Bilateral Rib Research Articles

Prediction of outcomes in chest trauma patients using chest trauma scoring system: A prospective observational study.

Background and Aims:Prognostication of chest trauma patients by scoring systems is of vital importance to predict morbidity and mortality. We aimed to predict outcomes in chest trauma patients using chest trauma scoring system (CTS) in Indian patients.Methods:This was a prospective observational study done in a trauma care centre at a tertiary care teaching public hospital. CTS was calculated by scores of age, severity of pulmonary contusion, number of rib fractures and presence of bilateral rib fractures. Final CTS ranges from 2 to 12. We evaluated CTS to predict outcome that is mortality as primary objective and development of complications like pneumonia and need for ventilator support as secondary objective in Indian population.Results:Data were collected from 30 patients and they were divided into two groups, CTS <5 (15) and CTS ≥5 (15). High CTS ≥5 was statistically significantly associated with high incidence of pneumonia (P = 0.046), increased requirement of mechanical ventilation (P = 0.025) and mortality (P = 0.035) in chest trauma. Area under the ROC for mortality shows that the test is acceptable (0.75) and at CTS score 5.5 maximum sensitivity is 87.5% and specificity is 68%.Conclusion:This study concludes that a CTS ≥5 is associated with poor outcomes. This scoring system may be used to identify patients at risk of complications and institute early intensive focussed care.

An Interobserver Agreement Study with a New Classification for Rib Fractures.

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.

Surgical rib fixation: Does increase case volume lead to improved outcomes?

Background: Surgical rib fixation in displaced rib fracture has been associated with positive patient outcomes in the literature. There is no data in the literature detailing the volume related outcomes in centres that offer surgical rib fixation in these patients.Methods: A retrospective review was conducted on surgical rib fixation cases performed from 2014 to 2018, with the early phase (EP) consisting of cases performed in the 2014-2017 period and the recent phase (RP) consisting of cases performed in 2018 to date. Variables for comparison included, indication for intervention, pain outcomes, and length of stay (LOS).Results: The five-year period yielded 37 cases. In the EP, 17 cases were performed, compared to 20 cases in the RP. The chest AIS scores were >3 for all cases with an average ISS of 21 in the EP compared to 19 in the RP. All patients underwent surgical rib fixation within 96 hours of admission. Pain was the predominant indication for intervention in the EP (65%, n = 11) compared to the RP where deformity and respiratory support (55%, n = 11) were the chief indicators. Subjective pain improvement was in favour of RP by 2.5 days. The average LOS was 546 hours days in the EP group, and 391 hours in the RP group. More anatomically difficult posterior and bilateral rib fixation cases were carried out in the RP group. Follow-up rate between the EP and RP were 75% vs 85% respectively with no hardware or pulmonary complications.Conclusion: Preliminary data analysis from the authors' institution suggests surgical rib fixation can be conducted with minimal complication. Increased case volume might improve outcomes related to subjective pain scores, length of stay, and complexity of surgical technique.

Odd Aspects of Hemochromatosis, a Widespread Disease

Odd Aspects of Hemochromatosis, a Widespread Disease Abstract. This case series is written to investigate the odd aspects of hemochromatosis, a frequently encountered disease in our latitudes (and even a widespread disease in Ireland). One patient presented with bilateral digital artery occlusion and another one with bilateral rib fractures. Quite often, hemochromatosis comes with a surprise.

Simultaneous Bilateral Microtia Reconstruction Using Single-Expanded Postauricular Flap Without Skin Grafting.

Auricular reconstruction in patients with congenital microtia permits craniofacial balance and harmony, especially in patients with bilateral microtia. However, published techniques usually require skin grafting, which can lead to color mismatch and visible scarring. Some surgeons prefer to reconstruct the auricle of each side separately, which prolongs the complete cycle of surgery and increases suffering of the patient. In this study, we introduce a modified technique using single expanded flaps without skin grafting to achieve simultaneous bilateral auricular reconstruction. Between January 2012 and January 2017, a total of 54 patients with bilateral microtia underwent auricular reconstruction with expanded single flaps. Simultaneous bilateral auricular reconstruction was accomplished through 3 surgical stages. In the first stage, bilateral postauricular skin was expanded using 2 kidney-shaped tissue expanders. In the second stage, bilateral rib cartilage was harvested using minimal incisions, allowing 2 modified 3-layer frameworks to be fabricated. Each framework was then inserted into the pocket through the same incision with subsequent closure using 2-layer suture. In the third stage, the reconstructed ears were further trimmed, if necessary, and the lobules and tragus reconstructed. All the patients were followed up for 6 to 24 months. During follow-up, patients were satisfied with surgical outcome in terms of size, shape, location, detailing, and symmetry of the bilateral ears in more than 50 cases. Only 4 demonstrated postoperative complications. No skin necrosis, exposure of cartilage, or infection was observed or postoperative chest deformities. Simultaneous bilateral auricular reconstruction using single expanded flaps combined with a modified 3-layer cartilage framework is an effective technique for patients with bilateral microtia.

MDS/Secondary AML Associated with Type I Gaucher Disease

[Introduction]Gaucher disease is one of lysosomal diseases, and it is an extremely rare disease characterized by anemia, thrombocytopenia, splenomegaly, multiple pathologic fractures and so on. It has been reported that Gaucher disease often merges with blood malignant diseases. However, there are no reports of myelodysplastic syndrome/secondary AML (MDS/s-AML) concomitant with type I Gaucher disease. Furthermore, we carried out parallel treatment of enzyme replacement therapy for type I Gaucher disease and azacitidine therapy for MDS/s-AML.[Case]A 69-year-old woman admitted to our hospital because of multiple abnormal fractures. She was diagnosed of MDS (refractory anemia) in 2011 by a previous doctor. As anemia and thrombocytopenia gradually worsened on May 2017, she was transferred to our department on August 8, 2017. At the time of visit, typical pneumonia determined with chest X-P and CT has been observed and high value of CRP (11.0mg/dl) was existed. Pneumonia improved promptly with antibiotic therapy, however, high value of CRP continued, and bilateral chest and right back pain got worse. We carried out plain CT and MRI (DWIBS). In results, splenomegaly, bilateral rib fracture and osteolytic changes in the right iliac bone were observed. Although bone marrow biopsy was performed twice without significant findings, Gaucher disease has been suspected and glucocerebrosidase activity was measured. As expected, a significant decrease of the enzyme activity was observed. Finally, a diagnosis of type I Gaucher disease was made. We started enzyme replacement therapy for glucocerebrosidase. Therefore, reduction of splenomegaly and independency of transfusion were induced by several replacement therapy. Further, multiple bone fracture lesions have improved. Further, juvenile leukocyte including myeloblasts in peripheral blood (PB) also decreased. Therefore, we suspected that the replacement therapy improved not only several symptoms of Gaucher disease, but several hematological findings of MDS. However, WT1-mRNA in the peripheral blood has gradually increased. Moreover, progression of MDS/s-AML was observed after two months. We selected azacitidine therapy in considering of performance state of the patient. In addition to enzyme supplementation therapy, azacitidine therapy was performed in parallel. After several treatment of azacitidine, blasts in PB were decreased significantly with independency of transfusion.[Conclusion]We deeply indicate that the combination of enzyme replacement therapy and azacitidine therapy is useful for cases of MDS/s-AML associated with Gaucher disease. There is a possibility that the reduction of the enzyme is involved not only in Gaucher disease but in the ontogeny of blood diseases such as MDS. The effects of enzyme replacement therapy of Gaucher's disease for MDS/s-AML should be discussed. DisclosuresNo relevant conflicts of interest to declare.

Case 1: Multiple Fractures at Birth

A female neonate is born at 33 weeks of gestation via urgent cesarean section secondary to severe preeclampsia with hemolysis, elevated liver enzymes, and low platelet count syndrome. On examination, her weight is 1.18 kg (1st percentile), length 39.5 cm (5th percentile), and head circumference 27 cm (1st percentile). She is well appearing with white sclera, normal tone, and appropriate reflexes. She has scaphocephaly, a soft skull, proptosis with shallow orbits, low-set ears, swelling of the right wrist, a widened fontanelle, prominent knobs along her ribs, and frontal bossing. Laboratory results are notable for normal serum calcium, low serum phosphorous, elevated parathyroid hormone, low 25-hydroxyvitamin D, elevated 1,25-dihydroxyvitamin D, normal urine electrolytes, and negative findings on New York State newborn screening (Table 1). Radiographs obtained shortly after birth show bony demineralization, metaphyseal flaring particularly at the wrists and knees, metaphyseal fractures, and bilateral rib fractures (Fig). The maternal history is significant for 5 previous miscarriages, nonadherence with taking prenatal vitamins, a diet containing minimal dairy products, and modest dress for religious observance, with limited skin exposure to natural sunlight. The parents are consanguineous. View this table: Table 1. Initial Laboratory Testing Figure. Frontal view of the chest demonstrates bone demineralization, flaring of the metaphyses at the wrist (arrows), and metaphyseal fractures (arrowheads). Bilateral rib fractures are noted (asterisk). Knee films demonstrated …

Двухэтапный остеосинтез двусторонних множественных многофрагментарных переломов ребер у больных с выраженной дыхательной недостаточностью

Двухэтапный остеосинтез двусторонних множественных многофрагментарных переломов ребер у больных с выраженной дыхательной недостаточностью

Bioarchaeological evidence of care provided to a physically disabled individual from Pachacamac, Peru

This paper presents a bioarchaeology of care case study based on the skeletonized remains of an elderly female with a congenital condition that compromised both mobility and independence in undertaking certain basic tasks, and which generated requirements for long-term care in the form of both direct support and accommodation. The remains show evidence of bilateral cervical ribs, severe osteoarthritic destruction in the right shoulder joint, and a healed skull trepanation. The remains were recovered from a cemetery dating to the initial part of the Late Intermediate Period at the archaeological site of Pachacamac, Peru. The subject has been identified as belonging to an Ychsma ayllu. This paper applies the bioarchaeology of care methodology in considering the implications of care provision within the Ychsma socialcontext, and suggests that caregiving may have been a relatively common practice in this complex society. This case study is a good example of how the application of social theory through the bioarchaeology of care approach can enrich bioarchaeological studies.

Bilateral distal ureteral transection in the setting of blunt trauma

A 69-year-old obese man was involved in a high-speed head-on motor vehicle collision. He was tachycardic and normotensive on arrival. He subsequently developed hemodynamic instability requiring blood transfusion. On examination...

A study of clinical profile of hypospadias cases at a medical college hospital of South Gujarat, India

Background: Hypospadias is a common congenital anomaly in which the anterior urethra is incompletely developed and does not extend to the tip of the glans penis. The present study was aimed to study clinical profile of hypospadias cases at a medical college hospital of southern Gujarat.Methods: This prospective study was conducted at a tertiary care hospital of South Gujarat, India including 32 patients of hypospadias. Data collected for each patient included age, sex, demography, and major symptoms, duration of symptoms and relevant past and treatment history.Results: Out of 32, 9 (28%) patients are between 4 years to 6 years of age and mean age of presentation of patients of hypospadias is 7.55 years. Twenty seven (84%) patients of Hypospadias were associated with prepucial hood, 17 (53%) patients of Hypospadias were associated with meatal stenosis, 6 (19%) patients of hypospadiasis were associated with severe chordee and 2 (6%) patients associated with narrow urethral plates.Conclusions: T Most cases of hypospadias were presented at age 9 years and below. Most common type of hypospadias was coronal and distal penile followed by penoscrotal type. Hypospadias was associated with prepucial hood (84%), meatal stenosis (53%), Chordee (19%) and narrow urethral plates (6%) out of total cases. Hypospadias was associated with undescended testis, bilateral retractile testis, cervical rib, mental retardation and microcephaly with mental retardation, squint and bifid tongue.

Surgical Treatment of Spinal Deformities in Young Paraplegic Children with Intraspinal Tumors

Bilateral vertical expandable prosthetic titanium rib (VEPTR) treatment using rib-to-pelvis constructs without touching the spine is a safe surgical technique to correct scoliosis while still allowing further MRI or neurosurgical interventions. In this retrospective cohort study, 4 paraplegic children with spinal deformity after intraspinal tumors and 4 children with neuromuscular diseases were compared. VEPTR treatment was able to considerably reduce the main scoliotic curve in both patient groups (41 vs. 40%). However, the tumor group constantly showed more severe curve progression over time and less favorable pelvic obliquity control. In conclusion, bilateral VEPTR can be expected to be less satisfying in children with tumors.

Bilateral Multiple Rib Fractures and Hump-Like Shadows on Chest Roentgenogram

A 58-year-old female with rheumatoid arthritis (RA), osteoarthritis of the bilateral knees, thoracic vertebral compression fractures, steroid-induced osteoporosis, and immune thrombocytopenia (ITP) presented with bilateral side chest pain. She had been treated with prednisolone for RA and ITP for 10 years. On her current visit, a chest roentgenogram revealed bilateral rib fractures and hump-like shadows. A chest computed tomography scan revealed multiple rib fractures accompanied by hematoma that pressed fractured ribs into the bilateral lungs. Regarding abnormal shadows on the chest roentgenogram, blood discharge from the fractured ribs formed the hematoma, causing the hump-like shadows

Outcomes after rib fractures in geriatric blunt trauma patients

IntroductionRib fractures after blunt trauma contribute substantially to morbidity and mortality in the elderly. MethodsRetrospective review of 255 patients ≥65 years old at a level 2 trauma center over 6 years, who sustained blunt trauma resulting in rib fractures. Outcomes measured include mortality, hospital length of stay(LOS), intensive care unit(ICU) admission, ICU LOS, need for MV, and MV days. ResultsThere were 24 deaths (9.4%), of which 7 were early (<24 h). 130 patients (51%) were admitted to ICU, and 49 (19.2%) required MV. Mean ICU and MV days were 5.9 and 6.3, respectively. ICU admission was predicted by a base deficit <-2.0, ISS>15, bilateral rib fractures, pneumothorax or hemothorax on chest x-ray (All p < 0.001), as well as hypotension, GCS<15, and 1st rib fractures (All p < 0.05). Mortality was predicted by a base deficit < -5.0, GCS score of 3(Both p < 0.001), as well as hypotension, ISS≥25, RTS <7.0, bilateral pneumothoraces, 1st rib fractures, and >5 rib fractures (All p < 0.05). ConclusionRib fractures in elderly blunt trauma patients are associated with significant mortality and morbidity, but outcomes can be predicted to improve care.

Prevalence of Cervical Rib in Western Nepal

Introduction: Cervical rib is usually asymptomatic. It is usually detected incidentally when radiograph is done for other reasons. Cervical rib has been found to be symptomatic in about 10% of cases. This study was carried out to evaluate the prevalence of cervical ribs and percentage of symptomatic patients among Nepalese population in western development region.Methods: Total of 3600 chest and cervical spine radiographs of patients done for various purposes in radiology department were evaluated for presence of cervical rib. Study was carried out during September 2013 to February 2014. Patients of 16 years and above were included in the study. History was also noted to see if patients with cervical rib were symptomatic. SPSS version 17 software was used in data analysis.Results: Prevalence of cervical ribs was found to be 1.1 % with higher rate in females. Among 39 patients with cervical rib; bilateral cervical ribs was seen in 46.2 %. Cervical rib was more common on right side, seen in 38.5 % of cases. It was seen on left side in 15.4 % of cases. Cervical rib was found to be symptomatic in 10.25 % of patients. Among them; two patients presented with pain in arm and other two presented with hard swelling in right cervical region.Conclusion: The cervical rib is common in our population. Patients with pain, numbness in arm and swelling in cervical region should be evaluated for cervical rib.

The modified Ravitch approach for the management of severe anterior flail chest with bilateral sternochondral dislocations: a case report

The management of flail chest continues to evolve as scientific evidence and surgical experience accumulates. Flail chest injuries that span the sternum present a rare and complicated injury pattern that can be challenging to manage both medically and surgically. Our patient is a 69-year-old involved in a high-speed motor vehicle crash with respiratory failure secondary to an anterior flail chest. Tomographic examination confirmed a sternal fracture with bilateral sternochondral dislocations and multiple rib fractures. The rib fractures created a lateral flail segment which extended towards the right side. An open Pectus exposure with a right anterolateral extension (modified Ravitch approach) and osteosynthesis plates accomplished stabilization of the chest wall, and contributed to weaning from mechanical ventilation.

Diagnostic challenges of prolonged post-treatment clearance of Plasmodium nucleic acids in a pre-transplant autosplenectomized patient with sickle cell disease

BackgroundAutosplenectomy, as a result of sickle cell disease, is an important risk factor for severe malaria. While molecular methods are helpful in providing rapid and accurate infection detection and species identification, the effect of hyposplenism on result interpretation during the course of infection should be carefully considered.Case presentationA 32-year old autosplenectomized Nigerian male with severe sickle cell disease was referred to the National Institutes of Health for allogenic hematopoietic stem cell transplant. Despite testing negative for malaria by both smear and PCR 2 weeks after arrival in the USA, the patient developed fever and diffuse bilateral lower rib cage and upper abdominal pain 2 weeks later and subsequently tested positive for Plasmodium falciparum. Parasitaemia was tracked over time by microscopy and nucleic acid tests to evaluate the therapeutic response in the setting of hyposplenism. The patient showed prompt resolution of patent infection by microscopy but remained positive by molecular methods for > 30 days after treatment initiation.ConclusionWhile molecular testing can provide sensitive Plasmodium nucleic acid detection, the persistence of Plasmodium nucleic acids following adequate treatment in functionally asplenic patients can lead to a diagnostic dilemma. In such patients, clinical response and peripheral blood smears should guide patient management following treatment. Nonetheless, in pre-transplant patients at high-risk for pre-existing Plasmodium infections, highly sensitive molecular assays can be useful to rule out infection prior to transplantation.

A pathology not be overlooked in blunt chest trauma: Analysis of 181 patients with bilateral pneumothorax.

Bilateral pneumothorax (BPTx) can become tension PTx and a cause of mortality, especially in severe multi-trauma patients. The purpose of this study was to analyze the incidence, morbidity, mortality, and associated factors of BPTx in multi-trauma patients in order to highlight the importance of the management of these cases, as well as complications, morbidity, and mortality. The data of 181 patients with BPTx, from a total of 3782 trauma patients, were reviewed retrospectively. The details recorded were age, gender, mechanism of trauma, radiological findings, co-existing thoracic and extra-thoracic injuries, incidence of intubation, mortality, and injury severity score (ISS). The association between laterality of rib fracture, hemothorax, subcutaneous emphysema, and BPTx, and the effect of age and gender on these injuries, mortality, and ISS were analyzed. The patient group included 144 males, and the mean age was 36.07±15.77 years. The primary cause of trauma was a motor vehicle accident, seen in 67 (37.0%) patients. Bilateral rib fractures were detected in 75 (41.4%) patients. Hemothorax accompanied PTx in 41 (22.6%) patients bilaterally. The laterality of the rib fracture and hemothorax demonstrated a significant difference in the patient group over 60 years of age (p=0.017, p=0.005). Co-existing bilateral thoracic injuries were detected more often in this group. Twelve (17.6%) patients with only blunt chest trauma and 56 (82.4%) patients with multi-trauma were intubated. The difference between the 2 groups was not significant (p=0.532). The overall mortality rate was 18.2%. A comparison of ISS and mortality between the groups revealed no significant difference (p=0.22). The incidence of BPTx after multi-trauma is approximately 5%, so it must be taken into consideration, especially in severe multi-trauma patients, to reduce mortality. Older age and the number of rib fractures were determined to be risk factors for morbidity and mortality in trauma with BPTx.

Augmentation of the Nasal Dorsum Using the Multistrip Autologous Cartilage Technique.

Nasal augmentation is a popular modern technique requested by many Asian people. There are two kinds of autologous cartilage used to augment the nose at present: carved as a monobloc or diced into pieces. Each approach has its pros and cons. The authors performed their surgical technique on a group of 28 patients. Twenty of these patients had undergone rhinoplasties performed before referral to our hospital; eight of these patients had undergone a primary rhinoplasty. Bilateral conchal, nasal septum, or rib cartilage was harvested; deep temporal fascia or abdominal muscle fascia to be prepared for packing stripped cartilage was also removed at this time. The cartilage was placed on a plastic cutting board and cut into strips with a transverse section of 1 × 1 mm. Then, these strips were packed and covered by fascia to form the grafts. The median follow-up was 23 months (range, 12 to 48 months). Twenty-two patients were satisfied with their augmented noses. Through examinations, biopsies, and magnetic resonance imaging scans, less resorption was observed with the multistrip autologous cartilage technique. Junctional stepoffs, excessive prominence, and slanting grafts occurred in three patients, two of whom had revisions. Using multistrip autologous cartilage grafts is an easier method to perform and could be another alternative technique for augmentative and reconstructive rhinoplasties.

A confounding rib variation: bilateral symmetric aberrant posterior rib articulations and bridgings

Although mild bone angulation with osseous enlargement often suggests fractures with callus formation, in some cases the diagnosis is synchondrosis. We present a rare variation of the chest wall in a 15-year-old male with a history of lymphoma. Bilateral multi-level posterior rib enlargements revealing mild 18F-fluorodeoxyglucose uptake were detected via positron-emission tomography/computed tomography. The variations were identified as healing fractures, although the more accurate diagnosis was determined to be multi-level posterior rib synchondroses with consecutive bridgings. Although variant bone anatomies are commonly seen in radiological practice, such multiple symmetrical posterior rib synchondroses associated with consecutive bridgings and articulations have not been clearly demonstrated before. Awareness of such a rare combination of a well-known variation is crucial for radiologists to exclude malignancies, possibility of fracture and suspicion of child abuse.