Fractures of the manubrium sterni: treatment options and a possible classification of different types of fractures.

BACKGROUND: Sternum fractures are mostly located on the sternal corpus, seldom on the manubrium. Fractures of the sternal manubrium are, however, more frequently associated with severe concomitant injuries of thoracic organs, and therefore deserve special attention. In addition, in its function as a capstone in between the anterior chest wall and the shoulder girdle, it is exposed to a multiplicity of forces. Therefore the questions arise what types of fractures are observed in today's clinical practice, how to classify them and which treatment options are available. This study reports on different types of fractures which involve the manubrium sterni. METHODS: Between January 2012 and October 2014, data was collected from all severely injured patients (ISS ≥16), which received a CT scan of the thorax in our Level-I-Trauma Center and retrospectively analyzed concerning sternal fractures. Fracture type, collateral injuries, age, and information about the circumstances of the accident were noted. RESULTS: Of 890 evaluable patients, 154 (17.3%) had a fracture of the sternum and 23 (2.6%) of the manubrium. Fractures of the manubrium appeared in following types: A-type-transverse fracture (n=11) in 1st intercostal space by direct blunt trauma or flexion of the torso with sagittal instability; B-type-oblique fracture (n=9) by seat belt injury with rotatory instability; C-type-combined, more fragmentary fracture (n=3) by direct blunt trauma with simultaneous flexion of the torso and multi directional instability. Fractures only little dislocation were treated conservatively, and unstable fractures were surgically stabilized (n=10). CONCLUSIONS: In summary, three main types of fractures could be found. A-type fractures were stabilized with a longitudinal plate osteosynthesis and B-type fractures with transverse positioned plates. To treat complex C-type fractures, plates with a T- or H-form could be a good solution. Level of evidence: Level III retrospective prognostic cohort study.

Lenalidomide enhances MOR202-dependent macrophage-mediated effector functions via the vitamin D pathway.

Macrophages are key mediators of the therapeutic effects exerted by monoclonal antibodies, such as the anti-CD38 antibody MOR202, currently introduced in multiple myeloma (MM) therapy. Therefore, it is important to understand how antibody-mediated effector functions of myeloma-associated macrophages (MAMs) are regulated. Here, we focused on the effects of vitamin D, a known regulator of macrophage effector functions. Consequently, it was the aim of this study to assess whether modulation of the vitamin D pathway alters the tumoricidal activity of MAMs. Here, we demonstrate that MAMs display a defective vitamin D pathway with reduced expression level of CYP27B1 and limited tumoricidal activity which can be restored by the IMiD lenalidomide in vitro. Furthermore, our data indicate that the vitamin D pathway of MAMs from MM patients does recover during an IMiD-containing therapy shown by an improved MOR202-mediated cytotoxic activity of these MAMs against primary MM cells ex vivo. Here, the ex vivo cytotoxic activity could be further enhanced by vitamin D supplementation. These data suggest that vitamin D holds a key role for the effector functions of MAMs and that vitamin D supplementation in IMiD combination trials could further increase the therapeutic efficacy of anti-CD38 antibodies such as MOR202, which remains to be investigated in clinical studies.

Analysis on the Age Distribution of Sternum Fractures.

BACKGROUND: Sternum fractures (SFs) are described as a rare entity of bony fractures. Various accident mechanisms may cause SF such as the direct impact of traffic accidents and also by indirect mechanisms within the framework of falls. Osteoporotic fractures also play an increasing role in SF, but no reliable data on the age distribution of SF in a representative collective have been published so far. MATERIAL AND METHODS: The age distribution of all inpatients treated with SF (S22.2) in Germany from 2005 to 2012 using diagnosis-related group-based routine data was evaluated. Various accident statistics are included in the interpretation of age peaks. RESULTS: A total of 47,893 patients (24,960 as main diagnosis and 22,933 as secondary diagnosis) were included in the study. SF is a rarity in childhood, with a share of 1.83% before the age of 16 years, followed by a sudden increase in the frequency up to the age of 20 years. A decrease in the frequency is observed up to the age of 35 years before it increases again to the age of 75 years. Three age peaks can be observed at 18, 55, and 75 years. Those who are older than 65 years account for 43.3% of total SF. DISCUSSION AND CONCLUSION: The first age summit after the age of 16 years shows an identical course to the frequency of traffic accidents of this age group, as well as the decline to the fourth decade and the subsequent resurgence up to the fifth decade. After 65 years, the incidence of accidents increases, in particular, the risk of falling in elderly people. In the context of a weaker bone structure, low falls are a common course for fragility fractures. The present analysis of routines shows for the first time the age distribution of the SF taking into account all hospital cases of the observation period.

Reduced invasive and muscle-sparing operative approaches to the posterolateral chest wall provide an excellent accessibility for the operative stabilization! : Minimized approaches to the posterolateral chest wall.

PURPOSE: Stabilizing techniques for flail chest injuries are described through wide surgical approaches to the chest wall, especially in the most affected posterior and lateral regions. Severe morbidity due to these invasive approaches needs to be considered due to dissection of the scapular guiding muscles and the risk of injuries to neurovascular bundles. This study discusses possibilities for minimized approaches to the posterior and lateral regions. METHOD: Ten fresh-frozen cadavers in lateral decubitus position were observed on both sides. Each surgical arm was kept mobile during the procedure. Approaches were performed following a standard protocol with muscle-sparing incisions starting with 5 cm in length and extending to 10 and 15 cm. The accessible surface comparing the extensions was measured. Visible ribs were counted. In a next step, MatrixRib® Plates were fixed to those ribs to prove the feasibility of rib stabilization through limited approaches. RESULTS: Combinations of the posterior and lateral minimized approaches allow surgical fixation of 6-9 and 7-11 ribs through 5 and 10 cm incisions, respectively. In the case of an extreme expansion of a rib fracture series, an access extension can be made to 15 cm to be able to adequately supply the entire hemithorax using two approaches. CONCLUSION: Extensive invasive surgical approaches to the thoracic wall can be replaced by reduced invasive and muscle-sparing access combinations. A free-moving positioning of the arm and an accurate preoperative plan for minimizing approaches are essential. Minimally invasive plate techniques are very helpful adjuncts.

The Operative Management of Flail Chest Injuries with Concomitant Sternal Fracture.

Background: Flail Chest Injuries (FCI) are one of the most severe thoracic injuries. Moreover, an additional sternal fracture (SF) even worsens the outcome, such as the duration of mechanical ventilation, therefore an surgical fixation of the fractures could be considered in certain cases to improve the weaning from the ventilator. This paper aims to emphasize on the management of different types of SF in FCI. Methods: All surgically treated cases (2012-2016) that showed the combination of FCI and SF have been evaluated for their clinical details, the morphology of the fractures and the technical aspects of the surgical procedure in a retrospective investigation. Results: All of the SF (n=15) had been fixed by locked plate osteosynthesis through a median approach in a supine position. Three main regions of the sternum showed the need for different fixation strategies: the upper manubrium, central and lower corpus sterni. Concomitant rib fractures were addressed either through the same approach or through additional limited incisions. Conclusions: Combinations of SF and FCI are high risc injuries with high demand on surgical skills. They can be properly fixed with a locking plate osteosynthesis through a combination of limited incisions employing different types of plates depending on the type of SF.

Surgical Stabilization of Costoclavicular Injuries - A Combination of Flail Chest Injuries and a Clavicula Fracture.

Background: Flail chest injuries (FCI) are associated with a high morbidity and mortality rate. As a concomitant clavicle fracture in FCI even worsens the outcome, the question is how can those costoclavicular injuries (CCI) be managed surgically. Methods: 11 patients with CCI were surgically treated by a locked plate osteosynthesis of the Clavicle and the underlying ribs through limited surgical approaches under general anesthesia. Patients were followed up after 2, 6, 12, 26 and 52 weeks. Results: All patients showed severe chest wall deformity due to severely displaced fractures of the ribs and the clavicle. They were suffering from pain and restriction of respiratory movements. The chest wall could be restored to normal shape in all cases with uneventful bone healing and a high patient convenience. Fractures of the clavicle and the second rib were managed through an innovative clavipectoral approach, the others through standard approaches to the anterolateral and the posterolateral chest wall. Two patients complained about numbness around the lateral approach and lasting periscapular pain. Conclusions: Surgical stabilization might be the appropriate therapy in CCI with dislocated fractures since they would cause severe deformity and loss of function of the chest wall and the shoulder.

Comparative studies of different types of osteosynthesis on the human corpse preparation in bilateral antero-lateral flail chest.

INTRODUCTION: Bilateral flail chest injuries are challenging in treatment and comparatively often require an operative stabilization of the anterior chest wall to re-establish normal physiological conditions of the chest wall in shape and statics. Various procedures have been described which are technically sophisticated for the surgeon. Consequently there is an increasing interest in potentials of operative care and their effectiveness on the anterolateral chest wall. MATERIALS AND METHODS: 12 Human cadavers were prepared and the natural Sternum Position (NP) was marked. A digital probe was fixed to the sternum at the height of the 4th intercostal space in order to measure and compare the stability of the thorax. Readings were taken of the sternal displacement at 1-5cm sagittal distance from NP in starting conditions and from every combination of materials. Serial osteotomies were performed on 2 locations on ribs 2-8 to induce bilateral flail chest. Afterwards the stabilization was achieved with different implants: RESULTS: The osteotomies lead to a subsidence of the sternum occurred to almost 75 mm from NP which corresponds to a maximal unstable situation. The unstable chest wall showed substantially more stabilization through the use of locking plates. Our materialcombinations showed a stability of up to 60% of normal. The more ribs were treated osteosynthetically, the higher the stability of the chest wall. DISCUSSION AND CONCLUSIONS: Locking plate fixation offers anatomically realignment of the ribs whereas metal strut support only lifts up the chest wall, but could not provide realignment of the dislocated ribs.

Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries?

BACKGROUND: Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants. METHODS: 11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred. RESULTS: Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years.. CONCLUSIONS: A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.

Concomitant Sternal Fracture in Flail Chest: An Analysis of 21,741 Polytrauma Patients from the TraumaRegister DGU®.

Background Isolated sternal fractures (SFs) rarely show complications, but their influence in a thorax trauma of the seriously injured still remains unclear. Methods A retrospective analysis of the TraumaRegister DGU® was performed involving the years 2009 to 2013 (Injury Severity Score [ISS] ≥ 16, primary admission to a trauma center). Cohort formation: Unilateral and bilateral flail chest (FC) injuries with and without a concomitant SF, respectively. Results In total, 21,741 patients (25% female) met the inclusion criteria, with 3,492 (16.1%) showing SF. Unilateral FC patients were on average 53.6 ± 18.4 years old, and bilateral FC patients were on average 55.2 ± 17.7 years old. The ISS in unilateral FC and bilateral FC amounted to 31.2 ± 13.0 and 43.4 ± 13.1 points, respectively. FC with an SF occurred more frequently as an injury to car occupants and less frequently as an injury to motorcyclists or in injuries due to falls. Conclusion Patients with an SF additional to an FC had longer hospital and intensive care unit stays and were longer artificially respirated than those patients without an SF. SF indicates possible cardiac and thoracic spine injuries.

A multimodal approach to ankle instability: Interrelations between subjective and objective assessments of ankle status in athletes.

The aim of this retrospective cohort study is to investigate the association between different subjective and objective assessments of ankle function in a population of athletes with or without functional ankle instability (FAI). 29 athletes with a history of ankle spraining were divided into two groups according to their ankle status: 16 with FAI (initial ankle sprain with residual functional instability) (age 24.6 ± 3.1 years), and 13 COPERS (initial ankle sprain without residual instability) (age 25.3 ± 4.4 years). The assessment of each individual's ankle function was based on three approaches: The "functional-ankle-ability-measure" (FAAM) assessing subjective ankle functionality, measures of sensorimotor control as objective functional measurements and MRI-based T2-mapping as a quantitative marker of compositional joint status. Pearson's product-moment-correlation coefficient, student's t-test and analysis-of-variance were used for statistical analysis. Significant group differences existed for subjective ankle function (FAAM, p = 0.04) and MRI-data mainly in the medial compartment of the ankle joint (p ≤ 0.05). We found unique associations between T2-mapping results and sensorimotor scores in the COPER (r = -0.756-0.849), and "FAI"-group (r = 0.630-0.657). The location and magnitude differed between groups. No correlations existed between these measures and the FAAM. This exploratory study provides preliminary evidence for potential interrelations between various diagnostic measures of ankle function and structure in individuals with and without FAI. We found associations between MRI-results and selected measures of sensorimotor control, indicating a potential link between loss of ankle function and early joint degeneration. Despite these interrelations, each of the different assessment options appears to contain unique information on ankle functionality important in a clinical assessment.