Do multiple fractures affect risk of fixation failure after surgical treatment of midshaft clavicle fracture? A retrospective cohort study.

BACKGROUND: Surgical treatment of midshaft clavicle fractures is associated with quick recovery and low risk of non-union. However, fixation failure may occur in case of severe comminution fractures. Moreover, clinical outcomes may be affected when clavicle fractures occur in combination with other injuries, particularly those involving the lower extremities, as the use of crutches or walkers may hinder the process of rehabilitation by adding strain on the acromioclavicular (AC) joint, resulting in possible fixation failure. This study aims to identify risk factors for fixation failure of midshaft clavicle fractures and elucidate the role of combined fractures in treatment outcomes. METHODS: This study included patients diagnosed with midshaft clavicle fractures who underwent initial surgery between January 2012 and November 2021 at a designated regional trauma center hospital. Retrospective evaluation of fixation failure was carried out in 352 patients with midshaft clavicle fractures using standard clinical evaluation protocols and conventional radiographs. The prevalence of fixation failure and the effects of several demographic variables on the risk of fixation failure and non-union were examined. Multivariate logistic regression analysis was carried out to identify independent risk factors for fixation failure. RESULTS: Fixation failure occurred in 40 patients (11.4%). Multivariate analysis identified comminution [odds ratio (OR) 3.532, p value = 0.003, 95% confidence interval (CI) 1.55-8.05)] and fewer number of screws (OR 0.223, p value = 0.022, 95% CI 0.06-0.80) as risk factors for fixation failure. Surgical techniques using wire cerclage reduced the chances of fixation failure in comminuted fractures (OR 0.63, p value = 0.033, 95% CI 0.05-0.80). Combined fractures that required rehabilitation using walkers or crutches increased the risk of non-union (OR 19.043, p value = 0.032, 95% CI 1.28-282.46). CONCLUSIONS: Additional fixation of comminuted fractures using cerclage can reduce the risk of treatment failure, while multiple fractures or rehabilitation for ambulation increases the risk of the same. LEVEL OF EVIDENCE: III.

A Young Patient with Multiple Pathological Fractures.

A 26-year-old male was asymptomatic and active until the age of 19 years. At the age of 20 years, he underwent lithotripsy for ureteral stones. As he grew older, he experienced bone pain, recurrent bilateral shoulder dislocations, and long bone fractures following minor trauma for which he was operated. Currently, he presented with another long bone fracture following minor trauma. Investigations showed increased serum calcium (11.5 mg/dL), 24-hour urinary calcium (420 mg/24 hours; 100-300 mg/day), and intact parathyroid hormone (PTH) (1688 pg/mL; 10-55 pg/mL). Serum phosphorus was 2.0 mg/dL (2.8-4.5 mg/dL) and 25-OH vitamin D was 10 ng/mL, both of which were decreased. He had normal vitamin B12 levels, complete blood count, kidney function test, liver function test, and thyroid profile. An ultrasound of the abdomen showed multiple bilateral renal calculi and gallbladder (GB) calculus. Calcitonin and 24-hour urinary catecholamine were within the normal range. His X-rays showed multiple lytic lesions in bones, multiple renal calculi, urinary bladder calculus, and fracture shaft of left femur (Figs 1 and 2). He was diagnosed with primary hyperparathyroidism with osteitis fibrosa cystica. He was not willing for further investigations.

Classic Metaphyseal Lesions among Victims of Abuse.

OBJECTIVE: To use legal statements by perpetrators to gain new insights into the causative mechanism of classic metaphyseal lesion (CML). The CML, so called "corner fracture," is considered a highly specific marker for abuse in infants. However, the precise correlation between CMLs and abusive head trauma is still unknown. STUDY DESIGN: In this retrospective observational study, we selected 67 cases with at least 1 CML from a 15-year cohort of legally prosecuted child abuse cases. Their clinical, radiologic, and forensic records were analyzed. In 27 cases, the perpetrator confessed to abusing the child and described the events. Potential associations with subdural hematoma and with confession were evaluated using 2 separate binary logistic regression models. RESULTS: All 67 infants showed other signs of abuse. Median age was 3.4 months. Over 65% had multiple CMLs. Knees and ankles were predominantly involved (64%). Only CMLs of the shoulder were significantly associated with subdural hematoma (P = .03). Different-age fractures were more common in the nonsubdural hematoma group (P = .01). In the group with confessions, perpetrators admitted inflicting violent indirect skeletal forces (torsion, traction, compression, and forced movements). The most common circumstance was diapering (44%), reported by male perpetrators only (P = .03) followed by dressing/undressing (30%). The violence was habitual in 67% of cases. CONCLUSIONS: This unique forensic case series shows that CMLs are caused by violent acts inflicted most during physical care of infants. The frequency of habitual violence responsible for CMLs deserves greater attention.

A case report depicting patient's installation on the fracture table when an ankle spanning external fixator is already in place.

BACKGROUND: Fractures of the proximal and diaphyseal femur are frequently internally fixed using a fracture table. Moreover, some femoral neck fractures may be treated with total hip arthroplasty using a direct anterior approach and a traction table. Fracture and traction tables both use a boot tightly fitted to the patient's foot in order to: 1) obtain fracture reduction by traction and adequate rotation exerted on the slightly abducted or adducted extremity; or 2) adequately expose the hip joint using traction, rotation and extension to implant total hip arthroplasty components. In some instances, multiply injured patients may present with both a proximal or diaphyseal femur fracture and a diaphyseal or distal tibia or ankle fracture necessitating an ankle spanning external fixator on the same limb. Frequently, the tibia or ankle fracture has to be treated first, and standard use of the fracture or traction table may be thereafter difficult due to the external fixator construct preventing tight fitting of the boot to the patient's foot. CASE PRESENTATION: In order to address this situation, the authors describe a simple technique allowing rigid fixation of the limb with an ankle spanning external fixator to the traction or fracture table, providing accurate control of the position of the lower limb in all planes for adequate fracture reduction and fixation or total hip arthroplasty. The technique is exemplified with a clinical case. CONCLUSIONS: This technique allows an efficient way to: 1) timely stabilize diaphyseal or distal tibia or ankle fractures; and 2) subsequently use all the advantages of a fracture or traction table to adequately reduce and fix proximal or diaphyseal femur fractures, or optimally expose femoral neck fractures for total hip arthroplasty using a direct anterior approach.

The speedboat vertebral fracture: a hazard of holiday watersports.

PURPOSE: The purpose of this study was to describe and characterise spinal fractures sustained by watercraft occupants due to splashdown of light watercraft when riding over uneven water surfaces. METHODS: A retrospective review of all patients presenting with these injuries to St Luke's and Mater Dei state hospitals in Malta over a 10-year period was undertaken to determine patient demographics, the nature of spinal injuries sustained and the incidence of any associated extra-spinal injuries. RESULTS: Twenty-one patients (mean age 41.2 years) suffered 25 fractures. Injuries were seasonal, occurring exclusively between the months of May and October. One patient was local whilst 20 were from other countries. All fractures were Magerl type A fractures and occurred around the thoracolumbar junction. The L1 vertebra was most commonly affected (12 patients). Four patients sustained two vertebral fractures. There were no extra-spinal injuries. CONCLUSIONS: Watercraft splashdown can transmit significant forces to occupants, resulting in Magerl type A vertebral fractures around the thoracolumbar junction. These injuries occur under compression. They are highly consistent in their morphology and localisation and should be excluded in individuals complaining of back pain after watercraft use. Almost all patients were from outside Malta and injuries were seasonal, providing opportunities for targeted injury prevention campaigns.

Cardiothoracic injuries after CardioPump CPR: a report of two cases and review of the literature.

Although many clinical trials have demonstrated its efficacy during active compression-decompression cardiopulmonary resuscitation (ACD-CPR), the Ambu® CardioPump seems likely to cause severe and sometimes lethal injuries. In this paper, we report two cases observed at the Institute of Legal Medicine of Nancy, France. A 67-year-old man collapsed in the street, in the presence of witnesses, and without any sign of trauma. The autopsy revealed a flail chest, a wound of the left ventricle, a rupture of the right ventricle, and a wrenching of the inferior vena cava. A 71-year-old woman was found in her apartment during an accidental fire. The autopsy revealed a sternal fracture, many rib fractures, and a perforation of the superior vena cava, the pericardium, and the heart. Despite articles focusing on complications of the use of the CardioPump in the late 1990s, this technique is still used in practice. These two cases emphasize that iatrogenic injuries must be taken into account in the CardioPump benefit/risk balance and the relevance of its daily use.

Distal tibial triplane fracture with ipsilateral tibial shaft fracture: A case series.

BACKGROUND & PURPOSE: Distal tibial Triplane fracture with ipsilateral tibial shaft fracture is a rare but important problem. This rarely reported combination of injuries if not recognised may lead to deleterious consequences. METHODS/PATIENTS: The local database of all emergency admissions was scrutinised to identify subjects before interrogation of the clinical notes and relevant radiographic imaging. FINDINGS: This paper reports a series of five children who were found to have triplane fracture of the distal tibia with concomitant ipsilateral fracture of the tibial shaft. CONCLUSIONS: We suggest that a high index of suspicion for concomitant fractures should be maintained in the presence of either triplane fracture of the distal tibia or tibial shaft fractures in the peri-adolescent child. Minimum appropriate imaging should include orthogonal full length plain radiographs of the tibia as well as formal ankle radiographs.

[Acute exacerbation of chronic CLL with multiple pathological fractures : A rarity]. / Akute Exazerbation einer chronischen CLL mit multiplen pathologischen Frakturen : Eine Seltenheit.

Chronic lymphatic leukaemia (CLL) is one of the most common leukaemic diseases in middle Europe. Pathological fractures are rare findings in patients with CLL. The diagnosis of CLL is in most cases an incidental finding as it often stays asymptomatic for years. This article presents an interesting case of a 65-year-old male patient with known asymptomatic CLL for 5 years and fractures of the proximal femur and proximal radius after trauma. During the hospital stay the patient suffered multiple pathological fractures with histological findings of bony infiltration of the CLL and an acute phase, which was treated by combination chemotherapy.

Styloid Process Fracture Associated With Maxillofacial Trauma: Incidence, Distribution, and Management.

PURPOSE: Fracture of the styloid process of the temporal bone has been infrequently reported. The present study evaluated the incidence, causes, distribution, and management of styloid process fracture in association with other maxillofacial fractures. MATERIALS AND METHODS: A prospective evaluation of patients with maxillofacial trauma over a period of 1 year was carried out and patients' characteristics, mode and distribution of injury, and length of styloid process were recorded. Patients were divided into 5 groups based on the site of maxillofacial fracture and into 2 groups based on styloid process length to evaluate their association with styloid process fracture. The authors' unit protocol was carried out for management of styloid process fracture. RESULTS: Of 84 patients with maxillofacial trauma, 27 patients (14 men, 13 women; mean age, 25.7 ± 8.92 yr) had styloid process fracture. The most common cause of injury was road traffic accidents. Mandibular and multiple facial fractures accounted for most concomitant styloid process fractures. The mean length of the styloid process in patients with fracture was 2.46 ± 0.89 cm and no relevant association was present between the length and fracture of the styloid process. All patients responded well to initial conservative management. CONCLUSION: Styloid process fractures are relatively common injuries in developing countries and a meticulous examination is essential for prompt diagnosis and adequate care.

A rare case of multiple phosphaturic mesenchymal tumors along a tendon sheath inducing osteomalacia.

BACKGROUND: Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by renal phosphate wasting, hypophosphatemia, reduction of 1,25-dihydroxyl vitamin D, and bone calcification disorders. Tumors associated with TIO are typically phosphaturic mesenchymal tumors that are bone and soft tissue origin and often present as a solitary tumor. The high production of fibroblast growth factor 23 (FGF23) by the tumor is believed to be the causative factor responsible for the impaired renal tubular phosphate reabsorption, hypophosphatemia and osteomalacia. Complete removal of the tumors by surgery is the most effective procedure for treatment. Identification of the tumors by advanced imaging techniques is difficult because TIO is small and exist within bone and soft tissue. However, systemic venous sampling has been frequently reported to be useful for diagnosing TIO patients. CASE PRESENTATION: We experienced a case of 39-year-old male with diffuse bone pain and multiple fragility fractures caused by multiple FGF23-secreting tumors found in the hallux. Laboratory testing showed hypophosphatemia due to renal phosphate wasting and high levels of serum FGF23. Contrast-enhanced MRI showed three soft tissue tumors and an intraosseous tumor located in the right hallux. Systemic venous sampling of FGF23 revealed an elevation in the right common iliac vein and external iliac vein, which suggested that the tumors in the right hallux were responsible for overproduction of FGF23. Thereafter, these tumors were surgically removed and subjected to histopathological examinations. The three soft tissue tumors were diagnosed as phosphaturic mesenchymal tumors, which are known to be responsible for TIO. The fourth tumor had no tumor structure and was consisting of hyaline cartilage and bone tissue. Immediately after surgery, we noted a sharply decrease in serum level of FGF23, associated with an improved hypophosphatemia and a gradual relief of systematic pain that disappeared within two months of surgery. CONCLUSION: The authors reported an unusual case of osteomalacia induced by multiple phosphaturic mesenchymal tumors located in the hallux. Definition of tumors localization by systemic venous sampling led to successful treatment and cure this patient. The presence of osteochondral tissues in the intraosseous tumor might be developed from undifferentiated mesenchymal cells due to high level of FGF23 produced by phosphaturic mesenchymal tumors.

Solitary Frontal Sinus Fractures Compared to Multiple Facial Fractures, Energy Impact Dependency.

Frontal sinus fractures account for 2% to 15% of maxillofacial injuries. Up to 66% to 87% of the patients with frontal sinus fractures experience associated facial fractures. The majority of classifications used today categorize frontal sinus fractures depending on the integrity of the anterior table, posterior table, and the nasofrontal outflow. A retrospective study was performed, which included 24 patients diagnosed with frontal sinus fractures. Treatment in all patients consisted of open reduction and bone fixation. We analyzed population variables, injury etiology, fracture site, associated craniofacial injuries, surgical technique employed, handling of the nasofrontal duct, and postoperative complications. The most frequent etiology was falling accidents. Fifty-eight percent of the fractures involved both the anterior and posterior tables. Sixty-six percent experienced associated facial fractures. Fifty percent of frontal sinus fractures were treated by open reduction internal fixation as the only treatment, 33.3% underwent sinus obliteration, and 16.6% were treated with cranialization. Frontal sinus fractures resulting from high-energy impact exhibited additional facial bone fractures in 100% of the cases, whereas fractures following low-energy impact showed involvement of additional facial fractures in only 27% of the cases. In this report, we suggest a modification to the anteroposterior classification of frontal sinus fractures. In addition to the involvement of the anterior and posterior walls and the degree of dislocation, high and low energy impact can direct us to the involvement of additional facial fractures and influence the surgical strategy.

A Rare Case of Infantile Myofibromatosis Presenting to the Emergency Department as Undiagnosed Long Bone Fractures.

Infantile myofibromatosis is a disorder of mesenchymal tumors that usually presents within the first 2 years of life. Most patients initially present because of the presence of visible or palpable subcutaneous tumors. We report a case of a fussy 5-week-old infant who presented to an emergency department with bilateral femur fractures initially thought to be due to nonaccidental trauma or a metabolic bone disorder. She was ultimately diagnosed after admission with infantile myofibromatosis after taking an extensive family history and after further laboratory and radiologic evaluation. There are no previously published cases of undiagnosed infantile myofibromatosis presenting to the emergency department, especially with multiple long bone fractures.

Noncontiguous double-level unstable spinal injuries.

PURPOSE: Noncontiguous double-level unstable spinal injuries (NDUSI) are uncommon and have not been well described. In this study, we aimed to better understand the patterns of NDUSI, in order to recommend proper diagnostic and treatment methods, as well as to raise awareness among traumatologists about the possibility of these uncommon injuries. METHODS: A total of 710 consecutive patients with spine fractures were treated for >9 years since 2007 at a single regional trauma center. Of them, 18 patients with NDUSI were reviewed retrospectively. RESULTS: The incidence of NDUSI was 2.5 % of all spine fractures. In 17 of 18 patients (94.7 %), NDUSI was caused by a high-energy trauma. Nine patients (50.0 %) exhibited complete neurological deficit. Spinal cord injury occurred in the cranial injured region in all American Spinal Injury Association grade A cases. In one case, a second fracture was overlooked at the initial examination. CONCLUSION: NDUSI are common in cases of high-energy trauma and should be taken into consideration at the initial examination. A second fracture may be easily overlooked because of the high frequency of concomitant severe spinal cord injury in the cranial injured region and/or loss of consciousness due to associated injuries. To avoid overlooking injuries, full spine computed tomography is useful at the initial examination. Operative reduction and internal fixation with instrumentation through a posterior approach is recommendable for cases of NDUSI. In elderly patients, a very rapid stabilizing surgery should be planned before aspiration pneumonia occurs or the pulmonary condition worsens.

A case of severe osteomalacia caused by Tubulointerstitial nephritis with Fanconi syndrome in asymptomotic primary biliary cirrhosis.

BACKGROUND: Primary biliary cirrhosis (PBC) is an immune-mediated chronic cholestatic liver disease, characterized by increased concentrations of serum IgM and the presence of circulating anti-mitochondrial antibodies. Although bone diseases such as osteoporosis or osteodystrophy are commonly associated with PBC, osteomalacia which is caused by abnormal vitamin D metabolism, mineralization defects, and phosphate deficiency has not been recognized as a complication of PBC. CASE PRESENTATION: We report the case of a 49-year-old Japanese woman who complained of multiple fractures. Hypophosphatemic osteomalacia was diagnosed from a low serum phosphorus level, 1,25-dihydroxyvitamin D3 level, high levels of bone specific alkaline phosphatase and the findings of bone scintigraphy, although a bone biopsy was not performed. Twenty four hour urine demonstrated a low renal fractional tubular reabsorption of phosphate, increased fractional excretion of uric acid and generalized aminoaciduria. An intravenous bicarbonate loading test suggested the presence of proximal renal tubular acidosis (RTA). These biochemical data indicated Fanconi syndrome with proximal RTA. A kidney biopsy demonstrated the features of tubulointerstitial nephritis (TIN). The patient was also suspected as having primary biliary cirrhosis (PBC) because of high levels of alkaline phosphatase, IgM and the presence of anti-mitochondrial M2 antibody, though biochemical liver function was normal. Sequential liver biopsy was compatible with PBC and the diagnosis of PBC was definite. After administration of 1,25 dihydroxyvitamin D3, neutral potassium phosphate, sodium bicarbonate for osteomalacia and subsequent predonizolone for TIN, symptoms of fractures were relieved and renal function including Fanconi syndrome was ameliorated. CONCLUSION: In this case, asymptomatic PBC was shown to induce TIN with Fanconi syndrome with dysregulation of electrolytes and vitamin D metabolism, which in turn led to osteomalacia with multiple fractures. Osteomalacia has not been recognized as a result of the renal involvement of PBC. PBC and its rare complication of TIN with Fanconi syndrome should be considered in adult patients with unexplained osteomalacia even in the absence of liver dysfunction.

Pelvic Apophyseal Avulsion Fractures: A Retrospective Review of 228 Cases.

BACKGROUND: The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of pelvic apophyseal avulsion fractures. METHODS: A retrospective records review of imaging and clinical documentation was performed for patients diagnosed with pelvic apophyseal avulsion fractures at our institution from 2007 to 2013. Patient's Risser score, triradiate status, fracture location, size, and displacement were recorded based on initial injury radiographs. Further clinical and radiographic chart review was utilized to determine mechanism of injury, presence of multiple/bilateral injuries, nonunion, chronic pain, as well as any surgical interventions performed. RESULTS: We identified 225 patients diagnosed with 228 apophyseal avulsion fractures with mean age of 14.4 years. Males represented 76% of the patients. Anterior inferior iliac spine (AIIS) avulsions were the most common, representing 49% of all avulsion fractures, followed by anterior superior iliac spine (30%), ischial tuberosity (11%), and iliac crest (10%). The most common mechanism of injury was sprinting/running (39%) followed by kicking (29%), but the mechanism varied by fracture type with 50% of AIIS avulsions caused by kicking. Multiple pelvic fractures were identified in 6% of patients. Pain >3 months out from initial injury was present in 14% of all patients and AIIS avulsion fractures were 4.47 times more likely to have chronic pain. Five nonunions were identified, 4 of which were ischial tuberosity avulsions. Initial fracture displacement >20 mm increased the risk of nonunion by 26 times. Surgical treatment was indicated in 3% of cases. CONCLUSIONS: In this series, nearly all pelvic avulsion fractures (97%) were managed successfully with a conservative approach. Contrary to prior studies, AIIS avulsions represented half of the avulsion fractures. AIIS and ischial tuberosity fractures are at increased risk of developing future pain and nonunions, respectively. Patients and families need to be counseled about this possibility because future intervention may be necessary. LEVEL OF EVIDENCE: Level IV-therapeutic.

Traumatic Tricuspid Valve Rupture after Blunt Chest Trauma - A Case Report and Review of the Literature.

INTRODUCTION: Despite the high frequency of thoracic injuries secondary to traffic related accidents, the blunt cardiac valve rupture is extremely rare. METHOD: Case report and review of the literature using PubMed/MEDLINE and EMBASE databases. RESULT: A 38 year old female patient, victim of car accident was admitted. On primary survey the patient was conscious, cooperative and hemodynamic and respiratory stable. On secondary survey was found a bilateral open leg fracture and a seat belt sign. Whole body Computed Tomography revealed minimal haemorrhagic contusion of the cortex, left hemopneumothorax and right pneumothorax, bilateral rib fractures, liver contusion, left femoral neck fracture and fracture to the lumbar spinal column. After bilateral pleurostomy, the patient becomes hemodynamically unstable, but with no signs of external bleeding. The transthoracic echocardiography revealed an acute severe tricuspid regurgitation with hepatic veins reflux. After orthopaedic surgeries, the tricuspid valve rupture was managed by replacing the valve with a bioprostheses. The hospital stay was 122 days. CONCLUSION: Only a high index of suspicion may reveal blunt cardiac lesions as a cause for hemodynamic instability in acute setting.

Cement augmentation for vertebral fractures in patients with multiple myeloma.

Objective of our study was to assess the outcome of cement augmentation in patients with multiple myeloma. We reviewed 12 patients with 48 vertebral fractures. Mean age was 62.5 years. Average length of follow-up was 27.5 months. Expected survival was less than 12 months in 2 patients and more than 12 months in the remaining patients. After surgery mean survival was 32.5 months. Mean correction in vertebral angle was 3.6°. Karnofsky score was more than 70 in 5 patients, 50-70 in 6 and less than 50 in 1 patient preoperatively, while it was more than 70 in all patients postoperatively. Preoperative mean ODI was 72%. After surgery it was 46% at 6 weeks and 14% at 12 months. All patients reported improvement in their pain status after surgery. Cement augmentation is a safe and effective way of treating symptoms of multiple myeloma, which occur due to vertebral metastases. It results in excellent pain control and improvement in quality of life.

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR. METHODS: A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able. RESULTS: Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home. CONCLUSION: Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed. LEVEL OF EVIDENCE: Therapeutic, Level V.