Shoulder Pain - Don't Forget First Rib Fractures.

First rib fractures are uncommon, mainly in paediatric population, considering its anatomic features and their skeleton plasticity. Traditional teaching usually characterizes it as a hallmark of severe trauma. Herein, to unfold awareness to an unnoticed diagnosis, we describe two paediatric cases of isolated first rib fracture in adolescents without a clear identifiable cause nor an underlining trauma mechanism. Neurovascular injuries should always be investigated, as fracture of the first rib with ensuing callus formation is a rare but fearing cause of thoracic outlet syndrome. We highlight the scarcity of reports on isolated first rib fractures outside of sports medicine, as well as the importance of considering this otherwise easily missed diagnosis in a common complaint in children.

Surgical fixation of traumatic sternal manubrium dislocation and right-sided rib fractures following a motorcycle accident.

This brief report discusses the diagnosis, management and surgical intervention of a man in his 30s presenting with a rare traumatic sternal manubrium dislocation following a motorcycle crash, accompanied by multiple concomitant rib fractures. The severity and complexity of the patient's injuries necessitated an operative approach for his sternomanubrial dislocation, emphasising the importance of multidisciplinary coordination, accurate diagnosis and prompt surgical intervention. The report provides valuable insights into the successful application of open reduction and internal fixation with plating in a real-world setting, which resulted in positive patient outcomes, despite the rarity and severity of this type of trauma. It further underscores the need for additional research to advance best practices for managing traumatic sternal manubrium dislocations in the context of high-impact injuries.

Small Hemothoraces Not Drained on Admission: Initial Volume Predicts Need for Intervention.

BACKGROUND: Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX. METHODS: A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400 mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48 hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48 hours and up to 6 months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant. RESULTS: Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134) ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68 mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20 days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome. CONCLUSION: For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.

[Surgical Stabilization of Traumatic Multiple Rib Fractures Using Absorbable Osteosynthesis Agent(u-HA/PLLA Composite Material)].

In case that met several indication criteria with 4 or more rib fractures, we performed surgical stabilization of multiple fractured ribs using a plate and screw system( Super FIXORB MX) that was made of uncalcined hydroxyapatite (u-HA)/poly-L-lactic acid (PLLA) composite material with excellent bioactivity and absorbability. We report our clinical experience of 7 cases in which this device was used. Although there is still room for further consideration of the technique and the strength of the device itself, computed tomography( CT) images taken 9 months after surgery showed that the fixative device was almost assimilated with the bone at the fracture repair site in cases where fixation was successful.

[The Surgical Indication of Multiple Rib Fractures of Patients by Traumas and Timing of the Surgical Stabilization of Rib Fractures].

It's reported that 10% of the inpatients by traumas have fractured ribs. It's easy to judge if it's the case of flail chest, or respiratory failure due to airway injury or pulmonary contusion. There is no guideline for treatments of a patient who has multiple ribs fractures without respiratory failure. We did the surgical stabilization of rib fractures for 10 cases from 2020 to October 2023. As a result, we find out useful surgical indication for treatment of rib fractures.

The application of electrical impedance tomography and surgical outcomes of thoracoscope-assisted surgical stabilization of rib fractures in severe chest trauma.

Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fractures. More studies have claimed that early video-assisted thoracoscopic surgery with surgical stabilization of rib fractures (SSRF) results in a good prognosis in patients with major trauma. This study aimed to verify the outcomes in patients with chest trauma whether SSRF was performed. Consecutive patients who were treated in a medical center in Taiwan, for traumatic events between January 2015 and June 2020, were retrospectively reviewed. This study focused on patients with major trauma and thoracic injuries, and they were divided into groups based on whether they received SSRF. We used electrical impedance tomography (EIT) to evaluate the change of ventilation conditions. Different scores used for the evaluation of trauma severity were also compared in this study. Among the 8396 patients who were included, 1529 (18.21%) had major trauma with injury severity score > 16 and were admitted to the intensive care unit initially. A total of 596 patients with chest trauma were admitted, of whom 519 (87%) survived. Younger age and a lower trauma score (including injury severity scale, new injury severity score, trauma and injury severity score, and revised trauma score) account for better survival rates. Moreover, 74 patients received SSRF. They had a shorter intensive care unit (ICU) stay (5.24, p = 0.045) and better performance in electrical impedance tomography (23.46, p < 0.001). In patients with major thoracic injury, older age and higher injury survival scale account for higher mortality rate. Effective surgical stabilization of rib fractures shortened the ICU stay and helped achieve better performance in EIT. Thoracoscope-assisted rib fixation is suggested in severe trauma cases.

Hardware failure for anterior chest wall and costal cartilage injuries: A single-center experience.

BACKGROUND: Often missed in blunt chest wall injury, costal cartilage injuries can cause chest wall instability, refractory pain, and deformity. Notably, there is only a small amount of evidence regarding hardware performance when applied to costal cartilage. In a prior multicenter study, hardware failure rate was found to be approximately 3% following surgical stabilization of rib fractures (SSRFs) for all fracture locations. The aim of the current study was to evaluate hardware performance for costal cartilage injuries. METHODS: All patients undergoing SSRF performed at our institution from 2016 to 2022 were queried, including both acute and chronic injuries. Both radiographic and clinical follow-up were retrospectively reviewed to evaluate for hardware failure defined as plate fracture, malposition, or screw migration following cartilage fixation. RESULTS: After screening 359 patients, 43 were included for analysis. Mean age was 64 years, and 67% of patients were male. Median number of fractures per patient was 7 with 60% of patients sustaining a flail chest injury pattern. Median total plates per operation was 6 and median costal cartilage plates was 3. In total, 144 plates were applied to the costal cartilage for the group. Mean follow-up was as follows: clinical 88 days, two-view plain radiography 164 days, and chest computed tomography 184 days. Hardware failure was observed in 3 of 144 plates (2.1%), in three separate patients. Two cases were asymptomatic and did not require intervention. One patient required revisional operation in the acute setting. CONCLUSION: In our institution, hardware failure for costal cartilage fractures was observed to be 2.1%. This aligns with prior reports of hardware failure during SSRF for all injury locations. Surgical stabilization of anterior and cartilaginous chest wall injury with appropriate plate contouring and fixation technique appears to provide adequate stabilization with a relatively low rate of hardware malfunction. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern?

INTRODUCTION: The progression of pulmonary contusions remains poorly understood. This study aimed to measure the radiographic change in pulmonary contusions over time and evaluate the association of the radiographic change with clinical outcomes and surgical stabilization of rib fractures (SSRF). METHODS: This retrospective cohort study included adults admitted with three or more displaced rib fractures or flail segment on trauma CT and when a chest CT was repeated within one week after trauma. Radiographic severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion Score (BPC18). Logistic regression was performed to evaluate the relation between SSRF and worsening contusions on repeat CT, adjusted for potential confounders. RESULTS: Of 231 patients, 56 (24%) had a repeat CT scan. Of these, 55 (98%) had pulmonary contusion on the first CT scan with a median BPC18 score of 5 (P25-P75 3-7). Repeat CTs showed an overall decrease of the median BPC18 score to 4 (P25-P75 2-6, P = .02), but demonstrated a worsening of the pulmonary contusion in 16 patients (29%). All repeat CTs conducted within 12 hours post-injury demonstrated increasing BPC18. Radiographic worsening of pulmonary contusions was not associated with SSRF, nor with worse respiratory outcomes or intensive care length of stay, compared to patients with radiographically stable or improving contusions. DISCUSSION: In patients with severe rib fracture patterns who undergo repeat imaging, pulmonary contusions are prevalent and become radiographically worse within at least the first 12 hours after injury. No association between radiographic worsening and clinical outcomes was found.

Use of robotic C-arm cone-beam computed tomography in surgical stabilization of rib fractures.

INTRODUCTION: The effectiveness of using intraoperative robotic C-arm cone-beam computerized tomography (CT) to locate rib fractures during surgery was compared to using pre-operative CT. METHODS: Patients diagnosed with multiple rib fracture and treated surgically in the hospital between January 2019 and September 2020 were included. The study included two groups of patients. One group had their rib fractures identified using pre-operative CT, while the other group had their fractures localized using intraoperative cone-beam CT during surgery. The operative time, blood loss, number of incisions, length of incision, duration of chest drains, visual analogue scale (VAS) score, and duration of post-operation stays were measured. RESULTS: A total of 12 patients received intraoperative cone-beam CT, while the remaining 18 patients only received pre-operative CT. Statistical analysis showed that the group treated with cone-beam CT had lower blood loss (p = 0.012), shorter incisions (p = 0.005), and better post-operation VAS scores (p = 0.027). There were also non-significant trends towards fewer incisions, shorter operation times, and shorter duration of chest drains in the group treated with cone-beam CT. CONCLUSIONS: Intraoperative localization of rib fracture sites with cone-beam CT is an effective method for rib fracture stabilization.

Better late than never-a single-center review of delayed rib fixation for symptomatic rib fractures and nonunions.

BACKGROUND: Surgical stabilization of rib fractures (SSRFs) has become an emerging therapy for treatment of patients with rib fractures. More commonly, it is used in the acute setting; however, delayed SSRF can be utilized for symptomatic rib fracture nonunions. Here, we describe our institution's experience with delayed SSRF, hypothesizing it is safe and resolves patient symptoms. METHODS: This is a retrospective review of patients presenting to our Level I trauma center to undergo delayed SSRF for symptomatic nonunions from January 2017 to September 2022. Delayed SSRF was defined as SSRF over 2 weeks in the outpatient setting. Basic demographics were obtained. Outcomes of interest included mean pain score (preoperatively and postoperatively), intensive care unit (ICU) and hospital length of stay (LOS), and resolution of preoperative symptoms, specifically chest wall instability, with return to activities of daily living (ADLs). RESULTS: Forty-four patients met inclusion criteria with a total of 156 symptomatic nonunion rib fractures that received delayed SSRF. The average age was 59.2 ± 11.9 years and median number of days from injury to SSRF was 172.5 (interquartile range, 27.5-200). The average number rib fractures plated per patient 3.5 ± 1.8. Only three patients required ICU admission postoperatively for no longer than 2 days. Median hospital LOS was 2 days (interquartile range 1-3 days). Average preoperative and postoperative pain score was 6.8 ± 1.9 and 2.02 ± 1.5, respectively ( p < 0.001). Chest wall instability and preoperative symptoms resolved in 93.2% of patients postoperatively ( p < 0.001). Two patients (4.5%) had postoperative complications that resolved after additional surgical intervention. Rib fracture healing was demonstrated on radiographic imaging during postoperative follow-up. CONCLUSION: Delayed SSRF is safe and demonstrates significant resolution of preoperative symptoms by decreasing pain, improving chest wall stability, and allowing patients to return to activities of daily living. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Pros and cons of rib unfolding software: a reliability and reproducibility study on trauma patients.

BACKGROUND: Examination of all 24 ribs on axial computed tomography (CT) slices might become a leeway and rib fractures (RF) may easily overlook in daily practice. Rib unfolding (RU), a computer-assisted software, that promises rapid assessment of the ribs in a two-dimensional plan, was developed to facilitate rib evaluation. We aimed to evaluate the reliability and reproducibility of RU software for RF detection on CT and to determine the accelerating effect to determine any drawback of RU application. METHODS: Fifty-one patients with thoracic trauma formed the sample to be assessed by the observers. The characterization and distribution of RFs on CT images in this sample were recorded independently by the non-observers. Regarding the presence or ab-sence of RF, CT images were assessed blindedly by two radiologists with 5 years (observer-A) and 18 years (observer-B) of experience in thoracic radiology. Each observer assessed the axial CT and RU images on different days under non-observer supervision. RESULTS: A total of 113 RFs were detected in 22 patients. The mean evaluation time for the axial CT images was 146.64 s for ob-server-A and 119.29 s for observer-B. The mean evaluation time for RU images was 66.44 s for observer-A and 32.66 s for observer-B. A statistically significant decrease was observed between the evaluation periods of observer-A and observer-B with RU software compared to the axial CT image assessment (p<0.001). The inter-observer κ value was 0.638, while the intra-observer results showed moderate (κ: 0.441) and good (κ: 0.752) reproducibility comparing the RU and axial CT assessments. Observer-A detected 47.05% non-displaced fractures, 48.93% minimally displaced (≤2 mm) fractures, and 38.77% displaced fractures on RU images (p=0.009). Ob-server-B detected 23.52% non-displaced fractures, 57.44% minimally displaced (≤2 mm) fractures, and 48.97% displaced fractures on RU images (p=0.045). CONCLUSION: RU software accelerates fracture evaluation, while it has drawbacks including low sensitivity in fracture detection, false negativity, and underestimation of displacement.

Quantitative evaluation of bone marrow characteristics in occult and subtle rib fractures by spectral CT.

PURPOSE: The present study aimed to determine whether the water content change in the medullary cavity of occult rib fractures by spectral computed tomography (CT). METHODS: The material decomposition (MD) images were reconstructed using the water-hydroxyapatite basis material pairs from spectral CT. The water contents of the medullary cavity in subtle or occult rib fractures and the symmetrical sites of the contralateral ribs were measured, and their difference was calculated. The absolute value of the water content difference was compared to patients without trauma. An independent samples t-test was adopted to compare the consistency of the water content in the medullary cavity of the normal ribs. Intergroup and pairwise comparisons were applied to the difference in water content among the subtle/occult fractures and normal ribs, followed by receiver operating characteristic curve calculations. p < 0.05 was considered to have a statistically significant difference. RESULTS: A total of 100 subtle fractures, 47 occult fractures, and 96 pairs of normal ribs were included in this study. The water content of the medullary cavity in the subtle and occult fractures was both higher than that in their symmetrical sites with the difference value of 31.06 ± 15.03 mg/cm3 and 27.83 ± 11.40 mg/cm3, respectively. These difference values between the subtle and occult fractures were not statistically significant (p = 0.497). For the normal ribs, the bilateral water contents were not statistically different (p > 0.05) with a difference value of 8.05 ± 6.13 mg/cm3. The increased water content of fractured ribs was higher than that of normal ribs (p < 0.001). According to the classification based on whether the ribs were fractured, the area under the curve was 0.94. CONCLUSIONS: The water content measured on MD images in spectral CT in the medullary cavity increased as a response to subtle/occult rib fractures.

Pain Control and Point-of-Care Ultrasound: An Approach to Rib Fractures for the Austere Provider.

Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

Rib fractures in adult horses as a cause of poor performance; diagnosis, treatment and outcome in 73 horses.

BACKGROUND: Rib fractures in adult horses are poorly documented. OBJECTIVES: To describe the presenting signs, diagnosis, treatment and outcome of horses diagnosed with rib fracture. STUDY DESIGN: Retrospective case series. METHOD: The clinical records and diagnostic images of all adult horses diagnosed with a rib fracture at three referral centres over a 15-year period were reviewed. RESULTS: Seventy-three horses met the inclusion criteria. Horses presented due to either resistance to ridden work and poor performance (n = 41), lameness (n = 21) or trauma (n = 7). In four horses, the presenting complaint was not recorded. Clinical assessment and palpation localised the site of injury in 18/47 cases where recorded. Nuclear scintigraphic examination identified all fracture sites in which it was performed (59/59). In 10/24 horses, radiographic examination confirmed rib fracture. Ultrasonographic examination confirmed rib fracture in 58/59 horses (98%; 95% CI 92-100). Six horses underwent surgery due to ongoing clinical signs and non-healing fracture; all other horses were managed conservatively. Fifty-five horses were available for long-term follow up (>1 year), of which 28 (51%; 95% CI 38-64) returned to their previous level of exercise. Twelve horses did not return to their previous level of exercise due to lameness unrelated to the rib fracture and seven horses were subjected to euthanasia, of which three were as a result of the rib fracture. Eight horses did not return to their previous level of exercise for other reasons. MAIN LIMITATIONS: Incomplete data set due to retrospective case series. CONCLUSIONS: Although uncommon, rib fractures should be considered in cases of reduced performance or resistance during ridden exercise. Palpation may be unrewarding. Scintigraphy and ultrasonography are useful in identifying the fracture site. Rib fractures in horses carry a fair prognosis and can be managed conservatively in most cases.