Pectoralis Muscle Index as Predictor of Outcomes in Patients With Severe Blunt Chest Wall Injury.

INTRODUCTION: Sarcopenia has been shown to portend worse outcomes in injured patients; however, little is known about the impact of thoracic muscle wasting on outcomes of patients with chest wall injury. We hypothesized that reduced pectoralis muscle mass is associated with poor outcomes in patients with severe blunt chest wall injury. METHODS: All patients admitted to the intensive care unit between 2014 and 2019 with blunt chest wall injury requiring mechanical ventilation were retrospectively identified. Blunt chest wall injury was defined as the presence of one or more rib fractures as a result of blunt injury mechanism. Exclusion criteria included lack of admission computed tomography imaging, penetrating trauma, <18 y of age, and primary neurologic injury. Thoracic musculature was assessed by measuring pectoralis muscle cross-sectional area (cm2) that was obtained at the fourth thoracic vertebral level using Slice-O-Matic software. The area was then divided by the patient height in meters2 to calculate pectoralis muscle index (PMI) (cm2/m2). Patients were divided into two groups, 1) the lowest gender-specific quartile of PMI and 2) second-fourth gender-specific PMI quartiles for comparative analysis. RESULTS: One hundred fifty-three patients met the inclusion criteria with a median (interquartile range) age 48 y (34-60), body mass index of 30.1 kg/m2 (24.9-34.6), and rib score of 3.0 (2.0-4.0). Seventy-five percent of patients (116/153) were male. Fourteen patients (8%) had prior history of chronic lung disease. Median (IQR) intensive care unit length-of-stay and duration of mechanical ventilation (MV) was 18.0 d (13.0-25.0) and 15.0 d (10.0-21.0), respectively. Seventy-three patients (48%) underwent tracheostomy and nine patients (6%) expired during hospitalization. On multivariate linear regression, reduced pectoralis muscle mass was associated with increased MV duration when adjusting for rib score and injury severity score (ß 5.98, 95% confidence interval 1.28-10.68, P = 0.013). CONCLUSIONS: Reduced pectoralis muscle mass is associated with increased duration of MV in patients with severe blunt chest wall injury. Knowledge of this can help guide future research and risk stratification of critically ill chest wall injury patients.

Blunt chest wall trauma: Rib fractures and associated injuries.

ABSTRACT: Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes.

Rib Season: Temporal Variation in Chest Wall Injuries.

INTRODUCTION: Trauma to the chest wall is one of the most common injuries suffered. Knowing whether there are regular and reproducible changes in frequency or severity of certain injury types may help resource allocation and improve prevention efforts or outcomes; however, no prior studies have evaluated seasonal variation in chest wall injuries (CWIs). We aimed to determine if CWIs vary annually in a consistent distinct temporal variation. METHODS: Using an established traumatic blunt CWI database at a single urban level 1 trauma center, patients with a moderate-to-severe (chest wall Abbreviated Injury Score (AIS) ≥2) CWI were reviewed. A subpopulation of predominant chest wall injury (pCWI) was defined as those with a chest wall AIS ≥3 and no other anatomic region having a higher AIS. Demographics, injury patterns, mechanisms of injury, and AIS were collected in addition to date of injury over a 4-y period. Data were analyzed using descriptive statistics as well as Poisson time-series regression for periodicity. Seasonal comparison of populations was performed using Student's t-tests and Analysis of Variance (ANOVA) with significance assessed at a level of P < 0.05. RESULTS: Over a 4-y period nearly 16,000 patients presented with injury, of which 3042 patients were found to have a blunt CWI. Total CWI patients per year from 2014 to 2017 ranged from 571 to 947. Over this period, August had the highest incidence for patients with any CWI, moderate-to-severe injuries, and pCWI. February had the lowest overall injury incidence as well as lowest moderate-to-severe injury incidence. January had the lowest pCWI incidence. Yearly changes followed a quadratic sinusoid model that predicted a peak between incidence, between June and October, and the low season. A low season was found to be December-April. Comparing low to high seasons of injured patient monthly means revealed significant differences: total injuries (69.94 versus 85.56, P = 0.04), moderate to severe (62.25 versus 78.19, P = 0.06), and pCWI (25.25 versus 34.44, P = 0.01). Analysis of injuries by mechanism revealed a concomitant increase in motorcycle collisions during this period. CONCLUSIONS: There appears to be a significant seasonal variation in the overall incidence of CWI as well as severe pCWI, with a high-volume injury season in summer months (June-October) and low-volume season in winter (December-April). Motorcycle accidents were the major blunt injury mechanism that changed with this seasonality. These findings may help guide resource utilization and injury prevention.

EarLy Exercise in blunt Chest wall Trauma: a feasibility trial (ELECT Trial).

BACKGROUND: The aim was to complete a feasibility study that would test the methods of the main trial, that will investigate whether early thoracic and shoulder girdle exercises reduce chronic pain in patients with blunt chest wall trauma, when compared with normal care. METHODS: A single centre, parallel, feasibility randomised controlled trial was completed at a University Teaching Hospital in Wales between June and September 2019. Adult patients with blunt chest wall trauma, admitted to hospital for greater than 24 hours, with no concurrent, immediately life-threatening injuries, were included. The intervention was a simple physiotherapy programme comprising thoracic and shoulder girdle exercises. Feasibility outcome measures included: primary outcomes: (1) 80% or more of identified eligible patients were approached for potential recruitment to the trial (2) 30% or less of approached, eligible patients dissented to participate in the trial; secondary outcomes: (3) follow-up data for patient secondary outcomes can be collected for 80% or more of patients, (4) there should be no greater than 10% increase in serious adverse events in the intervention group compared with the control group. RESULTS: A total of 19/19 (100%) patients were deemed eligible for the trial and were approached for participation, 5/19 (26%) eligible patients declined to participate in the trial, follow-up data were collected for n=10/14 (71%) patients and there were no serious adverse events reported in either group. CONCLUSIONS: We have demonstrated that a fully powered randomised clinical trial of the EarLy Exercise in blunt Chest wall Trauma Trial is feasible. TRIAL REGISTRATION NUMBER: ISRCTN16197429.

Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score.

BACKGROUND: To improve care for nonintubated blunt chest wall injury patients, our Level I trauma center developed a treatment protocol and a pulmonary evaluation tool named "PIC Protocol" and "PIC Score," emphasizing continual assessment of pain, incentive spirometry, and cough ability. OBJECTIVE: The primary objective was to reduce unplanned intensive care unit admissions for blunt chest wall injury patients using the PIC Protocol and the PIC Score. Additional outcomes included intensive care unit length of stay, ventilator days, length of hospital stay, inhospital mortality, and discharge destination. METHODS: This was a retrospective cohort study comparing outcomes of rib fracture patients treated at our facility 2 years prior to (control group) and 2 years following PIC Protocol use (PIC group). The protocol included admission screening, a power plan order set, the PIC Score patient assessment tool, in-room communication board, and patient education brochure. Outcomes were compared using independent-samples t tests for continuous variables and Pearson's χ2 for categorical variables with α set to p < .05. RESULTS: There were 1,036 patients in the study (control = 501; PIC = 535). Demographics and injury severity were similar between groups. Unanticipated escalations of care for acute pulmonary distress were reduced from 3% (15/501) in the control group to 0.37% (2/535) in the PIC group and were predicted by a preceding fall in the PIC Score of 3 points over the previous 8-hr shift, marking pulmonary decline by an acutely falling PIC Score. CONCLUSIONS: The PIC Protocol and the PIC Score are easy-to-use, cost-effective tools for guiding care of blunt chest wall injury patients.

Epidemiology of injury and illness in 153 Australian international-level rowers over eight international seasons.

AIM: To report the epidemiology of injury and illness in elite rowers over eight seasons (two Olympiads). METHODS: All athletes selected to the Australian Rowing Team between 2009 and 2016 were monitored prospectively under surveillance for injury and illness. The incidence and burden of injury and illness were calculated per 1000 athlete days (ADs). The body area, mechanism and type of all injuries were recorded and followed until the resumption of full training. We used interrupted time series analyses to examine the association between fixed and dynamic ergometer testing on rowers' injury rates. Time lost from illness was also recorded. RESULTS: All 153 rowers selected over eight seasons were observed for 48 611 AD. 270 injuries occurred with an incidence of 4.1-6.4 injuries per 1000 AD. Training days lost totalled 4522 (9.2% AD). The most frequent area injured was the lumbar region (84 cases, 1.7% AD) but the greatest burden was from chest wall injuries (64 cases, 2.6% AD.) Overuse injuries (n=224, 83%) were more frequent than acute injuries (n=42, 15%). The most common activity at the time of injury was on-water rowing training (n=191, 68). Female rowers were at 1.4 times the relative risk of chest wall injuries than male rowers; they had half the relative risk of lumbar injuries of male rowers. The implementation of a dynamic ergometers testing policy (Concept II on sliders) was positively associated with a lower incidence and burden of low back injury compared with fixed ergometers (Concept II). Illness accounted for the greatest number of case presentations (128, 32.2% cases, 1.2% AD). CONCLUSIONS: Chest wall and lumbar injuries caused training time loss. Policy decisions regarding ergometer testing modality were associated with lumbar injury rates. As in many sports, illness burden has been under-recognised in elite Australian rowers.

Prognostic prediction tools and clinician communication: a qualitative study of the effect of the STUMBL tool on clinical practice.

BACKGROUND: In recent years, researchers and clinicians have been developing prognostic prediction tools (PPTs) as a way of identifying patients at risk of deterioration. The use of PPTs in the clinical environment not only impacts the risk of adverse outcomes for patients, but the use of these tools also effect clinical practice. Much attention has been paid to the clinical performance of PPTs. But more insight is needed on how the use of PPTs impacts clinical practice. The objective of this study was to map some of the ways in which PPTs effect clinical practice. The STUMBL (STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients) feasibility trial evaluated the use of a new prognostic prediction tool (PPT) to guide the management blunt chest wall trauma patients in the emergency departments (ED). The trial was undertaken between October 2016 and September 2018 and conducted at four sites in England and Wales. Nested within the feasibility trial was a qualitative study aimed at understanding how ED clinicians experienced and used the PPT. The qualitative methods included a focus group and telephone interviews with 9 ED clinicians. This study focused on participant perceptions of the feasibility and use of the STUMBL tool on clinical practice in the ED. RESULTS: Clinical practice is reshaped as a result of the introduction of the STUMBL PPT into the clinical environment. The PPT enhanced reflexive awareness of prognostic practice; facilitated communication between patients and professionals; helps to guide patient outcomes; and provides a common ground for clinician discussion on prognostication. CONCLUSIONS: The qualitative data collected offered useful insights into the ways in which the tool changes clinical practice. This was a small study of the effect of one kind of PPT on clinical practice. Nevertheless, this study maps areas in which clinical practice is affected by the introduction of a PPT into the clinical environment. More research is needed to better understand these effects, and to understand how these tools become embedded in clinical practice over the longer term.

Blunt trauma related chest wall and pulmonary injuries: An overview.

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

The importance of increased awareness for delirium in elderly patients with rib fractures after blunt chest wall trauma: a retrospective cohort study on risk factors and outcomes.

BACKGROUND: Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma. METHODS: A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months. RESULTS: Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance. CONCLUSION: Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome.

BACKGROUND: Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course. METHODS: We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview. RESULTS: From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49-63] with a median ISS of 21 [IQR 16-29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12-68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred. CONCLUSIONS: In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule. Trial registration number KEK BASEC Nr. 2016-01679.

Using 3-Dimensional Modeling to Customize Titanium Plates for Repair of Chest Wall Trauma.

BACKGROUND: Open reduction and internal fixation of rib fractures is recommended to decrease mortality, shorten the duration of mechanical ventilation, and lower hospital length of stay. Prosthetic titanium plates are frequently used to repair chest wall trauma, and are typically contoured to the patient's anatomy at the time of implant in the operating room. We describe the use of 3-dimensional (3D) digitally corrected rapid prototyping to generate a model of a patient's skeletal anatomy for the purposes of preoperative customization of standard titanium plates for fixation of rib fractures. METHODS: A computed tomography imaging Digital Imaging and Communication in Medicine data set was segmented. Rib fractures were virtually realigned using the mirrored normal anatomy as a guide. The model was printed and used to customize titanium rib fixation plates prior to the procedure. RESULTS: Preoperative shaping of 5 titanium plates using the final 3D model required a total of 5.65 minutes. Surgical fixation of 4 of the patient's 5 fractures was accomplished using the titanium plates that were preoperatively shaped using our 3D model. DISCUSSION: We demonstrate successful use of a digitally rendered model to preoperatively customize standard titanium rib fixation plates. Compared with intraoperative contouring of rib fixation plates, we believe that this approach facilitates repair of complex rib fractures, saving time in the operating room. We believe this technique can improve the accuracy of reductions, increase the ease and efficiency of these procedures, and afford benefits in reducing surgical stress on patients who have already suffered significant trauma.

[Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]. / Epidemiologie, Verletzungsentitäten und Behandlungspraxis der Thoraxwandverletzungen : Aktuelle wissenschaftliche Erkenntnisse und Therapieempfehlungen.

BACKGROUND: Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed. OBJECTIVE: A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options. MATERIAL AND METHODS: Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO­/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed. RESULTS AND DISCUSSION: Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.

[Injuries of the posterior and lateral chest wall-importance of an additional clavicular fracture]. / Verletzungen der posterioren und lateralen Brustwand ­ Bedeutung einer zusätzlichen Klavikulafraktur.

BACKGROUND: Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show a high incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to a loss of function of the shoulder and a pronounced deformation of the chest wall. OBJECTIVE: This article shows the origin and clinical importance of FCI. What importance does a concomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively? MATERIAL AND METHODS: After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in a corpse study and then put into practice. RESULTS AND CONCLUSION: This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the 2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and a marked deformation of the thoracic wall are present. Remaining misalignments are associated with a simultaneous loss of function of the chest wall and shoulder.

[Lesions of the anterior chest wall-significance of additional fractures of the spine]. / Verletzungen der anterioren Brustwand ­ Bedeutung zusätzlicher Frakturen der Wirbelsäule.

BACKGROUND: Fractures of the anterior chest wall are rare among the total number of fractures. They include sternal fractures (SF) and the adjacent cartilaginous structures of the ribs. The accident mechanism can allow conclusions to be drawn about which further accompanying injuries may be present, e.g. rib and spinal fractures. OBJECTIVE: The present work is intended to give an overview of injuries of the anterior chest wall. It includes clinical aspects as well as imaging and popular literature. MATERIAL AND METHODS: Included are injury constellations of the anterolateral chest wall, in particular of the sternum in combination with injuries of the spinal column in the sense of a sternovertebral injury (SVI). Possible treatment strategies were reviewed and the corresponding advantages and disadvantages are presented. RESULTS: In symptomatic fractures of the anterior chest wall, their operative stabilization should be considered in order to restore the stability of the trunk. In addition, rib fractures in direct trauma and spinal injuries in indirect trauma are often included in the treatment. CONCLUSION: In the case of injuries of the thoracic trunk, this must always be regarded as a unit and must therefore be clarified in the context of the clinical examination and diagnostic apparatus. The possible accident mechanism can allow conclusions to be drawn about possible injury patterns, e.g. in the sense of SVIs.

Benign Posttraumatic Pseudopneumoperitoneum.

OBJECTIVE: The objective of our study was to retrospectively determine the anatomic distribution of chest wall ectopic gas resembling pneumoperitoneum (i.e., pseudopneumoperitoneum) and its relationship with trauma mechanisms and clinical outcomes using CT. MATERIALS AND METHODS: Investigators from two separate trauma referral centers screened 492 chest, abdomen, and pelvis CT examinations of patients who had sustained any form of trauma between 2010 and 2015. After excluding 186 patients with recognized causes of ectopic gas, 306 patients (211 men and 95 women; mean age, 44.5 years; range, 6-95 years) remained for analysis by two radiology residents in center 1 and a radiology resident in center 2. Positive cases were reviewed by all investigators, including an experienced fellowship-trained abdominal radiologist. The anatomic location of the pseudopneumoperitoneum, injury severity score, trauma velocity (high speed vs low or unknown speed), trauma mechanism, clinical findings on follow-up, and exploratory laparotomy data were collected for patients with pseudopneumoperitoneum. Two hundred consecutive nontrauma CT examinations from 2015 were selected as control cases by a resident in center 1. The t test and chi-square test were used for determining associations. RESULTS: Pseudopneumoperitoneum was identified in 5.2% of patients, occurring bilaterally adjacent to the lower six costochondral junctions, and was significantly more common with high-velocity trauma than with low-velocity trauma (p = 0.010). None of the patients with pseudopneumoperitoneum had evidence of perforated hollow viscus at surgery (n = 2) or on clinical follow-up (n = 14). No patients had unnecessary surgery due to pseudopneumoperitoneum. CONCLUSION: Pseudopneumoperitoneum is a posttraumatic phenomenon centered near the lower six costochondral junctions. Recognizing these findings may help prevent unnecessary laparotomy in the trauma setting.

Late costal osteomyelitis with a cutaneous fistula after flame burns: a case report.

Chest wall defects are an unusual complication of burn injury, generally seen after high-voltage electrical burns. Here we report the case of a 57-year-old man who developed costal chondritis and osteomyelitis 23 months after flame injury, which covered 50% of the total body surface area. Management included the resection of two ribs and coverage with an omental flap, overlaid by a split-thickness skin graft during the same surgical procedure. Declaration of interest: The authors have no conflict of interest to declare.

Pedicled full-thickness abdominal flap combined with skin grafting for the reconstruction of anterior chest wall defect following major electrical burn.

Successful reconstruction of extensive anterior chest wall defect following major electrical burn represents a very challenging surgery. Herein we report the first case using pedicled full-thickness abdominal flap combined with skin grafting to treat this injury with severe infection and exposure of pericardium and ribs in a Chinese patient. Following the performance of chest debridement to remove necrotic and infected tissues and the injection of broad-spectrum antibiotics to reduce infection, a pedicled full-thickness abdominal flap was used to cover the exposed pericardium and ribs, and skin grafting from the right leg of the patient was done to cover the exposed vital tissues. The patient was followed up for a total of 3·5 years, and satisfactory cosmetic and functional outcomes were obtained without complications. This report provides an effective method for the surgeons who encounter similar cases where reconstruction of extensive anterior chest wall is required.

A Twenty-Three-Year-Old Man with a Chronic Anterior Chest Wall Wound, Eosinophilia, and Elevated IgE-Job's Syndrome.

A 23-year-old man presented with a chronic anterior chest wall wound. Previously he had a split thickness skin graft in the area in where the wound bed had become infected, developing a thick purulent drainage. The infected skin graft was excised. Histologic examination of the failed graft revealed skin with surface ulceration, focal abscess formation, deep penetrating acute and chronic inflammation with numerous eosinophils, and granulomatous changes demonstrating a foreign body-type reaction to fungal hyphae (highlighted by periodic acid-Schiff staining, Figures 1A-E). The patient's past medical history included scoliosis, acute lower back pain, right shoulder degenerative joint disease, atopic dermatitis, lymphadenitis, rhonchi, insomnia, depression, and a long history of recurrent infections, particularly cutaneous staphylococcal and candida albicans infections, often accompanied by a purulent drainage. Review of the patient's laboratory studies revealed chronically elevated alkaline phosphatase, with highly elevated serum IgE (2,922 IU/ml) and eosinophilia (925/µL3) since childhood. Other lab studies were unremarkable, except for episodic elevations of the white blood cell count. The patient's family history was largely unremarkable and the patient's parents and siblings had no histories of unusual infections.

[Chest Wall Injury].

The thoracic wall protects the heart, great vessels, lungs, trachea, and bronchus, which are organs important for maintaining respiration/circulation, against external forces. Therefore, injury of the thoracic wall may necessitate emergency treatment. Such injury primarily consists of rib and sternal fractures. In particular, fractures of 2 or more consecutive ribs with each rib being fractured at 2 or more sites and serial rib fracture with sternal fracture lead to reverse thoracic movement involving contraction on inhalation and expansion on expiration. Such thoracic injury is termed flail chest. Injury of the thoracic wall, such as flail chest, markedly influences the prognosis. Therefore, it is necessary to promptly evaluate the general condition, involving respiratory/circulatory kinetics, confirm the presence or absence of concomitant injury, such as bruises of the lungs/heart, and accurately select therapeutic strategies, including artificial respiration and surgical intervention.