Efectividad de la reconstrucción de la oreja con cartílago costal en el tratamiento de microtias / Effectiveness of Auricle Reconstruction with Costal Cartilage for the Treatment of Microtias

Introducción: La reconstrucción de la oreja en la actualidad es un problema difícil de solucionar. Se han propuesto varias técnicas quirúrgicas y solo las que se basan en el uso de cartílago costal autólogo son las que se aceptan a nivel mundial. Objetivo: Evaluar la efectividad de la técnica de reconstrucción del pabellón auricular descrita por Burt Brent. Métodos: Se realizó un estudio cuantitativo con diseño descriptivo de corte transversal con 41 pacientes que presentaron microtia congénita o perdida adquirida de la oreja; a quienes se les realizó reconstrucción auricular con cartílago costal autólogo tratados en el Hospital "William Soler", el Centro de Investigaciones Médico-Quirúrgica y Clínica Central "Cira García" en el Servicio de Cirugía Plástica desde 1994 hasta 2019. Se describió y se documentó la técnica empleada descrita por Burt Brent. Se utilizó una escala de 10 puntos que se basó en la anatomía auricular normal para la valoración de los resultados. Resultados: Se encontraron 32 pacientes portadores de microtia congénitas (78,04 %) y 9 pérdidas traumáticas (21,95 %), predominó el sexo femenino (56,09 %). La incidencia fue mayor en el lado derecho (68,75 %) en pacientes con microtia congénita. En el 95 % de los casos se alcanzaron resultados favorables y satisfactorios. Conclusiones: La reconstrucción del pabellón auricular requiere el empleo de un fragmento de cartílago costal de suficiente tamaño, forma y proyección. La clave consiste en esculpir un marco cartilaginoso de la oreja y mantener estos detalles a través de la piel lo más semejante a la oreja normal. Para un resultado satisfactorio se requiere una alta especialización.

Introduction: Auricle reconstruction is, nowadays, a difficult problem to solve. Several surgical techniques have been proposed and only those based on the use of autologous costal cartilage are accepted worldwide. Objective: To evaluate the effectiveness of the auricle reconstruction technique described by Burt Brent. Methods: A quantitative study with a cross-sectional descriptive design was carried out with 41 patients who presented congenital microtia or acquired loss of the ear and who were performed auricle reconstruction with autologous costal cartilage in the plastic surgery service at Hospital "William Soler", Centro de Investigaciones Médico-Quirúrgicas and Clínica Central "Cira García", from 1994 to 2019. The used technique described by Burt Brent was, in turn, described and documented. A 10-point scale based on the normal atrial anatomy was used to assess the outcomes. Results: Thirty-two patients with congenital microtia (78.04 %) and nine traumatic losses (21.95 %) were found, with a predominance of the female sex (56.09 %). The incidence was higher on the right side (68.75 %) in patients with congenital microtia. Favorable and satisfactory outcomes were achieved in 95 % of cases. Conclusions: Auricle reconstruction requires the use of a costal cartilage piece of enough size, shape and projection. The key is to sculpt a cartilaginous framework of the ear and to maintain these details through the skin as close as possible to the normal ear. A high level of specialization is required for a satisfactory outcome.

Vomiting-induced costal cartilage fracture: a case report.

The use of ultrasonography as a first line imaging test in cases of possible costal cartilage fracture can be pivotal. In this case report, we present the case of a patient with a suspected atraumatic vomiting-induced costal cartilage fracture. The costal cartilage fracture was non-displaced and incomplete, thus not visible in a Computed Tomography scan. When Ultrasound imaging was employed at the area of tenderness, soft tissue edema and hematoma around the cartilage were visualized. High level of suspicion for a cartilage fracture in this case revealed a subtle osseous injury.

Insights to enhance the examination of tool marks in human cartilage.

This work deals with the examination of tool marks in human cartilage. We compared the effectiveness of several cleaning methods on cut marks in porcine cartilage. The method cleaning by multiple casts achieved the significantly highest scores (P = 0.02). Furthermore, we examined the grain-like elevations (dots) located on casts of cut cartilage. The results of this study suggest that the casting material forms these dots when penetrating cartilage cavities, which are areas where the strong collagen fibres leave space for the chondrocytes. We performed fixation experiments to avoid this, without success. In addition, 31 casting materials were compared regarding contrast under light-microscope and 3D tool marks scanner. Under the light-microscope, brown materials achieved significantly higher values than grey (P = 0.02) or black (P = 0.00) whereas under the 3D scanner, black materials reached higher contrast values than grey (P = 0.04) or brown (P = 0.047). To compare the accuracy and reproducibility of 6 test materials for cartilage, we used 10 knives to create cut marks that were subsequently scanned. During the alignment of the individual signals of each mark, the cross-correlation coefficients (Xmax) and lags (LXmax) were calculated. The signals of the marks in agarose were aligned with significantly fewer lags and achieved significantly higher cross-correlation coefficients compared to all tested materials (both P = 0.00). Moreover, we determined the cross-correlation coefficients (XC) for known-matches (KM) per material. Agarose achieved significantly higher values than AccuTrans®, Clear Ballistics™, and gelatine (all P = 0.00). The results of this work provide valuable insights for the forensic investigation of marks in human costal cartilage.

Prevelance of the costal cartilage fracture on the computerised tomography in chest trauma.

INTRODUCTION: Radiography remains limited in costal cartilage injuries, and sonography, CT and MR imaging turns out to be more sensitive in the detection of cartilage injuries. This study aims to determine the frequency of costal cartilage fractures detected in the CT images of the patients with high energy chest trauma and to evaluate the association of costal cartilage fracture with the complications of trauma. METHODS: The CT images of 93 patients aged 18-91 years with a trauma admitted to the Emergency Department of the State Hospital between February 2019 and June 2019 were studied retrospectively. Thorax CT images of 93 patients who presented to the emergency department with blunt chest trauma with AIS > 2 were retrospectively investigated by a radiologist with a board certificate who had 15 years of experience in the field. RESULTS: Costal cartilage fracture was identified in 39 of 93 patients with severe chest trauma. Among the 93 chest trauma patients admitted to the emergency department between February and June 2019, the prevalence of costal cartilage was calculated as 41.93%. Note that the most common costal cartilage fractures in the study group were identified in the 6th, 7th, 8th and 1st costal cartilages. Another significant relationship (p = 0.007) was found between costal cartilage calcification and cartilage fracture. CONCLUSION: Costal cartilage fractures frequently occur in blunt thoracic trauma with multiple rib fractures and are of clinical importance as they lead to the instability of chest wall. The incidence of cartilage fractures increases in elderly patients with costal cartilage calcification.

Cough-induced costal cartilage fracture.

We present two cases of atraumatic costal cartilage fracture secondary to violent coughing. Although costal cartilage fractures due to trauma and bony rib fractures due to violent coughing have been described, to our knowledge there have been no prior reported cases of cough-induced costal cartilage fracture. It is important for radiologists to consider costal cartilage fractures, which are often more subtle than osseous injuries, in patients with chest pain, and understand that they may not always be preceded by direct trauma. Identifying this injury is clinically important and will prevent patients from undergoing unnecessary examinations to rule out a cardiac cause of chest pain or a pulmonary embolism.

Simultaneous Surgical Treatment of Sternum and Costal Cartilage Fractures.

Studies have confirmed that, for severe flail chest or sternal fractures and even multiple rib fractures, surgical treatment can effectively reduce hospital stay and relieve chest wall pain. However, fixation of multiple costal cartilage fractures in such a small area is a challenge if an internal fixator is simply placed directly on the sternum. This case report shares a method of simultaneous fixation of multiple costal cartilage and sternal fractures through a small incision, and it is also appropriate for multiple costal cartilage fractures without sternal fracture.

Fracture of the Costal Cartilage: Presentation, Diagnosis, and Management.

A 52-year-old woman sustained a fracture of the left 7th costal cartilage after a ski injury. She presented complaining of painful clicking over the area. Initial imaging studies were negative for fracture; however, 3-dimensional reconstruction of a chest computed tomography scan, formatted to costal cartilage, revealed the fracture. She was offered and underwent surgical fixation of the fracture with a plate and 4 screws using a biaxial, convergent construct. Postoperatively, her symptoms resolved. In this case report, we review the rationale for fixation of costal cartilage, including a summary of previous literature pertaining to this relatively rare thoracic injury.

Influence of rib impact on thoracic gunshot trauma.

INTRODUCTION: The influence of rib impact on thoracic gunshot trauma remains unclear, despite its high occurrence. This study therefore investigates the effect of rib impact on a bullet's terminal properties and injury severity. METHODS: Two bullets were used: 5.56×45 mm (full charge and reduced charge) and 7.62×51 mm (full charge). For each bullet, three impact groups were tested: (1) plain 10% ballistic gelatin (control) conditioned at 4°C, (2) intercostal impact, and (3) rib impact, the latter two tested with samples of porcine thoracic walls embedded in gelatin. Analysis included penetration depth, trajectory change, yaw, fragmentation, velocity reduction, energy deposition and temporary and permanent cavity characteristics. RESULTS: No significant differences were observed for most variables. Differences were found between rib (and intercostal) impact and the control groups, suggesting that the inclusion of thoracic walls produces an effect more significant than the anatomical impact site. Effects were ammunition specific. For the 7.62×51 mm round, rib impact caused an earlier onset of yaw and more superficial permanent gelatin damage compared with plain gelatin. This round also formed a larger temporary cavity on rib impact than intercostal impact. Rib (and intercostal impact) created a smaller temporary cavity than the control for the 5.56×45 mm round. For the reduced-charge 5.56×45 mm round, rib and intercostal impact produced greater velocity reduction compared with plain gelatin. CONCLUSIONS: This study provides new insights into the role of rib impact in thoracic gunshot injuries, and indicates that the effects are ammunition dependent. Unlike the 5.56×45 mm rounds, rib impact with the 7.62×51 mm rounds increases the risk of severe wounding.

Complex Suicide by Self-stabbing and Drowning: A Case Report and a Review of Literature.

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self-stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma.

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ2 and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. © RSNA, 2017.

Sonographic diagnosis of a radiographically occult displaced fracture of a costal cartilage.

We report the case of a 22-year-old athlete who sustained a blunt thoracic trauma to the right chest causing a costal cartilage fracture. Plain radiographs revealed no abnormalities while sonographic (US) examination performed a week later because of persistent pain led to the diagnosis of a displaced fracture of the right tenth costal cartilage. A follow-up US examination confirmed the healing of the fracture and allowed the patient to return to competitive sport activity. We recommend the use of US in patients with persisting pain after thoracic trauma with negative plain radiographs of the ribs to rule out radiographically occult costal cartilage fractures. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:605-607, 2017.

Characteristics and time-dependence of cut marks and blunt force fractures on costal cartilages: an experimental study.

PURPOSE: The distinction between cut marks and blunt force injuries on costal cartilages is a crucial issue in the forensic field. Moreover, a correct distinction may further be complicated by decomposition, so the need arises to investigate the distinctive features of lesions on cartilage and their changes over time. METHODS: This study aimed to assess the stereomicroscopic features of cut marks (performed with six different knives) and blunt fractures (performed with a hammer and by means of manual bending) on 48 fragments of human costal cartilages. Moreover, in order to simulate decomposition, the cut and fractured surfaces were checked with stereomicroscopy and through casts after 1 and 2 days, 1 week, and 1, 2 and 4 months of drying in ambient air. RESULTS: In fresh samples, for single and unique cuts, striations were observed in between 44 and 88% of cases when non-serrated blades were used, and between 77 and 88% for serrated blades; in the case of "repeated" (back and forth movement) cuts, striations were detected in between 56 and 89% of cases for non-serrated blades, and between 66 and 100% for serrated blades. After only 1 week of decomposition the detection rates fell to percentages of between 28 and 39% for serrated blades and between 17 and 33% for non-serrated blades. Blunt force injuries showed non-specific characteristics, which, if properly assessed, may lead to a reliable distinction between different cut marks in fresh samples. The most evident alterations of the structure of the cartilage occurred in the first week of decomposition in ambient air. After one week of drying, the characteristics of cut marks were almost undetectable, thereby making it extremely challenging to distinguish between cut marks, blunt force fractures and taphonomic effects. CONCLUSION: The study represents a contribution to the correct assessment and distinction of cut marks and blunt force injuries on cartilages, providing a glimpse on the modifications such lesions may undergo with decomposition.