Journal of Trauma and Injury

Case Report

Traumatic arterial thoracic outlet syndrome after multiple rib fractures not including the first rib in Korea: a case report: Seock Yeol Lee; J Trauma Inj. 2024;37(2):158-160. Published online June 5, 2024; DOI: https://doi.org/10.20408/jti.2023.0081

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Abstract PDF: Arterial thoracic outlet syndrome (TOS) resulting from thoracic trauma is an exceedingly rare condition, typically caused by a fracture of the first rib or clavicle. In this report, the author presents a case of traumatic arterial TOS precipitated by multiple left rib fractures, notably excluding the first rib, following a fall from a 2-m high stepladder. The patient was treated successfully with first rib resection via a transaxillary approach, and the postoperative course was uneventful. The literature includes no known reports of traumatic arterial TOS in patients with multiple fractures that spare the first rib, making this the first documented case of its kind. In this instance, the patient sustained fractures to the fourth and fifth ribs. The TOS was likely not a direct result of the multiple rib fractures, which were located some distance from the thoracic outlet. Rather, it is hypothesized that the trauma from these fractures caused a soft tissue injury within the thoracic outlet, which ultimately led to the development of TOS.; Summary

Original Articles

Chest wall injury fracture patterns are associated with different mechanisms of injury: a retrospective review study in the United States: Jennifer M. Brewer, Owen P. Karsmarski, Jeremy Fridling, T. Russell Hill, Chasen J Greig, Sarah Posillico, Carol McGuiness, Erin McLaughlin, Stephanie C. Montgomery, Manuel Moutinho, Ronald Gross, Evert A. Eriksson, Andrew R. Doben; J Trauma Inj. 2024;37(1):48-59. Published online February 23, 2024; DOI: https://doi.org/10.20408/jti.2023.0065

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Abstract PDF: Purpose
Research on rib fracture management has exponentially increased. Predicting fracture patterns based on the mechanism of injury (MOI) and other possible correlations may improve resource allocation and injury prevention strategies. The Chest Injury International Database (CIID) is the largest prospective repository of the operative and nonoperative management of patients with severe chest wall trauma. The purpose of this study was to determine whether the MOI is associated with the resulting rib fracture patterns. We hypothesized that specific MOIs would be associated with distinct rib fracture patterns.
Methods
The CIID was queried to analyze fracture patterns based on the MOI. Patients were stratified by MOI: falls, motor vehicle collisions (MVCs), motorcycle collisions (MCCs), automobile-pedestrian collisions, and bicycle collisions. Fracture locations, associated injuries, and patient-specific variables were recorded. Heat maps were created to display the fracture incidence by rib location.
Results
The study cohort consisted of 1,121 patients with a median RibScore of 2 (0–3) and 9,353 fractures. The average age was 57±20 years, and 64% of patients were male. By MOI, the number of patients and fractures were as follows: falls (474 patients, 3,360 fractures), MVCs (353 patients, 3,268 fractures), MCCs (165 patients, 1,505 fractures), automobile-pedestrian collisions (70 patients, 713 fractures), and bicycle collisions (59 patients, 507 fractures). The most commonly injured rib was the sixth rib, and the most common fracture location was lateral. Statistically significant differences in the location and patterns of fractures were identified comparing each MOI, except for MCCs versus bicycle collisions.
Conclusions
Different mechanisms of injury result in distinct rib fracture patterns. These different patterns should be considered in the workup and management of patients with thoracic injuries. Given these significant differences, future studies should account for both fracture location and the MOI to better define what populations benefit from surgical versus nonoperative management.; Summary

Clinical characteristics of patients with the hardware failure after surgical stabilization of rib fractures in Korea: a case series: Na Hyeon Lee, Sun Hyun Kim, Seon Hee Kim, Dong Yeon Ryu, Sang Bong Lee, Chan Ik Park, Hohyun Kim, Gil Hwan Kim, Youngwoong Kim, Hyun Min Cho; J Trauma Inj. 2023;36(3):196-205. Published online September 5, 2023; DOI: https://doi.org/10.20408/jti.2023.0026

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Abstract PDF

Purpose
Surgical stabilization of rib fractures (SSRF) is widely used in patients with flail chests, and several studies have reported the efficacy of SSRF even in multiple rib fractures. However, few reports have discussed the hardware failure (HF) of implanted plates. We aimed to evaluate the clinical characteristics of patients with HF after SSRF and further investigate the related factors.
Methods
We retrospectively reviewed the electronic medical records of patients who underwent SSRF for multiple rib fractures at a level I trauma center in Korea between January 2014 and January 2021. We defined HF as the unintentional loosening of screws, dislocation, or breakage of the implanted plates. The baseline characteristics, surgical outcomes, and types of HF were assessed.
Results
During the study period, 728 patients underwent SSRF, of whom 80 (10.9%) were diagnosed with HF. The mean age of HF patients was 56.5±13.6 years, and 66 (82.5%) were men. There were 59 cases (73.8%) of screw loosening, 21 (26.3%) of plate breakage, 17 (21.3%) of screw migration, and seven (8.8%) of plate dislocation. Nine patients (11.3%) experienced wound infection, and 35 patients (43.8%) experienced chronic pain. A total of 21 patients (26.3%) underwent reoperation for plate removal. The patients in the reoperation group were significantly younger, had fewer fractures and plates, underwent costal fixation, and had a longer follow-up. There were no significant differences in subjective chest symptoms or lung capacity.
Conclusions
HF after SSRF occurred in 10.9% of the cases, and screw loosening was the most common. Further longitudinal studies are needed to identify risk factors for SSRF failure.

Summary

Citations

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Komplikationen nach operativer vs. konservativer Versorgung des schweren Thoraxtraumas
Lars Becker, Marcel Dudda, Christof Schreyer
Die Unfallchirurgie.2024; 127(3): 204. CrossRef

Outcomes after rib fractures: more complex than a single number: Kristin P. Colling, Tyler Goettl, Melissa L. Harry; J Trauma Inj. 2022;35(4):268-276. Published online August 5, 2022; DOI: https://doi.org/10.20408/jti.2021.0096

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Abstract PDF: Purpose
Rib fractures are common injuries that can lead to morbidity and mortality.
Methods
Data on all patients with rib fractures admitted to a single trauma center between January 1, 2008 and December 31, 2018 were reviewed.
Results
A total of 1,671 admissions for rib fracture were examined. Patients’ median age was 57 years, the median Injury Severity Score (ISS) was 14, and the median number of fractured ribs was three. The in-hospital mortality rate was 4%. Age, the number of rib fractures, and Charlson Comorbidity Index scores were poor predictors of mortality, while the ISS was a slightly better predictor, with area under the receiver operating characteristic curve values of 0.60, 0.55, 0.58, and 0.74, respectively. Multivariate regression showed that age, ISS, and Charlson Comorbidity Index score, but not the number of rib fractures, were associated with significantly elevated adjusted odds ratios for mortality (1.03, 1.14, and 1.28, respectively).
Conclusions
Age, ISS, and comorbidities were independently associated with the risk of mortality; however, they were not accurate predictors of death. The factors associated with rib fracture mortality are complex and cannot be explained by a single variable. Interventions to improve outcomes must be multifaceted.; Summary

National utilization of rib fracture fixation in the geriatric population in the United States: Jennifer M. Brewer, Leah Aakjar, Kelsey Sullivan, Vijay Jayaraman, Manuel Moutinho, Elan Jeremitsky, Andrew R. Doben; J Trauma Inj. 2022;35(3):173-180. Published online May 31, 2022; DOI: https://doi.org/10.20408/jti.2021.0076

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Abstract PDF

Purpose
The use of surgical stabilization of rib fractures (SSRF) has steadily increased over the past decade. Recent literature suggests that a larger population may benefit from SSRF, and that the geriatric population—as the highest-risk population—may receive the greatest improvement from these interventions. We sought to determine the overall utilization of SSRF in the United States.
Methods
The National Trauma Database was analyzed between 2016 and 2017. The inclusion criteria were all patients ≥65 years old with rib fractures. We further stratified these patients according to age (65–79 vs. ≥80 years old), the presence of coding for flail chest, three or more rib fractures, and intervention (surgical vs. nonoperative management). The main outcomes were surgical interventions, mortality, pneumonia, length of stay, intensive care unit length of stay, ventilator use, and tracheostomy.
Results
Overall, 93,638 patients were identified. SSRF was performed in 992 patients. Patients who underwent SSRF had improved mortality in the 65 to 79 age group, regardless of the number of ribs fractured. We identified 92,637 patients in the age group of 65 to 79 years old who did not undergo SSRF. This represents an additional 20,000 patients annually who may benefit from SSRF.
Conclusions
By conservative standards and the well-established Eastern Association for the Surgery of Trauma clinical practice guidelines, SSRF is underutilized. Our data suggest that SSRF may be very beneficial for the geriatric population, specifically those aged 65 to 79 years with any rib fractures. We hypothesize that roughly 20,000 additional cases will meet the inclusion criteria for SSRF each year. It is therefore imperative that we train acute care surgeons in this skill set.

Summary

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Incidence of adult rib fracture injuries and changing hospitalization practice patterns: a 10-year analysis
Sergio M. Navarro, Rafat H. Solaiman, Jilun Zhang, Ilitch Diaz-Gutierrez, Christopher Tignanelli, James V. Harmon
European Journal of Trauma and Emergency Surgery.2024; 50(4): 1719. CrossRef

Prognosis of Pulmonary Function in Patients with Multiple Rib Fractures: Hee Beom Park, Sung Youl Hyun, Jin Joo Kim, Yeon Sik Jang; J Trauma Inj. 2017;30(4):179-185. Published online December 30, 2017; DOI: https://doi.org/10.20408/jti.2017.30.4.179

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Abstract PDF

Purpose

Rib fracture is the most common complication of blunt thoracic trauma. We investigated the effect of rib fracture on pulmonary function in the conservatively treated patients.

Methods

From January 2000 to February 2017, we reviewed the records of 72 patients with rib fracture and pulmonary function tests were performed. According to the number of rib fractures, patients were classified into two groups: less than six fractured ribs (group A) and more than six fractured ribs (group B). The groups were compared concerning demographics, underlying diseases, associated thoracic injuries, surgery, mechanical ventilator times, days spent in the intensive care unit and pulmonary function test.

Results

There were no statistically significant differences in the demographic data between the two groups. Mean hospitalization was 13.5 days in group A and 27.0 days in group B (p<0.001). There was no statistically significant difference between the two groups in the pulmonary function test.

Conclusions

We conclude that pulmonary function is restored by conservative treatment in patients with rib fractures even if the number of rib fractures increases. In patients with multiple rib fractures, studies comparing open rib fixation and conservative treatment of long term pulmonary function are required.

Summary

Citations

Citations to this article as recorded by

Prevalence of chronic post-thoracotomy pain in patients with traumatic multiple rib fractures in South Korea: a cross-sectional study
Kun Hyung Kim, Chan Kyu Lee, Seon Hee Kim, Youngwoong Kim, Jung Eun Kim, Yu Kyung Shin, Junepill Seok, Hyun Min Cho
Scientific Reports.2021;[Epub] CrossRef
Yoga—An Alternative Form of Therapy in Patients with Blunt Chest Trauma: A Randomized Controlled Trial
Mallikarjun Gunjiganvi, Purva Mathur, Minu Kumari, Karan Madan, Atin Kumar, Rajesh Sagar, Sushma Sagar, Amit Gupta, Biplab Mishra, Altaf Hussain Mir, Mohini Meti, Subodh Kumar
World Journal of Surgery.2021; 45(7): 2015. CrossRef
Medicolegal Evaluation of Long-Term Respiratory Functions in Patients Injured Due to Traffic Accidents
Esra Dugral, Aydin Sanli, İsmail Ozgur Can
Cureus.2021;[Epub] CrossRef

Case Reports

Delayed Diaphragmatic Injury with Massive Hemothorax Due to Lower Rib Fracture: Woo Shik Kim, Joong Suck Kim; J Trauma Inj. 2015;28(2):79-82. Published online June 30, 2015; DOI: https://doi.org/10.20408/jti.2015.28.2.79

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Abstract PDF

Simple rib fracture is one of most common injury after blunt thoracic trauma found in approximately 7% to 40% of cases. Delayed traumatic diaphragmatic injury with massive hemothorax after rib fracture is rare but a potentially life-threatening condition. We present a rare case of a 79-year-old male with delayed diaphragmatic injury with massive hemothorax due to fracture of the lower ribs. Under thoracoscopy, hemothorax was evacuated, diaphragmatic rupture was identified and repaired, and the lower ribs were fixed with metal plate (s). Although simple lower rib fractures may be the only clinical finding, close observation and monitoring are required because of the possibility of diaphragmatic and/or intraabdominal organ injury.

Summary

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Fatal Delayed Hemothorax after Simple Rib Fracture
Minju Lee, Sang Bum Lim, Hye Jeong Kim, Sohyung Park, Hongil Ha
Korean Journal of Legal Medicine.2017; 41(2): 56. CrossRef

Delayed Aortic Injury Caused by a Posterior Rib Fracture: A Case Report: Chang Wan Kim, Seon Uoo Choi, Seon Hee Kim, Jae Hun Kim, Jung Joo Hwang, Hyun Min Cho, Seung Hwan Song, Jeong Su Cho; J Trauma Inj. 2015;28(1):31-33. Published online March 30, 2015; DOI: https://doi.org/10.20408/jti.2015.28.1.31

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Abstract PDF: Traumatic aortic injury is well recognized as a primary cause of instantaneous death in victims of thoracic blunt trauma presenting with an aortic rupture or dissection, particularly after a deceleration injury. However, a direct aortic injury caused by a fractured rib segment after blunt thoracic trauma is extremely rare. We report the case of a 43-year-old male patient who experienced an aortic injury caused by the sharp edge of a fractured rib after multiple rib fractures due to blunt thoracic trauma.; Summary

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