The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU®.

PURPOSE: Isolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax. METHODS: A retrospective analysis of the TraumaRegister DGU® (project 2017-10) was carried out involving the years 2009-2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF. RESULTS: 73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF. CONCLUSION: Due to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.

Lung Contusion in Polytrauma: An Analysis of the TraumaRegister DGU.

BACKGROUND: Thorax trauma frequently occurs in which injuries to the bony chest, lung contusions (LCs), and others are diagnosed. The significance of this violation is described very differently and is mostly based on monocentric data. METHODS: A retrospective analysis of the TraumaRegister DGU® (TR-DGU) dataset (Project 2014-062) was performed between 2009 and 2014 (injury severity score [ISS] ≥ 16, primary admission to a trauma center, no isolated traumatic brain injury). Patients with LC (Abbreviated Injury Scale [AIS] 3 + 4) were compared with the control group, and an analysis of different age groups was performed. RESULTS: A total of 49,567 patients were included, thereunder 14,521 (29.3%) without relevant thoracic trauma (TT); 95.9% blunt traumas. 18,892 patients (38.1%) had LC and 14,008 (28.3%) had severe LC with AIS 3 + 4; thereunder 72.7% males. For severe LC, the average age was the lowest (44.7 ± 19.7 years) and ISS the highest (30.4 ± 12.1 points).Intubation, intensive care, (multi-) organ failure, sepsis, and extrathoracic injuries were most common in severe LC. Shock, chest tubes, further thoracic injuries, and patient death occurred most frequently in TT without LC.Younger patients showed a higher incidence of LC than the older ones; however, high patient age was a highly significant risk factor for the development of complications and poor outcome. CONCLUSION: Since LC was present in almost 40% of the severely injured and was related to higher morbidity, LC should be detected and managed at the earliest possible time. Proper follow-ups employing chest X-rays and computed tomography (CT) scans are recommended.

Quantitative T2 Mapping Shows Increased Degeneration in Adjacent Intervertebral Discs Following Kyphoplasty.

OBJECTIVE: A minimally invasive treatment of osteoporotic and nonosteoporotic thoracic and lumbar spine fractures is cement augmentation (kyphoplasty). Little is known about the impact on adjacent intervertebral discs. A quantitative magnetic resonance imaging (MRI) approach in addition to morphological MRI is desirable to evaluate changes in the intervertebral disc. Our study aims to evaluate the feasibility of T2 mapping for the detection of subtle changes in the intervertebral discs in spines after kyphoplasty. DESIGN: Intervertebral discs were assessed by quantitative MRI (3.0 T) using T2 relaxation time mapping. Region of interest (ROI; 6 per disc) analyses were performed. The ROIs at the anterior and posterior edges were interpreted as annulus fibrosus (AF). The 2 very inner zones were regarded as nucleus pulposus (NP) and the regions in between as intermediate transition zone. We compared T2 relaxation time values of intervertebral discs adjacent to the vertebrae after kyphoplasty with those nonadjacent to vertebrae after kyphoplasty, especially in the NP. RESULTS: The analysis of the ROIs showed that the intervertebral discs of the adjacent vertebral segments are associated with reduced T2 values compared to those that are nonadjacent to the affected vertebrae. CONCLUSION: This study is to our knowledge the first investigation of intervertebral discs after kyphoplasty by quantitative MRI. Quantitative T2 mapping shows increased degeneration in adjacent intervertebral discs following kyphoplasty. Besides its contribution to a broader knowledge of postoperative changes after kyphoplasty, our findings may help to improve differentiation between healthy and degenerated intervertebral discs using these techniques.

Age Distribution and Concomitant Injuries in Pulmonary Contusion: An Analysis Based on Routine Data.

BACKGROUND: As the population ages, low-energy thoracic injuries are becoming increasingly relevant in individual injuries, particularly pulmonary contusions (PCs) and their common concomitant injuries. The objective of this study was to determine the prevalence and age distribution of thoracic trauma, especially PC, to make conclusions about common secondary diagnoses and developments in management. METHODS: A retrospective analysis of 209,820 cases, based on German routine data from the years 2009 to 2015, with a main diagnosis (MD) or secondary diagnosis (SD) of thoracic trauma (S27 according to ICD-10) was performed. The entire patient collective with a MD of S27 was examined as well as those with PCs (S27.31). RESULTS: In all 61,016 patients with a MD of S27, 7,558 (12.4%) had a MD of PC and among the 148,804 patients with a SD of S27, 58,247 patients (39.1%) had a SD of PC. PC occurs mostly in the age groups of 20 to 25, 45 to 50, and 70 to 75 years. The proportion of older people tends to be increasing. The most concomitant thoracic injuries were serial rib fractures (27.1%), pneumothorax (11.9%), and sternum fractures (6.2%). Computed tomography scan is the most common diagnostic tool in PC (MD >80%, SD >60%). Therapeutically, intensive care (>50%) and chest drainage are most important (MD: 12.5%, SD: 60.1%), while operative measures are rare (≤ 4%). CONCLUSION: PC shows a marked increase in the incidence, especially in older patients and as a companion diagnosis in thoracic injuries. It should be diagnosed early as well as its concomitant injuries to avoid complications.

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.

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.

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.

Injuries of the Medial Clavicle: A Cohort Analysis in a Level-I-Trauma-Center. Concomitant Injuries. Management. Classification.

Introduction: Although shoulder girdle injuries are frequent, those of the medial clavicle are widely unexplored. An applied classification is less used just as a standard management. Methods: A retrospective analysis of medial clavicle injuries (MCI) during a 5-year-term in a Level-1-Trauma-Center. We analyzed amongst others concomitant injuries, therapy strategies and the classification following the AO standards. Results: 19 (2.5%) out of 759 clavicula injuries were medial ones (11 A, 6 B and 2 C-Type fractures) thereunder 27,8% were displaced and thus operatively treated Locked plate osteosynthesis was employed in unstable fractures and a reconstruction of the ligaments at the sternoclavicular joint (SCJ) in case of their disruption. 84,2% of the patients sustained relevant concomitant injuries. Numerous midshaft fractures were miscoded as medial fracture, which limited the study population. Conclusions: MCI resulted from high impact mechanisms of injury, often with relevant dislocation and concomitant injuries. Concerning medial injury's complexity, treatment should occur in specialized hospitals. Unstable fractures and injuries of the SCJ ligaments should be considered for operative treatment. Midshaft fractures should be clearly distinguished from the medial ones in ICD-10-coding. Further studies are required also regarding a subtyping of the AO classification for medial clavicle fractures including ligamental injuries.

Injuries of the Sternoclavicular Joint - An Innovative Approach in the Management of a Rare Injury: Tight Rope Fixation of the Costo-Clavicular Ligament.

Background: The costoclavicular ligament (CCL) provides the most tight stability within the sternoclavicular joint (SCJ), followed by the most cited sternoclavicular ligaments (SCL). Their disruption may cause severe instability of the SCJ. Different treatment options, such as the use of plates, wires or autologous tendons are associated with mainly limited functional outcome. Could a stabilization of CCL next to an anatomic fixation of the SCL provide sufficient reconstruction of the SCJ? Methods: A 58-year-old male showed severe anterior and painful instability of the SCJ following a fall on his shoulder 8 weeks ago. The SCJ had been reconstructed in an open procedure with stabilization of the CCL employing 2 tight ropes and anatomical suture of the SCL. Follow-up was carried out 78 weeks after operation. Results: The reduction of the SCJ was successful. X-ray proved the anatomic position of the SCJ. Pain was decreased in between the first 6 weeks. The patient showed uneventful follow-up and returned to work 6 months after the procedureas a hard working farmer. Conclusions: Innovative stabilization of the CCL with tight ropes additional to a suture of the SCL may enable anatomic reconstruction of the SCJ considering cosmetic and functional results.

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.

The oblique fracture of the manubrium sterni caused by a seatbelt--a rare injury? Treatment options based on the experiences gained in a level I trauma centre.

INTRODUCTION: Sternal fractures are rare with 3-8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle. MATERIAL AND METHODS: Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®). RESULTS: Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization was performed. Follow up showed sufficient consolidation without complications. DISCUSSION: A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation.