Left Rib Fractures Research Articles

Posttraumatic aortic regurgitation and root pseudoaneurysm following blunt chest trauma: a case report

BackgroundThe simultaneous diagnosis of severe aortic regurgitation and aortic root pseudoaneurysm resulting from traffic injury is extremely rare. This report presents the case of a patient with Marfan syndrome who experienced aortic root pseudoaneurysm and subacute severe aortic regurgitation following a traffic accident.Case presentationA 64-year-old woman was diagnosed with Marfan syndrome 16 years ago and is undergoing ongoing follow-up at an outpatient clinic. Eight years previously, the patient underwent total arch replacement combined with J-graft open stent graft® (JGOS; Japan Lifeline Co., Tokyo, Japan) deployment for acute type A dissection. Five months before presentation, the patient suffered a left rib fracture in a traffic accident and received conservative management at a local hospital. The patient presented to the emergency room with worsening shortness of breath and orthopnea. Echocardiography revealed severe aortic regurgitation and moderate tricuspid regurgitation. Computed tomography revealed new-onset pseudoaneurysm at the aortic root. Surgical repair was successfully performed using a modified Bentall procedure with a bioprosthetic valve and tricuspid annuloplasty. Intraoperative findings revealed pseudoaneurysm with perforation of the right sinus of Valsalva. Although the left and right aortic valve leaflets were normal, the noncoronary leaflet exhibited a ruptured fibrous strand of a cusp fenestration, resulting in acute aortic regurgitation.ConclusionsThis case report highlights the rare occurrence of aortic root pseudoaneurysm and subacute aortic regurgitation following a traffic accident. In cases of blunt chest trauma, particularly in patients with Marfan syndrome, frequent examination is crucial to assess the possibility of posttraumatic aortic regurgitation and aortic injury.

Laparoscopic repair of a traumatic diaphragmatic hernia with repeated colon incarcerations 7 years after injury: a case report

BackgroundA diaphragmatic hernia is a prolapse of the abdominal organs into the thoracic cavity through a hole in the diaphragm. Traumatic diaphragmatic injuries are rare and usually occur after blunt or penetrating thoracic or abdominal traumas. Blunt diaphragmatic rupture rarely accounts for immediate mortality and may go clinically silent until complications occur which can be life threatening. It usually present late with intrathoracic herniation of abdominal viscera and carry a high mortality rate. We experienced a very rare case who showed repeated colon incarcerations 7 years after injury. And, we operated laparoscopically.Case presentationA 64-year-old man presented with multiple left rib fractures that occurred during an accident. After 7 years, he visited the emergency department with the chief complaint of left shoulder pain and epicardial pain after eating. He was diagnosed with transverse colon incarceration due to a left diaphragmatic hernia by computed tomography (CT) and X-ray imaging. Surgical repair was recommended, but he refused as the symptoms improved. Fourteen months later, the patient revisited the hospital in similar symptoms and improved spontaneously. He consulted our hospital for the surgical indication. We recommended that he undergo surgery, showing images of the X-ray and CT when his transverse colon was obstructed and he felt pain and when symptoms improved. Finally, he decided to undergo surgery. We performed diaphragmatic hernia repair with laparoscopic direct suturing in good view. The patient experienced an uneventful postoperative recovery period. The absence of diaphragmatic herniation recurrence was confirmed seven months after surgery.ConclusionsWe experienced a traumatic diaphragmatic hernia with repeated colon incarcerations 7 years after injury and performed surgical repair laparoscopically.

Fracture of the Second Rib: An Indirect Sign of Serious Trauma Like Fracture of the First Rib?

The first 3 ribs are anatomically well-protected, shielded by the large thoracic muscles, the shoulder girdle, and the arm. A significant force is required to fracture these ribs; thus, such fractures suggest a high-energy trauma and are associated with injuries to vital organs of the thorax, such as the aorta, the heart, the lungs and the great vessels. A retrospective analysis was conducted over a 10-year period at a single hospital. The study assessed patients with fractures of the second rib, including their concurrent injuries and the overall severity of their trauma. Among the 76 patients included in the study, the average age was 47.35 years, 81.5% were men, and 19.5% were women. Thirteen patients (17.1%) survived their injuries. The most common causes of injury were road traffic accidents (63%) and pedestrian injuries (22%). The patients who did not survive sustained injuries to an average of 5 additional organs, while survivors had injuries to an average of 2.07 additional organs. Left rib fractures were the most frequently observed (46%). The most serious concurrent injuries reported were to the aorta (5.26%), heart (10.52%), lung (52.36%), head (57.89%), liver (30.2%), spleen (26.31%), and kidney (17.1%). As indicators of serious injury to vital endothoracic organs, isolated fractures of the second rib should be considered equal to first rib fractures in clinical importance.

Left rib fractures during cardiopulmonary resuscitation are associated with hemodynamic variations in a pig model of cardiac arrest

BackgroundChest compressions (CC) are the cornerstone of cardiopulmonary resuscitation (CPR). But CC are also known to cause injuries, specifically rib fractures. The effects of such fractures have not been examined yet. This study aimed to investigate hemodynamic effects of rib fractures during mechanical CPR in a porcine model of cardiac arrest (CA). MethodsWe conducted a retrospective hemodynamic study in 31 pigs that underwent mechanical CC. Animals were divided into three groups based on the location of rib fractures: No Broken Ribs group (n = 11), Left Broken Ribs group (n = 13), and Right Broken Ribs group (n = 7). Hemodynamic measurements were taken at 10 seconds before and 10, 30, and 60 seconds after rib fractures. ResultsBaseline hemodynamic parameters did not differ between the three groups. Systolic aortic pressure was overall higher in the Left Broken Ribs group than in the No Broken Ribs group at 10, 30, and 60 seconds after rib fracture (p = 0.02, 0.01, and 0.006, respectively). The Left Broken Ribs group had a significantly higher right atrial pressure compared to the No Broken Rib group after rib fracture (p = 0.02, 0.01, and 0.03, respectively). There was no significant difference for any parameter for the Right Broken Ribs group, when compared to the No Broken Ribs group. ConclusionAn increase in main hemodynamic parameters was observed after left rib fractures while right broken ribs were not associated with any change in hemodynamic parameters. Reporting fractures and their location seems worthwhile for future experimental studies.

Abstract #1412436: Nonclassical Presentation of Hypophosphatasia

Hypophosphatasia (HPP) is a rare genetic disorder characterized by impaired mineralization (calcification of bones and teeth). The signs and symptoms of HPP vary widely and can appear from birth to adulthood. We report a case of delayed bone fracture healing in the setting of hypophosphatasia. A 48-year-old male patient with a past medical history of vitamin D deficiency was seen in the outpatient clinic for low ALP levels. He had delayed wound healing involving the left clavicular and multiple rib fractures after a motor vehicle accident that occurred in 2012, which ultimately needed multiple surgeries requiring 1.5 years to fully heal/fuse. This involved placing and removing multiple plates and screws as well as bone grafts. He denied other fractures, skeletal deformities, or dental problems. He does have normal development and does not have short stature. He has a history of vitamin D deficiency and is on vitamin D 2000 units daily. He was found to have a family history remarkable with two sons with low ALP and vitamin D beginning in childhood. The older son was noted to have lost his teeth early at age 3-4 years, with no history of fractures. Musculoskeletal examination: no swelling noted, and no tenderness was noted but the patient did have a bone spur on the elbow, knee, and heel. He is able to ambulate without assistance and was found to have no other skeletal deformity. Laboratory findings: ALP 31 U/L (Normal 34-122). Bone-specific alkaline phosphatase: 5.6 ug/L (Normal 6.5-20.1). Vitamin D 25 OH level: 84 (on replacement therapy). Calcium: 9.2 mg/dl, phosphorus 3.5 mg/dl, iPTH levels 23 pg/ml. DXA scan: shows T values on the lumbar spine of -1.8, right hip of -1.4, and right neck of -1.9, consistent with osteopenia. We checked vitamin B6 level: 1087.7 nmol/L, consistent with hypophosphatasia. The patient then underwent genetic testing and is positive for ALPL gene mutation (heterozygous). Both his 2 sons are positive for ALPL gene mutation. We present a case of hypophosphatasia with nonclassical presentations, his mild symptoms likely from incomplete penetration. HPP causes pathogenic variants in ALPL gene. This gene provides instruction for making an enzyme called tissue non-specific alkaline phosphatase (TNSALP) which plays an essential role in the mineralization of the skeleton and teeth. Mutation in the ALP gene leads to the production of an abnormal version of TNSALP that cannot participate effectively in the mineralization process. There is currently no cure for hypophosphatasia, however human recombinant enzyme replacement therapy called asfotase alfa is now available.

Osteogenesis Imperfecta: One Disease, Two or More Faces: A Case Report

Being such a rare condition in paediatrics, osteogenesis imperfecta (OI) is not a diagnosis which is made often. It is however, a diagnosis necessitating early diagnosis and timeous and effective management to improve morbidity and increase the quality of life for our patients. We report two cases of osteogenesis imperfecta in this case report to highlight the different phenotypic presentations. Both of these patients are unique in their presentations and each case highlights the importance of a high clinical index of suspicion by the practitioner in making the diagnosis of osteogenesis imperfecta. The first case is a patient who was diagnosed with osteogenesis imperfecta on day one of life. She had disproportionate short stature, blue sclera, a small chest and bowing of her lower limbs with swellings and tenderness over both of her femurs. A babygram radiograph revealed multiple fractures, with the presence of callus formation at some fracture sites suggesting intrauterine fractures. The second case is a patient who had normal anthropometry and was well at birth. She was subsequently diagnosed at two weeks of age when she presented to the Chris Hani Baragwanath Academic Hospital with an E. coli meningitis and she was suspected to have a right clavicular fracture and possibly rib fractures as she had pain on palpation over these areas. She was noted to have no blue sclera. Subsequent X-rays confirmed a right clavicular fracture as well as left and right rib fractures at different stages of healing. A lateral skull radiograph revealed Wormian bones. With no available genetic testing in South Africa, both diagnoses were made clinically. Both of our patients were started on zoledronic acid at three months of age and were followed up by the Metabolic Unit at the Chis Hani Baragwanath Academic Hospital. This case report of two patients highlights the characteristics important in diagnosing and treating this uncommon condition with varying phenotypical presentations, thus ensuring that the diagnosis is not missed or misdiagnosed: one disorder, two different faces.

Foot Drop after Hip Surgery – An Anaesthetic Perspective

To the Editor, Foot drop is characterized by reduced muscle strength in the ankle dorsiflexors and inability to lift the forefoot. Foot drop occurring after an orthopedic procedure can occur due to various causes [1-5] (Figure 1). Epidural anaesthesia may sometimes attract undue attention in such a situation and presence of an epidural air pocket does not rule it out altogether as a cause. We describe an algorithmic approach to investigate the cause of foot drop after acetabular surgery performed under combined spinal-epidural anaesthesia. A 35-year-old male, American Society of Anesthesiologists’-physical status (ASA-PS) II patient admitted with an alleged history of road-traffic accident and left acetabulum and 3rd–5th left rib fractures and hemothorax. He was initially managed for hypovolemic shock and mechanically ventilated for three days in the intensive care unit. The acetabular fracture was stabilized with tibial skeletal traction under local anesthesia. After hemodynamic stabilization, and an ICU stay duration of five days, he was planned for an acetabular fracture repair by posterior approach under combined spinal epidural anaesthesia. The preoperative evaluation and patient preparation were done as per institutional guidelines. Under aseptic precautions, combined spinal anaesthesia was applied in sitting position and midline approach at L3–L4 interspace. Epidural anaesthesia was given using 18 G Tuohy’s needle using the loss of resistance to 3 ml air at a depth of 5 cm and catheter fixed at 11 cm. The spinal anaesthesia was given with 26 G in the same lumbar space, with a clear flow of cerebrospinal fluid and 15 mg of 0.5% bupivacaine (hyperbaric) was given. The procedures were uneventful, and the patient did not report any paresthesia. The duration of surgery was 210 minutes, and 0.5% bupivacaine 5 mL was administered after 2 hours. The intraoperative period was uneventful. The postoperative analgesia was managed with epidural 0.125% bupivacaine (isobaric) with 2 μg/ml fentanyl infusion at 0.05–0.1 ml/kg/hour. On the second postoperative day, on initiating passive limb physiotherapy, the patient complained of difficulty in upward movement of ankle joint of operated limb. The clinical examination and investigations are depicted in Figure 2. A non-contrast computed tomography of the spine showed air pockets in the lumbar epidural space without hematoma (Figure 3). Initially, the epidural air pocket was considered the cause. However, this was unlikely due to the unilateral and singular peripheral nerve involvement. The diagnosis of left deep peroneal nerve injury that could have occurred due to tibial pin was made. He was initiated on limb physiotherapy and foot drop splint was applied. He was discharged with tablet diclofenac 50 mg 8th hourly and vitamin B12. On follow-up, 7 days after discharge with good physiotherapy and regular medications the patient had regained full power of dorsi-flexion.

1300: TWO CASES OF MULTIPLE TRAUMA PATIENTS WITH SEVERE CHEST TRAUMAS TREATED STRATEGICALLY USING VV ECMO

Introduction: VV-ECMO is widely used for severe respiratory failure due to endogenous diseases. Alternatively, there is little experience with its use for chest traumas. In this report, we describe two cases of severe chest traumas in which VV-ECMO was introduced and saved the patient’s life. Description: Case 1: A man in his 20s was injured in a collision accident with a passenger car while riding on the rear seat of a motorcycle. He was diagnosed with multiple left rib fractures, left hemopneumothorax, bilateral lung contusions, thoracolumbar rupture fracture, and left humerus fracture. The patient was intubated, and a left thoracic drain was inserted. The respiratory condition of the patient worsened because of increased subcutaneous emphysema caused by bronchial injury and bleeding in the airway; therefore, VV-ECMO was introduced on the third day. The bronchial injury was healed conservatively, and the patient was weaned off from VV-ECMO on the 10th day after spontaneous respiration was eliminated during respiratory support with VV-ECMO. The patient was transferred to the hospital on the 42nd day. Case 2: A man in his 70s was injured when his chest was caught in a commercial elevator. He was diagnosed with bilateral hemopneumothorax, tracheobronchial injury, aortic injury, 5th thoracic vertebra dislocation, and multiple rib fractures. Tracheal intubation and bilateral thoracic drains were inserted, and TAE was performed for multiple vascular injuries, including the internal thoracic artery. The VV-ECMO was performed on the same day because of the patient’s massive hemothorax and worsening respiratory condition due to bronchial injury. Thoracic endovascular aortic repair, bronchial repair, and posterior thoracic fusion were performed with a sufficient respiratory support by VV-ECMO. Furthermore, the patient was weaned off from VV-ECMO on the 24th day. The patient was transferred to the hospital on the 53rd day. Discussion: These experiences demonstrated that ECMO is useful not only for endogenous diseases but also for chest traumas. Currently, there is no fixed opinion on the treatment strategies including surgeries and the anticoagulants use under VV-ECMO. Therefore, decisions must be made on a case-by-case basis.

Management of Rib Avascular Necrosis Complicated by Osteomyelitis in a Patient With Sickle Cell Anemia

Abstract Introduction Avascular necrosis of the rib is a rare presentation of sickle cell anemia's vaso-occlusive crisis. This report describes the case of a 45-year-old man known to have sickle cell anemia presenting with rib avascular necrosis complicated by osteomyelitis. The patient came to the outpatient department with left lateral chest wall pain. Antibiotics produced no improvement. A computed tomography scan of the chest revealed a left sixth rib fracture with a thick fluid collection consistent with pus. The patient was taken to surgery and underwent necrotic bone debridement and pus drainage. The patient showed improvement and became afebrile after the surgery. Conclusion The lack of distinct clinical indicators and low occurrence of rib avascular necrosis can lead to misdiagnosis and mismanagement of the disease.

Evaluation of Traumatic Vertebra and Rib Fractures

Background: In our study, we aimed to examine the relationship between trauma-related thoracic vertebral fractures and/or rib fractures location, age and gender. Methods: Between January 1, 2020 and December 31, 2020, 100 patients with trauma-related thoracic vertebral fracture and/or rib fracture were included in the study. Rib fractures and thoracic vertebral fractures were analyzed according to age, gender, level and fracture type. The correlation between rib and vertebral fractures was investigated. Results: 72% of the patients were male and 28% were female, mean age was 48.49 ± 18.83. Thoracic vertebral corpus fractures were detected most frequently in T8 in 22 patients and in T1 in at least 1 patient. Spinous process fracture was found to be highest in T2 with 9 patients, and 1 patient each in T5, T6, and T12. Transverse processes fracture was seen in T9 with a maximum of 5 patients. Rib fractures were observed more frequently on the right. Displaced rib fractures were most common in the 6th and 7th ribs, and non-displaced rib fractures were observed in the 5th ribs with 9 patients. Left rib fractures were most common in the 5th rib, with 6 displaced patients and 8 non-displaced patients. When the thoracic vertebral fractures and rib fractures were examined depending on the age variable, it was determined that the fractures in the T2 spinous, T3 spinous, T5 corpus and T8 vertebral corpus, and rib fractures in the right 4,6,8,10 and left 2 and 4 differ depending on the age variable (p<0.05). When thoracic vertebral fractures and rib fractures were analyzed depending on gender, a correlation was found between T7 vertebral body fractures and left 6th rib fractures (p<0.05). Conclusion: The coexistence of vertebral and rib fractures should be kept in mind in trauma patients, and plans for diagnosis and treatment should be made accordingly.

Association of thoracic cage fractures and pericardial effusion in blunt trauma.

Several case reports suggest that penetrating thoracic cage fractures are an important cause for hemopericardium and cardiac tamponade following blunt trauma. However, the prevalence of this mechanism of injury is not fully known, and considering this association may provide a better understanding of the utility of cardiac component of the FAST (Focused Assessment with Sonography for Trauma). To determine the association of thoracic cage fractures and pericardial effusion in patients with blunt trauma. We performed a retrospective, multicenter cohort study using the Trauma Quality Improvement Program (TQIP) database (2015-2017) of adults ≥18years of age whose mechanism of injury was either a fall or motor vehicle accident. Thoracic cage fractures were defined as any rib or sternum fracture. The primary outcome was the presence of pericardial effusion. Confounding variables were accounted for using multivariable logistic regression. We included 1,673,704 patients in the study; 226,896 (14%) patients had at least one thoracic cage fracture. A pericardial effusion was present in 4923 (0.3%) patients. When a thoracic cage fracture was present, the odds of having a pericardial effusion was significantly higher (adjusted Odds Ratio [aOR] 6.5 [95% CI: 6.1-7.0]). Patients with left and right-sided rib fractures had similar odds of a pericardial effusion (aOR 1.2 [95% CI 1.04-1.4]). Sternal fractures carried the highest odds of having a pericardial effusion (aOR 11.1 [9.9-12.3]). Thoracic cage fractures secondary to blunt trauma represent a significant independent risk factor for the development of a pericardial effusion. Our findings lend support for the mechanism of bony injuries causing penetrating cardiac trauma. Given these findings, and the fact that many thoracic cage fractures are detected after the initial evaluation, we support maintaining the cardiac view in the FAST examination for all blunt trauma patients.

TRAUMATIC CHEST WALL INJURY WITH DIAPHRAGMATIC RUPTURE AND LUNG HERNIATION

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Traumatic diaphragmatic injuries are a rare injury that can occur after chest wall trauma. Injury to the diaphragm and its surrounding structures can easily be missed as the patients often have polytrauma. We present a case of a penetrating injury with blunt traumatic chest wall injury with diaphragm rupture and herniation of the left lung through the chest wall after a motorcycle collision. CASE PRESENTATION: A 24-year-old male presented to the hospital as a trauma alert after a motorcycle crash. The patient was found to have a large open chest wound with exposed lung and diaphragm. He was taken for CT imaging and found to have a left apical pneumothorax, left lung contusion, left rib fractures 2-10, and a grade 2 spleen laceration. The patient was taken for emergent exploration of his left chest wound. The patient was found to have disruption of his left chest wall and diaphragmatic attachments with rupture of the lateral aspect of his diaphragm at the level of rib 5-6. The wound was explored with evidence of injury to the left inferior lateral lobe of his lung. The lung did not require any resection. The entire left diaphragm was examined with the central tendon of the left diaphragm found to be intact, the diaphragm was repaired along the lateral edge and reattached to the costal cartilage laterally along the chest wall. The left chest was washed out and a chest tube was placed. The patients remaining hospital course was uneventful, and his chest tube was removed with no signs of air leaks. DISCUSSION: There are no specific signs of diaphragmatic injury or rupture on physical exam. Missed diaphragmatic injuries can result in major morbidity or mortality for the patient. All diaphragmatic injuries should be examined along with all surrounding structures at the time of diagnosis. Most diaphragmatic injuries occur on the left side as the right side is protected by the liver. We highly recommend CT imaging to examine the upper abdomen and chest. In the case of our patient which is rare, we were able to visualize his chest wall injury with his diaphragmatic injury on physical exam. When diagnosed early we recommend repair through the abdomen, but if found late repair through the chest is a better approach. In our case we were able to re-approximate the diaphragm to the chest wall. CONCLUSIONS: Traumatic injuries to the diaphragm can be tough to diagnose at times when there is not obvious injury noted to the diaphragm. We recommend full exposure of the diaphragmatic surface and examination of the surrounding organs and structures to rule out further injury that is not obvious on first examination. The diaphragm should be repaired and then reattached to the chest wall along its costal cartilage laterally. Complete repair with reattachment will allow the patient to avoid morbidity and mortality of a chronic diaphragmatic injury that could lead to impaired respiratory or chest wall function. REFERENCE #1: DeBarros, M., Martin, M.J. Penetrating Traumatic Diaphragm Injuries. Curr Trauma Rep 1, 91-101 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response No relevant relationships by Alyssa Ritchie, source=Web Response

Competency in Chest Radiography Interpretation by Junior Doctors and Final Year Medical Students at a Teaching Hospital.

Background Chest radiography (CXR) is a widely used imaging technique for assessing various chest conditions; however, little is known on the medical doctors' and medical students' level of skills to interpret the CXRs. This study assessed the residents, medical officers, house officers, and final year medical students' competency in CXRs interpretation and how the patient's clinical history influences the interpretation. Methods We conducted a cross-sectional study in the Cape Coast Teaching Hospital in the Central Region of Ghana among 99 nonradiologists, comprising 10 doctors in residency programmes, 18 medical officers, 33 house officers, and 38 final year medical students. The data collection was done with a semistructured questionnaire in two phases. In phase 1, ten CXRs were presented without patient's clinical history. Phase 2 involved the same ten CXRs presented in the same order alongside the patient's clinical history. Participants were given 3 minutes to interpret each image. Median and interquartile ranges were used to describe continuous variables, while frequencies and percentages were used to describe categorical variables. Test of significant difference and association was conducted using a Wilcoxon rank-sum test/Kruskal–Wallis test and chi-square (X2) test, respectively. Results The average score for interpreting CXRs was 7.0 (IQR = 5–8) and 4.0 (IQR = 3-4), when CXRs were, respectively, presented with and without clinical history. No significant difference was seen in average scores regarding the levels of formal training. Without clinical history, only 40.0% of residents, 22.2% of medical officers, 24.2% of house officers, and 13.2% of medical students correctly interpreted CXRs, while more than 75% each of all categories correctly interpreted CXRs when presented with clinical history. However, all participants had difficulties in identifying CXR with pneumothorax (27.3% vs. 30.3%), pneumomediastinum or left rib fracture (8.1% vs. 33.3%), and lung collapse (37.4% vs. 37.4%) in both situations, with and without patient clinical history. Conclusion The patient's clinical history was found to greatly influence doctors' competence in interpreting CXRs. We found a gap in doctors' and medical students' ability to interpret CXRs; hence, the development of this skill should be improved at all levels of medical training.

SHOT IN THE CHEST, SAVED BY THE HEART

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Situs inversus, a rare autosomal recessive condition, has an incidence of 1:6000 to 1: 12,000 live births. [1,2] This case presents a rare scenario in which a patient who sustained a gunshot wound to the left side of his chest was saved by his previously undiagnosed medical condition. CASE PRESENTATION: A 28-year-old male with no reported past medical history presented to hospital after sustaining a gunshot wound to his left chest. On arrival, he was alert and oriented with a GCS of 15. He complained of severe left sided chest pain. His EKG (Figure 1) was suggestive of dextrocardia with a right axis deviation and lead I demonstrating inversion of the P wave. Figure 1: The EKG shows lead 1 with a negative P wave axis and negative QRS complex, with AVF showing a positive QRS deflection. Chest x-ray was significant for a large left sided hemopneumothorax, left rib fractures (6/12), and a left sided pulmonary contusion (figure 1). He underwent medical stabilization and chest tube placement which can be seen in (figure 2). A CT of the abdomen (figure 3) showed a left sided liver with grade 3 laceration; he also had a grade 1 left renal laceration with free air above the kidney. His thoracic and abdominal imaging demonstrated evidence of situs inversus totalis. The patient underwent a laparotomy, including a hepatic laceration repair, with placement of a left sided chest tube which drained 400 ml of blood. Despite surgical intervention and having the chest tube for 7 days, the patient had persistent drainage despite broad spectrum antibiotic therapy. He then underwent video-assisted thoracoscopic surgery (VATS) for evacuation of retained hemothorax. The patient recovered and was discharged with rehabilitation. DISCUSSION: Dextrocardia is defined as a cardiac position that is a mirror image of normal position. Situs inversus totalis is when thoracic and abdominal viscera are reversed including dextrocardia. Physical examination is significant for the presence of right-sided heart sounds on auscultation, with the apical impulse located on the right side of the chest. In addition to the physical examination, EKG supports the diagnosis of dextrocardia. EKG will show right axis deviation, an inverted P-wave and QRS complex in lead I, dominant S waves in leads I and V1 to V6, and reversed R wave progression in the precordial leads. CONCLUSIONS: This is the first report of a gunshot wound to the chest saved by undiagnosed condition of situs inversus totalis with dextrocardia. It is astonishing that this patient is alive and recovering due to the rare condition of dextrocardia with situs inversus. Had this patient had standard anatomy, he would have most likely died as the bullet would have directly pierced the heart. Reference #1: 1. Blegen HM. Surgery in situ s inversus. Ann Surg. 1949;129:244–59. [PMC free article] [PubMed] [Google Scholar] Reference #2: 2. Bohun CM, Potts JE, Casey BM, Sandor GG. A population-based study of cardiac malformations and outcomes associated with dextrocardia. Am J Cardiol. 2007;100:305–9. [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Bryan Curry, source=Web Response no disclosure on file for Joseph Reimon; No relevant relationships by Benjamin Sinyor, source=Web Response No relevant relationships by Balarama Surapaneni, source=Web Response

AN ATYPICAL PRESENTATION OF CLASSICAL HODGKIN LYMPHOMA

TYPE: Abstract Publication TOPIC: Disorders of the Mediastinum PURPOSE: We describe a 27-year-old male with no past medical history presenting with pleuritic chest pain. The patient was vomiting and while retching, he felt a popping sensation in his substernal chest wall, soon followed by a severe, pleuritic substernal pain. Upon further investigation, he also complained of a 2-month history of early satiety, unintentional weight loss, and night sweats. He had a 10-year smoking history, however, he denied alcohol, illicit drug or steroid use, occupational exposure, recent travel, or a family history of cancer. METHODS: Physical examination revealed substernal tenderness, supraclavicular and axillary lymphadenopathy, and splenomegaly. CBC, CMP, troponin were unremarkable. Chest CTA revealed extensive osteolytic bony destruction with cortical breakthrough of the sternum anteriorly measuring 6.5cm, associated with a pathological sternum fracture. A left third rib fracture was also found. Also noted was a lobulated mass in the anterior right upper lobe, contiguous with mediastinal and right hilar lymphadenopathy. RESULTS: The chest pain was attributed to the sternum and rib fractures and managed conservatively. Auto-immune and malignancy-related investigations were unremarkable. Left axillary lymph node excision biopsy showed nodular sclerosis classical Hodgkin lymphoma. CONCLUSIONS: Despite the 2-month history of B symptoms described by our patient, he initially presented only due to the severe, sudden pleuritic chest pain caused by the pathologic osteolytic sternum and rib fractures. Our patient had no other identifiable cause for the fractures. CLINICAL IMPLICATIONS: Although pathologic fractures in lymphoma are not uncommon, upon review of the literature, Hodgkin lymphoma presenting with a pathologic sternum fracture appears to be extremely rare. DISCLOSURE: No significant relationships. KEYWORDS: hodgkin lymphoma, Pathologic sternum fracture

MON-370 Treatment of Parathyroid Storm in a Patient with Traumatic Brain Injury: A Reversible Comatose State

Background:Parathyroid storm, also known as parathyroid crisis, is a rare and under-recognized endocrine emergency due to severe hypercalcemia in patients with primary hyperparathyroidism. It is characterized by significantly elevated parathyroid hormone (PTH) levels even up to 20 times above the normal limit along with calcium levels >15 mg/dl, leading to multiorgan dysfunction, notably altered mental status and acute kidney injury. Risk of mortality is high without urgent parathyroidectomy. We describe a case of a patient with acute traumatic brain injury and parathyroid storm with PTH >1700 pg/ml (11-51) and Ca 15.4 mg/dl (8.6-10.4) in whom resection of a parathyroid adenoma reversed the comatose state.Clinical Case:Our patient is a 68 year-old male with no significant past medical history who sustained a fall off a 12-foot ladder complicated by right intracranial bleed s/p hemicraniectomy and multiple fractures, including left clavicle fracture with possible subclavian artery injury, left rib fractures, and right hip fracture s/p ORIF. The patient had a brief, partial improvement of mental status, followed by comatose state in the setting of rapidly rising calcium levels and acute kidney injury. In the setting of blood transfusions, the patient had an initial Ca of 8.8 mg/dl (8.6-10.4) on admission. The calcium levels rose over a week to 15.4 mg/dl with albumin of 2.4 g/dl (3.9-5.0), PTH levels from 953 pg/ml to >1700 pg/ml (11-51) after tracheostomy, and creatinine from 0.69 mg/dl to peak of 2.0 mg/dl (0.60-1.30). In spite of IV hydration, calcitonin, cinacalcet up to 90mg twice daily, pamidronate 60mg IV, and several sessions of hemodialysis, the patient’s calcium did not normalize, and the patient remained comatose. Other labs showed phosphorus nadir of 1.4 mg/dl (2.3-4.4), 25-OH VitD 13 ng/ml (20-50), 1,25-OH VitD 9.8 pg/ml (19.9-79.3), VitA 0.6 mg/L (0.3-0.9), PTHrP <2.0 pmol/L (0.0-2.3), normal SPEP/UPEP, and peak CK of 569 U/L (63-474). Sestamibi scan showed intense tracer uptake within a nodule near the suprasternal notch, and parathyroid 4D-CT showed a left 17mm pretracheal lesion with cystic degeneration along the superior margin of the manubrium. The patient subsequently underwent parathyroidectomy of an ectopic cystic mass with normalization of calcium and PTH levels. Pathology revealed a 0.8 gram, 1.5 x 1.0 x 0.3 cm enlarged, hypercellular parathyroid. The patient woke up from his comatose state immediately after surgery with progressive improvement in mental status back to baseline, other than left-sided weakness.Conclusion:Our case highlights the importance of surgical management as an effective cure for parathyroid crisis and underscores the associated critical and significant rise in calcium and PTH levels, which was resistant to medical treatment.

来院時心停止の蘇生後に偶然診断された肺癌の1例(A case of lung cancer in a patient diagnosed by chance after resuscitation of cardiopulmonary arrest on arrival)

要旨症例は76歳の男性。4日前に階段を転落した後からの左側胸部痛と呼吸苦を主訴に当院を独歩受診し，外来の廊下で突然卒倒した。目撃者により心停止を認識され，心肺蘇生を受けつつERに搬入。初期心電図波形は無脈性電気活動で，アドレナリン1mg静脈内投与と気管挿管を含む二次救命処置により自己心拍再開。蘇生後の胸部単純X線写真にて大量の左胸水貯留と縦隔右方偏位を認め，鈍的胸部外傷に伴う大量血胸と診断し，直ちに胸腔ドレナージを施行。中等度血性胸水2,100mLが排出され，バイタルサインは改善した。その後に撮影した単純CT画像にて左多発肋骨骨折を確認。ICU入室後，集中治療により意識・呼吸・循環は順調に回復し，第2病日に気管挿管チューブを抜管。第5病日に撮影した造影CT画像にて最大径46mmの左肺腫瘍と縦隔リンパ節・骨・副腎転移を認め，胸水細胞診の結果class Vと判定され，肺癌と診断。第7病日にICUを退室して呼吸器内科に転科，第64病日に神経学的後遺症なく転院となった。本症例の心停止は，癌性胸水が緩徐に貯留した状態に外傷性の血性胸水が負荷されたことにより緊張性胸水の状態となり，それまで代償性に維持し得ていた呼吸循環動態が破綻して閉塞性ショックと低酸素血症に陥ったことが原因のoncologic emergencyであったと推定された。

Complex chest wall injury and repair complicated by empyema

A 24-year-old man presented to the emergency department after blunt thoracic trauma. As a vested rider, he was competing in a rodeo bull riding competition when he was thrown and...

A paediatric case of severe tracheobronchial injury successfully treated surgically after early CT diagnosis and ECMO safely performed in the hybrid emergency room

BackgroundIn paediatric trauma patients, tracheobronchial injury can be a rare, life-threatening trauma. In 2011, we instituted a new trauma workflow concept called the hybrid emergency room (Hybrid ER) that combines a sliding CT scanning system with interventional radiology features to permit CT examination and emergency therapeutic intervention without moving the patient. Extracorporeal membrane oxygenation (ECMO) can lead to cannula-related complications. However, procedures supported by moveable C-arm fluoroscopy and ultrasonography equipment can be performed soon after early CT examination. We report a paediatric patient with tracheobronchial injury diagnosed by CT examination who underwent rapid resuscitation and safe installation of veno-venous (VV) ECMO in our Hybrid ER and was successfully treated by surgery.Case presentationA 11-year-old boy was admitted to our Hybrid ER suffering blunt chest trauma. His vital signs were unstable with low oxygen saturation. Early CT examination was performed without relocation. CT revealed bilateral hemopneumothorax, bilateral lung contusion, left multiple rib fractures, and right bronchus intermedius injury. Because his oxygenation was severely low with a PaO2/FiO2 ratio (P/F) of 109, he was at very high risk during transport to the operating room and changing to one-lung ventilation. Thus, we established VV ECMO in the Hybrid ER before we performed thoracotomy under left lung ventilation in the operating room. After the P/F ratio improved, he was transferred to the operating room under VV ECMO. We performed middle- and lower-lobe resection and sutured the stump of the right bronchus intermedius to treat the complete tear of this branch. After his respiratory function recovered, VV ECMO was removed on postoperative day 5. After in-patient rehabilitation, he was discharged home on postoperative day 68 without sequelae.Conclusions It is feasible to perform VV ECMO in the Hybrid ER, but one case does not conclude it is safe. In this case, the blood oxygenation improved, but there are no evidence to support the safety of the procedure or the advantage of ECMO initiation in the Hybrid ER rather than in the operating room.

MON-505 An Atypical Case of Osteoporosis Related to Pregnancy and Lactation

Background: Osteoporosis is rare in premenopausal patients without predisposing risk factors. A few case reports have described vertebral or hip fractures in young females due to pregnancy and lactation associated osteoporosis (PLAO). A proposed mechanism for PLAO is maternal bone resorption during pregnancy due to inadequate calcium stores to meet both maternal and fetal demands as well as hormone mediated trabecular bone demineralization to supplement calcium in maternal milk. We present a case of PLAO in a postpartum patient who suffered multiple atraumatic fractures of her vertebrae, clavicle, rib, and pelvic rami. To our knowledge, this is a unique combination of fractures that has not been previously reported. Clinical Case: A 38 year-old gravida 2 para 2 female presented for evaluation of back pain that started two months after she delivered her second child and while breastfeeding. Relevant past medical history included left hip chondrosarcoma that was treated with hemipelvectomy five years prior, with a concomitant diagnosis of right hip fracture while breastfeeding her first child. Subsequent imaging had been negative for chondrosarcoma recurrence or metastases. Prior to her first pregnancy, there was no history of trauma, glucocorticoid use, personal or family history of fracture, smoking, or alcohol use. Spinal imaging revealed vertebral compression fractures at T9, T12, and L5. Bone biopsies were negative for malignancy. Retrospective review of imaging after the first delivery and during lactation revealed incidental right clavicular and left rib fractures. Evaluation for secondary causes of osteoporosis, including total corrected calcium, ionized calcium, alkaline phosphatase, parathyroid hormone, thyroid-stimulating hormone, serum protein electrophoresis, and 24-hour urine cortisol were all normal. 25-OH vitamin D level was 30 (30-100 ng/mL), bone-specific alkaline phosphatase (BSAP) was elevated at 21.6 (range 5.3-19.5 mcg/L), and collagen type I c-telopeptide (sCTx) was 342 (range 60-650 pg/mL). DXA revealed Z scores of -2.9, -3.1, and -2.6 at the lumbar spine, femoral neck, and total hip respectively. Calcium carbonate-vitamin D 1000 mg-400 IU twice daily and breastfeeding cessation were recommended, followed by zoledronate 5mg IV. Three months later, BSAP and sCTx had decreased to 11.8 and 101 respectively. The patient has since been fracture free. Discussion: PLAO is exceedingly rare. Initial manifestations may include low trauma or atraumatic fractures of non-weight-bearing sites such as the clavicle. The diagnosis may be delayed due to the initial presentation of non-specific pain in an otherwise healthy female without risk factors. Increasing awareness and pursuing further research into the etiology of this disorder could lead to the development of appropriate guidelines for prevention of fractures in these patients.