Outcomes in patients with fractured ribs: middle aged at same risk of complications as the elderly.

AIMS: Rib fractures occur in up to 10% of hospitalised trauma patients and are the most common type of clinically significant blunt injury to the thorax. There is strong evidence that elderly patients have worse outcomes compared with younger patients. Evolving evidence suggests adverse outcomes start at a younger age. The aim of this study was to explore the effect of age on outcomes in patients with rib fractures in Northland, New Zealand. METHOD: A two-year retrospective study of patients admitted to any Northland District Health Board hospital with one or more radiologically proven rib fracture was performed. Patients with an abbreviated injury scale score >2 in the head or abdomen were excluded. The study population was stratified by age into three groups: >65, 45 to 65 and <45 years old. RESULTS: 170 patients met study inclusion criteria. Patients <45 had a significantly shorter length of stay (LOS) and lower rates of pneumonia compared to patients 45 and older, despite a higher Injury Severity Score and pulmonary contusion rate. There was no difference seen between groups in rates of intubation, ICU admission, mortality, empyema or acute respiratory distress syndrome. CONCLUSION: This study found higher rates of pneumonia and an increased LOS in patients 45 and older despite their lower overall injury severity when compared to patients under 45. Patients aged 45-64 had outcomes similar to patients >65. Future clinical pathways and guidelines for patients with rib fractures should consider incorporating a younger age than 65 in risk stratification algorithms.

Multiple Fractures of Cervical Vertebrae Combined with Arcuate Foramen and Vertebral Artery Occlusion: A Case Report and Literature Review.

BACKGROUND: The arcuate foramen is a complete or partial bony bridge over the vertebral artery groove of atlas. The mechanism of the arcuate foramen is not clearly understood. Omission of the arcuate foramen sometimes causes lethal iatrogenic injury during spinal surgery. CASE PRESENTATION: We describe a patient who was diagnosed with multiple fractures of the cervical vertebrae, arcuate foramen, and right vertebral artery occlusion based on clinical and radiological exams. After conservative treatment, he resumed a normal and productive life. CONCLUSIONS: Arcuate foramen is a common variation that causes symptoms such as dizziness, headache, and migraine. If the patient does not develop severe symptoms, conservative treatment can achieve very good results without the necessity to remove the bone bridge. When serious symptoms occur, surgical treatment to resect the bony ridges can relieve the symptoms dramatically.

Safety and Efficacy of Multilevel Thoracolumbar Vertebroplasty in the Simultaneous Treatment of Six or More Pathologic Compression Fractures.

PURPOSE: To assess the safety and efficacy of multilevel thoracolumbar vertebroplasty in the simultaneous treatment of ≥ 6 painful pathologic compression fractures. MATERIALS AND METHODS: Retrospective review was conducted of 50 consecutive patients treated with vertebroplasty for ≥ 6 pathologic compression fractures in a single session for pain palliation at a tertiary single cancer center from 2015 to 2019. Outcomes measured included procedural safety according to Common Terminology Criteria for Adverse Events (CTCAE), change in 4-week postprocedure back pain by numeric rating scale (NRS), comparison of daily opioid medication consumption, and development of skeletal-related events. RESULTS: A total of 397 pathologic compression fractures were treated during 50 sessions (mean, 7.9 per patient ± 1.5). Mean procedure duration was 162 minutes ± 35, mean postoperative hospitalization duration was 1.6 days ± 0.9, and mean follow-up duration was 401 days ± 297. Seven complications were recorded, including 1 case of symptomatic polymethyl methacrylate pulmonary embolism. No major complications (CTCAE grade 4/5) were reported. NRS pain score was significantly decreased (5.0 ± 1.8 vs 1.7 ± 1.4; P < .0001), with a mean score decrease of 3.3 points (66%). Opioid agent use decreased significantly (76 mg/24 h ± 42 vs 45 mg/24 h ± 37; P = .0003), with a mean decrease of 30 mg/24 h (39%). Skeletal-related events occurred in 7 patients (14%). CONCLUSIONS: Multilevel vertebroplasty for ≥ 6 pathologic compression fractures is safe and provides significant palliative benefit when performed simultaneously.

A tough and novel dual-response PAA/P(NiPAAM-co-PEGDMA) IPN hydrogels with ceramics by photopolymerization for consolidation of bone fragments following fracture.

In this work, a novel dual-response hydrogel for enhanced bone repair following multiple fractures was investigated. The conventional treatment of multiple bone fracture consists on removing smaller bone fragments from the body in a surgery, followed by the fixation of the bone using screws and plates. This work proposes an alternative for this treatment via in situ UV-initiated radical polymerization of a novel IPN hydrogel composed of PAA/P(NiPAAM-co-PEGDMA) incorporated with ceramic additives. The influence of different additives on mechanical properties and sensitivity of the polymer, as well as the prepolymer mixture, were investigated in order to analyse the suitability of the composites for bone healing applications. This material exhibited an interpenetrating network, confirmed by FTIR, with ceramics particles dispersed in between the polymer network. These structures presented high strength by tensile tests, sensitivity to pH and temperature and a decrease on Tg values of NiPAAm depending on the amount of PEGDMA and ceramics added; although, the addition of ceramics to these composites did not decrease their stability drastically. Finally, cytotoxicity tests revealed variations on the toxicity, whereas the addition of TCP presented to be non-toxic and that the cell viability increased when ceramics additives were incorporated into the polymeric matrix with an increased reporter activity of NF-κB, associated with aiding fibroblast adhesion. Hence, it was possible to optimise feedstock ratios to increase the applicability of the prepolymer mixture as a potential treatment of multiple fractures.

Comparison of the Effectiveness of Surgical Versus Nonsurgical Treatment for Multiple Rib Fractures Accompanied with Pulmonary Contusion.

OBJECTIVE: To compare the effectiveness of surgical versus nonsurgical treatment for multiple rib fractures accompanied with pulmonary contusion. METHODS: The clinical records of consecutive 167 patients with multiple rib fractures accompanied with pulmonary contusion, who were treated from June 2014 to June 2017, were retrospectively analyzed. Of them, 75 and 92 underwent surgery (surgery group) and non-surgical treatment (non-surgery group), respectively. Patient pain score, complications, length of hospital stay, cost of hospitalization, and post-treatment 3-month follow-up results were compared. RESULTS: The mean number of days and moderate pain in the surgery group was significantly lower than that of the non-surgery group (p <0.01). The incidence of post-treatment complications was significantly lower in the surgery group than in the non-surgery group. The length of hospital stay of the surgery group was also significantly shorter than that of the non-surgery group (p <0.01). The cost of hospitalization was significantly higher in the surgery group than in the non-surgery group (p <0.01). The chest computed tomography (CT) scan which was performed 3 months after the treatment revealed that the surgery group had a better recovery than the non-surgery group. Physical recovery of the surgery group was also significantly better than that of the non-surgery group. CONCLUSION: Surgery to treat multiple rib fractures (≥ 4 fractures) accompanied with pulmonary contusion is safe and effective.

Long-term follow-up after rib fixation for flail chest and multiple rib fractures.

PURPOSE: Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures. METHODS: All adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone. RESULTS: Of the 864 patients admitted with ≥ 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18-34) and 21 (IQR 16-29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62-1) and 0.79 (0.62-0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal. CONCLUSIONS: We show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.

Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study.

BACKGROUND: Over the years, a trend has evolved towards operative treatment of flail chest although evidence is limited. Furthermore, little is known about operative treatment for patients with multiple rib fractures without a flail chest. The aim of this study was to compare rib fixation based on a clinical treatment algorithm with nonoperative treatment for both patients with a flail chest or multiple rib fractures. METHODS: All patients with ≥ 3 rib fractures admitted to one of the two contributing hospitals between January 2014 and January 2017 were retrospectively included in this multicenter cohort study. One hospital treated all patients nonoperatively and the other hospital treated patients with rib fixation according to a clinical treatment algorithm. Primary outcome measures were intensive care length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. To control for potential confounding, propensity score matching was applied. RESULTS: A total of 332 patients were treated according to protocol and available for analysis. The mean age was 56 (SD 17) years old and 257 (77%) patients were male. The overall mean Injury Severity Score was 23 (SD 11) and the average number of rib fractures was 8 (SD 4). There were 92 patients with a flail chest, 37 (40%) had rib fixation and 55 (60%) had non-operative treatment. There were 240 patients with multiple rib fractures, 28 (12%) had rib fixation and 212 (88%) had non-operative treatment. For both patient groups, after propensity score matching, rib fixation was not associated with intensive care unit length of stay (for flail chest patients) nor with hospital length of stay (for multiple rib fracture patients), nor with the secondary outcome measures. CONCLUSION: No advantage could be demonstrated for operative fixation of rib fractures. Future studies are needed before rib fixation is embedded or abandoned in clinical practice.

Actualización en politrauma pediátrico / Update on Pediatric Polytrauma

El trauma pediátrico es la principal causa de mortalidad en el paciente pediátrico, pero a pesar de esto sigue siendo mucho menor su incidencia respecto al trauma adulto. en el pasado la atención se limitaba a extrapolar los conocimientos adquiridos en el adulto para atender a los niños, pero gracias a importantes campañas de concienciación y prevención se han desarrollado sistemas protocolizados de atención al paciente pediátrico específicos. El objetivo de esta revisión es dar una visión global sobre el estado actual de la atención al paciente politraumatizado, haciendo especial hincapié en las actualizaciones y particularidades de este grupo de edad

Pediatric trauma is the leading cause of mortality in children, but it comprises a almost insignificant part of the overall politraumatic events in the hole population. pediatric attention used to be a copy of the well-developed adult trauma protocols, but, thanks to a great concienciation campaigns carry on for the governments specific pediatric trauma scores and protocols has been developed. the aim of this review is to provide a global overview of the current-state in this issue as well as to emphasize on pediatric particularities and actualizations

Challenges experienced during rehabilitation after traumatic multiple rib fractures: a qualitative study.

BACKGROUND: People with multiple rib fractures rarely receive rehabilitation aimed specifically at their chest wall injuries. This research explores patient perceptions of rehabilitation and recovery. MATERIALS AND METHODS: A qualitative study exploring how a purposive sample of 15 people with traumatic multiple rib fractures at a Major Trauma Centre in the United Kingdom make sense of their recovery. Data collected during one-to-one interviews 4 to 9 months after injury. Transcripts analysed using Interpretative Phenomenological Analysis. RESULTS: Struggling with breathing and pain: Difficulties with breathing and pain were initially so severe ?it takes your breath away? and people felt scared they may not survive. These symptoms gradually improved but feeling "out of puff" often persisted. Life on hold: Healing was considered a natural process which people couldn't influence, creating frustration whilst waiting for injuries to heal. Many believed they would never fully recover and accepted limitations. Lucky to be alive: All participants expressed a sense of feeling lucky to be alive. The seriousness of injury prompted a change in attitude to make the most of life. CONCLUSION: Rib fractures can be painful, but also frightening. A rehabilitation intervention promoting pain management, normalises trauma and restores physical activity may improve recovery. Implications for Rehabilitation Patients identified challenges with rehabilitation throughout the entire recovery journey, and their rehabilitation needs evolved with time. People find it difficult to regain pre-injury fitness even after their fractures heal and pain subsides. A belief there is nothing that can be done to help rib fractures contributed to people lowering their expectations of achieving a full recovery and developing a sense of "making do". Rehabilitation and patient education after traumatic multiple rib fractures should focus on improving pain management, respiratory fitness and emotional well-being.

Distal radius nonunion after epiphyseal plate fracture in a 15 years old young rider.

BACKGROUND AND AIM OF THE WORK: Radius and ulna fractures are the most common long bone fractures in children and adolescents. The majority of these injuries involve the distal metaphyseal portion of the radius associated or not to physeal plate injuries. Because of the high remodelling potential of the distal radius in growing children most injuries heal without complication after closed reduction and immobilization in a long arm cast. Nonunions of closed distal radius fracture are an extremely rare occurrence especially in paediatric population. Methods: In this report, we describe a rare case of distal radius fracture nonunion in a 15-years old male rider treated conservatively with cast immobilization. Eight months later he underwent surgical closed reduction and fixation with kirschner wire and cannulated screw. Results: Follow-up at 2 years showed satisfying radiological and functional outcomes. The patient ultimately returned to ride 3 months following surgery. Conclusions: Nonunion is rarely seen in distal radius fractures in healthy children and adolescents, and there are few studies in the literature. Treatment of the nonunion must be individualized and the results are not entirely predictable.

Interventions for Treating 3- or 4-part proximal humeral fractures in elderly patient: A network meta-analysis of randomized controlled trials.

BACKGROUND: The fractures of proximal humerus have a high incidence in elderly patients, especially 3- or 4-part fracture. There are 4 main treatments including nonoperation, open reduction and internal fixation(ORIF), hemiarthroplasty(HA) and reverse shoulder arthroplasty(RSA). However, which one is the optimal choice remains a controversial topic. METHODS: Through the search of three electronic databases (PubMed, Embase, and Cochrane), the randomized controlled trials of 3- or 4-part proximal humeral fracture, until the end of July 2017, which is concerned with the elderly patients, were identified. The quality evaluation of each study was evaluated, Constant score and reoperation rates were extracted and analyzed. We used R(R i386 3.3.2) and the package of gemtc to perform our network meta-analysis. RESULTS: Seven randomized controlled experiments with a total number of 347 patients were brought into our network meta-analysis. The rank probability plot of Constant score showed that the RSA had significantly the highest Constant score and lower reoperation than other treatments. The other way around, the efficacy of ORIF was the poorest. The rank for the Constant score was: RSA, HA, nonoperation and ORIF. The rank for the reduction in total reoperation rates was: RSA, nonoperation, HA and ORIF. CONCLUSIONS: The statistical result suggested that RSA has become a beneficial choice to treat displaced 3-or 4-part fracture in elderly patients, that might result in more favorable clinical outcomes and reduction of reoperation rates than other methods performed for the same indication. But the ORIF is the worst.

Styloid Process Fracture Associated With Maxillofacial Trauma: Incidence, Distribution, and Management.

PURPOSE: Fracture of the styloid process of the temporal bone has been infrequently reported. The present study evaluated the incidence, causes, distribution, and management of styloid process fracture in association with other maxillofacial fractures. MATERIALS AND METHODS: A prospective evaluation of patients with maxillofacial trauma over a period of 1 year was carried out and patients' characteristics, mode and distribution of injury, and length of styloid process were recorded. Patients were divided into 5 groups based on the site of maxillofacial fracture and into 2 groups based on styloid process length to evaluate their association with styloid process fracture. The authors' unit protocol was carried out for management of styloid process fracture. RESULTS: Of 84 patients with maxillofacial trauma, 27 patients (14 men, 13 women; mean age, 25.7 ± 8.92 yr) had styloid process fracture. The most common cause of injury was road traffic accidents. Mandibular and multiple facial fractures accounted for most concomitant styloid process fractures. The mean length of the styloid process in patients with fracture was 2.46 ± 0.89 cm and no relevant association was present between the length and fracture of the styloid process. All patients responded well to initial conservative management. CONCLUSION: Styloid process fractures are relatively common injuries in developing countries and a meticulous examination is essential for prompt diagnosis and adequate care.

Case Report of Serratus Plane Catheter for Pain Management in a Patient With Multiple Rib Fractures and an Inferior Scapular Fracture.

We placed a superficial serratus anterior plane catheter in an elderly woman with dementia and elevated clotting times who presented with multiple rib fractures after a mechanical fall. She was not a surgical candidate, and treatment consisted of conservative management with physical therapy and pain control. She was not a candidate for a patient-controlled analgesia regimen because of her dementia. Given her elevated international normalized ratio, thoracic epidural and paravertebral analgesia was also contraindicated. We placed an ultrasound-guided serratus anterior plane catheter, allowing titratable continuous infusion in a trauma patient, resulting in excellent analgesia without adverse effects.

[Surgical treatment of a complex adolescent carpal fracture : A rare injury to the growing skeleton]. / Versorgung einer komplexen jugendlichen Handwurzelfraktur : Eine seltene Verletzung am wachsenden Skelett.

We report the case of a 15-year-old boy with combined fractures of the scaphoid, capitate, and hamate that represents a rare variation of the well-known Fenton's syndrome. Fixation was performed for the unstable fractures of the scaphoid and capitate with the use of cannulated Herbert screws and K­wires respectively. K­wires were removed after 6 months, with subsequent physiotherapy. After 6 months, CT confirmed complete consolidation of the two surgically treated carpal fractures and the conservatively treated fracture of the hamate. Regarding function, the patient is able to incorporate the hand into his school-related activities and has a good range of motion, with strong closure of the fist.

Rereduction for Redisplacement of Both-Bone Forearm Shaft Fractures in Children.

BACKGROUND: There is a high rate of redisplacement after closed reduction and cast treatment of displaced both-bone forearm shaft fractures in children. Little evidence is available on the efficacy of rereduction of these redisplaced fractures. This study evaluates the impact of rereduction on radiographic outcomes and compares the cost to surgical stabilization. METHODS: This retrospective study included 31 children (mean age, 6.3 y; 18 boys) treated with rereduction for redisplacement of a displaced both-bone forearm shaft fracture between 2008 and 2013. Angulation was measured on anteroposterior and lateral radiographs of the radius and ulna at injury, after reduction, at redisplacement, after rereduction, and at fracture union. Average procedure costs for rereduction and surgical stabilization were calculated. RESULTS: Initial reduction decreased apex volar angulation (initially >20 degrees) of both bones to a median of ≤2 degrees. After an average of 15 days (range, 4 to 35 d), apex volar angulation of the radius worsened to 9 degrees, and apex ulnar angulation worsened to >10 degrees for both bones. For every 5 days after initial reduction, apex ulnar angulation of the radius worsened by 4 degrees. Rereduction reduced apex ulnar and volar angulation of both bones to <5 degrees, which was maintained after cast removal. There were no complications. The average procedure cost for rereduction was $2056 compared with $4589 for surgical stabilization with or without implant removal. CONCLUSION: Rereduction of both-bone forearm shaft fractures after redisplacement following initial closed reduction had satisfactory radiographic outcomes and is a safe, effective, and less expensive option than surgical stabilization. LEVEL OF EVIDENCE: Level IV-therapeutic.

[Operative versus non-operative treatment for three- or four-part proximal humeral fractures in elderly patients: a meta-analysis of randomized controlled trials].

Objective: To evaluate the efficacy of operative and non-operative treatment for three- or four-part proximal humeral fractures in elderly patients by meta-analysis. Methods: The literature search was performed in Cochrance Library, Medline, Embase, SinoMed, CNKI, Wanfang data and CQVIP databases for operative and non-operative treatment of three- or four-part proximal humeral fractures in elderly patients, and searches of conference proceedings were also conducted. The data were extracted and a meta-analysis was performed using RevMan 5.3. The outcome measures included Constants score, pain and incidence rates of AVN, reoperation, osteoarthritis, nonunion. Results: Six randomized controlled trials involving 264 patients were included in the meta-analysis. The differences of Constant scores (MD=0.47, 95% CI:-4.35-5.28, P=0.85), incidence of ANV (OR=0.56, 95% CI:0.25-1.24, P=0.15), incidence of osteoarthritis (OR=0.56, 95% CI:0.19-1.68, P=0.30), incidence of nonunion (OR=0.43, 95% CI:0.13-1.43, P=0.17) between operative group and non-operative group were not statistically significant. Operative treatment was better in pain score (MD=1.01, 95% CI:0.12-1.19, P=0.03) and had statistically significant higher reoperative rate (OR=3.97, 95% CI:1.45-10.92, P=0.007). Conclusions: No evidence support that there is difference in Constant score and incidence rate of ANV, osteoarthritis, nonunion between operative and non-operative treatment for three- or four-part proximal humeral fractures in elderly patients. More high quality randomized controlled trials are required to determine which treatment is more efficient.

A case of severe osteomalacia caused by Tubulointerstitial nephritis with Fanconi syndrome in asymptomotic primary biliary cirrhosis.

BACKGROUND: Primary biliary cirrhosis (PBC) is an immune-mediated chronic cholestatic liver disease, characterized by increased concentrations of serum IgM and the presence of circulating anti-mitochondrial antibodies. Although bone diseases such as osteoporosis or osteodystrophy are commonly associated with PBC, osteomalacia which is caused by abnormal vitamin D metabolism, mineralization defects, and phosphate deficiency has not been recognized as a complication of PBC. CASE PRESENTATION: We report the case of a 49-year-old Japanese woman who complained of multiple fractures. Hypophosphatemic osteomalacia was diagnosed from a low serum phosphorus level, 1,25-dihydroxyvitamin D3 level, high levels of bone specific alkaline phosphatase and the findings of bone scintigraphy, although a bone biopsy was not performed. Twenty four hour urine demonstrated a low renal fractional tubular reabsorption of phosphate, increased fractional excretion of uric acid and generalized aminoaciduria. An intravenous bicarbonate loading test suggested the presence of proximal renal tubular acidosis (RTA). These biochemical data indicated Fanconi syndrome with proximal RTA. A kidney biopsy demonstrated the features of tubulointerstitial nephritis (TIN). The patient was also suspected as having primary biliary cirrhosis (PBC) because of high levels of alkaline phosphatase, IgM and the presence of anti-mitochondrial M2 antibody, though biochemical liver function was normal. Sequential liver biopsy was compatible with PBC and the diagnosis of PBC was definite. After administration of 1,25 dihydroxyvitamin D3, neutral potassium phosphate, sodium bicarbonate for osteomalacia and subsequent predonizolone for TIN, symptoms of fractures were relieved and renal function including Fanconi syndrome was ameliorated. CONCLUSION: In this case, asymptomatic PBC was shown to induce TIN with Fanconi syndrome with dysregulation of electrolytes and vitamin D metabolism, which in turn led to osteomalacia with multiple fractures. Osteomalacia has not been recognized as a result of the renal involvement of PBC. PBC and its rare complication of TIN with Fanconi syndrome should be considered in adult patients with unexplained osteomalacia even in the absence of liver dysfunction.