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1.
Ann R Coll Surg Engl ; 102(1): e4-e6, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31509003

RESUMO

Thoracoabdominal hernia following blunt trauma is extremely rare. Abdominal viscera are more likely to herniate into the thorax if there is traumatic diaphragmatic rupture. We report the case of a patient presenting with a traumatic thoracoabdominal hernia containing part of the right lobe of the liver and the hepatic flexure of the colon. The hernia migrated cranially, to protrude through a seventh intercostal defect despite the diaphragm remaining fully intact. The need for early multispecialty (thoracic and hepatobiliary) surgical repair is highlighted, with improvements in surgical outcome for a complex trauma case by using a novel chest-wall reconstruction technique.


Assuntos
Hérnia Diafragmática Traumática/cirurgia , Herniorrafia/métodos , Ferimentos não Penetrantes/cirurgia , Acidentes por Quedas , Hérnia Diafragmática Traumática/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas das Costelas/etiologia , Fraturas das Costelas/cirurgia , Telas Cirúrgicas , Técnicas de Sutura , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ferimentos não Penetrantes/etiologia
2.
J Trauma Acute Care Surg ; 88(2): 249-257, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804414

RESUMO

BACKGROUND: The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. METHODS: Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. RESULTS: One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). CONCLUSION: In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. LEVEL OF EVIDENCE: Therapeutic, level II.


Assuntos
Fixação de Fratura/métodos , Fraturas Múltiplas/cirurgia , Hemotórax/epidemiologia , Dor Pós-Operatória/diagnóstico , Fraturas das Costelas/cirurgia , Adolescente , Adulto , Idoso , Feminino , Fraturas Múltiplas/complicações , Fraturas Múltiplas/diagnóstico , Hemotórax/etiologia , Hemotórax/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapia , Estudos Prospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Índices de Gravidade do Trauma , Resultado do Tratamento , Adulto Jovem
3.
J Surg Res ; 246: 476-481, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31668607

RESUMO

INTRODUCTION: Rib fractures are a major problem in trauma patients, and the associated pain is not well understood. Measuring total pain experience, duration, and intensity could facilitate comparisons of treatments. This study was intended to evaluate the feasibility of quantifying pain over the course of an admission and identify factors associated with increased pain experience in adults with rib fractures. METHODS: Patients admitted to a level I trauma center with rib fractures between 2015 and 2017 were included. Maximum pain score (verbal or nonverbal) was captured for each hospital day. Total pain was defined as the sum of the area under the curve (AUC) of the max pain scores plotted against time. A general linear model was used to determine demographic, injury, and clinical predictors of the pain AUC. RESULTS: We identified 3713 patients. Increased pain experienced (greater AUC) was associated with age group 40-59 y compared with 18-39 y (B = 6.1, P = 0.002); Injury Severity Score 9-14 (B = 11.5, P < 0.001) and ≥16 (B = 36.9, P < 0.0001); patients with flail chest versus multiple rib fractures (B = 17.1, P < 0.001); and patients who underwent rib fixation (B = 20.7, P = 0.004). Decreased pain experience was observed for male gender (B = -3.7, P = 0.032) and blunt mechanism of injury (B = -13.7, P < 0.0001). CONCLUSIONS: This study demonstrates the feasibility of measuring patients' total pain experience over the duration of their admission. Pain is a subjective but relevant measure of patients' experience. Our study identifies a number of predictive factors, some expected and some unexpected. Increased overall experience pain following fixation may be the result of severe pain before intervention.


Assuntos
Tórax Fundido/diagnóstico , Fixação Interna de Fraturas/efeitos adversos , Dor Musculoesquelética/diagnóstico , Medição da Dor/métodos , Fraturas das Costelas/complicações , Adolescente , Adulto , Fatores Etários , Estudos de Viabilidade , Feminino , Tórax Fundido/etiologia , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor Musculoesquelética/etiologia , Estudos Retrospectivos , Fraturas das Costelas/diagnóstico , Fraturas das Costelas/cirurgia , Índice de Gravidade de Doença , Fatores Sexuais , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , Adulto Jovem
4.
BMC Surg ; 19(1): 123, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31462238

RESUMO

BACKGROUND: There are few reports regarding a lung or diaphragm trapped by a fractured rib. This study aimed to describe the clinical presentations, diagnosis, and management of these intrathoracic pathologies. METHODS: We retrospectively reviewed the database at our institute for patients with rib fractures who underwent thoracoscope-assisted surgical stabilization of rib fracture (SSRF). We analyzed the demographic data, mechanism of trauma, presentations, operative findings, and subsequent management strategies. RESULTS: A total of 38 consecutive patients who underwent SSRF were analyzed. Three patients had a trapped lung and one had a trapped diaphragm. Abnormal radiographic findings were observed in 50% of cases. The median waiting time for surgery was 25 days. Surgery was indicated for intractable dynamic pain following conservative treatment. A definitive diagnosis was made during thoracoscopic exploration. Thoracoscopic repair and resection were used for trapped lungs and thoracoscopic release for a trapped diaphragm. We subsequently performed SSRF for unhealed rib fractures. CONCLUSION: As per our analysis, the incidence of a trapped lung or diaphragm was 10.5%. If a patient presents with persistent intractable dynamic pain, thoracoscopic exploration with concurrent SSRF may be a feasible and effective treatment option.


Assuntos
Diafragma/patologia , Pulmão/patologia , Fraturas das Costelas/cirurgia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fraturas das Costelas/complicações , Resultado do Tratamento , Adulto Jovem
5.
J Surg Res ; 244: 205-211, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31299437

RESUMO

BACKGROUND: Rib fractures are a common consequence of traumatic injury and can result in significant debilitation. Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments. However, commercial rib fixation has only recently become clinically prevalent, and we hypothesize that significant variability exists in its utilization based on injury pattern and trauma center. METHODS: The Pennsylvania Trauma System Foundation database was queried for all multiple rib fracture patients occurring statewide in 2016 and 2017. Demographics including the presence of flail and the occurrence of rib fixation was abstracted. Outcomes were compared between the fixation group and all other rib fracture patients. Deidentified treating trauma center was used to elicit center-level disparities. RESULTS: During the study period, there were 12,910 patients with multiple rib fractures, of which 135 had flail segments. 57 patients underwent rib fixation, and 10 of which had a flail segment. Compared with the nonoperative cohort, those who underwent rib fixation were younger (52.5 versus 61.5, P = 0.0009), similar in gender (68% versus 62% male, P = 0.373), and race (80% versus 86% White, P = 0.239). The rib fixation group had higher Injury Severity Scores (19.4 versus 15.4 P = 0.0011). The timing of rib fixation was most frequent within 1 wk of injury but extended out through 3 wk; the occurrence of pulmonary complications had a similar distribution. The frequency of rib fixation rates within trauma centers was not associated with rib fracture patient volume, and 37.1% of multiple rib fracture patients were cared for at centers that did not perform rib fixation. CONCLUSIONS: Rib fixation is infrequently used at trauma centers in Pennsylvania. It is used more frequently in nonflail injuries, and its use may be associated with the occurrence of pulmonary complications. Significant center-level variation exists in rib fixation rates among multiple fractured patients. A significant number of patients are cared for at centers that do not perform rib fixation. Further research is needed to illicit better-defined indications for operative fixation, and opportunities exist to further the penetrance of this practice to all trauma centers.


Assuntos
Tórax Fundido/cirurgia , Fixação de Fratura/estatística & dados numéricos , Fraturas Múltiplas/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Fraturas das Costelas/cirurgia , Adulto , Idoso , Feminino , Tórax Fundido/etiologia , Fraturas Múltiplas/complicações , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Centros de Traumatologia/estatística & dados numéricos
6.
Chirurgia (Bucur) ; 114(3): 352-358, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31264573

RESUMO

Background: No consensus exists about the indication for surgical rib fixation in patients with rib fractures. Comparison between studies is difficult since a classification system is lacking for rib fractures. We introduced the first classification system for rib fractures, analogue to the Muller AO classification system and tested the classification with an interobserver agreement study. Methods: The classification is build up by four characters: the first one describes the rib number, the second character describes the location of the fracture in cranial-caudal fashion, the third character describes the fracture type and the fourth character described the subtype of the fracture. An interobserver agreement study was performed with the new classification. Results: Twenty CT scans of patients with rib fractures were analyzed. A total of 197 unilateral and bilateral rib fractures were scored by four reviewers. The interobserver agreement was substantial [Fleiss of 0.62 (95% CI 0.59 0.65)]. Conclusion: This is the first classification for rib fractures worldwide. The interobserver agreement of the classification was substantial. This classification is the first step in identifying patients who would benefit from surgical rib fixation.


Assuntos
Fraturas das Costelas/classificação , Fraturas das Costelas/diagnóstico por imagem , Humanos , Variações Dependentes do Observador , Reprodutibilidade dos Testes , Fraturas das Costelas/cirurgia , Tomografia Computadorizada por Raios X
7.
J Cardiothorac Surg ; 14(1): 105, 2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31186011

RESUMO

BACKGROUND: Rib fractures account for a fairly high proportion of chest injuries, ranging from 55 to 80%. The most common mechanisms of injury include: traffic accident, extrusion and falls from significant heights. Besides, the surgical treatment of multiple rib fractures has been accepted by more and more medical professionals. We reported 5 clinical cases of patients with multiple rib fractures undergoing open reduction and internal fixation using 3D printing technology. CASE PRESENTATION: Retrospective analysis of 5 clinical cases of multiple rib fractures from January 2017 to August 2018 in our hospital. A preoperative CT thin slice scan was used to reconstruct the 3D model according to the scanning results, and 3D printing technology was adopted to prepare the rib model. Preoperative reconstruction of the rib's normal shape and lock plate for the shaped ribs was created according to reconstructed model. For multiple fractures especially patients with severely deformed rib shape, it is suggested to intraoperative shape directly to the metal bone plate fixed on the ribs on both ends of the fracture line, in order to establish a basic support frame. The other various fracture section can be fixed on the lock plate respectively. Postoperative chest radiographs of the 5 patients showed that the internal fixations were in good and natural shape. The thoracic contour was well formed and symmetrically with the contralateral side. CONCLUSION: Making the rib model and the pre-shaped titanium alloy rib locking plate using 3D printing technology, provided a more minimally invasive and precisely individualized treatment for some rib fracture operations.


Assuntos
Placas Ósseas , Fixação Interna de Fraturas/métodos , Fraturas Múltiplas/cirurgia , Redução Aberta/métodos , Impressão Tridimensional , Fraturas das Costelas/cirurgia , Acidentes por Quedas , Acidentes de Trânsito , Feminino , Fixação Interna de Fraturas/instrumentação , Fraturas Múltiplas/diagnóstico por imagem , Fraturas Múltiplas/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Redução Aberta/instrumentação , Período Pós-Operatório , Radiografia , Estudos Retrospectivos , Fraturas das Costelas/diagnóstico por imagem , Fraturas das Costelas/etiologia , Tomografia Computadorizada por Raios X
9.
Am Surg ; 85(5): 474-478, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-31126359

RESUMO

Thoracic analgesia plays a key role in management and outcomes of rib fractures and can generally be broken down into oral or parenteral medication administration and regional analgesia. Surgical stabilization of rib fractures (SSRF) may be an underused resource in the management of rib fractures. This study describes recent trends in rib fracture management and outcomes. National Trauma Data Bank datasets from 2008 to 2014 were reviewed. Patients with three or more rib fractures were identified, and the frequencies of epidural analgesia (EA), other regional analgesia, and SSRF were analyzed. Those older than 65 years were more likely to be admitted to the ICU but had shorter ICU length of stay, lower intubation, and need for tracheostomy rates. In addition, those older than 65 years had about 2.5 times higher mortality (6.3% vs 2.6%, P < 0.001). EA was used in only 3 per cent of the population and more commonly in the older than 65 years group (3.7% vs 2.8%, P < 0.001). Regardless of age, SSRF was more commonly performed when compared with the placement of EA (5.8% vs 3%). This difference was even greater in the younger than 65 years group, where 7 per cent underwent SSRF. Utilization of EA remains low nationally. SSRF should be considered not only for chest wall stabilization but also as an analgesic modality in selected patients. A more complete accounting of analgesic care in rib fracture patients is needed to allow a more detailed analysis of analgesia for rib fracture-related pain to elucidate optimal treatment.


Assuntos
Fixação de Fratura , Fraturas das Costelas/cirurgia , Adulto , Idoso , Analgesia Epidural , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fraturas das Costelas/etiologia , Resultado do Tratamento
10.
J Cardiothorac Surg ; 14(1): 83, 2019 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-31036030

RESUMO

BACKGROUND: To investigate the application of 3D printing technology combined with percutaneous Minimally Invasive Plate Oseoynthesis (MIPO) and thoracoscopic techniques in the treatment of long comminuted rib fractures. CASE PRESENTATION: One case of multiple rib fractures with abnormal respiratory disease (including rib 3 and 4 of long comminuted fractures) due to a fall injury was selected. The 3D model of comminuted rib fracture was reconstructed and printed according to the thin-layer CT scan results. After the fracture model was restored to the normal rib anatomy, the metal plate was accurately shaped according to the 3D rib shape. CONCLUSIONS: 3D printing technology combined with MIPO technology under thoracoscopy in the minimally invasive treatment of long-range comminuted rib fractures, greatly reduced the time and improved the accuracy of intraoperative fixation, reduced the difficulty of surgery, patient injury, and perfectly reconstructed the chest wall. Application of the 3D printing technique to make the rib model and pre-mold the metal plate combined the thoracoscopic MIPO technology provides less invasive and accurate individualized treatment for complex rib fractures.


Assuntos
Fixação Interna de Fraturas/métodos , Fraturas Cominutivas/cirurgia , Impressão Tridimensional , Fraturas das Costelas/cirurgia , Toracoscopia , Acidentes por Quedas , Placas Ósseas , Fraturas Cominutivas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Procedimentos Cirúrgicos Reconstrutivos , Fraturas das Costelas/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento
11.
J Trauma Acute Care Surg ; 87(3): 599-605, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31045734

RESUMO

BACKGROUND: Rib fracture is a common injury and can be associated with complications and a high mortality rate. There has been growing interest in surgical rib fixation as a treatment for rib fracture. However, results from previous studies are conflicting, and conclusive results regarding the efficacy of surgical rib fixation for rib fracture are lacking. This study aimed to investigate if surgical rib fixation improves prognosis in patients with traumatic rib fractures. METHODS: Using the Japan Trauma Data Bank, a nationwide trauma registry, we identified patients 18 years or older with rib fracture between 2004 and 2015. The primary outcome was in-hospital mortality. Logistic regression analysis was used to estimate a propensity score to predict reception of surgical rib fixation. We used a 1:4 propensity score matching analysis to compare patients who underwent surgical rib fixation with those who did not. RESULTS: Overall, 236,698 patients were registered in the database, and 37,571 were eligible for propensity score matching analysis. This analysis included 147 patients who underwent surgical rib fixation and 588 as controls. The in-hospital mortality rate was significantly lower in patients who underwent surgical rib fixation than in those who did not (4.8% vs. 16.2%, respectively; absolute difference: -11.4%; 95% confidence interval: -14.8% to -8.0%). CONCLUSION: This study showed that surgical fixation may reduce in-hospital mortality in patients with rib fracture. Surgical rib fixation may offer a better modality for the management of selected patients with rib fracture. LEVEL OF EVIDENCE: Therapeutic, level III.


Assuntos
Fixação Interna de Fraturas/mortalidade , Fraturas das Costelas/cirurgia , Escala Resumida de Ferimentos , Estudos de Casos e Controles , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Necrotério , Pontuação de Propensão , Sistema de Registros , Estudos Retrospectivos , Fraturas das Costelas/mortalidade
12.
Medicine (Baltimore) ; 98(20): e15683, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096506

RESUMO

RATIONALE: Rib fractures are common among patients with blunt chest wall trauma and often represent life-altering injuries. PATIENT CONCERNS: A 31-year-old woman presented with right chest trauma, with pain and bleeding as a result of a traffic accident 1 hour previously. DIAGNOSES: Chest computed tomography showed open chest trauma, multiple rib fractures, flail chest, hemopneumothorax, and lung contusion on the right side. INTERVENTIONS: We decided to perform debridement via emergency, thoracoscopic exploration to remove blood and contaminants from the chest cavity. Thereafter, the third to seventh fractured ribs were fixed and reconstructed using the matrix rib internal fixation system, followed by suturing of the incision according to the original anatomical level. OUTCOMES: The patient was discharged 15 days after surgery, and recovered well with satisfactory results. LESSONS: We believe that initial chest reconstruction with internal fixation in the first stage following thorough debridement may be suitable for treating flail chest, and could save the patient's life in the early stages. However, the decision to perform the first-stage operation for the open contaminated wound should be carefully considered.


Assuntos
Acidentes de Trânsito , Fixação Interna de Fraturas/métodos , Fixadores Internos , Fraturas das Costelas/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Desbridamento/métodos , Feminino , Tórax Fundido/terapia , Humanos , Fraturas das Costelas/terapia , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/terapia
13.
Eur J Trauma Emerg Surg ; 45(4): 623-630, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30989244

RESUMO

PURPOSE: The usefulness of chest wall stabilization after blunt chest wall trauma with unstable rib fractures has recently been intensely discussed. Thereby, the surgical approach seems to influence outcome, mortality and the long-term complication rate including chronic chest pain, thoracic deformity and quality of life. Here, we present the outcome after surgical stabilization of unstable rib fractures using intramedullary splints and plate osteosynthesis. METHODS: n = 50 patients were enrolled in this trial. Surgical stabilization was performed using intramedullary splints and/or plate osteosynthesis. Video-assisted thoracoscopy was performed in all patients for the inspection of the thoracic cavity and to exactly localize the fractured ribs. The pre- and postoperative pain course was documented using the visual analog scale. RESULTS: A total of n = 50 patients (10 females, mean age 63 years) were included into the analysis. All patients presented with traumatic serial rib fractures with a mean of 3 fractured ribs (range 2-8 ribs) and an unstable thorax wall. Rib osteosynthesis was performed using intramedullary splints (n = 17 patients), locking plates (n = 17 patients), or a combined use of both procedures (n = 16 patients). Mean operating time was 80 min (31-161 min). No major complications were seen intra- and postoperatively. Mean hospital stay was 8 ± 2 days (2-21 days). In all patients, excellent chest wall stability was achieved. Moreover, a significant reduction of pain was observed (2.6 ± 0.3 postoperatively vs. 8 ± 1.15 preoperatively, p < 0.0001) already during the hospital stay. CONCLUSIONS: Rib osteosynthesis is a safe and effective treatment option for patients with unstable rib fractures after blunt chest wall trauma. It leads to a significant reduction of the trauma-associated pain caused by the rib fractures and supports a quick recovery of the patients.


Assuntos
Fixação Interna de Fraturas/métodos , Dor Musculoesquelética/prevenção & controle , Fraturas das Costelas/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos , Tomografia Computadorizada por Raios X
14.
PLoS One ; 14(4): e0216170, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31022284

RESUMO

INTRODUCTION: The timing of surgical stabilization of rib fractures remains controversial. We hypothesized that early surgical stabilization (within 3 days of injury) can improve clinical outcome in patients with severe rib fractures and respiratory failure. The aim of this study was to analyze the impact of early surgical stabilization of rib fractures on the perioperative results, clinical outcomes, and medical costs of patients with severe rib fractures and respiratory failure. METHODS: This was a retrospective comparative study based on a prospectively collected database at a single institute. Patients with severe rib fractures and respiratory failure who underwent surgical stabilization were classified into early (within 3 days of injury) and late (more than 3 days after injury) groups. Outcome measures included operation time, duration of mechanical ventilation, intensive care unit stay, hospital stay, complication rate, mortality rate, and medical cost. RESULTS: A total of 33 patients were enrolled (16 and 17 in the early and late groups, respectively). The demographics, trauma mechanism, associated injuries, and severity of trauma were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (median 36 vs. 90 hours, p = 0.03), intensive care unit stay (median 123 vs. 230 hours, p = 0.004), and hospital stay (median 12 vs. 18 days, p = 0.005); and lower National Health Insurance costs (median 6,617 vs. 10,017 US dollars, p = 0.031). The early group tended to have lower rates of morbidity and mortality, but the difference was not statistically significant. CONCLUSION: Early surgical stabilization of rib fractures in selected patients may significantly shorten their duration of mechanical ventilation, and intensive care unit and hospital stays, while incurring less medical costs.


Assuntos
Insuficiência Respiratória/complicações , Fraturas das Costelas/complicações , Fraturas das Costelas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Pessoa de Meia-Idade , Duração da Cirurgia , Insuficiência Respiratória/economia , Estudos Retrospectivos , Fraturas das Costelas/economia , Adulto Jovem
15.
BMJ Case Rep ; 12(2)2019 Feb 09.
Artigo em Inglês | MEDLINE | ID: mdl-30739088

RESUMO

An elderly female with multiple comorbidities was involved in a pedestrian vehicle accident and sustained blunt chest trauma, arriving at a resource-poor hospital in rural South Africa. She had multiple bilateral rib fractures with a unilateral flail segment that caused her to develop respiratory failure. She was intubated and sent to the intensive care unit (ICU) for ventilation. She developed hospital and ventilator acquired pneumonia. She subsequently had hypoxic arrests on two separate occasions and two failed extubations. Despite inadequate access to provisions, this patient was taken to theatre for rib fracture fixation as an attempt to improve her lung function and get her off the ventilator. She was extubated two days after the procedure and discharged from ICU 4 days thereafter. On her follow-up, she reported that she had returned to normal daily living and tasks.


Assuntos
Tórax Fundido/cirurgia , Fixação Interna de Fraturas , Respiração Artificial/métodos , Insuficiência Respiratória/terapia , Fraturas das Costelas/cirurgia , Acidentes de Trânsito , Extubação , Feminino , Tórax Fundido/complicações , Recursos em Saúde , Humanos , Intubação Intratraqueal , Pessoa de Meia-Idade , Pedestres , Insuficiência Respiratória/etiologia , Fraturas das Costelas/complicações , África do Sul
16.
Asian Cardiovasc Thorac Ann ; 27(2): 105-109, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30646757

RESUMO

BACKGROUND: Rupture of the costal margin is uncommon. Whilst most often seen after major trauma, we describe its occurrence in patients with no direct chest trauma. METHODS: A search was performed in our thoracic surgery database for all patients with rupture of the costal margin. Patients were excluded if the injury was a result of trauma. Data were collected on sex, age, body mass index, profession, past medical history, smoking status, presenting complaint, mechanism of injury, and management. RESULTS: There were 9 patients with rupture of the costal margin that was caused in all cases by a severe coughing fit. All patients were male and the mean age was 62.5 years (range 47-76 years). Chronic obstructive pulmonary disease was present in 6 cases. Presentations included a palpable defect (5 cases), cough (9 cases), and chest pain (6 cases). On radiological examination, all patients had widening of the rib space, 4 had associated rib fractures, and 5 had lung herniation. Time from injury to presentation was 12 months (range 1-24 months). All patients underwent surgery and were followed-up for 59 months (range 8-129 months). Two patients suffered major complications in the immediate postoperative period. CONCLUSIONS: Rupture of the costal margin, in the absence of direct trauma, is characterized by pain, a palpable defect, and lung herniation. It is associated with widening of the rib space and rib fractures, and can be treated surgically with success but not without significant risks.


Assuntos
Tosse/complicações , Fraturas Espontâneas/etiologia , Hérnia/etiologia , Caixa Torácica , Fraturas das Costelas/etiologia , Idoso , Dor no Peito/etiologia , Bases de Dados Factuais , Fraturas Espontâneas/diagnóstico por imagem , Fraturas Espontâneas/cirurgia , Hérnia/diagnóstico por imagem , Hérnia/terapia , Herniorrafia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Caixa Torácica/diagnóstico por imagem , Caixa Torácica/cirurgia , Fraturas das Costelas/diagnóstico por imagem , Fraturas das Costelas/cirurgia , Ruptura Espontânea , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
17.
Clin Orthop Relat Res ; 477(1): 193-205, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30247228

RESUMO

BACKGROUND: Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial. QUESTIONS/PURPOSES: The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores. METHODS: We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed. RESULTS: The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27-0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07-0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00-0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09-0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05-0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20-0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470). CONCLUSIONS: This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life. LEVEL OF EVIDENCE: Level I, therapeutic study.


Assuntos
Fixação de Fratura/efeitos adversos , Fraturas Múltiplas/cirurgia , Complicações Pós-Operatórias/etiologia , Fraturas das Costelas/cirurgia , Cuidados Críticos/métodos , Fixação de Fratura/mortalidade , Consolidação da Fratura , Fraturas Múltiplas/complicações , Fraturas Múltiplas/mortalidade , Humanos , Tempo de Internação , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Respiração Artificial , Fraturas das Costelas/complicações , Fraturas das Costelas/mortalidade , Medição de Risco , Fatores de Risco , Resultado do Tratamento
18.
Injury ; 50(1): 119-124, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30442372

RESUMO

INTRODUCTION: Multiple rib fractures have been shown to reduce quality of life both in the short and long term. Treatment of rib fractures with operative fixation reduces ventilator requirements, intensive care unit stay, and pulmonary complications in flail chest patients but has not been shown to improve quality of life in comparative studies to date. We therefore wanted to analyse a large cohort of multiple fractured rib trauma patients to see if rib fixation improved their quality of life. METHODS: Retrospective review (January 2012 - April 2015) of prospectively collected data on 1482 consecutive major trauma patients admitted to The Alfred Hospital with rib fractures. The main outcome measures were Quality of Life over 24 months post injury assessed using the Glasgow Outcome Scale Extended (GOSErate) and Short Form (SF12) health assessment forms and a pain questionnaire. RESULTS: 67 (4.5%) patients underwent rib fixation and were older, with a higher incidence of flail chest injury, and higher AIS and ISS scores than the remainder of the cohort. Rib fixation provided no benefit in pain, SF-12 or GOSErate scores over 24 months post injury. CONCLUSIONS: This study has not been able to demonstrate any quality of life benefit of rib fixation over 24 months post injury in patients with major trauma.


Assuntos
Tórax Fundido/psicologia , Tempo de Internação/estatística & dados numéricos , Dor/psicologia , Qualidade de Vida/psicologia , Fraturas das Costelas/psicologia , Traumatismos Torácicos/psicologia , Adulto , Idoso , Analgesia/estatística & dados numéricos , Austrália , Feminino , Tórax Fundido/fisiopatologia , Tórax Fundido/cirurgia , Fixação Interna de Fraturas , Consolidação da Fratura/fisiologia , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Respiração Artificial , Estudos Retrospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/fisiopatologia , Fraturas das Costelas/cirurgia , Inquéritos e Questionários , Traumatismos Torácicos/complicações , Traumatismos Torácicos/fisiopatologia , Traumatismos Torácicos/cirurgia , Fatores de Tempo , Adulto Jovem
19.
Rev Bras Anestesiol ; 69(1): 91-94, 2019.
Artigo em Português | MEDLINE | ID: mdl-30392675

RESUMO

INTRODUCTION: The erector spinae plane block is a newly described and effective interfascial plane block for thoracic and abdominal surgery. This case report describes a patient with multiple rib fractures undergoing ultrasound-guided continuous erector spinae plane block for analgesia. CASE REPORT: A 37-year-old male patient was taken for surgical fixation of multiple rib fractures. At the end of the surgery, using ultrasound-guided longitudinal parasagittal orientation 3cm to the lateral aspect of the T5 spinous process and an in-plane technique, 20mL 0.25% bupivacaine was administered between the erector spinae muscle and the transverse process, and a catheter was then inserted in the same plane. Before the end of surgery, 1g paracetamol and 50mg dexketoprofen were administered. Postoperative analgesia was applied with patient controlled analgesia method using 0.25% bupivacaine via the catheter. The patient's Visual Analogue Scale score at rest in the first 24h was 0. The patient was monitored for 3 days with Visual Analogue Scale<4, and the catheter was removed on postoperative day 4. No opioid requirement other than paracetamol and dexketoprofen occurred during this time. No postoperative complications were recorded. DISCUSSION: The erector spinae plane block is an alternative to paravertebral, intercostal, epidural or other regional techniques. It may be a suitable technique in anesthesia and algology practice due to providing analgesia in the postoperative period with a catheter in the erector spinae plane.


Assuntos
Analgesia/métodos , Fraturas Múltiplas/cirurgia , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Fraturas das Costelas/cirurgia , Adulto , Humanos , Masculino , Músculos Paraespinais
20.
Injury ; 50(1): 101-108, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30482587

RESUMO

AIM: To estimate and compare lung volumes from pre- and post-operative computed tomography (CT) images and correlate findings with post-operative lung function tests in trauma patients with flail chest undergoing stabilizing surgery. PATIENTS AND METHODS: Pre- and post-operative CT images of the thorax were used to estimate lung volumes in 37 patients who had undergone rib plate fixation at least 6 months before inclusion for flail chest due to blunt thoracic trauma. Computed tomography lung volumes were estimated from airway distal to each lung hilum by outlining air-filled lung tissue either manually in images of 5 mm slice thickness or automatically in images of 0.6 mm slice thickness. Demographics, pain, range of motion in the thorax, breathing movements and Forced Vital Capacity (FVC) were assessed. Total Lung Capacity (TLC) measurements were also made in a subgroup of patients (n = 17) who had not been intubated at time of the initial CT. Post-operative CT lung volumes were correlated to FVC and TLC. RESULTS: Patients with a median age of 62 (19-90) years, a median Injury Severity Score (ISS) of 20 (9-54), and a median New Injury Severity Score (NISS) of 27 (17-66) were enrolled in the study. Median follow-up time was 3.9 (0.5-5.6) years. Two patients complained of pain at rest and when breathing. Pre-operative CT lung volumes were significantly different (p < 0.0001) from post-operative CT lung volumes, 3.51 l (1.50-6.05) vs. 5.59 l (2.18-7.78), respectively. At follow-up, median FVC was 3.76 l (1.48-5.84) and median TLC was 6.93 l (4.21-8.42). Post-operative CT lung volumes correlated highly with both FVC [rs = 0.75 (95% CI 0.57‒0.87, p < 0.0001)] and TLC [rs = 0.90 (95% CI 0.73‒0.96, p < 0.0001)]. The operated thoracic side showed decreased breathing movements. Range of motion in the lower thorax showed a low correlation with FVC [rs = 0.48 (95% CI 0.19‒0.70, p = 0.002)] and a high correlation with TLC [rs = 0.80 (95% CI 0.51‒0.92, p < 0.0001)]. CONCLUSIONS: Post-operative CT-lung volume estimates improve compared to pre-operative values in trauma patients undergoing stabilizing surgery for flail chest, and can be used as a marker for lung function when deciding which patient with chest wall injuries can benefit from surgery.


Assuntos
Tomografia Computadorizada de Feixe Cônico , Tórax Fundido/fisiopatologia , Volume Expiratório Forçado/fisiologia , Fraturas das Costelas/cirurgia , Traumatismos Torácicos/fisiopatologia , Capacidade Pulmonar Total/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Tórax Fundido/cirurgia , Seguimentos , Fixação Interna de Fraturas , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Mecânica Respiratória , Traumatismos Torácicos/complicações , Traumatismos Torácicos/cirurgia , Resultado do Tratamento , Adulto Jovem
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