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1.
Unfallchirurgie (Heidelb) ; 127(3): 180-187, 2024 Mar.
Artículo en Alemán | MEDLINE | ID: mdl-37964040

RESUMEN

Traumatic injuries of the thorax can entail thoracic wall instability (flail chest), which can affect both the shape of the thorax and the mechanics of respiration; however, so far little is known about the biomechanics of the unstable thoracic wall and the optimal surgical fixation. This review article summarizes the current state of research regarding experimental models and previous findings. The thoracic wall is primarily burdened by complex muscle and compression forces during respiration and the mechanical coupling to spinal movement. Previous experimental models focused on the burden caused by respiration, but are mostly not validated, barely established, and severely limited with respect to the simulation of physiologically occurring forces. Nevertheless, previous results suggested that osteosynthesis of an unstable thoracic wall is essential from a biomechanical point of view to restore the native respiratory mechanics, thoracic shape and spinal stability. Moreover, in vitro studies also showed better stabilizing properties of plate osteosynthesis compared to intramedullary splints, wires or screws. The optimum number and selection of ribs to be fixated for the different types of thoracic wall instability is still unknown from a biomechanical perspective. Future biomechanical investigations should simulate respiratory and spinal movement by means of validated models.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Pared Torácica , Humanos , Pared Torácica/cirugía , Fracturas de las Costillas/complicaciones , Traumatismos Torácicos/complicaciones , Fenómenos Biomecánicos , Tórax Paradójico/etiología
2.
Am Surg ; 90(4): 695-702, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37853722

RESUMEN

INTRODUCTION: The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution's experience in the surgical management of ASIC injuries. METHODS: A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series. RESULTS: 6 patients met inclusion criteria, all males aged 37-78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge. CONCLUSIONS: This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.


Asunto(s)
Tórax Paradójico , Fracturas Óseas , Traumatismos Torácicos , Pared Torácica , Masculino , Humanos , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Costillas , Traumatismos Torácicos/cirugía , Esternón
3.
J Trauma Acute Care Surg ; 96(3): 471-475, 2024 Mar 01.
Artículo en Inglés | MEDLINE | ID: mdl-37828658

RESUMEN

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.


Asunto(s)
Cartílago Costal , Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Pared Torácica , Humanos , Masculino , Persona de Mediana Edad , Femenino , Pared Torácica/diagnóstico por imagen , Pared Torácica/cirugía , Estudios Retrospectivos , Traumatismos Torácicos/complicaciones , Fracturas de las Costillas/diagnóstico por imagen , Fracturas de las Costillas/cirugía , Tórax Paradójico/etiología
4.
Am Surg ; 90(2): 303-305, 2024 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-38124319

RESUMEN

Early surgical stabilization of rib fracture (SSRF) improves outcomes in patients with flail physiology and severely displaced fractures. We present two cases of patients with severe chest injury and large flail segment who underwent SSRF while on veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patients developed respiratory failure within 24 hours of admission requiring VV-ECMO. The extent of their chest wall injury limited pulmonary mechanics prohibiting transition off VV-ECMO. Therefore, SSRF was performed on hospital days 2 and 3 and while on VV-ECMO support. Stabilizing the chest wall allowed for improved ventilation and successful decannulation from VV-ECMO on postoperative days 3 and 4. Ultimately, both achieved a functional recovery and were discharged home. These cases demonstrate a unique thoracic damage control strategy wherein SSRF is performed while on VV-ECMO. Improving chest stability and pulmonary mechanics with SSRF allowed for safe transition off VV-ECMO and achieved a favorable long-term outcome.


Asunto(s)
Oxigenación por Membrana Extracorpórea , Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Heridas no Penetrantes , Humanos , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/cirugía , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/cirugía , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Estudios Retrospectivos
5.
J Surg Res ; 295: 647-654, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38103322

RESUMEN

INTRODUCTION: Nonoperative management (NOM) along with supportive care has been the adopted approach for traumatic rib fractures; however, surgical approaches have emerged recently to treat this common pathology. Despite this, there are no guidelines for surgical rib fixation in patients with traumatic rib fractures. METHODS: An institutional review board-approved retrospective cohort study was performed at the Puerto Rico Trauma Hospital aiming to compare the outcomes and complications between patients with traumatic rib fractures who undergo surgical fixation and their counterparts with NOM. The study period comprised from January 2016 through July 2020. Outcomes were evaluated with negative binomial and logistic regressions. RESULTS: Fifty patients were identified for the surgical rib fixation group, who were matched to 150 patients who received NOM. The majority of patients were male (91.5%), with a median (interquartile range) age of 53 (29) years. Concomitant chest injuries were significantly more prevalent in the operative group, such as flail segment (P < 0.001), number of fractures (P < 0.001), and displaced rib fractures (P < 0.001). Although hospital length of stay was 25% (95% confidence interval: 1.02-1.54) longer in the surgical group, this intervention was associated with an 85% (95% confidence interval: 0.03-0.70) lower mortality rate when compared to conservative management. CONCLUSIONS: Rib fixation may offer some benefits in selected patients with traumatic rib fractures, such as those with bilateral rib fractures, multiple displaced rib fractures, flail segment, and concomitant thoracic injuries. This study may serve as a guide for treatment strategy and patient selection regarding the surgical management of traumatic rib fractures.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Humanos , Masculino , Femenino , Persona de Mediana Edad , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/cirugía , Estudios Retrospectivos , Tórax Paradójico/etiología , Traumatismos Torácicos/complicaciones , Tiempo de Internación , Costillas , Fijación Interna de Fracturas/efectos adversos
6.
Medicina (Kaunas) ; 59(11)2023 Nov 20.
Artículo en Inglés | MEDLINE | ID: mdl-38004095

RESUMEN

Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Humanos , Tórax Paradójico/epidemiología , Tórax Paradójico/etiología , Estudios Retrospectivos , Fracturas de las Costillas/epidemiología , Fracturas de las Costillas/etiología , Accidentes de Tránsito , Equipos de Seguridad , Vehículos a Motor
7.
Ned Tijdschr Geneeskd ; 1672023 09 21.
Artículo en Holandés | MEDLINE | ID: mdl-37742123

RESUMEN

Patients with rib fractures are a heterogenous group of patients who are treated by general practitioners as well as by specialized trauma surgeons. We present three patients with rib fractures with different degrees of thoracic trauma and therefore treatments differ significantly. The cornerstone in the treatment of rib fractures remains attaining adequate analgesia and breathing exercises. The last decade, there has been an increase in the utilization of rib fixation, however, precise indications remain unknown. It has proven effective in patients with flail chest on mechanical ventilation in whom it decrease intensive care and hospital length and reduces mortality. In case of prolonged (> 3 months) pain, dyspnea or a clicking sensation one could think of a nonunion of the rib fracture. Rib fixation can relieve these complaints in about 60% of the patients, however due to a high implant irritation rate and secondary operation to remove the osteosynthesis is common.


Asunto(s)
Analgesia , Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Humanos , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/cirugía , Manejo del Dolor , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Dolor
8.
JBJS Case Connect ; 13(3)2023 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-37561659

RESUMEN

CASE: We report on a 35-year-old man presenting with disabling pain secondary to multiple rib nonunions and a costochondral dislocation 5 months after sustaining a chest wall crush injury. He underwent surgical reconstruction of the chest and was followed for 2 years. Surgical exposure to the heart was necessary during open reduction of the flail segment, followed by costochondral joint fixation with plates and screws. Although he was a workers' compensation patient, he returned to full gainful employment. CONCLUSION: Open reduction and internal fixation of a symptomatic, chronically displaced, precordial, flail segment can relieve pain and promote return to baseline function.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Pared Torácica , Masculino , Humanos , Adulto , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Fracturas de las Costillas/diagnóstico por imagen , Fracturas de las Costillas/cirugía , Fracturas de las Costillas/complicaciones , Fijación Interna de Fracturas/efectos adversos , Costillas/lesiones
9.
Int J Surg ; 109(4): 729-736, 2023 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-37010189

RESUMEN

BACKGROUND: Traumatic flail chest results in respiratory distress and prolonged hospital stay. Timely surgical fixation of the flail chest reduces respiratory complications, decreases ventilator dependence, and shortens hospital stays. Concomitant head injury is not unusual in these patients and can postpone surgical timing due to the need to monitor the status of intracranial injuries. Reducing pulmonary sequelae also assists in the recovery from traumatic brain injury and improves outcomes. No previous evidence supports that early rib fixation can improve the outcome of patients with concomitant flail chest and traumatic brain injury. RESEARCH QUESTION: Can early rib fixation improve the outcome of patients with concomitant flail chest and traumatic brain injury? STUDY DESIGN AND METHODS: Adult patients with blunt injuries from the Trauma Quality Improvement Project between 2017 and 2019 were eligible for inclusion. Patients were divided into two treatment groups: operative and nonoperative. Inverse probability treatment weighting was used to identify the predictors of mortality and adverse hospital events. RESULTS: Patients in the operative group had a higher intubation rate [odds ratio (OR), 2.336; 95% CI, 1.644-3.318; p <0.001), a longer length of stay (coefficient ß , 4.664; SE, 0.789; p <0.001), longer ventilator days (coefficient ß , 2.020; SE, 0.528; p <0.001), and lower mortality rate (OR], 0.247; 95% CI, 0.135-0.454; p <0.001). INTERPRETATION: Timely rib fixation can improve the mortality rate of patients with flail chest and a concomitant mild-to-moderate head injury.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Tórax Paradójico , Fracturas de las Costillas , Adulto , Humanos , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Fracturas de las Costillas/cirugía , Estudios de Cohortes , Mejoramiento de la Calidad , Tiempo de Internación , Fijación Interna de Fracturas/métodos , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/cirugía , Estudios Retrospectivos
10.
Gen Thorac Cardiovasc Surg ; 71(7): 403-408, 2023 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-36905532

RESUMEN

OBJECTIVE: Anterior flail chest frequency represents a significant case of ventilator insufficiency. Surgical stabilization of acute phase of trauma is considered to effectively shorten the period of ventilation compared to conservative treatment using mechanical ventilation. We have applied minimally invasive surgery to stabilize the injured chest wall. METHODS: Surgical stabilization of predominantly anterior flail chest segments was performed using one or two bars as per the Nuss procedure, during the acute phase of chest trauma. Data from all patients were examined. RESULTS: Ten patients received surgical stabilization using the Nuss method between 1999 and 2021. All patients had already been mechanically ventilated prior to surgery. The mean period from trauma to surgery was 4.2 days (range, 1-8 days). The number of bars used was one for 7 patients, and two for 3 patients. The mean operation time was 60 min (range, 25-107 min). All patients were extubated from artificial respiration without surgical complications or mortality. Mean total ventilation period was 6.5 days (range, 2-15 days). All bars were removed in a subsequent surgery. No collapses or fracture recurrences were observed. CONCLUSION: This method is simple and effective for fixed anterior dominant frail segment.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Pared Torácica , Humanos , Tórax Paradójico/diagnóstico por imagen , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Traumatismos Torácicos/complicaciones , Pulmón , Respiración Artificial/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Fracturas de las Costillas/complicaciones
11.
Eur J Orthop Surg Traumatol ; 33(6): 2337-2345, 2023 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-36401000

RESUMEN

PURPOSE: The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies. METHODS: All adult (≥ 18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed. RESULTS: A total of 223 patients were admitted with concurrent ipsilateral rib and scapula fractures. A total of 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only, and seven patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax and revision surgery) between groups. CONCLUSION: Injury severity resulted in different treatment modalities. As a result, different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible; however, the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Adulto , Humanos , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/cirugía , Estudios Retrospectivos , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Traumatismos Torácicos/complicaciones , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Resultado del Tratamiento , Tiempo de Internación
12.
Artículo en Inglés | MEDLINE | ID: mdl-36498097

RESUMEN

Flail chest, a severe chest injury, is caused by multiple rib fractures. The open reduction and internal fixation (ORIF) of rib fractures is an effective treatment; however, the patients' subsequent condition remains unsatisfactory in terms of the activities of daily living (ADL) and pain. No research study has, as yet, reported on hospital-based rehabilitation of patients who had undergone an ORIF. Our aim was to evaluate the efficacy of hospital-based rehabilitation of flail chest post-ORIF patients. Physical therapists assessed the pain, functional independence measure (FIM), and the Berg balance test. A total of three females and four males (mean age 59.43 ± 18.88) were hospitalized. A significant reduction in pain was observed (7.00 ± 1.83 upon admission to 4.10 ± 2.05 pre-discharge (Z = -2.07, p = 0.027). A significant improvement in FIM (69.43 ± 14.86 upon admission to 113.57 ± 6.40 pre-discharge, Z = -2.37, p = 0.018), and the Berg balance test (35.23 ± 5.87 upon admission to 49.50 ± 3.40 pre-discharge, Z = -2.37, p = 0.018), was observed. Upon admission, all the patients required moderate to complete ADL assistance. Upon discharge, all were independent for all ADL functions. Patients after flail chest post-ORIF can benefit from hospital-based rehabilitation.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Masculino , Femenino , Humanos , Adulto , Persona de Mediana Edad , Anciano , Fracturas de las Costillas/cirugía , Fracturas de las Costillas/complicaciones , Actividades Cotidianas , Tórax Paradójico/cirugía , Tórax Paradójico/etiología , Dolor/complicaciones , Hospitales , Estudios Retrospectivos
13.
J Card Surg ; 37(12): 5521-5523, 2022 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-36285534

RESUMEN

BACKGROUND: Chest compressions during cardiopulmonary resuscitation (CPR) may cause sternal or rib fractures and chest wall instability. This can complicate medical management and significantly impair respiratory function. Surgical management of flail chest is technically demanding, and it becomes even more challenging if the patient requires a concomitant cardiac procedure. CASE PRESENTATION: A 78-year-old male suffered a cardiac arrest and sustained sternal and bilateral rib fractures during a successful CPR. He underwent a concomitant coronary artery bypass grafting and aortic valve replacement combined with stabilization of the chest wall. We discuss the possibility of fixation of bilateral rib fractures and its role in postoperative recovery after cardiac surgery. CONCLUSIONS: Chest wall stabilization for an already fragile patient, with impaired respiratory system performance, could help improve overall outcomes, pulmonary function, weaning from mechanical ventilation, and rehabilitation. It may be used together with a cardiac procedure for a life-threatening cardiac pathology.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Reanimación Cardiopulmonar , Tórax Paradójico , Fracturas de las Costillas , Masculino , Humanos , Anciano , Fracturas de las Costillas/etiología , Fracturas de las Costillas/cirugía , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Respiración Artificial/efectos adversos , Reanimación Cardiopulmonar/efectos adversos
14.
Trials ; 23(1): 732, 2022 Sep 02.
Artículo en Inglés | MEDLINE | ID: mdl-36056421

RESUMEN

BACKGROUND: Persistent pain and disability following rib fractures result in a large psycho-socio-economic impact for health-care system. Benefits of rib osteosynthesis are well documented in patients with flail chest that necessitates invasive ventilation. In patients with uncomplicated and simple rib fractures, indication for rib osteosynthesis is not clear. The aim of this trial is to compare pain at 2 months after rib osteosynthesis versus medical therapy. METHODS: This trial is a pragmatic multicenter, randomized, superiority, controlled, two-arm, not-blinded, trial that compares pain evolution between rib fixation and standard pain medication versus standard pain medication alone in patients with uncomplicated rib fractures. The study takes place in three hospitals of Thoracic Surgery of Western Switzerland. Primary outcome is pain measured by the brief pain inventory (BPI) questionnaire at 2 months post-surgery. The study includes follow-up assessments at 1, 2, 3, 6, and 12 months after discharge. To be able to detect at least 2 point-difference on the BPI between both groups (standard deviation 2) with 90% power and two-sided 5% type I error, 46 patients per group are required. Adjusting for 10% drop-outs leads to 51 patients per group. DISCUSSION: Uncomplicated rib fractures have a significant medico-economic impact. Surgical treatment with rib fixation could result in better clinical recovery of patients with uncomplicated rib fractures. These improved outcomes could include less acute and chronic pain, improved pulmonary function and quality of life, and shorter return to work. Finally, surgical treatment could then result in less financial costs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04745520 . Registered on 8 February 2021.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Humanos , Estudios Multicéntricos como Asunto , Dolor , Ensayos Clínicos Pragmáticos como Asunto , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/diagnóstico , Fracturas de las Costillas/cirugía , Costillas
15.
Kyobu Geka ; 75(10): 878-882, 2022 Sep.
Artículo en Japonés | MEDLINE | ID: mdl-36155586

RESUMEN

A traumatic chest wall injury is a condition that is often encountered in medical practice, but the underlying pathophysiology varies widely depending on the circumstances of the injury and the patient's background. The chest wall, which protects vital organs and provides respiratory movement, can be a life-threatening emergency when injured, thus it is important to respond promptly and appropriately. Because a penetrating chest wall trauma is often associated with intra-thoracic organ damage, it is important to consider an emergency thoracotomy in cases involving massive hemorrhage or air leakage. The ribs and sternum are primarily injured in patients with blunt wall trauma. Flail chest, which is defined as multiple bifocal fractures of the ribs or multiple rib fractures with a sternal fracture, causes respiratory failure secondary to paradoxical respiration. The main treatment for flail chest is ventilatory care and surgical treatment, although early rib fixation has been reported to improve prognosis in recent years. There are several types of devices to fix the ribs and sternum, but selection criteria have yet to be established.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Pared Torácica , Heridas no Penetrantes , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Fijación Interna de Fracturas/efectos adversos , Humanos , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/diagnóstico por imagen , Fracturas de las Costillas/cirugía , Traumatismos Torácicos/complicaciones , Traumatismos Torácicos/cirugía , Pared Torácica/cirugía , Heridas no Penetrantes/complicaciones
16.
J Trauma Acute Care Surg ; 93(6): 781-785, 2022 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-36121905

RESUMEN

BACKGROUND: In 2019, we sought to develop a chest wall injury and reconstruction clinic (CWIRC) to treat patients with chest wall pain and rib fractures. This initiative was fueled by the recognition of an unmet need and evolving research demonstrating improved patient care and experience. We will describe the evolution of this clinic program from an acute care surgery/general surgery (ACS/GS) clinic to a CWIRC. METHODS: We identified outpatient encounters generated from a general surgery clinic staffed by a physician and nurse practitioner team. A retrospective cohort review was performed to identify all outpatient encounters and surgeries associated with these encounters from January 1, 2017, to November 30, 2021. Outpatient and operative work relative value unit (wRVU) production as well as payer mix was compared as the primary outcome. RESULTS: Over this time period, the number of clinic interactions decreased (2017-284 vs. 2021-229). Clinic productivity increased however from 181 wRVUs in 2017 to 295 wRVUs in 2021. The CWIRC patient visits increased from 4% to 70%. In addition, telehealth visits increased from 0% to 23% of encounters. The operative wRVU productivity attributable to outpatient clinic visits increased (2017-253 vs. 2021-591). Combined, the CWIRC resulted in an overall growth of 104% in total wRVUs. The payer mixes for patients with rib diagnosis have a higher number of Blue Cross Blue Shield, Medicare, and Managed Care compared with ACS/GS. The most common diagnosis was rib fracture initial evaluation (37%), rib fracture subsequent encounter (25%), rib pain (24%), and flail chest initial evaluation (4%). CONCLUSION: The initiation of a CWIRC increased wRVU production despite a decrease in clinical encounters. These clinics may produce more wRVUs per encounter than ACS/GS clinics. An underserved population has been identified of chest wall pathology patients presenting for initial evaluation as outpatients. Further investigation into this concept is warranted to serve this population. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Pared Torácica , Anciano , Estados Unidos , Humanos , Fracturas de las Costillas/cirugía , Fracturas de las Costillas/complicaciones , Pared Torácica/cirugía , Estudios Retrospectivos , Pandemias , Medicare , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Traumatismos Torácicos/complicaciones , Instituciones de Atención Ambulatoria , Dolor/epidemiología
17.
Kyobu Geka ; 75(8): 602-605, 2022 Aug.
Artículo en Japonés | MEDLINE | ID: mdl-35892299

RESUMEN

A 57-year-old man presented to our hospital with multiple rib fractures and pleural effusion caused by a traffic accident. We inserted a chest tube and diagnosed him with hemothorax. We performed damage control surgery with right thoracotomy in the emergency room to confirm the bleeding point. The main sources of bleeding were multiple rib fractures and lung injury. We performed partial lung resection and gauze packing into the thoracic cavity and confirmed the stability of the patient's hemodynamics. The next day, we performed a second-look operation at which we fixed the rib fractures and confirmed hemostasis. When fixing the ribs, we used a bioabsorbable plate instead of a metal plate. It has been reported that bioabsorbable plates are less susceptible to infection than metal plates. After the operation, the patient's respiratory condition stabilized, and no signs of infection were noted. In our experience, rib fixation using absorbent plates is useful in surgery that requires attention to infection.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Implantes Absorbibles , Placas Óseas/efectos adversos , Tórax Paradójico/diagnóstico por imagen , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Fijación Interna de Fracturas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Fracturas de las Costillas/diagnóstico por imagen , Fracturas de las Costillas/cirugía
18.
Gen Thorac Cardiovasc Surg ; 70(11): 985-992, 2022 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-35657504

RESUMEN

OBJECTIVES: Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video­assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest. METHODS: From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported. RESULTS: VATS­assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post­operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury. CONCLUSIONS: Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.


Asunto(s)
Tórax Paradójico , Fracturas de las Costillas , Humanos , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/cirugía , Cirugía Torácica Asistida por Video/efectos adversos , Hemotórax/cirugía , Estudios de Seguimiento , Estudios Retrospectivos , Tiempo de Internación
19.
J Surg Res ; 276: 221-234, 2022 08.
Artículo en Inglés | MEDLINE | ID: mdl-35390577

RESUMEN

BACKGROUND: Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse. METHODS: A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality. RESULTS: Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation. CONCLUSIONS: Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.


Asunto(s)
Tórax Paradójico , Neumonía , Fracturas de las Costillas , Fracturas de la Columna Vertebral , Tórax Paradójico/etiología , Tórax Paradójico/cirugía , Fijación Interna de Fracturas/efectos adversos , Humanos , Tiempo de Internación , Neumonía/etiología , Estudios Retrospectivos , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/cirugía , Costillas
20.
Interact Cardiovasc Thorac Surg ; 34(5): 768-774, 2022 05 02.
Artículo en Inglés | MEDLINE | ID: mdl-35134941

RESUMEN

OBJECTIVES: Blunt chest trauma after mechanical resuscitation manoeuvres appears to have a significant impact on the often complicated course. Due to a lack of data in the literature, the purpose of this study was to investigate the feasibility and immediate outcome of chest wall stabilization for flail chest in this vulnerable patient population. METHODS: We retrospectively reviewed the medical records of patients after cardiopulmonary resuscitation between January 2014 and December 2018 who were diagnosed with flail chest. We attempted to compare patients after surgery with those after conservative treatment. RESULTS: Of a total of 56 patients with blunt chest trauma after mechanical resuscitation and after coronary angiography, 25 were diagnosed with flail chest. After the exclusion of 2 patients because of an initial decision to palliate, 13 patients after surgical stabilization could be compared with 10 patients after conservative therapy. Although there was no significant difference in the total duration of ventilatory support, there was a significant advantage when the time after stabilization to extubation was compared with the duration of ventilation in the conservative group. The presence of pulmonary contusion, poor Glasgow Coma Scale score or the development of pneumonia negatively affected the outcome, but additional sternal fracture did not. CONCLUSIONS: Surgical stabilization for chest wall instability is well tolerated even by this vulnerable patient population. Our results should be used for further randomized controlled approaches. It is necessary to evaluate the situation with all parameters in an interdisciplinary manner and to decide on a possible surgical therapy at an early stage if possible.


Asunto(s)
Reanimación Cardiopulmonar , Tórax Paradójico , Fracturas de las Costillas , Traumatismos Torácicos , Heridas no Penetrantes , Reanimación Cardiopulmonar/efectos adversos , Tórax Paradójico/diagnóstico por imagen , Tórax Paradójico/etiología , Tórax Paradójico/terapia , Fijación Interna de Fracturas/métodos , Humanos , Respiración Artificial/efectos adversos , Estudios Retrospectivos , Fracturas de las Costillas/diagnóstico por imagen , Fracturas de las Costillas/etiología , Fracturas de las Costillas/cirugía , Traumatismos Torácicos/cirugía , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugía
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