identified, and 23 met inclusion criteria. The AGREE rating resulted in four guidelines that were strongly recommended and five that were recommended with alterations. Three comprehensive tables of recommendations were produced: procedural, maintenance, and infectious assessment. A panel of experts came to consensus agreement on the final format of the best practice recommendations, which included 30 summary recommendations. CONCLUSIONS: Our process combined assessing existing guidelines methodology with expert opinion to produce a best practice list of guidelines that could be fashioned into local care routines by practicing physicians. The American College of Surgeons guidelines program believes this process will help validate the clinical utility of existing guidelines and identify areas needing further investigation to determine practical validity.