Multiple Rib Fractures Research Articles

Admission Forced Vital Capacity Adds a Predictive Physiologic Tool to Triage Patients Suffering Rib Fractures: A Prospective Observation Trial.

Patients with rib fractures are at high risk for morbidity and mortality. This study prospectively examines bedside percent predicted forced vital capacity (% pFVC) in predicting complications for patients suffering multiple rib fractures. The authors hypothesize that increased % pFVC is associated with reduced pulmonary complications. Adult patients with =3 rib fractures admitted to a level I trauma center, without cervical spinal cord injury or severe traumatic brain injury, were consecutively enrolled. FVC was measured at admission and % pFVC values were calculated for each patient. Patient were grouped by % pFVC <30% (low), 30-49% (moderate), and =50% (high). A total of 79 patients were enrolled. Percent pFVC groups were similar except for pneumothorax being most frequent in the low group (47.8% vs. 13.9% and 20.0%, p = .028). Pulmonary complications were infrequent and did not differ between groups (8.7% vs. 5.6% vs. 0%, p = .198). Increased % pFVC was associated with reduced hospital and intensive care unit (ICU) length of stay (LOS) and increased time to discharge to home. Percent pFVC should be used in addition to other factors to risk stratify patients with multiple rib fractures. Bedside spirometry is a simple tool that can help guide management in resource-limited settings, especially in large-scale combat operations. This study prospectively demonstrates that % pFVC at admission represents an objective physiologic assessment that can be used to identify patients likely to require an increased level of hospital care.

Challenges in surgery of deep burns

Introduction. Full-thickness burns pose a significant challenge in terms of surgical management, particularly when concurrent trauma of other organs is involved. Traditional treatment of deep burns includes early excision or debridement of necrotic tissue, followed by skin grafting or flap reconstruction. There are numerous challenges such as poor overall general condition, polytrauma, questionable wound bed viability, limited donor sites. Thus, we have to consider skin substitutes. INTEGRAR is an acellular dermal substitute which creates a native dermis. The aim of this case was to share our experience of the treatment by skin substitutes in a polytraumatized burn patient. Case outline. We present a case report of a 46-year-old man with severe work-related contact burn wounds associated with multiple rib and vertebral fractures, as well as lungs contusion with localized bilateral hemothorax. Patient suffered from third-degree burns to the lower extremities, extending to scrotal and gluteal area, which included 15% of the total body surface area. The patient underwent early excision of necrotic tissues with subsequent skin autografting on the right leg; however, due to partial failure of autografts, we had to perform allografting followed by autografting because of limited local donor sites and poor general condition. Successive debridement and partial osteotomy resulted in the left knee defect with exposed patella. Therefore, in order to reconstruct the consequent defect and prevent joint contracture, the defect was finally covered by INTEGRAR. Conclusion. Our experience has highlighted that INTEGRAR prevents functional disability and furthermore, it leads to optimal aesthetic results.

Spontaneous fractures and hypocuprosis in pen-backgrounded Holstein calves

Bone fractures are a frequent cause of limp in cattle, being pre-existing bone lesions among the predisposing factors. However, there is scant information about the natural occurrence of bone disease. This report aimed to describe an outbreak of spontaneous fractures associated with hypocuprosis in pen-backgrounded calves. Hind limp and irreversible recumbency were noticed in 9-month-old calves of a dairy farm from Córdoba province (Argentina). The issue was only evident in males fed a diet composed (DM) of 57% wet corn, 24% dry corn distiller grains, and 19% corn silage. No mineral mix was supplied. Accumulated morbidity and fatality rates were 5.8 and 100%, respectively. Two autopsies were performed, observing multiple femoral and rib fractures. Severe hypocupremia, very low copper levels in the liver and plasma, deficient dietary copper levels, normocalcemia, marginal hypophosphatemia, and high sulfate concentrations in the water supply were determined. Except for the decreased bone quantity and the multiple fractures, no bone lesion was observed, confirming osteoporosis as the pathological diagnosis, and hypocuprosis as the etiology.

Aortic Injury in Blunt Trauma: Stay Sharp to Save Lives

A 21-year-old lady presented following a high velocity road traffic accident as a pillion rider. She was hemodynamically stable at presentation and complained of chest pain which was considered to be due to the multiple rib fractures she had sustained. However, a computed tomography of the thorax showed a Society for Vascular Surgery Grade II aortic injury for which she underwent endovascular repair. This case reviews the various presentations of blunt trauma associated aortic injuries and the implications of emergent management.

Prospective study on incidence of adult respiratory distress syndrome in blunt injury chest

Background: This study was done to find out prospectively the incidence of adult respiratory distress syndrome (ARDS) in a random group of patients sustaining blunt trauma to the chest of any etiology and to study the factors involved in its causation and outcome.Methods: Totally 150 patients who admitted in surgical wards and casualty of Stanley Medical College, Tamil Nadu during the period of March 2021 to February 2022 were studied. A thorough clinical examination of the patient was then done to identify any injury to the organs in the chest. This was then followed by investigations if the patient was stable enough not to warrant any emergency surgical intervention and data were collected outcomes were studied.Results: Out of 150 patients, 74 of them had road traffic accidents, 39 of them had history of assault, 32 of them had fall from height regarding clinical manifestations 34 of them had dyspnea, 58 of them had single rib fracture, 48 of them had multiple rib fractures, 32 of them had pneumothorax, 19 of them had hemothorax, 8 of them had hemopneumothorax, 34 of them had flail chest, 20 of them had lung contusion 2 of them had diaphragmatic injury. In view of outcome, out of 150 patients, one of them had ARDS, 47 of them had thoracostomy, two of them had mechanical ventilation, one of them had laparotomy and seven of them died.Conclusions: According to this study, the incidence of ARDS in blunt injury of chest was &lt;1% in this study. Road traffic accidents have been the most common reason for blunt injury of chest.

K-Rod: An Innovative Method of Personalized Rib Splinting for Expeditious Management of Flail Chest in Acute Care Settings

Flail chest is a severe type of multiple rib fracture that can cause ventilation problems and respiratory complications. Historically, flail chest has been mainly managed through pain control and ventilatory support as needed. Operative fixation has recently become popular for the condition, and some studies have revealed its potentially positive effects on the outcomes of patients with flail chest. However, for those for whom surgery is unsuitable, few treatment options, other than simply providing analgesia, are available. Herein, we introduce our innovative method of applying personalized rib splinting for quick management of flail chest, which is easy, tailor-made, and has significant effects on pain reduction.

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.

Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study

Introduction Analgesia is key to successful conservative, nonsurgical management of patients admitted to the hospital with multiple rib fractures. Recently, new fascial plane regional anesthesia techniques have become widely available. We hypothesized that since the introduction of these new regional analgesia techniques, for patients over the age of 65 years, the effect of increasing numbers of rib fractures has been mitigated. Methods A retrospective study of patients admitted for the management of rib fractures between 2017 and 2020 was performed. Patients not admitted to the hospital, under the age of 65 years, or with chest trauma other than rib fractures were not eligible for inclusion. The primary outcome of interest was mortality. The secondary outcomes were the incidence of pneumonia and intensive care unit admission. Results were reported as the odds ratio and its 95% confidence interval and associated p-value. Statistical significance was set at [Formula: see text] &lt; 0.05. Results Overall, 252 patients were included and 142 patients received a regional anesthesia. The mortality rate was 4% (n = 10) with no association between mortality and number of rib fractures ( p = 0.215). Twenty-four patients (9.5%) developed pneumonia during their hospital stay, again with no association with an increasing number of rib fractures. The intensive care unit admission rate was 13.1% (n = 33) and correlated with an increasing number of fractures (odds ratio = 1.15; 95% confidence interval = 1.01 to 1.31; p = 0.038). Conclusion Management including liberal utilization of regional anesthesia for at-risk patients appears to mitigate the effect of increasing numbers of rib fractures on the incidence of mortality and pneumonia.

Fatal blast injuries in tyre blowouts: two autopsy case reports

BackgroundFatal blast injuries are generally reported as a consequence of explosions, mainly in terrorist events, work-related detonations, or domestic settings. Although quite rare, blast injuries of high kinetic energy can be seen in tyre blowouts and are very dangerous and potentially lethal because of their unpredictability. This phenomenon is rarely reported in the existing forensic literature.The aim of this study was to report two cases of fatal truck tyre bursts and to discuss the mechanisms leading to the burst and the pattern of injuries.Case presentationsCase 1 was of a 58-year-old truck driver man who was standing nearby a detached tyre that was being inflated in a repair shop when the burst occurred. The tyre struck him in the face and threw him. The medicolegal autopsy showed a right periorbital haematoma, a large wound of the left parietal scalp, a diffuse subarachnoid haemorrhage, an atlanto-occipital dislocation, a fracture of the hyoid bone, multiple rib fractures, and lacerations of the ascending aorta and the pulmonary arteries. Case 2 involved a young man of 24-year-old, a worker in a tyre repair shop, who was inflating a truck’s tyre when it burst violently. The injuries sustained included bleeding from the right ear, fractures of the facial bones, a left hemispheric subdural haematoma associated with the fracture of the skull base, a rib fracture, and diffuse areas of contusions to the lungs. Toxicological analyses were negative in both cases.ConclusionFatalities related to tyre blowout accidents are uncommon. The mechanisms leading to a blowout can be mechanical or chemical in origin, and the main danger of a burst often occurs when air enters the tyre during inflation. Internal damage caused by the pressure waves of the blast often exceeds what would be expected based on external signs alone.

Comparison of thoracic epidural and thoracic erector spinae plane block for pain relief of posterolateral rib fractures—a retrospective cohort study

BackgroundPain from rib fractures (posterior/lateral/anterior) is associated with significant pulmonary morbidity. Earlier epidural and paravertebral blocks were implemented in the algorithm for multimodal pain management of rib fracture pain. Administration of these blocks are fraught with challenges encountered in intensive care unit (ICU). The erector spinae plane block (ESPB) is a viable alternative in ICU set up.This retrospective study compared continuous thoracic ESPB and continuous thoracic epidural analgesia (TEA) [n=28 versus n=24] for polytrauma patients who sustained unilateral multiple rib fractures (MRFs), i.e., more than 3 admitted in ICU. Demography data were noted and compared. Outcome measures were block efficacy in terms of pain scores, opioid consumption (intravenous fentanyl), technical difficulties, and complications.ResultsAge, gender, and sides of ribs fractures were comparable in all groups. Pain scores and fentanyl consumption were significantly better in patients who received TEA.ConclusionsThough statistically significant analgesic efficacy was observed with continuous TEA for managing pain due to unilateral posterolateral MRFs, the small sample size was a major limitation. Further prospective comparative study including effects on incentive spirometry and effectiveness of chest physiotherapy is warranted. However, continuous ESPB is simple and safe to perform with few theoretical contraindications.

Hospital-Based Rehabilitation of Patients Who Had Undergone an Open Reduction and Internal Fixation of the Ribs Due to a Flail Chest: Case Series

Flail chest, a severe chest injury, is caused by multiple rib fractures. The open reduction and internal fixation (ORIF) of rib fractures is an effective treatment; however, the patients' subsequent condition remains unsatisfactory in terms of the activities of daily living (ADL) and pain. No research study has, as yet, reported on hospital-based rehabilitation of patients who had undergone an ORIF. Our aim was to evaluate the efficacy of hospital-based rehabilitation of flail chest post-ORIF patients. Physical therapists assessed the pain, functional independence measure (FIM), and the Berg balance test. A total of three females and four males (mean age 59.43 ± 18.88) were hospitalized. A significant reduction in pain was observed (7.00 ± 1.83 upon admission to 4.10 ± 2.05 pre-discharge (Z = -2.07, p = 0.027). A significant improvement in FIM (69.43 ± 14.86 upon admission to 113.57 ± 6.40 pre-discharge, Z = -2.37, p = 0.018), and the Berg balance test (35.23 ± 5.87 upon admission to 49.50 ± 3.40 pre-discharge, Z = -2.37, p = 0.018), was observed. Upon admission, all the patients required moderate to complete ADL assistance. Upon discharge, all were independent for all ADL functions. Patients after flail chest post-ORIF can benefit from hospital-based rehabilitation.

Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis.

Treatment for multiple rib fractures includes surgical stabilization of rib fractures (SSRF) or nonoperative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates versus NOM. Our study evaluated postoperative outcomes for multiple rib fracture patients following SSRF versus NOM in a real-world, all-comer study design. Multiple rib fracture patients with inpatient admissions in the PREMIER hospital database from October 1, 2015, to September 30, 2020, were identified. Outcomes included discharge disposition, and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, Abbreviated Injury Scale and Injury Severity Scores, and provider characteristics were determined for all patients. Patients were excluded from the cohort if they had a thorax Abbreviated Injury Scale score of <2 (low severity patient) or a Glasgow Coma Scale score of ≤8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting so that all patient data were kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links. A total of 203,450 patients were included, of which 200,580 were treated with NOM and 2,870 with SSRF. Compared to NOM, patients with SSRF had higher rates of home discharge (62% SSRF vs. 58% NOM) and lower rates of lung-related readmissions (3 months, 3.1% SSRF vs. 4.0% NOM; 12 months, 6.2% SSRF vs. 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF versus NOM was 1.166 (95% confidence interval [CI], 1.073-1.266; p = 0.0002). Similarly, ORs for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF versus NOM (OR [3 months], 0.764 [95% CI, 0.606-0.963]; p = 0.0227 and OR [12 months], 0.799 [95% CI, 0.657-0.971]; p = 0.0245). Surgical stabilization of rib fractures results in greater odds of home discharge and lower rates of lung-related readmissions compared with NOM at 12 months of follow-up. Therapeutic/Care Management; Level III.

Tailored Surgical Stabilization of Rib Fractures Matters More Than the Number of Fractured Ribs

Patients sustaining multiple rib fractures have a significant risk of developing morbidity and mortality. More evidence is emerging that the indication of surgical stabilization of rib fractures (SSRF) should expand beyond flail chest. Nevertheless, little is known about factors associated with poor outcomes after surgical fixation. We reviewed patients with rib fractures to further explore the role of SSRF; we matched two groups by propensity score (PS). A comparison of patients with blunt thoracic trauma treated with SSRF between 2010 and 2020 was compared with those who received conservative treatment for rib fractures. Risk factors for poor outcomes were analyzed by multivariate regression analysis. After tailored SSRF, the number of fractured ribs was not associated with longer ventilator days (p = 0.617), ICU stay (p = 0.478), hospital stay (p = 0.706), and increased nonprocedure-related pulmonary complications (NPRCs) (p = 0.226) despite having experienced much more severe trauma. In the multivariate regression models, lower GCS, delayed surgery, thoracotomy, and flail chest requiring mechanical ventilation were factors associated with prolonged ventilator days. Lower GCS, higher ISS, delayed surgery, and flail chest requiring mechanical ventilation were factors associated with longer ICU stays. Lower GCS and older age were factors associated with increased NPRCs. In the PS model, NPRCs risk was reduced by SSRF. The risk of NPRCs was reduced once ribs were surgically fixed through an algorithmic approach, and poor consciousness and aging were independent risk factors for NPRCs.

PSAT218 Technetium 99m-Methyl Diphosphonate (99mTc MDP) Radioguided Surgery in Patient With Tumor-Induced Osteomalacia (TIO)

Abstract Introduction TIO is a rare paraneoplastic syndrome of excess FGF23 secretion by mesenchymal tumors that results in myopathy, pain, weakness and osteomalacic fractures. Tumors are small and often difficult to locate, frequently delaying diagnosis. Surgery is considered definitive therapy, but recurrences remain common due to incomplete tumor resection. We present a novel approach of using Gallium (Ga) 68 DOTATATE PET/CT to identify the culprit tumor preoperatively followed by intraoperative 99mTc MDP radioguided surgical resection. Case Report A 41-year-old female presented with a four-year history of progressive weakness, fatigue, muscle and bone pain, and multiple subacute rib fractures and bilateral hip fractures with minimal trauma. On exam, she had proximal muscle weakness and walked with an antalgic gait aided by crutches. Laboratory evaluation revealed serum phosphorus of 2.1 mg/dL (2.5-4.5), tubular reabsorption of phosphate (TRP) of 78.9% (&amp;gt;85%), elevated alkaline phosphatase of 209 IU/L (31-125), 1,25 dihydroxy vitamin D [1,25 (OH)2 D] of 17 pg/ml (18-72) and serum FGF23 610 RU/ml (&amp;lt;180). Serum calcium, parathyroid hormone (PTH), estimated GFR and 25 hydroxy vitamin D were normal. Testing for genetic causes of hypophosphatemia was negative. With biochemical and genetic testing consistent with TIO, functional imaging was performed. Ga 68 DOTATATE PET/CT identified a single, 1.8 cm non-expansile sclerotic focus along the anterior left sixth rib with moderate uptake. She denied any recent trauma to the site. She was referred to thoracic surgery for a left sixth rib resection. Intraoperatively, she received 8.1 mCi Tc99m-MDP intravenously and the margin of the tumor was localized using a gamma probe allowing complete resection. Surgical pathology confirmed a 2.0 cm phosphaturic mesenchymal tumor (PMT)with widely negative margins. Postoperatively, her muscle strength, fatigue and ambulation improved significantly within six weeks and her serum phosphorus, TRP, 1,25 (OH)2 D normalized. Discussion Localization of PMTs is difficult because tumors are small and can be located anywhere in the body. Functional imaging using somatostatin analogs such Ga 68 DOTATATE PET/CT exploits the presence of somatostatin receptors expressed by many PMTs. Complete resection of PMTs can be challenging because they tend to be locally infiltrative along bone trabeculae. 99mTc MDP is a radiotracer localized to bone in proportion to osteoblastic activity as seen at sites of bony remodeling or bone metastasis. Accurate tumor localization and complete resection with widely negative margins are imperative for definitive treatment and cure. This case is unique in utilizing Ga 68 DOTATATE PET/CT for localization of the PMT paired with intraoperative 99mTc MDP in conjunction with a gamma camera for identifying tumor margins facilitating complete tumor resection and cure of the patient. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

ODP309 Ectopic Cushing's Syndrome: Importance of Methodical Approach to Hide and Seek

Abstract Cushing's syndrome (CS) is associated with high morbidity and fivefold excess mortality. Ectopic ACTH syndrome accounts for 20% of CS cases. It is crucial to identify and localize the source of extrapituitary ACTH secretion because surgical resection of the primary, often malignant, tumor has a high probability of cure with complete remission in 80% of cases. A 72-year-old female was admitted to a community hospital for lateral chest pain after a fall. She endorsed progressive weight gain, new HTN, emotional lability and worsening cognition over the prior 6 months. ACTH and cortisol levels were elevated. MRI brain failed to identify a pituitary lesion. CT chest showed multiple rib fractures and anterior mediastinal mass which was biopsied. While awaiting pathology results, IPS sampling attempted but aborted due to pulmonary edema necessitating ICU care. She was transferred to our institution for planned TSR of suspected pituitary adenoma. Examination showed Cushingoid features. Labs showed hypokalemia, high cortisol and high ACTH. MRI pituitary showed normal sella. MRI spine showed multilevel vertebral compression fractures. CT chest showed interval growth of mediastinal mass. A 1 mg dexamethasone suppression test failed to suppress ACTH and cortisol, confirming ACTH dependent hypercortisolism. A high dose 8 mg dexamethasone test failed to suppress ACTH and cortisol, a 10 mcg DDAVP stimulation test showed a flat response, with ACTH and cortisol levels remaining comparable before and after DDAVP injection. Dynamic testing therefore consistent with ectopic ACTH dependent hypercortisolism. Gallium-68 DOTA-TATE PET Scan demonstrated uptake in mediastinal mass suggestive of somatostatin receptor positive neuroendocrine tumor. Biopsy specimens processed at our institution showed cells positive for epithelial markers Cytokeratin and PAX8. Sample showed neuroendocrine differentiation with positive staining for Chromogranin A, synaptophysin and CD 117. Findings consistent with neuroendocrine thymic neoplasm. The patient was started on oral ketoconazole to control hypercortisolism. Surgical resection of tumor was planned with intent to cure CS. Ultimately, due to proximal myopathy and multiple vertebral fractures her performance status was too poor for safe tumor resection. Unfortunately, she died of complications related to CS while attempting preoperative rehabilitation. This case illustrates the importance of a timely, systematic evaluation for ACTH source in ACTH dependent hypercortisolism. Delay in CS diagnosis and localizing correct ACTH source led to missing the window of fitness for curative surgery. If ACTH is elevated, the most common source is pituitary neoplasia, however ectopic ACTH production must be ruled out. Dynamic testing including high dose dexamethasone suppression test, CRH and DDAVP stimulation tests should be used for preliminary localization of ACTH production. IPS sampling is invasive with greater potential for complications, as in the case of our patient. Therefore, it is only indicated if there are conflicting results from different dynamic tests and imaging studies. Presentation: No date and time listed

TRAUMATIC “ANGIOEDEMA”: EXTENSIVE SUBCUTANEOUS EMPHYSEMA MASQUERADING AS ANGIOEDEMA

<h3>Introduction</h3> COVID 19 pandemic related precautions have resulted in suboptimal physical examination of the patients which may have affected the patient care and training of medical professionals. We present a case of a patient whose subcutaneous emphysema was misdiagnosed as angioedema. <h3>Case Description</h3> 25 years old female with cerebral palsy and developmental delay presented to hospital in June, 2020 with asymmetric left facial and periorbital swelling which developed an hour after her regular Depo-Provera injection. She had elevated blood pressure readings with tachycardia without hives, respiratory or gastrointestinal symptoms. Facial swelling did not improve after IM epinephrine, IV steroids and antihistamines. Flexible laryngoscopy noted mild edema of lingual surface of the epiglottis. Allergy service was consulted to evaluate for drug-induced anaphylaxis. Our physical examination revealed significant asymmetric periorbital edema, neck and chest swelling with distant breath sounds and distinct palpable crepitus. Serum Trytpase and C1-Estrase inhibitor levels were normal at 3.2ug/L and 28 mg/dl, respectively. Emergent imaging was recommended, which demonstrated multiple rib fractures, pneumomediastinum with extensive chest wall subcutaneous emphysema tracking to extra-cranial soft tissue. Patient was intubated and chest tube was placed due to concerns for airway compromise. She stayed in ICU for one week before being discharged to home. <h3>Discussion</h3> Facial edema, concerning for angioedema, is potentially life threatening condition and an allergic reaction should be higher on the differential diagnoses. Our case represents a learning opportunity regarding other potentially life threatening conditions that can mimic angioedema, requiring higher index of clinical suspicion and thorough physical examination.

Morbidity and Mortality After Rib Fracture in Elderly Patients (>65 Years Old) Compared to a Younger Cohort (≤65 Years of Age) at Doctor Hospital Renaissance Health.

Traumatic rib fracture is a major cause of morbidity and mortality. Recent studies highlight the inadequacy of age and the number of rib fractures (NRFs) to assess patients' care needs, which may unnecessarily increase the burden of intensive care unit (ICU) admissions. Therefore, we sought to clarify the clinical outcomes of patients admitted to a level I trauma center with multiple blunt-trauma rib fractures by age and fracture location. We performed a retrospective cohort study of patients aged 18-95 admitted to Doctors Hospital at Renaissance Health with multiple rib fractures during 2017-2020. Patients with major vascular/cerebral injuries or emergency surgery from other injuries were excluded. The study population comprised 71 patients aged ≤65 and 53 patients aged >65 years. The primary study outcomes included mortality and non-home discharge. ICU length of stay (ICU-LOS), total hospital length of stay (HLOS), and days on the ventilator were the secondary outcomes. Study outcomes were also analyzed by stratifying patients by fracture location. Patients aged >65 years with multiple blunt-trauma rib fractures had lower mortality rates despite a higher prevalence of comorbidities but with higher rates of non-home discharges compared to younger patients. However, the mortality and non-home discharge odds ratios were not statistically significant. Also, median ICU-LOS and HLOS were numerically higher in geriatric patients but were not statistically significant. Nonetheless, younger patients required significantly more days of respiratory support than older patients. Similar differences were observed in the clinical outcome of patients ≤65 or >65 years when stratified by fracture locations. Young patients with blunt trauma rib fractures may have similar, if not worse, clinical outcomes than geriatric patients. These findings underscore the need for individual assessment of the patient's trauma severity independent of age, the number of rib fractures, or fracture location to reduce ICU burden.

Combined use of prefabricated rib-locking titanium plate with ultrasound-guided thoracic paravertebral nerve blockade in the treatment of multiple rib fractures among the elderly

This paper is aimed at investigating the efficacy of combining internal fixation using prefabricated rib-locking titanium plate with ultrasound-guided thoracic paravertebral nerve blockade in treating multiple rib fractures among the elderly. Retrospective analysis of 221 elderly patients with multiple rib fractures treated from February 2016 to November 2020. According to whether surgery was performed, they were divided into the plate-blockage combination group (surgical group, 102 cases) and conservative treatment group (non-surgical group, 119 cases). The surgical group consisted of 58 males and 44 females aged from 60 to 85 years old, with an average of (67.2±3.6 ) years old, who suffered from 3 to 12 rib fractures with an average of (5.3±2.1) fractures. The non-surgical group consisted of 66 males and 53 females aged from 60 to 84 years old with an average of (66.8±3.2) years old, who suffered from 2 to 11 rib fractures with an average of(6.1±2.3) fractures. The clinical data, efficacies observed, and complications associated with both groups were compared and analyzed. There was no significant difference in preoperative clinical data between two groups (P>0.05), and all patients were discharged smoothly. Pulmonary infection (P=0.028), atelectasis (P=0.032), respiratory failure (P=0.026), time to get out of bed (P=0.040), time to fracture healing (P=0.035), length of hospital stay in the operation group (P=0.043), visual analogue scale (VAS) at 3 days (P=0.028), 5 days(P=0.032), and 7 days(P=0.019), maximal voluntary ventilation (MVV) at 3 months after surgery (P=0.042), forced expiratory volume in one second (FEV1)(P=0.035), and maximal voluntary ventilation at 6 months, the maximal voluntary ventilation(MVV)(P=0.021) and forced FEV1(P=0.026) were all significantly better than those in non-surgical treatment group. For elderly patients with severe multiple rib fractures, the proposed plate-blockade combination can timely and effectively relieve pain, restore thoracic stability, shorten hospital stay, and reduce the incidence of complications such as pulmonary infections and acute respiratory distress syndrome(ARDS) compared with non-surgical treatments. Prefabricated rib-locking titanium plates have proved to demonstrate high clinical efficacy in treating multiple rib fractures among the elderly.

The influence of 10-year Nuss bar placement on bar removal: a case report

BackgroundThe Nuss bar is commonly used for minimally invasive correction of pectus excavatum and is usually removed within 2–3 years. Here, we report a case of 10-year bar placement after the Nuss procedure accompanied by unique complications of thoracic malformation that have not been described before. The asymmetric pectus carinatum caused by bar displacement and significant rib periosteal hyperplasia is described for the first time.Case presentationA 23-year-old man was admitted to our hospital due to the main complaint of obvious chest discomfort when lifting heavy weights. The bar removal was seriously delayed due to his loss to follow-up. Chest asymmetry and distant heart sounds were found during a physical examination. A chest CT scan demonstrated that the right end of the lower bar originally fixed outside the ribs had shifted into the thoracic cavity, and the left costal cartilage was obviously protruding. Additionally, the displaced bars were separated from the sternum and tightly attached to the pericardium, resulting in abnormalities of the anterior mediastinum. These secondary thoracic deformities made the patient extremely prone to massive hemorrhage or multiple rib fractures when sliding the bars out. However, serious consequences were avoided due to reasonable adjustments to the usual bar removal procedures.ConclusionThis case demonstrates a specific type of bar displacement caused by prolonged placement of the bars and highlights the importance of rigorous follow-up of patients after the Nuss procedure.

Effect of Regional Anesthesia Timing on Association with Delirium among Geriatric Trauma Patients with Multiple Rib Fractures

INTRODUCTION: Rib fractures cause significant morbidity among geriatric trauma patients, and elderly patients are at increased risk for delirium. Regional anesthesia (RA) has been shown to reduce the need for deliriogenic pain medications. We hypothesized that early use of RA may be associated with decreased delirium among this patient population. METHODS: We performed a retrospective review at our Level I trauma center to identify patients with 2 or more rib fractures from 2018 to 2019. We collected demographics, regional anesthesia type/timing, and outcomes including all Confusion Assessment Method (CAM) assessments recorded for each patient throughout their hospitalization. We calculated percentage of CAM negativity for each hospitalization (percentage of CAM negativity = negative CAM assessments/total CAM assessments × 100). RESULTS: A total of 636 patients with more than 1 rib fracture were identified. A total of 323 patients were older than 60 years. A total of 81 (25.1%) underwent RA (46 epidurals, 26 erector spinae blocks, 7 serratus anterior blocks, and 2 paravertebral blocks), and 242 (74.9%) did not receive RA. Mean percentage of CAM negativity was higher among RA patients than non-RA patients (95.1% vs 91.3%, p = 0.04); however, subgroup analysis showed patients receiving RA after 36 hours of admission had no difference in percentage of CAM negativity compared with non-RA patients (90.2% vs 91.3%, p = 0.78; Figure). Timing of RA did not affect in-hospital mortality, overall length of stay, ICU length of stay, or ventilator days.Figure.: CAM, Confusion Assessment Method.CONCLUSION: Among elderly trauma patients with multiple rib fractures, regional anesthesia use is associated with decreased rates of delirium; however, this effect is lost when RA is initiated more than 36 hours after admission.