Surgical treatment of rib fracture nonunion: A single center experience.

INTRODUCTION: In contrast to the emerging evidence on the operative treatment of flail chest, there is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe our standardized approach and report the outcome (e.g. patient satisfaction, pain and complications) after surgical treatment of a rib fracture nonunion. METHODS: A single centre retrospective cohort study was performed at a level 1 trauma centre. Symptomatic rib nonunion was defined as a severe persistent localized pain associated with the nonunion of one or more rib fractures on a chest CT scan at least 3 months after the initial trauma. Patients after initial operative treatment of rib fractures were excluded. RESULTS: Nineteen patients (11 men, 8 women), with symptomatic nonunions were included. Fourteen patients were referred from other hospitals and 8 patients received treatment from a pain medicine specialist. The mean follow-up was 36 months. No in-hospital complications were observed. In 2 patients, new fractures adjacent to the implant, without new trauma were observed. Furthermore 3 patients requested implant removal with a persistent nonunion in one patient. There was a mean follow-up of 36 months, the majority of patients (n = 13) were satisfied with the results of their surgical treatment and all patients experienced a reduction in the number of complaints. Persisting pain was a common complaint. Three patients reporting severe pain used opioid analgesics on a daily or weekly basis. Only 1 patient needed ongoing treatment by a pain medicine specialist. CONCLUSION: Surgical fixation of symptomatic rib nonunion is a safe and feasible procedure, with a low perioperative complication rate, and might be beneficial in selected symptomatic patients in the future. In our study, although the majority of patients were satisfied and the pain level subjectively decreases, complaints of persistent pain were common.

[A bomb attack in the Netherlands; how would we provide hospital care?] / Een bomaanslag in Nederland.

- There is an ever-present threat of large-scale incidents and disasters, such as terrorism and natural disasters.- Preparation and planning are the key to successful response to major incidents and disasters, which is why education, training sessions and exercises take place in the Netherlands.- Analysis of recent large-scale incidents in Europe and the USA emphasises the importance of adequate distribution of the wounded to centres where the correct care can be provided.- A major step has been taken in the Netherlands to provide for such an eventuality with the introduction of distribution plans for the wounded, and other initiatives such as a regional hospital disaster plan.- If a large-scale incident should take place the Netherlands also has a Major Incident Hospital at its disposal; this is a unique facility that can guarantee availability of 200 spare beds to the Netherlands healthcare system within 30 minutes.

[Emergency laparotomy in a trauma patient]. / De spoedlaparotomie bij een traumapatiënt.

- Emergency laparotomy in trauma patients can be part of the resuscitation process, is based on damage control principles and is therefore fundamentally different from elective laparotomy, for example in case of malignancies. - Indications for emergency laparotomy after trauma are based on haemodynamic instability of the patient and the procedure is focused on restoring the patient's physiological condition.- Haemodynamic and biochemical parameters are used to determine the rest of the strategy. In order to optimize the procedure, the entire treatment team should be practiced in this.- Fewer and fewer surgeons are carrying out general laparotomies and even fewer are carrying out emergency laparotomies after trauma.- Knowledge and skills about emergency laparotomy after trauma are at risk of disappearing because of this, not only for surgeons but also for other team members.- Increased centralisation, team training, more cooperation and consultation for specific indications may all contribute to expertise preservation.

Surgical Management of Rib Fractures: Strategies and Literature Review.

BACKGROUND AND AIMS: Rib fractures can cause significant problems in trauma patients, often resulting in pain and difficulty with respiration. To prevent pulmonary complications and decrease the morbidity and mortality rates of patients with rib fractures, currently there is a trend to provide surgical management of patients with flail chest. However, the indications for rib fracture fixation require further specification. MATERIAL AND METHODS: Past and current strategies are described according to a review of the medical literature. A systematic review was performed including current indications for rib fracture fixation. MEDLINE (2000-2013) was searched, as well as Embase (2000-2013) and Cochrane Databases, using the keywords rib, fracture, fixation, plate, repair, and surgery. RESULTS: Three retrospective studies were found that described different techniques for rib fracture fixation. The results demonstrated a reduced number of ventilation days, decreased long-term morbidity and pain, and satisfactory rehabilitation after surgical treatment. In addition to flail chest, age, Injury Severity Score, and the number of rib fractures were important predictive factors for morbidity and mortality. CONCLUSION: Surgical rib fracture fixation might be indicated in a broader range of cases than is currently performed. Prospective randomized trials are needed for further confirmation.

Systematic review and meta-analysis of antibiotic prophylaxis to prevent infections from chest drains in blunt and penetrating thoracic injuries.

BACKGROUND: No consensus exists as to whether antibiotic prophylaxis in tube thoracostomy as primary treatment for traumatic chest injuries reduces the incidence of surgical-site and pleural cavity infections. METHODS: A systematic literature search was performed according to PRISMA guidelines to identify randomized clinical trials on antibiotic prophylaxis in tube thoracostomy for traumatic chest injuries. Data were extracted by two reviewers using piloted forms. Mantel-Haenszel pooled odds ratios (ORs) were calculated with 95 per cent confidence intervals (c.i.). RESULTS: Eleven articles were included, encompassing 1241 chest drains in 1234 patients. Most patients (84·7 per cent) were men, and a penetrating injury mechanism was most common (856, 69·4 per cent). A favourable effect of antibiotic prophylaxis on the incidence of pulmonary infection was found, with an OR for the overall infectious complication rate of 0·24 (95 per cent c.i. 0·12 to 0·49). Patients who received antibiotic prophylaxis had an almost three times lower risk of empyema than those who did not receive antibiotic treatment (OR 0·32, 0·17 to 0·61). A subgroup analysis in patients with penetrating chest injuries showed that antibiotic prophylaxis in these patients reduced the risk of infection after tube thoracostomy (OR 0·28, 0·14 to 0·57), whereas in a relatively small blunt trauma subgroup no effect of antibiotic prophylaxis after blunt thoracic injury was found. CONCLUSION: Infectious complications are less likely to develop when antibiotic prophylaxis is administered to patients with thoracic injuries requiring chest drains after penetrating injury.

Function of rat skeletal muscles after storage at 10 degrees C in various preservation solutions.

1. The purpose of this study was to assess the potential of various preservation solutions, orginally designed for solid organs, to protect muscle function during cold storage. 2. The soleus (SOL) and the cutaneous trunci (CT) muscle from the rat were isolated and stored for 2, 4 or 8 h at 10 degrees C. The solutions used, listed in order from an intracellular to an extracellular-like composition, were: University of Wisconsin (UW), Euro-Collins (EC), HTK-Bretschneider (HTK), reversed St. Thomas' Hospital (ST2) and Krebs-Henseleit (KH). After cold storage, the muscles were tested by direct electrical stimulation to obtain the maximum twitch tension (Pt) and the maximum tetanus tension (P0). Subsequently, the muscles were prepared for morphological analysis. 3. In general, storage at 10 degrees C caused a gradual decrease of Pt and P0 with time. After 8 h of storage in the extracellular-like solutions KH and ST2, the P0 was about 50% (SOL) and 35% (CT) of control. Eight hours of storage in intracellular-like solutions resulted in a P0 of 50% of control for HTK, in a P0 of 40% (SOL) and 67% (CT) for UW, but in a P0 of 5% (SOL) and 26% (CT) for EC. These findings corresponded well with the morphological observations. 4. It is concluded that the effects of 10 degrees C storage on skeletal muscle function are not predominantly determined by the intra- or extracellular-like composition of the solutions used. Both UW and HTK were most effective (P0 > 50% of control) in preserving muscle function.