[Surgical Therapy of Slipping Rib Syndrome].

We have operated on two cases of slipped ribs syndrome( SRS). Both patients were men in their 40s with a history of right thoracic trauma who were referred to us because of unexplained lower thoracic pain. The left rib was positive for hooking maneuver (lift test), and dynamic ultrasonography showed narrowing of the intercostal space, which led to the diagnosis of SRS. in the first case, the tip of the ninth rib cartilage was excised, and the ninth and tenth rib cartilages were sutured and fixed with No.2 fiber wire in two places with Z sutures. In the second case, the tip of the ninth rib cartilage was excised, the eighth and ninth ribs and the ninth and tenth ribs were fixed with No.2 fiber wire with Z sutures as in the first case, and a 0.7 mm thick poly-L-lactide (PLLA) plate was added between the eighth and tenth rib cartilages. In both cases, the postoperative course was good and the pain disappeared. SRS should be recognized as a disease and surgical treatment should be used as therapy.

Stereomicroscopic analysis of cut marks inflicted by a knife with blade damage.

Skeletal cut mark analysis provides relevant information on the general class characteristics of suspect knife. However, there is a lack of research on the influence of blade damage on cut mark analysis. This study aimed to thoroughly investigate the effects of damaged knife blades on cut marks' morphological and morphometrical characteristics. Fifteen undamaged, non-serrated knives were used to cut human ribs to make control cut marks. The knife blades were then damaged by a series of cuts on the bones. A comparison was made between the control cuts and 3 groups of cut marks inflicted by blades that had been damaged to different degrees. The results showed that the damaged blades created wider cut marks than undamaged one. Kerf morphology was likely to imitate the cuts made by the serrated blades such as an elliptical shape, a V-shaped cross-section and the presence of coarse striations. Wear-related features can affect cut mark analysis as the marks left behind by blades damaged to different degrees showed dissimilar dimensions and morphologies. The findings of this study can be applied to a forensic investigation when cut marks were caused by a knife with a damaged blade.

Pediatric Ribs at Chest Radiography: Normal Variants and Abnormalities.

Normal variants and abnormalities of the ribs are frequently encountered on chest radiographs. Accurate identification of normal variants is crucial to avoid unnecessary investigations. A meticulous evaluation of rib abnormalities can provide valuable insights into the patient's symptoms, and even when no osseous condition is suspected, rib abnormalities may offer critical clues to underlying conditions. Rib abnormalities are associated with various conditions, including benign tumors, malignant tumors, infectious and inflammatory conditions, vascular abnormalities, metabolic disorders, nonaccidental injuries, malformation syndromes, and bone dysplasias. Abnormalities of the ribs are classified into three groups based on their radiographic patterns: focal, multifocal, and diffuse changes. Focal lesions are further subdivided into nonaggressive lesions, aggressive lesions, and infectious and inflammatory disorders. Radiologists should be aware of individual disorders of the pediatric ribs, including their imaging findings, relevant clinical information, and underlying pathogenesis. Differential diagnoses are addressed as appropriate. Since chest radiographs can suffice for diagnosis in certain cases, the authors emphasize a pattern recognition approach to radiographic interpretation. However, additional cross-sectional imaging may be necessary for focal lesions such as tumors or inflammatory conditions. Awareness of disease-specific imaging findings helps ascertain the nature of the lesion and directs appropriate management. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Open Reduction and Internal Fixation of a Chronic Precordial Flail Chest Segment: A Case Report.

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.

Pros and cons of rib unfolding software: a reliability and reproducibility study on trauma patients.

BACKGROUND: Examination of all 24 ribs on axial computed tomography (CT) slices might become a leeway and rib fractures (RF) may easily overlook in daily practice. Rib unfolding (RU), a computer-assisted software, that promises rapid assessment of the ribs in a two-dimensional plan, was developed to facilitate rib evaluation. We aimed to evaluate the reliability and reproducibility of RU software for RF detection on CT and to determine the accelerating effect to determine any drawback of RU application. METHODS: Fifty-one patients with thoracic trauma formed the sample to be assessed by the observers. The characterization and distribution of RFs on CT images in this sample were recorded independently by the non-observers. Regarding the presence or ab-sence of RF, CT images were assessed blindedly by two radiologists with 5 years (observer-A) and 18 years (observer-B) of experience in thoracic radiology. Each observer assessed the axial CT and RU images on different days under non-observer supervision. RESULTS: A total of 113 RFs were detected in 22 patients. The mean evaluation time for the axial CT images was 146.64 s for ob-server-A and 119.29 s for observer-B. The mean evaluation time for RU images was 66.44 s for observer-A and 32.66 s for observer-B. A statistically significant decrease was observed between the evaluation periods of observer-A and observer-B with RU software compared to the axial CT image assessment (p<0.001). The inter-observer κ value was 0.638, while the intra-observer results showed moderate (κ: 0.441) and good (κ: 0.752) reproducibility comparing the RU and axial CT assessments. Observer-A detected 47.05% non-displaced fractures, 48.93% minimally displaced (≤2 mm) fractures, and 38.77% displaced fractures on RU images (p=0.009). Ob-server-B detected 23.52% non-displaced fractures, 57.44% minimally displaced (≤2 mm) fractures, and 48.97% displaced fractures on RU images (p=0.045). CONCLUSION: RU software accelerates fracture evaluation, while it has drawbacks including low sensitivity in fracture detection, false negativity, and underestimation of displacement.

A probabilistic model for murder weapon identification using stab-marks in human ribs.

The aim of this article is to provide a scientific and statistical basis to identify the murder weapon in stabbing cases from the geometric characteristics of the stab-marks left on human ribs. For this purpose, a quantitative predictive model is developed, based on geometric measurements of the stab-mark and its location along the rib. A general method based on Bayesian inference and probabilities is used for the model development, rather than a deterministic model given its inability in certain occasions to identify the murder weapon. Following the process explained in this article to collect the stab-mark information required, the complete probabilistic model exposed attained a high accuracy in the identification of the murder weapon between two macroscopically identical blades with a microscopic alteration in one of them (more than 90% of correct identification is achieved).

First Rib Stress Fracture in an Adolescent Elite Tennis Player: A Case Report.

CASE: A 16-year-old, right-hand-dominant, Asian male, elite tennis player presented to the clinic with a 1-month history of left shoulder pain. Originally, the pathology was believed to be shoulder-based, but lack of improvement after several weeks of therapy warranted further imaging, which ultimately revealed a nondisplaced fracture of the posterior left first rib. CONCLUSION: Stress injuries are not uncommon in the sport of tennis, but atraumatic rib fractures are rare. Given the increase in youth sports specialization and overtraining and other risk factors such as adolescent age and race, it is important to keep rib stress fracture on the differential.

Micro-CT Imaging and Mechanical Properties of Ovine Ribs.

The use of ovine animal models in the study of injury biomechanics and modeling is increasing, due to their favorable size and other physiological characteristics. Along with this increase, there has also been increased interest in the development of in silico ovine models for computational studies to compliment physical experiments. However, there remains a gap in the literature characterizing the morphological and mechanical characteristics of ovine ribs. The objective of this study therefore is to report anatomical and mechanical properties of the ovine ribs using microtomography (micro-CT) and two types of mechanical testing (quasi-static bending and dynamic tension). Using microtomography, young ovine rib samples obtained from a local abattoir were cut into approximately fourteen 38 mm sections and scanned. From these scans, the cortical bone thickness and cross-sectional area were measured, and the moment of inertia was calculated to enhance the mechanical testing data. Based on a standard least squares statistical model, the cortical bone thickness varied depending on the region of the cross-section and the position along the length of the rib (p < 0.05), whereas the cross-sectional area remained consistent (p > 0.05). Quasi-static three-point bend testing was completed on ovine rib samples, and the resulting force-displacement data was analyzed to obtain the stiffness (44.67 ± 17.65 N/mm), maximum load (170.54 ± 48.28 N) and displacement at maximum load (7.19 ± 2.75 mm), yield load (167.81 ± 48.12 N) and displacement at yield (6.10 ± 2.25 mm), and the failure load (110.90 ± 39.30 N) and displacement at failure (18.43 ± 2.10 mm). The resulting properties were not significantly affected by the rib (p > 0.05), but by the animal they originated from (p < 0.05). For the dynamic testing, samples were cut into coupons and tested in tension with an average strain rate of 18.9 strain/sec. The resulting dynamic testing properties of elastic modulus (5.16 ± 2.03 GPa), failure stress (63.29 ± 14.02 MPa), and failure strain (0.0201 ± 0.0052) did not vary based on loading rate (p > 0.05).

Survival of sharp force trauma in burnt bones: effects of environmental factors.

This study investigates how environmental variables, such as temperature and rainfall, affect previously induced cut marks on burnt bones. This research used non-serrated and serrated blade knives to inflict trauma on Sus scrofa ribs (n = 240). The bones were later burnt and left for 1 month in a taphonomic experimental facility. Qualitative and quantitative examinations were conducted using macroscopic and microscopic techniques to assess specific characteristics of the cut marks. Any changes to the dimension and morphology of the cut marks as well as their level of fragmentation were recorded.This study has led to three important outcomes: (1) identification of pre-existing cut marks is possible in reconstructed burnt bone fragments; (2) cut marks from different types of knife blades showed dissimilar responses to heat and the environment; and (3) specific environmental variables affect burnt bone fragmentation. These results have implications for trauma analysis on burnt remains in forensic anthropology casework.

Variability and specificity of bone cutting mark properties in cases involving stabbing with knives.

Sharp force traumas are frequently encountered in stabbing crime victims. During an examination, the properties of cutting marks in bones are compared with the properties of suspect tools, particularly knives. Therefore, the variation and specificity of knife and cutting mark properties must be known. This article provides the variability and specificity of a set of knife blade and cutting mark properties. Plain and serrated knives are used to create experimental cutting marks in porcine ribs, knife properties are derived from surface acquisitions of the blades and mark properties from Micro-CT data. We consider two conditions, automated stabbing using a motorized stage and manual stabbing. In addition, we study the influence of maceration on marks. For knives, the blade edge angle, blade thickness, and bevel height, and for cutting marks, the shape, the wall angle, the width, and the bevel height are determined and compared. The results show that the relationship between corresponding properties of blades and marks depends on the knife type. For plain knives, the width and wall angle of the marks are dependent on the mark depth and are significantly smaller than the blade properties edge angle and width. For serrated knives, this is not the case. The mark shape only provides slight support for a knife type for marks deeper than the blade bevel height. In conclusion, mark properties are only specific for a particular knife brand and model if the blade properties differ significantly and assuming a specific knife type.

Knife cut marks inflicted by different blade types and the changes induced by heat: a dimensional and morphological study.

Detailed information on skeletal trauma analysis of burned bone is important to ascertain the manner and cause of death in forensic casework. This research used three different knife types, one with a non-serrated blade, one a fine-serrated blade, and one a coarse-serrated blade, to inflict trauma to manually macerated Sus scrofa ribs (n = 240), and these ribs were later exposed to heat. Qualitative and quantitative analyses were conducted using macroscopic and microscopic techniques to assess specific characteristics of the cut marks. Differences in cut mark dimension and morphology of the ribs were investigated. After heat exposure, the cut marks on the rib samples remained recognisable and did not alter considerably. A level of dimensional and morphological preservation was reliant on the cutting action and the features of the knife blade as well as surrounding bone injury. The cut marks inflicted by the non-serrated blade remained recognisable despite exposure to the burning process. However, the cut marks inflicted by the coarse-serrated blade were likely to change significantly when exposed to heat. This study leads to two important results: (1) identification of pre-existing cut marks prior to heat exposure is possible in reconstructed burned bone fragments, and (2) cut marks from different types of knife blades showed dissimilar responses to heat. The outcomes obtained in this study stressed the need to adopt great care with the effects of heat on skeletal trauma analysis.

Controversies in Surgery: Trauma.

As care of the injured patient continues to evolve, new surgical technologies and new resuscitative therapies can change the algorithms that drive trauma care. In particular, the advent of resuscitative endovascular balloon occlusion of the aorta has changed the way trauma surgeons treat patients in extremis. The science of resuscitation continues to evolve, leading to controversy about the optimal administration of fluid and blood products. Laparoscopy has given additional tools to the trauma surgeon to potentially avoid exploratory laparotomy, and rib fracture fixation can be beneficial in the proper patient.

Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation.

BACKGROUND: Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury-respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. METHODS: This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. RESULTS: There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18-0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04-0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61-9.45), physiotherapy OR 2.17 (95% CI 1.52-3.11), ICU doctor OR 6.13 (95% CI 3.94-9.55), ICU liaison OR 55.75 (95% CI 17.48-177.75), pain team OR 8.15 (95% CI 5.52 --12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64-3.94) and regional analgesia OR 8.8 (95% CI 3.39-22.79), incentive spirometry OR 8.3 (95% CI 4.49-15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43-39.2) in the intervention group compared to the control group in the post- period. CONCLUSION: The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. TRIAL REGISTRATION: ANZCTR: ACTRN12618001548224, approved 17/09/2018.

A study into the viability of Synbone® as a proxy for Sus scrofa (domesticus) ribs for use with 7.62 × 51 mm Full Metal Jacket ammunition in ballistic testing.

Forensic reconstructions and ballistic testing requires the use of consistent and repeatable simulants. Synthetic bone has been developed to be mechanically similar to human bone; however, it does not have the same viscoelastic properties. Bone acts as brittle and stiff material and fails instantly under high-energy events such as ballistic impacts. Consequently, bone simulants for use in ballistic testing should show comparable energy deposition to mammalian bones. This study aims to determine if Synbone® flat plates could be a viable proxy for Sus scrofa (domesticus) ribs in ballistic testing with 7.62 × 51 mm Full Metal Jacket ammunition. 5 mm, 6 mm and 12 mm quartered Synbone® plates were embedded into 10% ballistic gelatin and shot using 7.62 mm ammunition. The models were then analysed to compare the Synbone® to a previous Sus Scrofa (domesticus) rib study and focused on energy deposition, the number of fragments within the block, angle of deviation, onset of yaw, the temporary cavity, and the permanent wound channel. No significant difference was seen between the Sus Scrofa (domesticus) and the 5 mm Sybone®. There were significant differences observed between Sus Scrofa (domesticus) ribs and 6 mm Synbone® for the number of fragments, energy deposition and projectile tract diameter, and significant differences seen between Sus scrofa (domesticus) ribs and 12 mm Synbone® for the depth of onset of yaw, energy deposition and projectile tract diameter. This study indicates that the 5 mm Synbone® plate is a suitable proxy for Sus scrofa (domesticus) ribs for use with 7.62 × 51 mm FMJ ammunition in ballistic testing.

Crossbow injuries: A case report with experimental reconstruction study and a systematic review of literature.

In modern times crossbow - a ranged weapon diffused during Middle Ages - is increasing its popularity in recreational hunting and sports; crossbow bolts have a great penetration capacity, despite their low initial velocity. Great concerns emerge when considering that notwithstanding crossbow is a potentially lethal distance weapon, it is easy to obtain without having to undertake any tests on the buyer's mental or physical health. Although rare, crossbow injuries can be challenging for the forensic pathologist due to great similarities with other wounds pattern (gunshots wounds or injury due to sharp force). Especially when the arrow is removed from its original position or the body is decomposed, identification of the weapon can be difficult. According to forensic literature, suicides, homicides and non-lethal injuries by crossbow have been reported up to the present day. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) indications in the identification and selection of studies and reviewed a series of cases of both fatal and non-fatal crossbow injuries, according to the manner of death (homicide, suicide, accidental). The casuistic part of this paper deals with an attempted murder of a 21-year old man: a case of non-lethal crossbow injury of the thorax in which an interdisciplinary approach, involving forensic inspection, ballistic and radiology tests, led to solve the case.

Trunk Injuries in Athletes.

ABSTRACT: Trunk pain is a common cause of performance limitation and time away from sport in athletes. However, atraumatic trunk injuries are underrepresented in medical literature and underrecognized clinically. Delays in diagnosis and initiation of appropriate treatment can increase injury morbidity and return-to-play time. Currently, evidence-based guidelines for diagnosis and treatment of trunk pain in athletes are limited. Thus, we provide an overview of atraumatic sport-related injuries to the thoracic spine (disc herniation, scoliosis, kyphosis), ribcage (bone stress injury, costochondritis, Tietze syndrome, slipping rib syndrome, costovertebral or costotransverse joint dysfunction), and chest and abdominal wall musculature (intercostal, serratus anterior, oblique strains, regional myofascial pain), highlighting sport-specific biomechanical considerations. We aim to increase awareness of these causes of trunk pain among sports medicine providers in an effort to guide diagnostic and treatment recommendations that will ultimately improve overall musculoskeletal health in athletes.

Time to First Onset of Chest Binding-Related Symptoms in Transgender Youth.

BACKGROUND AND OBJECTIVES: Most transgender individuals assigned female at birth use chest binding (ie, wearing a tight garment to flatten chest tissue for the purpose of gender expression), often beginning in adolescence, to explore their gender identity. Although binding is often critical for mental health, negative physical side effects, ranging from chronic pain to rib fractures, are common. Time to first onset of symptoms is unknown. METHODS: A community-engaged, online, cross-sectional survey ("The Binding Health Project") enrolled 1800 assigned female at birth or intersex individuals who had ever used chest binding. Lifetime prevalence of 27 pain, musculoskeletal, neurologic, gastrointestinal, generalized, respiratory, and skin or soft tissue symptoms related to binding was assessed. Nonparametric likelihood estimation methods were used to estimate survival curves. RESULTS: More than one-half (56%) of participants had begun binding by age 21, and 30% had begun by age 18. In 18 of 27 symptoms, the majority of people who go on to experience the event will do so within the first binding-year, but several skin-related and rare but serious outcomes (eg, rib fracture) took longer to occur. Pain presents rapidly but continues to rise in intensity over time, peaking at >5 years of binding. CONCLUSIONS: Although many symptoms emerge quickly, others can take years to develop. Individuals and their clinicians can use this information to make informed decisions on how to structure binding practices and top surgery timing while meeting goals related to gender expression and mental health. Access to puberty blockers may delay initiation of binding, preventing binding-related symptoms in youth.

Biomechanical Response Targets of Adult Human Ribs in Frontal Impacts.

Thorax injuries mainly due to rib fractures have been associated with high rates of morbidity and mortality in motor vehicle crashes. Thoracic biomechanics has been studied extensively, but there are no robust biomechanical response targets for ribs that consider age, sex, body size, and vulnerability factors. The objective of this study was to generate biomechanical targets for human rib response with respect to age, sex, and body size. Two-hundred sixty-one ribs from 171 individuals were dynamically loaded to failure in anterior-posterior bending. Force and displacement at the time of fracture in young adults were greater than in older adults (p < 0.0001). Sex differences were found in those over 40 years old (p < 0.0001). Fracture force from 5th percentile female ribs was lower than 50th and 95th male (p < 0.005). Vulnerable ribs were successfully identified by examining the percentile of both force and displacement at the time of fracture in the proposed samples. The biomechanical targets generated in this study will have useful applications to computational thorax and rib models to aid in injury prevention measures.

Four Columns of the Thorax: Operative Decision-Making in the Setting of Complete Bony Instability.

Thoracic skeletal injury is a common outcome of motor vehicle accidents. Skeletal reconstruction is guided by anatomic and physiologic variables dictated by the injury complex. Here we describe a report of a patient who sustained complex trauma to the thorax leading to complete thoracic dissociation. Clinical and operative decision-making is discussed to inform the reader of a proposed ordered protocol and considerations for operative intervention and reconstruction.