Construction and Application of Rib Fracture Diagnosis Model Based on YOLOv3 Algorithm / 法医学杂志

OBJECTIVES@#The artificial intelligence-aided diagnosis model of rib fractures based on YOLOv3 algorithm was established and applied to practical case to explore the application advantages in rib fracture cases in forensic medicine.@*METHODS@#DICOM format CT images of 884 cases with rib fractures caused by thoracic trauma were collected, and 801 of them were used as training and validation sets. A rib fracture diagnosis model based on YOLOv3 algorithm and Darknet53 as the backbone network was built. After the model was established, 83 cases were taken as the test set, and the precision rate, recall rate, F1-score and radiology interpretation time were calculated. The model was used to diagnose a practical case and compared with manual diagnosis.@*RESULTS@#The established model was used to test 83 cases, the fracture precision rate of this model was 90.5%, the recall rate was 75.4%, F1-score was 0.82, the radiology interpretation time was 4.4 images per second and the identification time of each patient's data was 21 s, much faster than manual diagnosis. The recognition results of the model was consistent with that of the manual diagnosis.@*CONCLUSIONS@#The rib fracture diagnosis model in practical case based on YOLOv3 algorithm can quickly and accurately identify fractures, and the model is easy to operate. It can be used as an auxiliary diagnostic technique in forensic clinical identification.

Correlation of rib fracture patterns with abdominal solid organ injury: A retrospective observational cohort study / 中华创伤杂志(英文版)

PURPOSE@#Rib fractures are one of the most common causes of morbidity and mortality and are associated with abdominal solid organ injury (ASOI). The purpose of this study was to investigate the correlation of ASOI with the number, location, and involved segments of rib fracture(s) in blunt chest trauma.@*METHODS@#This retrospective cohort study was conducted on patients with blunt chest trauma over the age of 15 years, who were hospitalized with the diagnosis of rib fractures from July 2015 to September 2020. After ethic committee approval, a retrospective chart review was designed and patients with a diagnosis of rib fractures were selected. Patients who had chest and abdominopelvic CT scan were included in the study and additional data including age, gender, injury severity score, trauma mechanism, number and sides of the fractured ribs (left/right/bilateral), rib fracture segments (upper, middle, lower zone) and results of chest and abdominal spiral CT scan were recorded. The correlation between ASOI and the sides, segments and number of rib fracture(s) was assessed by Pearson's correlation coefficient.@*RESULTS@#Altogether 1056 patients with rib fracture(s) were included. The mean age was (42.76 ± 13.35) years and 85.4% were male. The most common mechanism of trauma was car accident (34.6%). Most fractures occurred in the middle rib zone (60.44%) and the most commonly involved ribs were the 6th and 7th ones (15.7% and 16.4%, respectively). Concurrent abdominal injuries were observed in 103 patients (34.91%) and were significantly associated with middle zone rib fractures.@*CONCLUSION@#There is a significant relationship between middle zone rib fractures and ASOI. Intra-abdominal injuries are not restricted to fractures of the lower ribs and thus should always be kept in mind during management of blunt trauma patients with rib fractures.

Analysis of Thoracic Aorta Injury in 27 Road Traffic Accident Deaths / 法医学杂志

OBJECTIVES@#To analyze the characteristics of thoracic aorta injury in road traffic accidents, to provide data reference for forensic identification.@*METHODS@#The data of 27 traffic accident death cases with thoracic aorta injury were analyzed according to relevant parameters including sex, age, mode of transportation, and thoracic aorta injury.@*RESULTS@#Aortic injury in traffic accidents was significantly more in males than females, and 74.1% cases were in the age range of 31-70 years. The most common mode of transportation was the motorcycle, followed by electric bike, most of which crashed with trucks. Most cases were accompanied by rib fractures and lung injuries. Thoracic aorta injury was the most common in ascending aorta, followed by aortic arch and thoracic aorta. Ascending aorta injury was most likely to occur in the range of 0-<1.6 cm from the aortic valve, while it was rare over 2.6 cm. Taking the aortic valve as the reference, the most common locations of injury were the anterior semilunar valve, followed by the right posterior semilunar valve and the left posterior semilunar valve. Thoracic aortic rupture occurred in 63.0% cases, and intima and media lacerations only occurred in 37.0% cases. A few deceased had aortic diseases.@*CONCLUSIONS@#The proximal part of the ascending aorta is prone to be injured because of the large external force of traffic accidents. The medical examiner should carefully examine the aortic injury in traffic accident deaths, and evaluate the relationship between the injury and the disease according to the condition and degree of aortic injury.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021) / 中华创伤杂志(英文版)

Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.

Manejo actualizado de las fracturas costales / Current management of rib fractures

RESUMEN Las fracturas costales son la lesión más frecuente en los traumatismos torácicos. La fijación de las fracturas ha estado dirigida clásicamente al volet costal. En los últimos años se han extendido las indi caciones a las fracturas múltiples desplazadas aun sin volet. Se consideran asimismo otras indicaciones de osteosíntesis menos frecuentes. La neumonía y contusión pulmonar graves que requieren asisten cia respiratoria mecánica son consideradas contraindicaciones para la fijación quirúrgica. La primera semana es el momento óptimo para su realización. Diversos dispositivos de fijación se han ideado; las placas de titanio son las más utilizadas. La osteosíntesis costal ofrece a los pacientes una recuperación más rápida con menor estadía hospitalaria y en cuidados críticos, así como mejor funcionalidad respi ratoria y menor dolor en el corto y largo plazo.

ABSTRACT Rib fractures are the most common injuries in chest trauma. Fracture fixation has been traditionally performed in flail chest patients. Over the past years, the indication has been extended to multiple, severely displaced non-flail pattern fractures. Other less common indications for osteosynthesis have also been considered. Severe pneumonia and lung contusion requiring mechanical ventilation are considered contraindication for surgical fixation. The optimal timing for the intervention is the first week. Several devices have been developed for fracture fixation; titanium plates are the most commonly used. Rib fixation offers patients a more rapid recovery with shorter length of hospital stay and of intensive care unit stay with improved respiratory function and pain management in the short and long term.

Blunt trauma related chest wall and pulmonary injuries: An overview / 中华创伤杂志(英文版)

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Exploring of the Mechanism of Rib Fracture Caused by Landing on Different Parts of the Trunk after Falls from Height Using Finite Element Method / 法医学杂志

Objective To study the mechanism of rib fracture caused by landing on different parts of the trunk using finite element method, and to provide some new techniques and new ideas for the reconstruction of the whole process of falls from height. Methods The finite element method was used to study the rib fracture of human security model THUMS4.0 caused by landing on different parts of the trunk. Then the model was compared with actual cases and the mechanism of rib fracture caused by falls from height was analyzed from a biomechanical point of view. Results There were some differences in the stress and strain distribution as well as the rib fracture sites when different parts touched the ground. Ribs on both sides of the body were fractured when the front of the trunk touched the ground, and the fractures were mainly located in the junction of the ribs and costal cartilage and the midaxillary line area. When the right anterior part of the trunk touched the ground, rib fracture occurred first on the side that touched the ground, and rib fractures were mainly located in the area from the right midaxillary line to the posterior axillary line, and junction of ribs on both sides and costal cartilage. When the back of the trunk touched the ground, the fracture sites were mainly located on the back of the ribs on both sides. When the right posterior part of the trunk touched the ground, multiple rib fractures were likely to occur in the parts that touched the ground. The plastic strains were mainly concentrated at the fracture sites, while the von Mises stresses were not only concentrated at the fracture sites, but also at other sites. Conclusion There are some differences in rib fracture location sites and injury mechanisms when different parts of the trunk touch the ground.

Clinical Application and Mechanical Analysis of the Treatment of Multiple Rib Fractures and Flail Chest Using Three-wings Rib Plate / 中国医疗器械杂志

This research evaluated the clinical efficacy of three-wings rib plate in the treatment of multiple rib fractures and flail chest with mechanical analysis and clinical verification. The model of rib and three-wings rib plate was reconstructed. The contact simulation with pretension stress was applied to the plate's fixation, and it was found that the bearable stress of the rib fractures after fixation increased from the result which indicated a good fixation efficacy of the plate. Clinical data of 53 cases of rib fractures and flail chest treated with three-wings rib plate in Shanghai Pudong Hospital of Fudan University were retrospectively analyzed. After the operation, the pain of the patients was relieved. Postoperative CT reconstruction of the chest showed good restoration of the rib fractures, which verified the clinical efficacy of three-wings rib plate. The three-wings rib plate showed a high value in clinical use for treatment of rib fractures.

Continuous serratus anterior plane block provides analgesia in multiple rib fractures: a case report / O bloqueio contínuo do plano serrátil anterior fornece analgesia em fraturas múltiplas de costelas: relato de caso

Abstract Thoracic trauma with rib fractures is a challenging condition due to the severe associated pain. Uncontrolled pain impairs breathing and an adequate pain control is necessary to provide comfort and to avoid further complications. Serratus Anterior Plane block is a procedure safe and easy to accomplish. The authors describe a case of thoracic trauma with rib fractures and respiratory compromise. Pain control was only achieved after performing a Serratus Anterior Plane block. The technique was done as described in the medical literature with placement of a catheter. Pain relief was achieved with a low concentration infusion of local anesthetic.

Resumo O trauma torácico com fraturas de costelas é uma condição desafiadora devido à dor intensa associada. O não controle da dor prejudica a respiração enquanto, o seu controle adequado é necessário para proporcionar conforto e evitar maiores complicações. O bloqueio do plano serrátil anterior é um procedimento seguro e fácil de fazer. Descrevemos um caso de trauma torácico com fraturas de costelas e comprometimento respiratório. O controle da dor só foi obtido após o bloqueio do plano serrátil anterior. A técnica foi aplicada conforme descrito na literatura médica, com a colocação de um cateter. O alívio da dor foi obtido com uma infusão de anestésico local em baixa concentração.

Continuous erector spinae plane block for postoperative analgesia of multiple rib fracture surgery: case report / Bloqueio do plano do eretor da espinha para analgesia pós-operatória de cirurgia de fratura de múltiplas costelas: relato de caso

Abstract Introduction: The erector spinae plane block is a newly described and effective interfascial plane block for thoracic and abdominal surgery. This case report describes a patient with multiple rib fractures undergoing ultrasound-guided continuous erector spinae plane block for analgesia. Case report: A 37-year-old male patient was taken for surgical fixation of multiple rib fractures. At the end of the surgery, using ultrasound-guided longitudinal parasagittal orientation 3 cm to the lateral aspect of the T5 spinous process and an in-plane technique, 20 mL 0.25% bupivacaine was administered between the erector spinae muscle and the transverse process, and a catheter was then inserted in the same plane. Before the end of surgery, 1 g paracetamol and 50 mg dexketoprofen were administered. Postoperative analgesia was applied with patient controlled analgesia method using 0.25% bupivacaine via the catheter. The patient's Visual Analogue Scale score at rest in the first 24 h was 0. The patient was monitored for 3 days with Visual Analogue Scale < 4, and the catheter was removed on postoperative day 4. No opioid requirement other than paracetamol and dexketoprofen occurred during this time. No postoperative complications were recorded. Discussion: The erector spinae plane block is an alternative to paravertebral, intercostal, epidural or other regional techniques. It may be a suitable technique in anesthesia and algology practice due to providing analgesia in the postoperative period with a catheter in the erector spinae plane.

Resumo Introdução: O bloqueio do plano do eretor da espinha é um bloqueio do plano interfacial recentemente descrito e eficaz para cirurgia torácica e abdominal. Neste relato descrevemos o caso de um paciente com fratura de múltiplas costelas, submetido ao bloqueio contínuo do plano do eretor da espinha guiado por ultrassom para analgesia. Relato de caso: Paciente do sexo masculino, 37 anos, encaminhado para fixação cirúrgica de fratura de múltiplas costelas. Ao final da cirurgia, usando a orientação parassagital longitudinal guiada por ultrassom 3 cm em relação à face lateral do processo espinhoso T5 e a técnica no plano, 20 ml de bupivacaína a 0,25% foram administrados entre o músculo eretor da espinha e o processo transverso, e um cateter foi então inserido no mesmo plano. Antes do final da cirurgia, 1 g de paracetamol e 50 mg de dexcetoprofeno foram administrados. A analgesia pós-operatória foi aplicada com o método de analgesia controlada pelo paciente, com bupivacaína a 0,25% via cateter. Na Escala Visual Analógica, o escore do paciente em repouso nas primeiras 24 h foi zero. O paciente foi monitorado por três dias com a Escala Visual Analógica < 4, e o cateter foi removido no quarto dia de pós-operatório. Exceto por paracetamol e dexcetoprofeno, não houve necessidade de outro agente opioide durante esse tempo. Não houve registro de complicação pós-operatória. Discussão: O bloqueio do plano do eretor da espinha é uma alternativa às técnicas paravertebrais, intercostais, epidurais ou outras técnicas regionais. Pode ser uma técnica adequada na prática de anestesia e algologia devido ao fornecimento de analgesia no período pós-operatório mediante um cateter no plano do eretor da espinha.

Lésions traumatiques spléniques et fractures costales de l'enfant à propos de 16 cas au CHU pédiatrique Charles de Gaulle de Ouagadougou

Objectif : Décrire les aspects échographiques des contusions spléniques de l'enfant au CHUP-CDG et rechercher une éventuelle association avec les lésions thoraciques à la radiographie standard.Patients et méthode : Il s'est agi d'une étude descriptive prospective réalisée du 1er Avril 2016 au 30 Novembre 2016. Elle a concerné les enfants âgés de 0 à 14 ans reçus dans le service de radiologie du CHUP-CDG pour contusion abdominale, qui ont présenté des lésions spléniques à l'échographie abdomino-pelvienne et bénéficié de radiographies complémentaires du gril costal gauche. Les caractéristiques sociodémographiques, les circonstances du traumatisme, le délai du diagnostic, les lésions échographiques spléniques, les autres lésions associées et les lésions radiographiques thoraciques. L'analyse des données a été réalisée à l'aide du logiciel de statistique Epi Info version 3.1.Résultats : Seize enfants, 11 garçons et 05 filles ont présenté une contusion splénique. Ils étaient âgés en moyenne de 09 ans, avec des extrêmes de 07 et de 14 ans. Les circonstances de survenue les plus fréquentes étaient constituées par les chutes d'arbre (dans 11 cas) et les accidents de la voie publique (dans 03 cas). L'exploration échographique a montré des contusions spléniques sévères, avec 75% de grade III de l'AAST, associées à un hémopéritoine (chez tous les 16 patients) et à un épanchement pleural (chez un patient). Aucune fracture costale n'a été observée. Conclusion : Les lésions spléniques post traumatiques étaient graves chez la majorité de nos patients mais n'étaient pas associées à des fractures costales. Cette étude préliminaire devrait être poursuivie dans le but d'indiquer ou non une radiographie thoracique complémentaire devant une lésion traumatique grave de la rate à l'échographie

Review of the Clinical Characteristics of Adrenal Gland Injury Following Blunt Trauma in a Single Institution

PURPOSE: Adrenal gland injuries in trauma are rare and usually misdiagnosed or underestimated in an emergency setting because they are asymptomatic and associated with severe abdominal injuries. This paper reviews the clinical characteristics of adrenal injuries. METHODS: A retrospective analysis of trauma patients who visited the authors' emergency center was performed from March, 2010 to December, 2017. The patient demographic data, injury mechanism & associated injuries, injury severity score, hospital stay, and mortality were retrieved and analyzed. RESULTS: Adrenal gland injuries were found in 52 patients: 73.1% (n=38) were males and the mean age was 43.6 years. Of the patients, 84.6% (n=44) had ISS ≥15. Right adrenal gland injuries occurred in 82.7% (n=43). The mechanism of injury was falls in 30.8% (n=16), motor vehicle accidents in 25.0% (n=13), and pedestrian accidents in 23.1% (n=12). Associated injures were liver injury (58.5%), rib fracture (52.8%), kidney injury (24.5%), pelvic bone fracture (20.8%), spine fracture (28.3%), and spleen injury (13.2%). The mean hospital stay was 34.2 days, and the intensive care unit stay was 9 days. The mortality rate was 3.8% (n=2). CONCLUSION: Adrenal gland injuries are common in males and frequent in the right side. Falls are the leading cause of injury. Most injuries have an associated injury at the abdominal or thoracic region. Adrenal injury is accompanied by high injury severity but showed a good prognosis.

Pericardial Tearing by Fall into Water Surface: An Autopsy Case / 대한법의학회지

Injuries caused by free-fall from heights represent a specific form of blunt trauma that can be difficult to interpret, especially when the impact medium is water. On autopsy practice, the immersed bodies with rib fractures and internal organ injuries were often encountered and many studies have reported that impact with the water surface could cause skeletal fracture and visceral organ rupture. The height of the fall and body orientation on impact are the most important factors determining the severity and range of these injuries. In the present case, the victim was a 69-year-old male who weighed 48 kg. Following were the autopsy findings: numerous pin-point epidermal injuries on the body surface (like those due to nibbling by fish), a massive soft tissue hemorrhage in the left upper chest, multiple rib fractures (3rd–7th left ribs), ballooning of the lungs, froth in the trachea and bronchus, pericardial tearing in the right anterolateral side (7-cm long), intra-pericardial hemorrhage, and focal hemorrhage in the adventitia of the intra-pericardial aorta. No sign of an external wound was observed in the left chest area. The cause of death was drowning, and the manner of death was suicide. Unfortunately, the site and height of fall were not investigated.

Treatment of Isolated Sternal Fracture with Ultrasound-Guided Paravertebral Nerve Block: a Case Report and Literature Review / 고신대학교의과대학학술지

In the case of isolated sternal fractures, conservative treatment with analgesics is common, but pain can persist for more than 10 weeks, which can significantly interfere with daily life. Ultrasound-guided paravertebral nerve block is reported to be a successful means of pain control in patients with chest wall injury or rib fracture.A 70-year-old female patient presented with anterior chest pain that had persisted for 2 weeks despite conservative treatment. Sagittal reconstruction chest computed tomography and sternum lateral oblique x-ray revealed an isolated sternal fracture. An ultrasound-guided bilateral paravertebral nerve block was performed for pain control. After performing the procedure twice at a 1-week interval, the patient reported complete pain alleviation, and no other problems were observed over the 3-month follow-up period.Ultrasound-guided bilateral paravertebral nerve block can help patients with isolated sternal fractures to manage pain and return to normal activities sooner than with oral analgesics.

Reconstrucción temprana en el tórax inestable con sistema de osteosíntesis torácico: Reporte de caso / Early unstable chest reconstruction with thoracic osteosynthesis: A case report

Se presenta el caso de un paciente varón con tórax inestable. Esta lesión es una entidad poco común que puede ser originada por múltiples traumatismos de alto impacto. El diagnóstico se estableció por signos clínicos y estudios de imágenes. El paciente recibió tratamiento quirúrgico con un sistema de osteosíntesis costal (StraCos®); se discuten los resultados obtenidos y sugerencias para casos de este tipo. (AU)

We present the case of a male patient with unstable chest, which is a rare entity that may be caused by high impact trauma. The diagnosis was stablished by clinical manifestations and image results. The patient received surgical treatment with a rib osteosynthesis. We discussed the results obtained and propose suggestions to manage this kind of patients. (AU)

Osteosíntesis de múltiples fracturas costales desplazadas en un paciente con tórax batiente / Osteosynthesis of multiple displaced costal fractures in a patient with flail chest

El tratamiento de las fracturas costales debe ser individualizado de acuerdo con la severidad de las lesiones y a la magnitud del trauma. El objetivo de esta investigación es presentar un caso donde se utilizaron láminas de titanio, en un paciente con fracturas múltiples de las costillas. Se reporta el caso de un paciente con múltiples fracturas costales de forma lineal y paralelas de los arcos costales con un tórax batiente, que llega al cuerpo de guardia con dolor torácico moderado y disnea. Aunque aún no existe suficiente evidencia científica a favor de los métodos de fijación costal, se realizó la fijación con láminas de titanio logrando la estabilidad de la pared, aliviando el dolor, mejorando la mecánica ventilatoria y logrando su rápida reincorporación a la sociedad(AU)

The treatment of costal fractures should be individualized according to the severity of the injuries and the magnitude of trauma. The objective of this investigation is to present a case where titanium plates were used in a patient with multiple rib fractures. We report the case of a patient with multiple rib fractures of a linear and parallel shape of the costal arches with a swinging thorax, who arrives the emergency room with moderate chest pain and dyspnea. Although there is still not enough scientific evidence that favors the costal fixation methods, the fixation with titanium plates was performed, achieving the stability of the wall, relieving pain, improving the ventilatory mechanics, and achieving the patient's quick reincorporation to the society(AU)

Fracturas costales simétricas asociadas a tos / Symmetrical rib fractures associated with chronic cough: report of one case

Cough may be associated with complications such as syncope, urinary incontinence, pneumothorax, and less frequently, pulmonary hernia and costal fractures. Chronic cough is a cause of rib fractures and when they occur it is likely to affect more than one rib. We report a 53 year-old obese male in treatment with enalapril 10 mg for hypertension with a dry cough lasting five months. He consulted for bilateral chest pain and a Chest X ray examination showed symmetrical fractures in the seventh left and right ribs. Enalapril was discontinued, cough and pain subsided in two weeks.

Takotsubo Syndrome Resulting from Traumatic Multiple Rib Fractures

Takotsubo syndrome, also known as stress-induced cardiomyopathy, is a transient cardiac syndrome that mimics acute coronary syndrome. This condition should be suspected if the patient presents with chest pain after intense emotional stress, accompanied by an abnormal electrocardiogram, elevated levels of myocardial enzymes, and left ventricular apical akinesia on echocardiography. Coronary angiography should be performed for prompt differentiation from ischemic heart disease. A 77-year-old female presented with traumatic multiple fractures of the left sixth and seventh ribs resulting from a violent strike. Clinical findings of physical examination, laboratory tests, electrocardiogram, and coronary angiography provided the diagnosis of Takotsubo syndrome. We performed conservative management including pain control, and the patient was uneventfully discharged seven days after admission.

Common Carotid Artery Dissection in Multiple Extracranial Injury: A Case Report / 대한신경손상학회지

Traumatic common carotid artery dissection (CCAD) is rare. To our knowledge, only 14 case reports have described traumatic CCAD previously. Here, we report a case of CCAD in a patient with severe trauma. A 50-year-old man was lying on the road after drinking alcohol when a car drove over him. Computed tomography (CT) revealed multiple rib fractures with hemopneumothorax, lung contusion, flail chest, large amount of hematoma with bladder rupture, and fractures on the C6 spinous process, sacral ala, iliac bone, and pubic ramus. Repair of the bladder rupture, exploratory thoracotomy, and open reduction of multiple rib fractures were performed. Right side hemiparesis was observed on hospital day 4. Brain CT showed a large acute left middle cerebral artery infarction. CT angiography showed focal carotid dissection at the left common carotid artery with intimal flap. The CCAD was located at the C6 level. Clexane (enoxaparin sodium) treatment was initiated. An abdominal CT scan revealed a huge retroperitoneal hematoma and increased amount of hematoma in the prevesical and perivesical space, 10 days later. The patient died two days later. Although traumatic CCAD is rare, this case report provides useful information for trauma surgeons regarding the treatment and diagnosis of similar cases.

Delayed massive hemothorax requiring surgery after blunt thoracic trauma over a 5-year period: complicating rib fracture with sharp edge associated with diaphragm injury

Delayed massive hemothorax requiring surgery is relatively uncommon and can potentially be life-threatening. Here, we aimed to describe the nature and cause of delayed massive hemothorax requiring immediate surgery. Over 5 years, 1,278 consecutive patients were admitted after blunt trauma. Delayed hemothorax is defined as presenting with a follow-up chest radiograph and computed tomography showing blunting or effusion. A massive hemothorax is defined as blood drainage >1,500 mL after closed thoracostomy and continuous bleeding at 200 mL/hr for at least four hours. Five patients were identified all requiring emergency surgery. Delayed massive hemothorax presented 63.6±21.3 hours after blunt chest trauma. All patients had superficial diaphragmatic lacerations caused by the sharp edge of a broken rib. The mean preoperative chest tube drainage was 3,126±463 mL. We emphasize the high-risk of massive hemothorax in patients who have a broken rib with sharp edges.