Chest Wall Injury Research Articles

Extracorporeal Membrane Oxygenation During Surgical Stabilization of Rib Fractures in Successful Management of Severe Blunt Chest Trauma.

Early surgical stabilization of rib fracture (SSRF) improves outcomes in patients with flail physiology and severely displaced fractures. We present two cases of patients with severe chest injury and large flail segment who underwent SSRF while on veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patients developed respiratory failure within 24hours of admission requiring VV-ECMO. The extent of their chest wall injury limited pulmonary mechanics prohibiting transition off VV-ECMO. Therefore, SSRF was performed on hospital days 2 and 3 and while on VV-ECMO support. Stabilizing the chest wall allowed for improved ventilation and successful decannulation from VV-ECMO on postoperative days 3 and 4. Ultimately, both achieved a functional recovery and were discharged home. These cases demonstrate a unique thoracic damage control strategy wherein SSRF is performed while on VV-ECMO. Improving chest stability and pulmonary mechanics with SSRF allowed for safe transition off VV-ECMO and achieved a favorable long-term outcome.

A114Multiple Trauma Simulation - An Introduction for Medical and Nursing Students

In a number of medical schools, students often feel unprepared to manage acutely unwell trauma patients, with a majority of students reporting they had received less than five hours of trauma-based teaching and clinical skills exposure [1]. Despite the lack of previous training, newly graduated doctors are often one of the first professionals to initiate assessment and management of trauma patients on arrival to hospital [2]. Our scenario design aims to help both medical and nursing students gain experience of multiple trauma patients in a simulated environment. We wished to incorporate the skills of prioritization, leadership, role allocation and delegation whilst also covering some technical skills of trauma management. This scenario aims to simulate a high-pressure, busy clinical environment where students can practise the management of patients requiring immediate care in a resuscitation room setting. The students were briefed collectively for the multiple trauma simulation, as if there were a ‘stand-by call’ as a pre-alert from the ambulance crew. The students were informed that there was a nearby road traffic accident and there would be three casualties arriving: a patient with a head injury who was on an anticoagulant, a patient who had a chest wall injury and a patient who had suffered burns at the scene. They were allocated 5-10 minutes to assist with assigning roles and identifying how they planned to divide up tasks before starting the simulation. The initial assessment and management plans were commenced by the students, and a member of the faculty team would come in around half-way through as a ‘senior emergency physician’, who could offer advice and guidance. Verbal and written feedback collected from both medical and nursing students was positive, with many stating that they felt their teamwork and leadership abilities had been enhanced. Multiple people commented on the impact of clear communication, task delegation and leadership on the outcome of the scenario. Several students also commented on the positive impact of multidisciplinary working by combining both medical and nursing students for simulation training, and felt they had a greater appreciation and understanding of each other’s roles. Students felt that their confidence in both technical and non-technical skills had improved as a result of participating in the scenario, and many felt they had learnt valuable leadership and teamwork abilities. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. Therapeutic/Care Management; Level V.

Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma.

Rib fractures are common injuries which can be associated with acute pain and chronic disability. While most rib fractures ultimately go on to achieve bony union, a subset of patients may go on to develop non-union. Management of these nonunited rib fractures can be challenging and variability in management exists. The Chest Wall Injury Society's Publication Committee convened to develop recommendations for use of surgical stabilization of nonunited rib fractures (SSNURF) to treat traumatic rib fracture nonunions. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject the recommendation. No identified studies compared SSNURF to alternative therapy and the overall quality of the body of evidence was rated as low. Risk of bias was identified in all studies. Despite these limitations, there is lower-quality evidence suggesting that SSNURF may be beneficial for decreasing pain, reducing opiate use, and improving patient reported outcomes among patients with symptomatic rib nonunion. However, these benefits should be balanced against risk of symptomatic hardware failure and infection. This guideline document summarizes the current CWIS recommendations regarding use of SSNURF for management of rib nonunion. Therapeutic/Care Management; Level IV.

Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration.

Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic. A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens. After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures. The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

A Retrospective Two-Year Review of the Outcomes of Surgical Rib Fixation Following Chest Wall Injury by the Multidisciplinary Chest Wall Injury Group in a Major Trauma Centre and the Change in Outcomes as the Service Has Developed.

Aims All English major trauma centres (MTCs) offer rib fixation, which the National Institute for Health and Care Excellence (NICE) guidance indicates in patients with multiple rib fractures or a flail segment; however, the data does not identify the appropriate patients. Our aims were to establish improvements in outcomes following rib fixation at our trust and then determine if the rib fixation service has improved. Methods We performed a matched cohort study whereby 32 patients who underwent rib fixation were independently matched with conservatively managed patients. We then performed a retrospective re-audit to compare outcomes with the matched cohort study. The outcomes analysed were mortality, critical care length of stay (LOS)and total hospital LOS. Results Our initial study revealed a 33.4% reduction in mortality in patients over 55 years. There was also a reduction in average total hospital LOS by 4.5 days in patients under 55 years when comparing rib fixation to conservative management. The results also revealed an average of 4.1 days from admission to operation, 12.7 days of critical care LOSand 29.1 days of total hospital LOS. The re-audit showed improvements in all outcomes. Time from admission to fixation was reduced to 2.1 days, critical care LOS was reduced to 7.5 daysand total hospital LOS was reduced to 20.7 days. Conclusions Reduced mortality and LOS reinforceevidence that rib fixation improves outcomes. The re-audit shows that patients are identified for fixation sooner, which is important as the evidence has not identified optimal time for fixation. LOS further decreased in our re-audit, which indicates that earlier fixation results in patients avoiding the sequelae of rib fractures.

Chest Wall Injuries in Athletes

Chest Wall Injuries in Athletes

Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1).

Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions. A retrospective registry evaluation of all patients (age > 15years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis. Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001). Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.

Timing of regional analgesia in elderly patients with blunt chest-wall injury

BackgroundRib fractures represent a typical injury pattern in older people and are associated with respiratory morbidity and mortality. Regional analgesia modalities are adjuncts for pain management, but the optimal timing for their initiation remains understudied. We hypothesized that early regional analgesia would have similar outcomes to late regional analgesia. MethodsWe retrospectively reviewed the American College of Surgeons Trauma Quality Improvement Program database from 2017 to 2019. We included patients ≥65 years old admitted with blunt chest wall trauma who received regional analgesia. We divided patients into 2 groups: (1) early regional analgesia (within 24 hours of admission) and (2) late regional analgesia (>24 hours). The outcomes evaluated were ventilator-associated pneumonia, mortality, unplanned intensive care unit admission, unplanned intubation, discharge to home, and duration of stay. Univariable analysis and multivariable logistic regression adjusting for patient and injury characteristics, trauma center level, and respiratory interventions were performed. ResultsIn the study, 2,248 patients were included. The mean (standard deviation) age was 75.3 (6.9), and 52.7% were male. The median injury severity score (interquartile range) was 13 (9–17). The early regional analgesia group had a decreased incidence of unplanned intubation (2.7% vs 5.3%, P = .002), unplanned intensive care unit admission (4.9% vs 8.4%, P < .001), and shorter mean duration of stay (5.5 vs 6.5 days, P = .002). In multivariable analysis, early regional analgesia was associated with decreased odds of unplanned intubation (odds ratio, 0.58; 95% confidence interval, 0.36–0.94; P = .026), unplanned intensive care unit admission (odds ratio, 0.60; 95% confidence interval, 0.041–0.86; P = .006), and increased odds of discharge to home (odds ratio, 1.27; 95% confidence interval, 1.04–1.55; P = .019). After multivariable adjustment, no significant difference was found for ventilator-associated pneumonia or mortality (odds ratio, 0.60; 95% confidence interval, 0.34–1.04; P = .070). ConclusionEarly regional analgesia initiation is associated with improved outcomes in older people with blunt chest wall injuries. Geriatric trauma care bundles targeting early initiation of regional analgesia can potentially decrease complications and resource use.

Costal margin injuries and trans-diaphragmatic intercostal hernia: Presentation, management and outcomes according to the Sheffield classification.

Costal margin rupture (CMR) injuries are under-diagnosed and inconsistently managed, while carrying significant symptomatic burden. We hypothesized that the Sheffield Classification system of CMR injuries would relate to injury patterns and management options. Data were collected prospectively between 2006 and 2023 at a major trauma center in the United Kingdom. Computed tomography scans were interrogated and injuries were categorized according to the Sheffield Classification. Clinical, radiologic, management and outcome variables were assessed. Fifty-four patients were included in the study. Intercostal hernia (IH) was present in 30 patients and associated with delayed presentation ( p = 0.004), expulsive mechanism of injury (i.e. such as occurs with coughing, sneezing, or retching), higher body mass index ( p < 0.001), and surgical management ( p = 0.02). There was a bimodal distribution of the level of the costal margin rupture, with IH Present and expulsive mechanism injuries occurring predominantly at the ninth costal cartilage, and IH Absent cases and other mechanisms at the seventh costal cartilage ( p < 0.001). There were correlations between the costal cartilage being thin at the site of the CMR and the presence of IH and expulsive etiology ( p < 0.001). Management was conservative in 23 and surgical in 31 cases. Extrathoracic mesh IH repairs were performed in 3, Double Layer Mesh Repairs in 8, Suture IH repairs in 5, CMR plating in 8, CMR sutures in 2, and associated Surgical Stabilization of Rib Fractures in 11 patients. There was one postoperative death. There were seven repeat surgical procedures in five patients. The Sheffield Classification is associated statistically with presentation, related chest wall injury patterns, and type of definitive management. Further collaborative data collection is required to determine the optimal management strategies. Therapeutic/Care Management; Level III.

Analysis of diagnoses of chest injuries in a Nigerian trauma center.

Chest injury is one of the most common types of trauma-related injuries accounting for about 10% of trauma admissions in emergency services. The injuries may be immediate, life-threatening, or potentially life-threatening based on diagnosis after initial assessment. This study is intended to analyze the pattern of diagnosis found in chest-injured patients in a trauma center of a developing country. This is a retrospective study carried out in the trauma center of the National Hospital Abuja, Nigeria, between January 2015 and December 2017, as an analysis of the existing trauma registry. Data procession was done using SPSS version 24.0. Results were presented in tables and figures. A total of 637 patients' data was studied, male to female ratio of 3.58 and mean age of 34.18 ± 11.34 years. More patients sustained isolated chest injury (59.5%) and blunt chest injury (78%). The most frequent diagnosis was chest wall soft tissue injury (CWSTI) (46.6%) despite the exclusion of minor chest wall injuries who did not require any form of observation. Haemothorax and rib fractures were the next most common diagnoses after CWSTI constituting 13.5% and 8.7%, respectively, while flail chest and aortic injuries were the least comprising 0.6% and 0.2%, respectively. The commonest associated injuries were traumatic brain injury (11.3%), extremity fractures (11.1%), and abdominal injuries (7.8%). Penetrating injuries were more significantly associated with male gender and isolated chest injuries (P < 0.001). Chest wall soft tissue injuries constitute a large proportion of chest injuries seen in our setting. Despite its relatively low importance in the medical literature, it should be given attention in resource-poor settings in order to minimize missed significant injuries in the absence of diagnostic facilities. Therefore, high index of suspicion and low threshold for observation should be practiced in this group of patients.

An impressive case of isolated thoracic impalement

A 61-year-old male construction worker was admitted to our Emergency Department due to being impaled in the chest after fall onto the long pole of his cement mixer. He was promptly scanned through the CT then transferred to theatre where unique technique for intubation was utilised prior to performing a Video Assisted Thoracoscopic Surgery exploration and extraction of the foreign object.Impalement injuries are classified into Types I or II depending on the direction of movement of the human body in relation to the foreign object. There currently is no consensus on the best management of chest wall injuries involving impalements. Our case utilised Video Assisted Thoracoscopic Surgery as the dominant method of intervention together with highly skilled anaesthetic preparation.The combined expert anaesthetic and surgical approach utilised collectively had a role in ensuring the best possible outcome for the patient.

Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials.

Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD -4.34, 95% CI -6.98, -1.69; p < 0.01; I2 = 87%; GRADE: very low; PI -13.51, 4.84); length of intensive care unit stay (WMD -4.62, 95% CI -7.19, -2.05; p < 0.01; I2 = 78%; GRADE: low; PI -12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD -5.39, 95% CI -11.38, -0.60; p = 0.08; I2 = 89%; GRADE: very low; PI -11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.

Injury pattern and clinical outcome in patients with and without chest wall injury after cardiopulmonary resuscitation.

Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI. This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied. Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0-43] vs. 3 [0-22]; p = 0.430), ICU-LOS (3 [0-48] vs. 3 [0-24]; p = 0.427), and H-LOS (5.5 [0-85] vs. 9.0 [1-53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007). Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI. Prognostic and Epidemiological; Level IV.

Clavicle fixation to reduce short-term analgesia and improve respiratory function in patients with chest wall injuries

IntroductionThe objective of this study was to determine if operative fixation of clavicle fractures in patients with non-operatively treated ipsilateral rib fractures is associated with a lower overall analgesic requirement and improved respiratory function.Materials and methodsA retrospective matched cohort study was conducted involving patients admitted to a single tertiary trauma centre having sustained a clavicle fracture with ipsilateral rib fracture/s between January 2014 and June 2020. Patients were excluded if brain, abdominal, pelvic, or lower limb trauma was identified. 31 patients with operative clavicle fixation (study group) were matched 1:1 to 31 patients with non-operative management of the clavicle fracture (control group) based on age, sex, number of rib fractures and injury severity score. The primary outcome was the number of analgesic types used, and the secondary outcome was respiratory function.ResultsThe study group required a mean of 3.50 types of analgesia prior to surgery which decreased to 1.57 post-surgery. The control group required 2.92 types of analgesia, reducing to 1.65 after the date of surgery in the study group. A General Linear Mixed Model indicated that the intervention (operative vs. non-operative management) had statistically significant effects on the number of required analgesic types (p < 0.001, eta_{{text{p}}}^{2} = 0.365), oxygen saturation (p = 0.001, eta_{{text{p}}}^{2} = 0.341, 95% CI 0.153–0.529) and temporal decline in daily supplemental oxygen requirement (p < 0.001, eta_{{text{p}}}^{2} = 0.626, 95% CI 0.455–0.756).ConclusionThis study supported the hypothesis that operative clavicle fixation reduces short-term in-patient analgesia use and improves respiratory parameters in patients with ipsilateral rib fractures.Level of evidenceLevel III therapeutic study.

Penetrating combat-related thoracic trauma (review)

Objective — to study in detail the mechanisms and to investigate the imaging manifestations of combat-related penetrating thoracic injuries.&#x0D; Materials and methods. To perform the work, a literature search was provided according to the criterion «Thoracic penetrating combat-related trauma». 32 literary sources were selected for this request. Frag­ments of the clinical experience described in the literature according to the selected sources were illustrated by our own clinical cases of patients who were treated in Kharkiv medical institutions in 2022 for penetrating combat-related thoracic injuries.&#x0D; Results and discussion. Among victims who received chest injuries, polytrauma was most often diagnosed, complicated by several mechanisms of injury associated with penetrating, blunt, and explosive injuries. Pneumothorax and pulmonary contusion were the most common chest injuries. Thoracic injuries, thoracic vascular injuries, and lung ruptures were associated with the highest mortality rates, whereas pulmonary contusions, pneumothorax, and chest wall injuries were associated with relatively lower mortality rates. Chest X-ray is the first-line imaging method during the initial assessment of thoracic trauma in combat and non-combat situations. Such an examination is particularly important in polytrauma situations where multiple fatal injuries can be rapidly diagnosed in order to rapidly triage and include such an injury in the initial evaluation. Tension pneumothorax, large hemothorax, chest fragmentation, and some other lesions can be quickly diagnosed with a portable chest X-ray. Computed tomography (CT) of the chest is an important component of the comprehensive trauma evaluation, which allows to diagnose life-threatening injuries in hemodynamically stable patients with suspected multiple injuries not identified on chest X-ray. Chest CT detects 20 % more pathologies compared to chest X-ray.&#x0D; Conclusions. Combat-related thoracic trauma continues to be a significant contributor to the mortality rates of those injured in military operations. A clear injury pattern and atypical imaging manifestations of thoracic trauma are important to recognize at an early stage because of the acuteness of this category of patients and the impact of an accurate diagnosis on clinical management. Chest X-ray remains the main diagnostic tool. However, in modern and well-equipped institutions, chest CT, video-assisted thoracoscopy, and ultrasound scanning of the abdominal and chest cavity play an important role in the diagnosis of thoracic trauma. Quick and high-quality diagnosis and treatment are possible only in direct cooperation between surgeons and radiologists.

Changes to breast structure and function across a woman's lifespan: Implications for managing and modeling female breast injuries

BackgroundFemale breasts change throughout a woman's life in response to fluctuating hormonal influences. Individuals managing active women and those modeling female breasts must understand these structural and functional changes across a female's lifespan because these changes affect breast injuries sustained by women. MethodsWe initially review female breast structure and function and then describe how breast structure changes across a woman's lifespan. Key studies about direct contact and frictional breast injuries are then summarized. Limitations of current breast injury research, gaps in knowledge about breast injuries incurred by specific populations, and the lack of breast injury models are also highlighted. FindingsWith minimal anatomical protection, it is unsurprising that breast injuries occur. Although research about breast injuries is scant, direct contact during blunt force trauma to the anterior chest wall and frictional breast injuries have been reported. There is a lack, however, of research documenting the incidence and severity of breast injuries incurred in occupational settings and in women's sports. Therefore, to design effective breast protective equipment, we recommend research to model and investigate the mechanisms and forces involved in breast injuries, particularly injuries sustained during sport. InterpretationThis unique review summarizes how female breasts change over a woman's life span, with implications for breast injuries sustained by females. Knowledge gaps about female breast injuries are highlighted. We conclude by recommending research required to develop evidence-based strategies to improve how we classify, prevent, and clinically manage breast injuries sustained by females. SummaryWe review changes to the breast across a woman's lifespan, highlighting implications for managing and modeling female breast injuries.

Focused transoesophageal TOE (fTOE): A new accreditation pathway.

The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.

In- and out-of-hospital outcomes following surgical stabilization of rib fractures in 80 years and older: A single-institution experience

BackgroundSurgical stabilization of rib fractures (SSRF) has demonstrated benefit in patients with flail chest and multiple displaced fractures. There is mounting evidence for SSRF following chest wall injury (CWI) for the geriatric trauma population. A recent multi-center retrospective study highlighted a mortality benefit even for those patients aged 80 years and older. The objective of this investigation was to review our institutional experience with both in- and out-of-hospital outcomes within this patient population following SSRF. MethodsA retrospective review of patients 80 years and older was performed at a high-volume level 2 trauma center from 2017 to 2021. SSRF volume is routinely >60 cases per year. Perioperative, inpatient, and outpatient data were collected as available. Primary outcomes were inpatient and 90-day mortality. Secondary outcomes included discharge on narcotics and freedom from narcotics at 30 days. Results50 patients were included for review. Mean age was 86 years and mechanism of injury was most often fall. 28 of 50 (56%) patients had flail chest (radiographic). Mean number of ribs fixated was 4.7 and time to surgery 2.5 days. Inpatient mortality was 3/50 (6%), 90-day mortality was 9/50 (18%) of which three were attributable primarily to CWI (6/50, 12%). Of patients with follow-up of 1 year and beyond, 27/28 were alive (96%). With respect to narcotic consumption, 45% (21/47) were discharged on narcotics with 90% (28/31; N limited by missing data) being narcotic-free at 30 days. ConclusionIn this high-risk patient population, inpatient mortality was comparably low to prior reports, though 90-day mortality was doubled when incorporating CWI-related deaths. Narcotic use was seen in the minority of patients upon discharge, and most progressed to being narcotic-free at 30 days post-hospitalization. Inpatient outcomes alone may not adequately define both the benefit and risk of SSRF performed in patients 80 years and older.

Chest Wall Injury Society Recommendations for Management of Surgical Site or Implant-Related Infections After Surgical Stabilization of Traumatic Rib or Sternal Fractures.

Background: Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involves open reduction and internal fixation of fractures with an implantable titanium plate to restore and maintain anatomic alignment. The presence of this foreign, non-absorbable material presents an opportunity for infection. Although surgical site infection (SSI) and implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for management of SSIs or implant-related infections after SSRF or SSSF. PubMed, Embase, Web of Science and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF who develop an SSI or an implant-related infection, there is insufficient evidence to suggest a single optimal management strategy. For patients with an SSI, systemic antibiotic therapy, local wound debridement, and vacuum-assisted closure have been used in isolation or combination. For patients with an implant-related infection, initial implant removal with or without systemic antibiotic therapy, systemic antibiotic therapy with local wound drainage, and systemic antibiotic therapy with local antibiotic therapy have been documented. For patients who do not undergo initial implant removal, 68% ultimately require implant removal to achieve source control. Conclusions: Insufficient evidence precludes the ability to recommend guidelines for the treatment of SSI or implant-related infection following SSRF or SSSF. Further studies should be performed to identify the optimal management strategy in this population.