Impact of Time of Surgery on the Outcome after Surgical Stabilization of Rib Fractures in Severely Injured Patients with Severe Chest Trauma-A Matched-Pairs Analysis of the German Trauma Registry.

Purpose: In severely injured patients with multiple rib fractures, the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results, and the indication and especially the right timing of an operation are the subject of a broad discussion. The aim of this study was to determine the influence of the time point of surgical stabilization of rib fractures (SSRF) on the outcome in a multicenter database with special regard to the duration of ventilation, intensive care, and overall hospital stay. Methods: Data from the TraumaRegister DGU collected between 2010 and 2019 were used to evaluate patients above 16 years of age with severe rib fractures [Abbreviated Injury Score (AIS) ≥ 3] who received an SSRF in a matched-pairs analysis. In this matched-pairs analysis, we compared the effects of an early SSRF within 48 h after initial trauma vs. late SSRF 3-10 days after trauma. Results: After the selection process, we were able to find 142 matched pairs for further evaluation. Early SSRF was associated with a significantly shorter length of stay in the intensive care unit (16.2 days vs. 12.7 days, p = 0.020), and the overall hospital stay (28.5 days vs. 23.4 days, p = 0.005) was significantly longer in the group with late SSRF. Concerning the days on mechanical ventilation, we were able to demonstrate a trend for an approximately 1.5 day shorter ventilation time for patients after early SSRF, although this difference was not statistically significant (p = 0.226). Conclusions: We were able to determine the significant beneficial effects of early SSRF resulting in a shorter intensive care unit stay and a shorter length of stay in hospital and additionally a trend to a shorter time on mechanical ventilation.

[Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]. / Epidemiologie, Verletzungsentitäten und Behandlungspraxis der Thoraxwandverletzungen : Aktuelle wissenschaftliche Erkenntnisse und Therapieempfehlungen.

BACKGROUND: Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed. OBJECTIVE: A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options. MATERIAL AND METHODS: Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO­/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed. RESULTS AND DISCUSSION: Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.

[Injuries of the posterior and lateral chest wall-importance of an additional clavicular fracture]. / Verletzungen der posterioren und lateralen Brustwand ­ Bedeutung einer zusätzlichen Klavikulafraktur.

BACKGROUND: Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show a high incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to a loss of function of the shoulder and a pronounced deformation of the chest wall. OBJECTIVE: This article shows the origin and clinical importance of FCI. What importance does a concomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively? MATERIAL AND METHODS: After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in a corpse study and then put into practice. RESULTS AND CONCLUSION: This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the 2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and a marked deformation of the thoracic wall are present. Remaining misalignments are associated with a simultaneous loss of function of the chest wall and shoulder.

[Lesions of the anterior chest wall-significance of additional fractures of the spine]. / Verletzungen der anterioren Brustwand ­ Bedeutung zusätzlicher Frakturen der Wirbelsäule.

BACKGROUND: Fractures of the anterior chest wall are rare among the total number of fractures. They include sternal fractures (SF) and the adjacent cartilaginous structures of the ribs. The accident mechanism can allow conclusions to be drawn about which further accompanying injuries may be present, e.g. rib and spinal fractures. OBJECTIVE: The present work is intended to give an overview of injuries of the anterior chest wall. It includes clinical aspects as well as imaging and popular literature. MATERIAL AND METHODS: Included are injury constellations of the anterolateral chest wall, in particular of the sternum in combination with injuries of the spinal column in the sense of a sternovertebral injury (SVI). Possible treatment strategies were reviewed and the corresponding advantages and disadvantages are presented. RESULTS: In symptomatic fractures of the anterior chest wall, their operative stabilization should be considered in order to restore the stability of the trunk. In addition, rib fractures in direct trauma and spinal injuries in indirect trauma are often included in the treatment. CONCLUSION: In the case of injuries of the thoracic trunk, this must always be regarded as a unit and must therefore be clarified in the context of the clinical examination and diagnostic apparatus. The possible accident mechanism can allow conclusions to be drawn about possible injury patterns, e.g. in the sense of SVIs.

[Anesthesia, ventilation and pain treatment in thoracic trauma]. / Narkose, Beatmung und Schmerztherapie beim Thoraxtrauma.

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

[Frequency and age distribution of combined sternovertebral injuries : Analysis of routine data from German hospitals 2005-2012]. / Häufigkeit und Altersverteilung sternovertebraler Kombinationsverletzungen : Analyse aus Routinedaten deutscher Krankenhäuser 2005­2012.

BACKGROUND: Combinations of sternal and spinal fractures often occur due to high velocity accidents and are associated with a high incidence of concomitant injuries. The anterior thoracic wall is described as the fourth column of torso stability, which is why sternovertebral injuries (SVI) present a high risk of sagittal deformation of the trunk, in particular injuries of the thoracic spine. To date, no studies have been published on the frequency distribution of the involved vertebral bodies in large patient groups. OBJECTIVES: This study was intended to elaborate a frequency distribution of vertebral fractures accompanying sternal fractures (SF) and examine the risk of a vertebral fracture accompanying a SF. MATERIAL AND METHODS: A total of 48,193 cases with the main or secondary diagnosis of a SF and 897,963 cases with vertebral fractures based on routine data of German hospitals from the years 2005-2012 were evaluated. A concomitant injury to the spinal column was examined for each vertebral body and then evaluated statistically. RESULTS AND CONCLUSIONS: Of all patients with a SF 30.96% also suffered from a vertebral fracture. Of these 3.11% were SF as the main diagnosis and 60.89% the secondary diagnosis. While vertebral fractures generally occurred most frequently in the region of the thoracolumbar transition and the second cervical vertebral body, the SVI showed a further frequency peak in the range from the lower cervical spine to the middle thoracic spine. The present study was able to show a frequency distribution of accompanying vertebral body injuries in a large and representative collective in the case of SF for the first time.

Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability.

PURPOSE: Stabilizing techniques of flail chest injuries usually need wide approaches to the chest wall. Three main regions need to be considered when stabilizing the rib cage: median-anterior with dissection of pectoral muscle; lateral-axillary with dissection of musculi (mm) serratus, externus abdominis; posterior inter spinoscapular with division of mm rhomboidei, trapezius and latissimus dorsi. Severe morbidity due to these invasive approaches needs to be considered. This study discusses possibilities for minimized approaches to the shown regions. METHOD: Fifteen patients were stabilized by locked plate osteosynthesis (MatrixRib®) between May 2012 and April 2014 and prospectively followed up. Flail chest injuries were managed through limited incisions to the anterior, the lateral, and the posterior parts of the chest wall or their combinations. Each approach was 4-10 cm using Alexis® retractor. RESULTS: One minimized approach offered sufficient access at least to four ribs posterior and laterally, four pairs of ribs anterior in all cases. There was no need to divide latissimus dorsi muscle. Trapezius und rhomboid muscles were only limited divided, whereas a subcutaneous dissection of serratus and abdominis muscles was necessary. A follow-up showed sufficient consolidation. COMPLICATIONS: pneumothorax (2) and seroma (2). CONCLUSION: Minimized approaches allow sufficient stabilization of severe dislocated rib fractures without extensive dissection or division of the important muscles. Keeping the arm and, thus, the scapula mobile is very important for providing the largest reachable surface of the rib cage through each approach.

[Bony injuries of the thoracic cage in multiple trauma : Incidence, concomitant injuries, course and outcome]. / Knöcherne Verletzung der Brustwand beim Polytrauma : Inzidenz, Begleitverletzungen, Verlauf und Outcome.

BACKGROUND: Thoracic trauma is considered to be responsible for 25 % of fatalities in multiple trauma and is a frequent injury with an incidence of 50 %. In addition to organ injuries, severe injuries to the bony parts of the thorax also occur and these injuries are described very differently mostly based on single center data. OBJECTIVES: The focus of this study was on a holistic presentation of the prevalence and the incidence of thoracic trauma in patients with multiple trauma from the data of the large collective of the TraumaRegister DGU® (TR-DGU) with the objective of an analysis of concomitant injuries, therapy options and outcome parameters. MATERIAL AND METHODS: A retrospective analysis was carried out based on the data set of the TR-DGU from the years 2009-2013. Inclusion criteria were an injury severity scale (ISS) score ≥ 16 and primary admission to a trauma center but isolated craniocerebral injury was an exclusion criterium. Patients were separated into two groups: those with rib fractures (RF) and those with flail chest (FC). RESULTS: A total of 21,741 patients met the inclusion criteria including 10,474 (48.2 %) suffering from either RF or FC. The mean age was 49.8 ± 19.9 years in the RF group and 54.1 ± 18.2 years in the FC group. Approximately 25 % were female in both groups, 98.1 % were blunt force injuries and the median ISS was 28.0 ± 11.2 in RF and 35.1 ± 14.2 in FC. Shock, insertion of a chest tube, (multi) organ failure and fatality rates were significantly higher in the FC group as were concomitant thoracic injuries, such as pneumothorax and hemothorax. Sternal fractures without rib fractures were less common (3.8 %) than concomitant in the RF (10.1 %) and FC (14 %) groups, as were concomitant fractures of the clavicle and the scapula. Out of all patients 32.6 % showed fractures of the thoracolumbar spine, 26.5 % without rib fractures, 36.6-38.6 % with rib fractures or monolateral FC and 48.6 % concomitant to bilateral FC. Thoracotomy was carried out only in isolated cases in RF and in 10.2 % of the FC group. Operative stabilization of the thoracic cage was carried out in 3.9-9.1 % of patients in the RF group and in 17.9-23.9 % in the FC group.

[Essential measures for prehospital treatment of severely injured patients: The trauma care bundle]. / Wesentliche Maßnahmen zur prähospitalen Versorgung schwerverletzter Patienten: Das Trauma Care Bundle.

BACKGROUND: In order to ensure adequate treatment and to avoid complications, care bundles are increasingly being implemented. These are comprehensive and evidence-based procedures for the treatment of individual diseases or injuries which should be carried out for every patient. The aim of this study was to define a care bundle for the prehospital treatment of severely injured patients. MATERIAL AND METHODS: The scientific contents of the bundle were gathered from the interdisciplinary evidence-based S3 guidelines for the treatment of severely injured patients by the German Trauma Society. The ABCDE scheme suggested by the prehospital trauma life support (PHTLS®) and the advanced trauma life support (ATLS®) functioned as a matrix for the individual elements in the bundles. The identified elements were finalized by a consensus process. RESULTS AND DISCUSSION: A bundle of six elements was suggested and a comprehensive summary of key items during prehospital management of severely injured patients was identified. In a next step the effectiveness of the care bundle should be evaluated in a clinical trial.

[Use of negative pressure wound therapy on surgical incisions (prevena™) after surgery of pectus deformities reduces wound complications]. / Einsatz einer präventiven, epikutanen Unterdrucktherapie (Prevena™) bei offener Korrektur von Deformitäten der vorderen Brustwand reduziert das Auftreten von Wundheilungsstörungen.

INTRODUCTION: Pectus surgery can lead to postoperative wound complications in some cases. The purpose of this study is to determine whether preventive negative pressure wound therapy (NPWT) could reduce wound complications after open pectus surgery. MATERIAL AND METHODS: 100 patients after open procedure for the treatment of pectus excavatum or pectus carinatum in the years 2010 to 2012 were retrospectively analysed. 50 patients treated with Prevena™ (KCI Medical Products GmbH, Wiesbaden, Germany) were compared with 50 patients whose wounds were covered with OPSITE® film (Smith & Nephew, Hamburg, Germany). Wound closure was performed following a standard procedure as well as the placement of subcutaneous drains. Therefore two comparable groups of patients were formed and analysed by standardised parameters. The wound dressing was placed epicutaneously immediately after wound closure in the operating room and removed after 5 days in each case. Follow-ups were performed immediately after removal of the wound dressing, at the time of discharge from hospital as well as 6 and 12 weeks after operation. The wounds were checked for tenderness, pain, secretion, redness and fistulas. RESULTS: The Prevena group showed 10 % wound complications which needed operative treatment, whereas the OPSITE group showed complications in 24 %. Some patients who were treated with Prevena showed superficial skin lesions at the rim of the foam and the film. All of these lesions healed well. CONCLUSION: Treating wounds postoperatively with preventive measures (NPWT) showed a remarkable reduction of wound complications following open pectus surgery whereas statistically the difference was not significant (p = 0.074).

Advancement of physical process by mental activation: a prospective controlled study.

According to the literature, patients who are significantly impaired by physical mobility limitations can be rehabilitated if the patient's working memory is used to capacity. The conclusion that periodic mental activity improves physical rehabilitation should be evaluated. This is a prospective, controlled, and randomized open study of patients who underwent a total hip arthroplasty (THA). Sixteen patients who played the video game Dr. Kawashima's Brain Training: How Old Is Your Brain? were compared in terms of rehabilitation progress to 16 individuals who did not play. Harris Hip and Merle d'Aubigné scores were evaluated 1 d preoperation and again 12 +/- 1 d postoperation. Preoperation, no significant differences in hip scores between the gaming and control groups were found (median Harris Hip score: 39 vs 33, respectively, p = 0.304; median Merle D'Aubigné score: 12 vs 9, respectively, p = 0.254). Postoperation, there were significant differences between the gaming and control groups (median Harris Hip score: 76.0 vs 56.5, respectively, p = 0.001; median Merle D'Aubigné score: 16.0 vs 13.5, respectively, p = 0.014). Within both groups, the posttest scores significantly improved; however, the increase for the gaming group was greater for both measures. Because the influence of age, sex, and level of education can be excluded, it can be assumed that mental activities can improve physical rehabilitation after THA.