Bilateral Rib Research Articles

Fibrotendinous band causing neurogenic Thoracic Outlet Syndrome in adolescent with bilateral cervical ribs

Thoracic Outlet Syndrome (TOS) describes a variety of symptoms caused by the compression of the neurovascular structures in the cervicoaxillary region as they leave the thorax toward the upper limbs. Causes of TOS are vascular and neurogenic, with neurogenic symptoms being the most common presentation (95% of patients). Symptoms related to neurogenic TOS include intrinsic hand muscle and thenar region atrophy and weakness, as well as medial hand and forearm numbness, which are all suggestive of lower trunk involvement. This condition is very rare in the pediatric population. We are reporting a case of true neurogenic TOS caused by a fibrotendinous band in an adolescent with bilateral cervical ribs who was submitted for surgical treatment at the right side.

Thoracic Injuries in earthquake-related versus non-earthquake-related trauma patients: differentiation via Multi-detector Computed Tomography

PURPOSE:Massive earthquakes are harmful to humankind. This study of a historical cohort aimed to investigate the difference between earthquake-related crush thoracic traumas and thoracic traumas unrelated to earthquakes using a multi-detector Computed Tomography (CT).METHODS:We retrospectively compared an earthquake-exposed cohort of 215 thoracic trauma crush victims of the Sichuan earthquake to a cohort of 215 non-earthquake-related thoracic trauma patients, focusing on the lesions and coexisting injuries to the thoracic cage and the pulmonary parenchyma and pleura using a multi-detector CT.RESULTS:The incidence of rib fracture was elevated in the earthquake-exposed cohort (143 vs. 66 patients in the non-earthquake-exposed cohort, Risk Ratio (RR) = 2.2; p<0.001). Among these patients, those with more than 3 fractured ribs (106/143 vs. 41/66 patients, RR = 1.2; p<0.05) or flail chest (45/143 vs. 11/66 patients, RR = 1.9; p<0.05) were more frequently seen in the earthquake cohort. Earthquake-related crush injuries more frequently resulted in bilateral rib fractures (66/143 vs. 18/66 patients, RR = 1.7; p<0.01). Additionally, the incidence of non-rib fracture was higher in the earthquake cohort (85 vs. 60 patients, RR = 1.4; p<0.01). Pulmonary parenchymal and pleural injuries were more frequently seen in earthquake-related crush injuries (117 vs. 80 patients, RR = 1.5 for parenchymal and 146 vs. 74 patients, RR = 2.0 for pleural injuries; p<0.001). Non-rib fractures, pulmonary parenchymal and pleural injuries had significant positive correlation with rib fractures in these two cohorts.CONCLUSIONS:Thoracic crush traumas resulting from the earthquake were life threatening with a high incidence of bony thoracic fractures. The ribs were frequently involved in bilateral and severe types of fractures, which were accompanied by non-rib fractures, pulmonary parenchymal and pleural injuries.

A Healthy Young Man Presenting with Multiple Rib Fractures

A 32-year-old, otherwise healthy man presented initially with right rib and sternal pain after lifting a heavy object. The patient also reported several rib fractures 1 year previously associated with coughing. On examination, the patient had bilateral rib tenderness. Chest x-ray revealed multiple healing fractures of the sixth, seventh, and eighth ribs. A bone scan demonstrated increased uptake in the sternum and bilaterally in the ribs. A complete blood count was normal with the exception of a platelet count of 61 000/uL (reference interval, 130 000–440 000/uL). Alkaline phosphatase, creatinine, and calcium were within reference intervals. Total protein and albumin were 67 g/L (reference interval, 61–79 g/L) and 44 g/L (reference interval, 35–48 g/L), respectively. Ig concentrations were decreased: IgG 6.07 g/L (reference interval, 7.51–15.60 g/L), IgA 0.31 g/L (reference interval, 0.69–2.09 g/L), and IgM 0.10 g/L (reference interval, 0.48–2.74 g/L). We performed serum protein electrophoresis (SPEP)5 and immunofixation using the Sebia Hydrasys®. SPEP showed no monoclonal band in the γ region but an unexplained band in the β region with a reduced γ-globulin concentration of 3.9 g/L (reference interval, 6–14 g/L). Serum immunofixation electrophoresis showed a prominent λ monoclonal band in the β region and hypogammaglobulinemia. Immunofixation studies for IgG, IgA, and IgM were negative for the presence of monoclonal bands. β2-Microglobulin was increased at 3.51 mg/L (reference interval, <1.85 mg/L). Twenty-four-hour urine collection was significant for a total protein of 0.54 g/24 h (reference interval, <0.15 g/24 h); urine protein electrophoresis (UPEP) and immunofixation revealed 2 monoclonal λ light chain bands. ### QUESTIONS TO CONSIDER 1. List the significant and atypical findings in this case. 2. Given the patient's SPEP and immunofixation results, what …

Cervical Rib causing Thrombosis of Subclavian Atery

We describe here an unusual case of thrombosis of left subclavian artery in a patient with cervical rib. The patient presented with features of ischaemia of left upper limb. X-ray chest revealed bilateral cervical ribs, longer on the left side. Color Doppler studies showed echogenic thrombus within the left subclavian artery. Angiography revealed complete occlusion of left subclavian artery. Embolectomy was done. She was planned for excision of rib.

Anomalias ósseas congênitas em Sotalia guianensis (Mammalia, Cetacea, Delphinidae) da costa centro-norte do Estado do Rio de Janeiro

Carcaças de botos-cinza Sotalia guianensis (van Bénéden, 1864) foram recuperadas entre 20 de agosto de 2001 e 13 de fevereiro de 2006, na costa centro-norte fluminense. A maior parte delas (85%) entre Barra de São João (22º35'S 41º59'W) e Quissamã (22º06'S 41º28'W). Foram estudadas as colunas vertebrais dos 20 exemplares que apresentavam mais de 60% das vértebras presentes. A coleção é formada por 75% de animais imaturos, e todos os esqueletos mostram alterações tafonômicas mínimas. Duas categorias de anomalias congênitas foram diagnosticadas, ambas relacionadas ao desenvolvimento do mesoderma paraxial. A sétima vértebra cervical (C7) foi a única afetada, as costelas cervicais e o não fechamento do arco neural atingiram 15 (75%) dos indivíduos analisados, dos quais três (15%) apresentam ambas as anomalias. Nove (45%) indivíduos apresentaram costelas cervicais uni ou bilateral, e nove (45%) indivíduos apresentaram não fechamento do arco neural; em todos os casos as vértebras contíguas eram normais. A ocorrência de anomalias nesta série do Rio de Janeiro é maior do que as referidas na literatura brasileira para outras séries de Sotalia do Amazonas, Ceará e Santa Catarina. A série de Sotalia descrita vem de uma região do litoral muito limitada e provavelmente representa uma população local. As costelas cervicais são geneticamente determinadas e podem estar concentradas por uma condição de grande proximidade biológica entre os animais; o não fechamento do arco pode ter também um componente ambiental, a ser investigado futuramente.

Supernumerary lumbar rib in human prehistory

Unlike their cervical counterparts, supernumerary lumbar ribs are generally considered to be of little clinical significance, though they do constitute a topic of anthropological interest. The two most complete Neandertal lumbar regions (Kebara 2 and Shanidar 3) both show evidence of articular facets for bilateral lumbar ribs and a high incidence of the condition has been reported in the prehistoric Sadlermiut Eskimo. This pilot study tests the association of bi‐iliac breadth with the presence of supernumerary lumbar rib in two wide‐bodied prehistoric populations: Pt. Hope Inupiat (n=25), Tierra del Fuegan/Aonikenk (n=25), and one narrow‐bodied prehistoric population: South African Zulu (n=25). Moreover, as mouse models have shown a correlation between 12th rib length and lumbar rib presence, this was also investigated. Of the populations studied, only the Pt. Hope Inupiat evinced lumbar ribs (16%) even though their bi‐iliac breadth was not significantly greater than that seen in the Tierra del Fuegan/Aonikenk. Additionally, significantly longer ribs were observed for the Pt. Hope Inupiats in agreement with the predicted model. These results suggest that the presence of supernumerary lumbar rib in human prehistory is indicative of other basic alterations of the axial skeleton and is most likely related to population history.Grant Funding Source: National Science Foundation Doctoral Dissertation Improvement Grant #0752723 and the Wenner‐Gren Foundation for Anthropological Research.

Resection of Primary Sternal Osteosarcoma and Reconstruction With Homologous Iliac Bone: Case Report

Primary sternal osteosarcoma is rare and has a poor prognosis. Here, we describe the case of a 44-year-old man with sternal osteosarcoma. He underwent subtotal sternectomy with partial resection of the bilateral ribs and left clavicle. Sternal reconstruction was performed with an iliac bone allograft, which was fixed by polyester suture. The patient had a normal postoperative course, followed by adjuvant chemotherapy. The allograft healed with correct integration, and have been no signs of recurrence and absorption during 14 years of follow-up. The homologous iliac bone is a good choice for sternal reconstruction because it can become a part of the host.

“Double cervical rib with uncommon presentation”

Double or Bilateral cervical ribs. Pseudo arthrosis of cervical rib with first rib causing neurovascular complication is a rare congenital anomaly. We report a case of young man who presented with intermittent claudication in the right hand and involvement of peripheral nerves. He had bilateral cervical ribs. Left side cervical rib was small. Right side cervical rib had pseudo arthrosis with first rib. There was total occlusion of subclavian artery beyond first part. Abnormal sensation in the inner aspect of hand and fingers. He was managed with subclavian to axillary artery bypass with 6 mm Goretex graft and excision of cervical rib on right side and division of all sclaenus muscles i.e. scelnus anterior, medium minimus with fibrous bands to free subclavian artery and nerves.

Progredient Neurogenic and Vascular Thoracic Outlet Syndrome Due to Bilateral Cervical Ribs

A 26-year-old man who is an airplane technician was admitted to our hospital with a 3-year history of progredient pain, weakening, and paresthesia in his left arm and shoulder, usually during elevation and working overhead on airplane engines. In his seventh year, bilateral cervical ribs have already been diagnosed.

Hypophosphatemic Osteomalacia after Low-Dose Adefovir Dipivoxil Therapy for Hepatitis B

A 40-yr-old male presented with a 5-month history of bone pain involving both knees, ankles, and several ribs with no antecedent trauma. He had an antalgic gait, tenderness involving the bony margins of both knees, but no synovitis. He had a history of chronic hepatitis B infection, receiving lamivudine at a daily dose of 100 mg for 43 months and adefovir dipivoxil (adefovir) at a daily dose of 10 mg for the past 29 months. He had been receiving tramadol hydrochloride intermittently for pain relief. Investigations revealed a reduced serum phosphate level of 2.0 mg/dl (0.64 mmol/liter), normal serum corrected calcium of 8.8 mg/dl (2.20 mmol/liter), PTH of 39 pg/ml (4.1 pmol/liter), 25-hydroxyvitamin D3 level of 24.4 ng/ml (61 nmol/liter), and 1,25-hydroxyvitamin D level of 57 pmol/liter. Bone-specific alkaline phosphatase was elevated at 85.4 g/liter (normal, 3.7–20 g/liter). The urine deoxypyridinoline/creatinine ratio was elevated at 11 nmol/mmol (normal, 2.3–5.4 nmol/ mmol) with an estimated glomerular filtration rate of 60.1 ml/min. A 24-h urinalysis demonstrated hyperphosphaturia at 1.054 g/d (34 mmol/d) [normal, 0.465– 0.93 g/d (15–30 mmol/d)], hypercalciuria at 580 mg/d (14.5 mmol/d) [normal, 100 –300 mg/d (2.5–7.5 mmol/d)], glycosuria, and massive aminoaciduria. The 24-h creatinine excretion was normal at 1.41 g/d (12.5 mmol/d) [normal, 1.02–2.03 g/d (9 –18 mmol/d)]. Calculated maximal tubular phosphate reabsorption was reduced at 0.3% (normal, 0.8 –1.3%). Magnetic resonance imaging of both knees revealed microfractures across the femoral and tibial metaphyses (Fig. 1). A whole body bone scan showed intense uptake at the subchondral bone of both knees and several bilateral ribs (Fig. 2A). The diagnosis of hypophosphatemic osteomalacia in the context of Fanconi’s syndrome secondary to adefovir therapy was made. Fanconi’s syndrome is a recognized complication of high-dose adefovir therapy when used in the treatment of HIV (1). However, at the time of writing, there were only two other published reports of hypophosphatemic osteomalacia after low-dose adefovir therapy (2, 3). Fifteen weeks after cessation of adefovir and after regular phosphate supplementation, the patient reported significant improvement in his knee and other bony pain. ISSN Print 0021-972X ISSN Online 1945-7197 Printed in U.S.A. Copyright © 2010 by The Endocrine Society doi: 10.1210/jc.2009-2051 Received September 23, 2009. Accepted October 27, 2009. * T.W. and C.M.G. are joint first authors. FIG. 1. Left knee coronal proton-density weighted magnetic resonance image. There are incomplete undisplaced fractures across the femoral and tibial metaphyses, consistent with recent insufficiency fractures. S P E C I A L F E A T U R E

Macroscopic Elastic Constitutive Relationship of Cast-in-Place Hollow-Core Slabs

The macroscopic Poisson ratio and elastic moduli of the cast-in-place hollow-core slab are researched in this paper. At first, the formulas for computing the Poisson’s ratio of cast-in-place hollowed slabs with bilateral ribs are deduced by theoretical means. Then, based on the characteristics of stress distribution, an effective sectional area method is proposed for computing both the bending and axial compressive elastic moduli of cylindrical hollow-core slabs at the transverse section, in which the boundary of the effective area is suggested to be at a radial distance with its vertical slope angle α0 =22.5° . Relevant formulas for computational purposes are also proposed. At last, the shear modulus of cylindrical hollow-core slab at the transverse section is proposed to be computed considering the bending-shear deformation of the varying rib and face sheets at a periodic segment, and relevant formulas for curved sides beam are also deduced. In the course of the study, the so-called transverse-rib-effec...

Nonsurgical management of traumatic cardiac pseudoaneurysms

CLINICAL SUMMARY A 50-year-old man presented to the emergency department (ED) after being involved in a motor vehicle collision. He had undergone coronary artery bypass grafting 10 years previously. In the ED, he was intubated and bilateral chest tubes were placed for bilateral pneumothoraces. Injuries included an extensive scalp laceration that was repaired in the ED, bilateral pulmonary contusions, bilateral rib fractures, right femur fracture, and right tibia/fibula fracture. Computed tomography scan of the chest, performed on arrival, showed a 5 3 8-cm anteroposterior 3 left-right (AP 3 LR) pseudoaneurysm of his right ventricle (RV). At the time of admission, the patient’s systolic blood pressure was 70 mm Hg and pulse rate was 108 beats/min. Physical examination revealed a fractured sternum in multiple locations, palpable as numerous floating islands. Vasopressors were necessary to sustain an adequate perfusion pressure. Twelve units of blood were transfused within the first 7 hours of admission. Echocardiography performed on admission demonstrated an akinetic and dilated RV infundibulum. Continuous color Doppler flow was observed within the RV outflow tract, suggesting blood flow into an RV pseudoaneurysm. No tricuspid regurgitant jet was seen to suggest severe pulmonary hypertension, which would increase the concern for pseudoaneurysm rupture. The echocardiogram showed no evidence of pericardial effusion or tamponade. Given the patient’s degree of hemodynamic instability, which was attributed to blood loss from his multiple long bone fractures, we concluded that any immediate cardiac intervention would entail prohibitively high operative risk. We were also concerned that reoperative sternotomy and subsequent closure would be

Maltrato infantil grave en la unidad de cuidados intensivos pediátricos

Objective To describe cases of severe child abuse admitted to PICU. Methods and patients It is a retrospective study (2000–2008) in which patients diagnosed with physical child abuse admitted to PICU were included. Other abuse patterns were excluded (severe negligence, sexual abuse or scalding). Results There were 8 patients included (3 boys and 5 girls). The median age was 5.2 months, with 6 patients were less than 7 months old. The most frequent sign was neurological symptoms: seizures (4 patients), subdural haematoma (2 patients), traumatic brain injury (1 patient). Other: haemothorax (1 patient) and cardiac arrest of no known aetiology (1 patient). The CT showed a subdural haematoma in 5 patients, 3 of which needed surgical drainage. Child abuse was confirmed using the social history and the presence of inflicted injuries. There were long bones fractures (tibia, ulna and radius, bilateral rib fractures) in 3 patients and 4 patients had retinal haemorrhages. There was one death and 3 had severe neurological after effects. Conclusion Severely abused children can be falsely diagnosed with a casual neurological disease. The most frequent injury is subdural haematoma with or without another injury associated to child abuse. It very important to diagnose child abuse in order to prevent recurrent injuries.

MRI findings in the young infant with brainstem disconnection and extracerebral features. Report of one case and review of the literature

We present the young infant with the extremely rare brain abnormality–brainstem disconnection. Additionally, several extracerebral abnormalities were diagnosed: bilateral anotia, micrognatia, hypertelorism, scoliosis, ribs and vertebral anomalies. MR brain examination precisely demonstrated absence of the pons, with disruption between midbrain and hypoplastic medulla oblongata. The thin strands connecting the medulla with the midbrain and medulla with both cerebellar hemispheres were revealed. The large hamartoma of the tuber cinereum was found. In this study we review case reports published previously.

Delayed Chylothorax Following Blunt Chest Trauma.

Chylothorax is a very rare disease, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. We report a case of a male patient involved in a car accident presenting a delayed chylothorax after blunt chest trauma with a bilateral serial rib fracture and fracture of the ninth thoracic vertebrae. The therapy includes thorax drainage, dietary modifications with total parenteral nutrition and, in severe cases, PEEP ventilation. Hematological monitoring is mandatory to detect metabolic abnormalities resulting from chyle loss. Surgical treatment is only required in cases of persistent or increasing intrathoracal chyle flow. Thoracoscopic ligation of the thoracic duct is then required.Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional and immunologic disorders, can result from chylothorax. Our patient was treated successfully by chest drainage and parenteral nutrition.

Rare association of hyper IgE syndrome with cervical rib and natal teeth

Hyper IgE syndrome (HIES) is a rare immunodeficiency syndrome characterized by a triad of cutaneous abscesses, mostly caused by Staphylococus aureus; pneumonia; and raised IgE levels. Nonimmunological associations include course facial features, multiple bone fractures, joint hyperextensibility, and retained primary dentition. Patients require long-term antibiotic therapy. We report here a classical case of HIES with rare associations of natal teeth, bilateral cervical ribs, and conductive deafness. The patient was being treated with monteleukast and dapsone.

Severe Snoring in a Child with Pycnodysostosis Treated with a Bilateral Rib Graft

Pycnodysostosis is a rare osteopetrotic disorder. This report describes a case of a 3(1/2)-year-old boy with pycnodysostosis who presented with severe snoring. The snoring was the result of a pharyngeal narrowing due to a hypoplastic mandible. Surgery consisted of a bilateral rib graft, which allowed an enlargement of the pharynx by acting both on an anterior projection of the chin and a decrease of the glossoptosis. A significant reduction of the snoring and an excellent mouth aperture were obtained. This technique is ideal for such patients presenting a high risk of infection, nonunion, and secondary fracture.

Complicações arteriais da síndrome do desfiladeiro torácico

As manifestações clínicas da síndrome do desfiladeiro torácico são predominantemente neurológicas, sendo as complicações arteriais raras, mas potencialmente graves. Entre elas, devemos citar os aneurismas com complicações embólicas e a trombose. Os autores relatam o caso de uma mulher de 37 anos com costela cervical bilateral que apresentou embolia no membro superior direito originada de um aneurisma pós-estenótico da artéria subclávia direita, além de apresentar ectasia da subclávia esquerda também por compressão.

Traumatic Rupture of Thoracic Aorta in Real-World Motor Vehicle Crashes

Objective. Traumatic rupture of thoracic aorta (TRA) was reported in the literature to be a major cause of death in motor vehicle crashes. This study aims at evaluating the most relevant risk factors of TRA. It also aims at analyzing the types of TRA as a function of car crash conditions and rib cage fractures. Methods. In-depth crash data collected from 1998 to 2006 as part of the Co-operative Crash Injury Study (CCIS) were retrospectively investigated to assess frontal, near-side, and far-side injury risks. This database includes 15,074 occupants with individual detailed autopsy reports. Multivariate statistical analyses were performed. The influence of the following variables on TRA occurrence was studied: gender and age of the involved occupant, ETS, compartment intrusion, and restraint system. Features of TRA and rib cage fractures were described thanks to autopsy data. Results. Although TRA occurred in only 1.2% of all occupants, TRA victims accounted for 21.4% of all fatalities. The incidence of TRA was found twice higher in side impacts (2.4%) than in frontal ones (1.1%). TRA injury risk increased with ETS, intrusion, and age and decreased with the absence of intrusion regardless of the impact direction. It also decreased for belted occupants in frontal impacts. Except for the site of injury, the TRA features were similar whatever the crash conditions. The multiple ribs fractures were the most common injuries associated with TRA (79.1%) and TRA victims with uninjured or slightly injured (AIS 1) rib cage were significantly younger (p < 0.0001) than other TRA victims. Whatever the impact type, the TRA victims sustained mostly bilateral rib fractures (68%). Results also emphasized a close relationship between the principal direction of force and the body side with more fractured ribs. However, whatever the impact type, the aortic injury site or the side of the thorax, fractures concerned mainly the 2nd up to the 7th ribs of TRA victims. Conclusions. This study emphasized four main variables influencing the TRA occurrence: ETS, compartment intrusion, age, and seat belt use. The results suggested that the injury site may be different depending on the occupant or the impact type. However, the typical TRA, i.e., a partial or complete aorta transection within the peri-isthmic region, affected any occupant independently of age and impact type. The high frequency of bilateral rib cage fractures observed in TRA victims and the significant influence of intrusion on TRA occurrence emphasized that the aortic injury mechanism mainly involves a severe direct chest impact or compression.

Histopathological basis for neurogenic thoracic outlet syndrome

To the best of the authors' knowledge, no report exists that has demonstrated the histopathological changes of neural elements within the brachial plexus as a result of cervical rib compression. Four hundred seventy-five consecutive human cadavers were evaluated for the presence of cervical ribs. From this cohort, 2 male specimens (0.42%) were identified that harbored cervical ribs. One of the cadavers was found to have bilateral cervical ribs and the other a single right cervical rib. Following gross observations of the brachial plexus and, specifically, the lower trunk and its relationship to these anomalous ribs, the lower trunks were submitted for immunohistochemical analysis. Specimens were compared with two age-matched controls that did not have cervical ribs. The compressed plexus trunks were largely unremarkable proximal to the areas of compression by cervical ribs, where they demonstrated epi- and perineurial fibrosis, vascular hyalinization, mucinous degeneration, and frequent intraneural collagenous nodules. These histological findings were not seen in the nerve specimens in control cadavers. The epineurium was thickened with intersecting fibrous bands, and the perineurium appeared fibrotic. Many of the blood vessels were hyalinized. The nerve fascicles contained frequent intraneural collagenous nodules in this area, and focal mucinous degeneration was identified. Cervical ribs found incidentally may cause histological changes in the lower trunk of the brachial plexus. The clinician may wish to observe or perform further evaluation in such patients.