Bilateral Rib Research Articles

Conservative management of esophageal perforation after a fall

INTRODUCTIONEsophageal perforation in the setting of blunt trauma is rare, and diagnosis can be difficult due to atypical signs and symptoms accompanied by distracting injury. PRESENTATION OF CASEWe present a case of esophageal perforation resulting from a fall from height. Unexplained air in the soft tissues planes posterior to the esophagus as well as subcutaneous emphysema in the absence of a pneumothorax on CT aroused clinical suspicions of an injury to the aerodigestive tract. The patient suffered multiple injuries including bilateral first rib fractures, C6 lamina fractures, C4–C6 spinous process fractures, a C7 right transverse process fracture with associated ligamentous injury and cord contusion, multiple comminuted nasal bone fractures, and a right verterbral artery dissection. Esophageal injury was localized using a gastrograffin esophagram to the cervical esophagus and was most likely secondary to cervical spine fractures. Because there were no clinical signs of sepsis and the esophagram demonstrated a contained rupture, the patient was thought to be a good candidate for a trial of conservative management consisting of broad spectrum intravenous antibiotics, oral care with chlorhexadine gluconate, NPO, and total parenteral nutrition. No cervical spine fixation or procedure was performed during this trial of conservative management. The patient was received another gastrograffin esophagram on hospital day 14 and demonstrated no evidence of contrast extravasation. DISCUSSIONEarly diagnosis and control of the infectious source are the cornerstones to successful management of esophageal perforation from all etiologies. Traditionally, esophageal perforation relied on a high index of clinical suspicion for early diagnosis, but the use of CT scan for has proved to be highly effective in diagnosing esophageal perforation especially in patients with atypical presentations. While aggressive surgical infection control is paramount in the majority of esophageal perforations, a select subset of patients can be successfully managed non-operatively. CONCLUSIONIn the setting of blunt trauma, esophageal perforation is rare and is associated with a high morbidity. In select patients who do not show any clinical signs of sepsis, contained perforations can heal with non-operative management consisting of broad spectrum antibiotics, strict oral hygiene, NPO, and total parenteral nutrition.

Restlessness in right upper limb as sole presentation of restless legs syndrome

Restless legs syndrome (RLS) rarely affects the upper limb during the initial course of disease. We present a patient who complained of symptoms suggesting RLS in the right upper limb as the sole manifestation of illness. Bilateral cervical ribs and depression were co-incidental findings. Patient responded well to dopaminergic therapy.

Male breast cancer presenting with bilateral pleural effusion

Male breast cancer presenting with bilateral pleural effusion

Rib fractures: Accidental or non-accidental

Introduction: We report an incidental discovery of multiple rib fractures in a wheezing child without a history of an injury or the presence of metabolic bone disease. As a result, the child was evaluated for the presence of non-accidental trauma. Case Report: An n-month-old African-American child was brought to the emergency department by his father with a 2-day history of fever, cough and breathing difficulty. After receiving nebulizer treatments, the child was still wheezing. A chest X-ray was obtained which showed bilateral fractures of the ribs. No history of trauma was provided. Given the radiographic findings, Child Protective Services was contacted and a report of child abuse was made. Conclusion: Child abuse is a complex phenomenon. Any skeletal injury in young children can be due to abuse. Rib fractures are uncommon in the pliable chest of a child. When discovered, however, they raise the suspicion of a non-accidental trauma. They are often uncovered during the assessment of children who present to the emergency department for unrelated reasons. The physician's ability to differentiate accidental from non-accidental trauma may depend on gathered information. This report emphasized the importance to evaluate for non-accidental trauma after the finding of bilateral rib fractures on a chest X-ray. Non-accidental trauma should be considered when there is evidence of injury without a history of trauma.

Post-traumatic lung pseudocysts: two case reports in ICU patients.

The traumatic lung pseudocyst is a rare complication of closed thoracic injury. We present two cases with traumatic lung pseudocyst who were admitted in our ICU. CASE 1: A 19 year old man was admitted in the ICU after a motorcycle accident. Chest CT revealed two well defined densities in the right upper lung lobe with presence of air bubbles within them. Four days after admission chest CT showed two cavitary lesions in the upper lobe. The patient showed gradual clinical improvement. Repeated chest CT after 6 months was normal. CASE 2: A 41 year old man was involved in a car-bicycle accident. The patient was admitted in the ICU with respiratory failure and flail chest. Chest CT revealed multiple bilateral rib fractures, right pneumothorax and contusions of the right lung. Two days after admission chest CT showed formation of lung pseudocyst. The patient was gradually stabilised and 22 days after the accident the chest CT revealed resolution of the pseudocysts. The traumatic lung pseudocyst is a rare complication of blunt thoracic trauma. The clinical course of traumatic lung pseudocyst is usually benign, unless complications such as pneumothorax or infection of the cavitary lesion arise. These lesions are more common in children and young adults.

Cervical Rib: It's Prevalence in Indian Population around Lucknow (UP)

Objective: The study was conducted to know the prevalence of cervical rib in Indian population especially in and around Lucknow and to compare the results with the other study reported in London population.Material and Method: The study was conducted on chest X-rays of 12950 cases done for various complaints of both male and female patients, irrespective of age and ethnicity who attended the Radiology Department of Era's Lucknow Medical College, Lucknow during a period of 7 months, that is from 01-09-2011 to 31-03-2012.Results: An incidence of 0.6% was observed with bilateral cervical rib being more common in both males and females and the incidence of cervical rib in females was 0.73% as compared to 0.49% in males.Conclusion: Indian population showed an overall incidence of 0.6% as compared to the London population showing an overall incidence of 0.74%. Bilateral cervical rib is more common in both male and females and left sided cervical rib being more common in males in comparison to right sided cervical rib in females.

Management of thoracic trauma in emergency service: Analysis of 1139 cases

Objective: Thoracic trauma is a common cause of significant morbidity and mortality. This study presents a series of thoracic trauma with the aim to assess epidemiologic features, distribution of pathologies, additional systemic injuries, diagnosis, management and outcome. Methodology: Between January 2007 and December 2011, all patients with thorax trauma admitted to the emergency service of our hospital were retrospectively reviewed with respect to age, gender, etiological factors, distribution of pathologies, additional systemic injuries, diagnosis, treatment modalities, referral and outcome. Results: A total of 1139 patients with thorax trauma were included in the study. Of these, 698 (61.3%) were male and 441 (38.7%) were female, and the average age was 54.17±17.39 years. 1090 (95.7%) of the patients had blunt trauma, whereas 49 (4.3%) had penetrating trauma. Etiological factors were falls in 792 (69.5%), motor vehicle accidents in 259 (22.8%), animal related accidents in 39 (3.4%) and penetrating injuries in 49 (4.2%) patients. It was found that 229 (20%) patients had single, 101 (8.9%) had double, 5 (3%) had three or more, 10 (0.9%) had bilateral rib fractures and 19 (1.7%) had sternal fracture. Pneumothorax was diagnosed in 58 (5.1%) patients, whereas hemothorax, hemopneuomothorax and other system injuries were diagnosed in 36 (3.2%), 38(3.3%) and 292 (25.6%) respectively. In our series, thirteen patients (mortality rate 1.1%) died as result of hemorrhagic shock (n=8), respiratory distress (n=3) and severe multiple trauma (n=2). Conclusion: Although majority of the patients with thorax trauma receive treatment as outpatients; thoracic traumas may be a life threatening condition, and should be identified and treated immediately. Mortality varies based on etiological factors, additional systemic pathologies, capabilities of the hospital especially diagnostic and treatment facilities in emergency services. We believe that a multidisciplinary approach to the patients with severe thorax trauma, and the opportunities of emergency bedside thoracotomy in emergency services will significantly reduce the morbidity and mortality.

Invasive Lobular Carcinoma of the Breast with Metastasis to the Colon

Purpose: A 49-year-old woman was diagnosed with a 1.2 cm right breast mass in 2007. The patient elected against a biopsy at the time. In late 2009, she presented to GI office with a six week history of abdominal pain, weight loss, and hematochezia. Patient denied personal or family history of breast or colon cancer. A colonoscopy revealed a solitary 6 mm ulcer with a firm nodule in sigmoid colon. Histopathological findings were compatible with infiltrating carcinoma of the colon. MRI showed skeletal metastases in thoracolumbar spine and bilateral ribs, and a 1.4 cm lesion in the liver. CA15-3 was 371 U/ML and CA 27.29 was 124 U/ML. A PET scan revealed a 3.8 cm hyper-metabolic area in the right breast and bony metastases. Histological examination of breast biopsy showed for a low grade ER/PR positive and HER-2/neu negative invasive lobular carcinoma. She was diagnosed with colonic metastasis of invasive lobular carcinoma of the breast. A mastectomy was recommended, however the patient initially refused. A bilateral oophorectomy revealed invasive lobular carcinoma. Patient ultimately agreed to a modified radical right mastectomy in September 2010. The primary tumor was 5.5 cm in diameter, grade 6/9 with lymphovascular and perineural invasion. All surgical margins were negative. She had metastases to 10 out of 13 axillary lymph nodes. Patient had stage IV, T4 N3a M1 invasive lobular carcinoma of breast. She was treated with tamoxifen, radiation therapy, and monthly zolendronic acid. As of June 2011, PET continues to show stable osseous metastatic disease. Metastatic gastrointestinal tumors originating from Invasive lobular carcinoma (ILC) are unusual, and colonic metastases are especially rare. The clinical manifestations are variable and may range from non-specific complaints to acute GI symptoms. It is imperative to differentiate between metastatic breast cancer and primary colon cancer as treatment strategies differ. As seen in our case, careful correlation of both endoscopic histology and primary breast cancer histology was essential. Therefore, a high index of clinical suspicion with early endoscopy in those with vague symptoms and history of breast cancer is recommended.Figure: No Caption available.

Predicting outcome of patients with chest wall injury

BackgroundRib fractures occur in 10% of injured patients, are associated with morbidity and mortality, and frequently necessitate intensive care unit (ICU) care. A scoring system that identifies the risk for respiratory failure early in the evaluation process may allow early intervention to improve outcomes. The aim of this study was to test the hypothesis that a scoring system based on initial clinical findings can identify patients with rib fractures at greatest risk for morbidity and mortality. MethodsA simple scoring system to stratify risk was developed and applied to patients through a retrospective trauma registry review. Points were assigned as follows: age < 45 years = 1 point, age 45 to 65 years = 2 points, age > 65 years = 3 points; <3 fractures = 1 point, 3 to 5 fractures = 2 points, >5 fractures = 3 points; no pulmonary contusion = 0 points, mild pulmonary contusion = 1 point, severe pulmonary contusion = 2 points, bilateral pulmonary contusion = 3 points; and bilateral rib fracture absent = 0 points, bilateral rib fracture absent present = 2 points. A review of trauma registry patients with rib fractures (June 2008 to February 2010) at a state-designated level 1 trauma center was performed. Data reviewed included age, number of fractures, bilateral injury, presence of pulmonary contusion, classification of the contusion, length of hospital stay, mechanical ventilation, ICU admission, and length of stay. The scoring system was retrospectively applied to 649 patients to determine validity. ResultsA score ≤ 7 indicated lower mortality (24 of 579 [4.2%]) compared with patients with scores > 7 (10 of 70 [14.3%]) (Fisher's 2-sided P = .0018). Patients with scores ≤ 6 were less likely to be admitted to an ICU (29.7%) compared with those with scores ≥ 7 (56.7%) (P < .0001). Patients with total scores < 7 were less likely to require intubation (20.6%) compared with those with scores ≥ 7 (40.0%) (P < .0001). Patients with scores ≤ 4 had shorter lengths of stay (36.0% <5 days) compared with those who had scores > 4 (59.7%) (P < .0001). ConclusionsA simple scoring system predicts the likelihood that patients will require mechanical ventilation and prolonged courses of care. A score of 7 or 8 predicted increased risk for mortality, admission to the ICU, and intubation. A score > 5 predicted a longer length of stay and a longer period of ventilation. This scoring system may assist in the earlier implementation of treatment strategies such epidural anesthesia, ventilation, and operative fixation of fractures.

Hypophosphatemic osteomalacia induced by low-dose adefovir therapy: focus on manifestations in the skeletal system and literature review

Osteomalacia is a metabolic bone disease that leads to softening of the bones and can be caused by hypophosphatemia. Large clinical studies of low-dose adefovir dipivoxil (adefovir) have found no evidence of renal tubular dysfunction leading to hypophosphatemia after 48weeks of treatment. We report two cases of low-dose adefovir-induced hypophosphatemic osteomalacia that initially presented with diffuse musculoskeletal pain. The first patient was a 62-year-old man with a 2-year history of bone pain involving the dorsal mid-thorax, lower anterior chest wall, right sacroiliac joint area, and both knees. The patient had been receiving adefovir for 5years before confirmation of hypophosphatemia and urinary phosphate wasting. Bone scintigraphy revealed multifocal lesions including multiple ribs, costochondral junctions, costovertebral junctions, sacrum, both posterior iliac bones, both proximal tibia, right calcaneus, and the left second metatarsophalangeal joint area, which were suggestive of metabolic bone disorder. Bone pain was significantly reduced within 3months after supplementation with phosphate and calcitriol. The second patient was a 54-year-old male who presented with an 18-month history of severe bone pain of the right medial knee and low back. The patient had been taking adefovir for approximately 40months before the development of bone pain. Laboratory data revealed hypophosphatemia and vitamin D deficiency. Bone scintigraphy showed increased uptake in bilateral ribs, sternum, both scapulae, both costovertebral junctions, both pelvic bones, medial cortex of the right proximal femur, right proximal tibia, and the left lateral tarsal bone. The symptoms improved by changing the antiviral agent from adefovir to entecavir. Because osteomalacia often presents with diffuse bone pain, non-specific radiologic findings and non-characteristic routine serum biochemical changes, the disease can be confused with various musculoskeletal diseases and a high index of suspicion is necessary for an early diagnosis in patients receiving adefovir therapy.

Cervical Ribs: A Common Variant Overlooked in CT Imaging

Cervical ribs are congenital variants that are known to cause TOS or brachial plexopathy in up to 10% of the affected individuals. We investigated how often cervical ribs are present on cervical spine CT scans to determine the incidence in humans and the percentage of reported cervical ribs. Cervical spine CT scans and the reports of 3404 consecutive adult patients were retrospectively reviewed to determine the presence of cervical ribs and whether they had been reported. Cervical ribs were found in 2.0% (67/3404) of the population. Of the 67 patients with cervical ribs, 27 (40.3%) had bilateral ribs. The prevalence of cervical ribs in women was twice that in men, 2.8% (39/1414) versus 1.4% (28/1990). Although African Americans accounted for 50.1% (1706/3404) and whites, 41.2% (1402/3404) of the patient population, African Americans were 70.1% (47/67) of patients with cervical ribs, whereas whites were 26.9% (18/67). Radiologists commented on 25.5% (24/94) of the cervical ribs in 25.4% (27/67) of patients. The prevalence of cervical ribs in the human population has been a source of uncertainty due to the degree of difficulty that comes in detecting this often subtle congenital variation. In our sample, the prevalence was 2.0% of patients. Our study determined that cervical ribs are underreported in patients undergoing cervical spine CT. Given the potential clinical implications of these anatomic variants, neuroradiologists must be more meticulous in identifying cervical ribs when reviewing cervical spine CT scans.

Gorham-Stout syndrome presenting in a 5-year-old girl with a successful bisphosphonate therapeutic effect

Gorham-Stout syndrome (GSS), also known as Gorham-Stout disease, massive osteolysis, disappearing bone disease or phantom bone, is a rare disorder of the musculo-skeletal system. It most commonly involves the skull, shoulder and pelvic girdle. Histological examination reveals a progressive osteolysis always associated with an angiomatosis of blood vessels and sometimes of lymphatics, which seemingly is responsible for the destruction of the bone. It is extremely rare that Gorham-Stout syndrome involves the bones of the entire body. A 5-year-old girl complaining of intermittent and dull back pain for 3 months was admitted to a local hospital. X-ray revealed left pleural effusion, and the patient was diagnosed with tuberculous pleurisy. Thus, anti-tuberculosis therapy was performed. However, it was not effective. A soft mass with significant tenderness was found in the upper segment of the right leg 50 days afterwards. X-ray revealed multiple osteolysis of the bilateral clavicle, scapula, rib, vertebral body, ilium, sacrum, femur and tibia. The biopsy from the right tibia disclosed that the lesion was composed of hyperplastic blood vessels and fibrous tissues similar to hemangioma. Based on the above clinical, radiological and histopathological findings, the clinical physician confirmed a diagnosis of Gorham-Stout disease, and prescribed oral anti-osteoclastic medications consisting of bisphosphonates. At present, the girl is alive and healthy, and new lesions have not been noted.

Thoracic outlet syndrome caused by pseudoarticulation of a cervical rib with the scalene tubercle of the first rib

A healthy 20-year-old man presented with a bony lump above the left clavicle associated with upper limb pain, numbness, and tingling. Examination in the surrender position elicited left hand weakness and pain with loss of the radial pulse. The patient had paresthesia of the ulnar border of the left hand but no interossei wasting. A lateral neck radiograph identified an unusual bony contour anteriorly at C7/T1 suggesting a cervical rib (A). Duplex ultrasound scan showed widely patent left axillary and subclavian arteries with the arm adducted but severe compression of the subclavian artery on abducting the arm to 90°. A subsequent computed tomography angiogram confirmed bilateral cervical ribs; the left articulating with an extended left transverse process of the seventh cervical vertebra, extending inferiorly to fuse with the first rib (B and C/Cover). The left subclavian artery passed immediately superior to this bony extension whereas the left vertebral artery lay immediately anterior to the origin of the cervical rib at C7. The right cervical rib was much smaller and not in proximity to the vessels. Intraoperatively, the left cervical rib was found to extend from the C7 transverse process to form a true joint with a hypertrophied scalene tubercle on the first rib; both the cervical rib and hypertrophied scalene tubercle were excised via the supraclavicular incision (D). A T1 sensory and motor neuropraxia was noted day 1 postsurgery which, together with his preoperative symptoms, completely resolved within 5 days and continued at 5-month follow-up. Cervical ribs are a known cause of arterial and neurogenic thoracic outlet syndrome. These congenital abnormalities occur in 1% of the population but are bilateral in 50%. Ninety percent are asymptomatic and do not require resection. Complete cervical ribs occur in approximately 25% of patients, most commonly attached to the first rib by a fibrous band, or more rarely, as in this case, via a true joint, often with the scalene tubercle. Surgical management involves removal of the cervical rib; if this does not provide adequate decompression of the subclavian artery and the brachial plexus, removal of the first rib should be done.

Use of Intrathecal Ziconotide for Frequent Severe and Intractable Sickle Cell Disease-Related Pain

Abstract 1062Many patients with sickle cell disease (SCD) have recurrent, severe vaso-occlusive pain crises, with profound consequences for their quality of life. These pain crises are sometimes responsive to medical management of the underlying disease or to palliative opioid or nonopioid therapies, but in other cases, the pain is intractable. In addition, patients with SCD are prone to chronic, debilitating pain from related conditions.We decided to test intrathecal (IT) ziconotide therapy using an implantable pump with the addition of a Personal Therapy Manager (PTM) patient control accessory in patients with SCD and severe, intractable pain. Ziconotide is a direct and selective inhibitor of N-type calcium channels, believed to reduce signaling in spinal pain pathways. In randomized, controlled trials, ziconotide has been shown to reduce severe chronic pain of various etiologies. We identified 2 patients with SCD and a history of prolonged, intractable pain as suitable candidates. After successful IT ziconotide bolus dose trials demonstrated the utility of ziconotide, these patients were implanted with programmable IT infusion pumps with PTM. Ziconotide was titrated to effect over several weeks.Patient 1 was a 29-year-old female with a history of SCD and hemoglobin of 7, MCV of 83, and platelet count of 297. She had been treated at major academic centers and by private practice hematologists with maximal medical therapy including hydroxyurea and folic acid. She was hospitalized about once a month in the previous 12 months for administration of IV opioids with patient-controlled analgesia (PCA). Currently she has evidence of aseptic necrosis of both hips, not improved by intra-articular steroid injections; she is not a candidate for joint replacements in view of her youth. She underwent a 1-mcg fluoroscopically directed IT bolus trial of ziconotide, with a reduction in her average visual analog scale (VAS) pain score of 9/10 to 0/10 for 48 hours, which was an unusual occurrence for her. She was able to sleep without difficulty and had improvement in her bilateral lower extremity, hip, rib, and back pain. A pump was then implanted for continuous IT infusion of ziconotide. She has not required emergency room visits or hospitalization for sickle cell crises since pump implantation. She is currently at 3.75 mcg/d of ziconotide with a PTM dose of 0.350 mcg every 3 hours and is interested in returning to work. She has not experienced any significant adverse events during the ziconotide titration phase.Patient 2 was a 31-year-old female with a history of hemoglobin S and thalassemia trait. She had bilateral avascular necrosis of the shoulders and hips and had been treated with chronic opioid therapy (fentanyl 50 mcg) but was still being hospitalized monthly for pain management. She had been treated at 2 major academic institutions as well as multiple community hospitals. The patient admitted to previous use of marijuana and cocaine in an effort to control her pain, as well as to obtaining pain medications from multiple physicians. She responded to a 7-mcg IT ziconotide trial with pain reduction from 8/10 to 0/10 for several days and then underwent implantation of a programmable pump with PTM. Following pump implantation she had satisfactory analgesia and did not require any emergency room visits for pain at a stable ziconotide dose of 1.5 mcg/d with a PTM dose of 0.150 mcg every 3 hours. This patient was receiving home refills and developed a pump pocket infection, requiring explantation of her IT infusion pump. Currently, she is poorly controlled on long-acting opioids and has requested reimplantation of her pump with ziconotide monotherapy.Here we describe 2 cases of successful pain management in SCD with IT ziconotide. While receiving continuous IT infusion of ziconotide, both patients were able to be titrated off of high-dose, long-acting opioids. In addition, the PTM proved useful for dosage finding during the titration phase as well as for aborting pain flares. We are in the process of studying a larger number of patients to better define the improvements achieved in functional status, analgesia, and healthcare savings with improved pain management using ziconotide in patients with SCD. Disclosures:McDowell:Azur Pharma: Speakers Bureau.

Bilateral first rib stress fractures in a female swimmer: a case report

Bilateral first rib stress fractures in a female swimmer: a case report

Mobile extracorporeal membrane oxygenation after traumatic freshwater submersion using bi-caval dual lumen catheter

Dear Editor, After traumatic freshwater submersion, severe respiratory failure and destructive lung injury are dreaded complications [1]. If conventional treatment fails to provide adequate oxygenation, veno-venous extracorporeal membrane oxygenation (VV-ECMO) is the only remaining treatment modality [2]. Yet, in the presence of concomitant trauma, the need for anticoagulation in VV-ECMO poses a therapeutic dilemma [3]. Here, we report two trauma patients treated with mobile VV-ECMO after freshwater aspiration despite an increased trauma-related bleeding risk. A 33-year-old healthy male fell off a tilted wagon, lost consciousness, and suffered from freshwater submersion, resulting in brain and lung contusion, and an injury severity score (ISS) of 26. Despite lung-protective ventilation and prone position, respiratory failure progressed (Murray score 3.0 [4]) and VV-ECMO was initiated within 24 h after admission. The further clinical course was uneventful and no additional pulmonary complications occurred. Successful weaning from ECMO was accomplished on day 11, followed by intensive care unit (ICU) discharge on day 13. A 24-year-old healthy male experienced freshwater aspiration after a quad bike accident, resulting in bilateral brain contusion, lung contusion, rib fractures, bilateral pneumothoraces, and splenic rupture grade II/VI (ISS 29). On day 6, the respiratory condition deteriorated (Murray score 3.5 [4]), necessitating VV-ECMO. The subsequent clinical course was complicated by persistent pneumothoraces, multiple pulmonary abscesses, empyema, and parenchymal destruction (Fig. 1a–c), ultimately allowing successful weaning from VV-ECMO (day 54), mechanical ventilation (day 66) and ICU discharge (day 69). Fig. 1 Serial chest CT scans on day 34 (a), 46 (b), and 58 (c) of VV-ECMO support in the 24-year-old male showing gradual improvement of pulmonary injury. Mobile VV-ECMO equipment mounted on the transport trolley (d). Bi-caval dual lumen catheter (e) optimally ... In both patients, referral on mechanical ventilation from the primary hospital to a tertiary academic center was considered impossible because of respiratory instability. Therefore, our mobile team comprising two experienced senior intensivists, an ICU nurse, and a perfusionist initiated VV-ECMO off-center before transport (Prolonged Life Support, Maquet®, Fig. 1d). One intensivist introduced a 27-French bi-caval dual lumen catheter (Avalon Elite, Avalon Laboratories®, Fig. 1e) via the right internal jugular vein, resulting in a blood flow of 4 L/min. Optimal catheter positioning was guided echocardiographically by the second intensivist adhering to a protocolized combined transthoracic-transesophageal approach using our mobile equipment (Philips CX 50) (Fig. 1f) [5]. The use of a single insertion site minimized the risk of cannula displacement, introduction of site bleeding, and infection while facilitating patient handling. In both patients no VV-ECMO related complications occurred. Considering the bleeding risk due to concomitant multitrauma, therapeutic anticoagulation was undesirable [3]. Consequently, the first patient received a half-therapeutic dose of unfractionated heparin intravenously (5,000 IU bolus), the second acetylsalicylic acid (100 mg) orally (300 mg bolus). In the absence of hemorrhagic complications, both patients switched to a therapeutic dosage of unfractionated heparin 48 h after the start of VV-ECMO. Severe but potentially reversible pulmonary injury can successfully be treated with VV-ECMO in trauma-related freshwater submersion. The combined advantages of mobile, off-center VV-ECMO initiation using a bi-caval dual lumen catheter in trauma patients have, to the best of our knowledge, not been described before. As pointed out earlier, this approach should be considered as a valid therapeutic option in this category of patients despite the assumed increased bleeding risk associated with multitrauma.

Convex Hemiepiphysiodesis

We performed a retrospective chart review of patients with nonadolescent idiopathic scoliosis who underwent open vertebral stapling for treatment of spinal deformity. The objective of this study was to determine the efficacy of vertebral stapling in patients with scoliosis. Measurements included initial deformity correction and maintenance of correction. Growth modulation has become a topic of interest recently in the spinal deformity literature. It refers to the tethering of growth on one side of the spine to allow for compensatory growth on the contralateral side, and, in theory, correction of scoliosis. Recent studies on endoscopic vertebral stapling have shown promising early results in adolescents with idiopathic scoliosis. Little is known about its applicability in patients with more "malignant" types of scoliosis. The medical records and radiographs of 11 children who underwent open vertebral stapling between June 2003 and August 2004 were reviewed. Patients with adolescent idiopathic scoliosis (AIS) were excluded. RESULTS.: Diagnoses included myelodysplasia, congenital scoliosis, juvenile, and infantile idiopathic scoliosis, Marfan syndrome, paralytic scoliosis, and neuromuscular scoliosis. The average age at surgery was 6 + 11 year. All patients were skeletally immature. Preoperative curves averaged 68° (22°-105°). Of the 11, six thoracic curves and five thoracolumbar curves were stapled. Four patients had minor curves, which were not stapled. Initial postoperative radiographs averaged 45° (24°-88°). Average follow-up was 22 month for our series (16-28 month). At final follow-up, scoliosis averaged 69° (36°-107°). Five of the 11 patients have subsequently undergone secondary surgical procedures for progression of scoliosis, including growing rod insertion in three, combined anterior/posterior spinal fusion in another, and bilateral vertical expandable prosthetic titanium rib insertion in a patient with myelodysplasia. Three of the remaining six patients are scheduled for secondary surgery. More than half of the patients in our series have undergone or are scheduled to undergo further spinal surgery, at an average of 2 year after anterior vertebral stapling. It is unclear if progression may be related to the young age at surgery, the relatively severe average preoperative curve magnitude, the nature of the underlying scoliosis, or a combination of these.

Intraoperative Pneumothorax Identified with Transthoracic Ultrasound

Intraoperative Pneumothorax Identified with Transthoracic Ultrasound

Bilateral first rib fractures with pseudoarthrosis in a weight lifter

Fractures of the first rib from direct blunt trauma are quite rare and are usually associated with major chest and abdominal injuries.1 Isolated fractures of the first rib as a result of various sports activities have been described in several reports.2, 3 There are very few reports of stress fracture of the first rib in weight lifters.4 We report a rare case of bilateral first rib fracture with resultant pseudoarthrosis in a young weight lifter. We also discuss the role of multi-detector computed tomography (MDCT) in the evaluation of such cases and review pertinent literature.

Congenital lower brachial plexus palsy due to cervical ribs

Congenital brachial plexus palsy (CBPP) usually occurs secondarily to intrapartum trauma, but this is not always the case. Cervical ribs have previously been reported to increase the risk of CBPP in association with birth trauma. We report the cases of two children (one female, one male) with congenital lower brachial plexus palsy in whom the presence of non-ossified cervical ribs was the only identified risk factor. In the female child magnetic resonance imaging (MRI) of the brain, spinal cord, and brachial plexus revealed no abnormality except for the presence of bilateral cervical ribs at the level of the seventh cervical (C7) vertebra. Chest radiography was normal, which suggested that the cervical ribs identified on the MRI were fibrous bands or cartilaginous ribs rather than ossified ribs. In the male child, MRI of the spine and brachial plexus was normal but he was noted to have bilateral cervical ribs at C7. These were not identifiable on chest radiography and, therefore, are likely to reflect fibrous bands or cartilaginous ribs.