Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report.

We present the case of a victim of a motor vehicle accident in his late 60s who suffered from severe torso injuries. He initially presented with abdominal and chest pain, and underwent emergency laparotomy for hemoperitoneum. After surgery, the patient developed pneumonia and septicemia, which were responsive to antibiotics. The patient was treated with mechanical ventilation in the intensive care unit for approximately 10 days and experienced a severe weight loss of approximately 30%, but slowly recovered without dyspnea. Notably, on hospital day 24, he experienced sudden respiratory distress and flail motion of the chest wall in a general ward. This late presentation of flail chest was attributed to non-union at rib fracture sites, and was likely exacerbated by malnutrition and osteomyelitis. Surgical stabilization of rib fractures and excision of the infected rib were successfully performed. The findings from this case highlight the complexity of managing delayed onset of flail chest. The findings from this case suggest the importance of vigilance for late emerging complications in patients with trauma, even when initial symptoms are absent.

Mean corpuscular volume as a prognostic factor for 30-day mortality in major trauma patients: a retrospective cohort study.

We investigated the clinical implications of the mean corpuscular volume (MCV) in patients with major trauma. This single-center retrospective review included 2021 trauma patients admitted to the intensive care unit between January 2016 and June 2020. We included 1218 patients aged [Formula: see text] 18 years with an injury severity score [Formula: see text] 16 in the final analysis. The clinical and laboratory variables were compared between macrocytosis (defined as MCV [Formula: see text] 100 fL) and non-macrocytosis groups. Cox regression analysis was performed to calculate the hazard ratios (HRs) of variables for 30-day mortality, with adjustment for other potential confounding factors. The initial mean value of MCV was 102.7 fL in the macrocytosis group (n = 199) and 93.7 fL in the non-macrocytosis group (n = 1019). The macrocytosis group showed a significantly higher proportion of initial hypotension, transfusion within 4 and 24 h, and 30-day mortality than the non-macrocytosis group. Age ([Formula: see text] 65 years), hypotension (systolic blood pressure [Formula: see text] 90 mmHg), transfusion (within 4 h), anemia (Hb < 12 g/day in women, < 13 g/day in men), and macrocytosis were significantly associated with 30-day mortality (adjusted HR = 1.4; 95% confidence interval 1.01-1.94; p = 0.046) in major trauma patients. Thus, initial macrocytosis independently predicted 30-day mortality in patients with major trauma at a Level I trauma center.

Successful endovascular treatment of an obstruction following the surgical repair of a traumatic portal vein injury: a case report.

Traumatic portal vein injury is rare, but the associated mortality rate ranges from 50% to 70%. The management of this injury is difficult and remains controversial. In this case report, we describe the successful endovascular treatment of an obstruction that developed following the surgical repair of a traumatic portal vein injury. A man in his mid-40s who had been injured in a car accident presented to our trauma center with abdominal pain, abdominal distension, and open wounds over both knees. Emergency laparotomy revealed a longitudinal rupture from the upper border of the pancreas to the mid-portion of the portal vein; his hemorrhage was successfully controlled surgically. However, postoperative abdominal computed tomography imaging revealed portal vein obstruction. One week after admission to the intensive care unit, an endovascular stent was successfully inserted into the patient's portal vein via a percutaneous transhepatic approach. The associated injuries, including the distal common bile duct obstruction, were successfully managed by choledochojejunostomy. The patient's postoperative recovery was uneventful. Thus, endovascular stent placement is an effective and safe means of treating an obstruction following the surgical repair of a traumatic portal vein injury.

Novel nomogram for predicting paradoxical chest wall movement in patients with flail segment of traumatic rib fracture: a retrospective cohort study.

Flail chest is a severe injury to the chest wall and is related to adverse outcomes. A flail chest is classified as the physiologic, paradoxical motion of a chest wall or flail segment of rib fracture (RFX). We hypothesized that patients with paradoxical chest wall movement would present different clinical features from patients with a flail segment. This retrospective observational study included patients with blunt chest trauma who visited our level 1 trauma center between January 2019 and October 2022 and were diagnosed with one or more flail segments by computed tomography. The primary outcome of our study was a clinically diagnosed visible, paradoxical chest wall motion. We used the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting. After a feature selection using the LASSO regression model, we constructed a multivariable logistic regression (MLR) model and nomogram. A total of five risk factors were selected in the LASSO model and applied to the multivariable logistic regression model. Of these, four risk factors were statistically significant: the total number of RFX (adjusted OR [aOR], 1.28; 95% confidence interval [CI], 1.09-1.49; p = 0.002), number of segmental RFX including Grade III fractures (aOR, 1.78; 95% CI, 1.14-2.79; p = 0.012), laterally located primary fracture lines (aOR, 4.00; 95% CI, 1.69-9.43; p = 0.002), and anterior-lateral flail segments (aOR, 4.20; 95% CI, 1.60-10.99; p = 0.004). We constructed a nomogram to predict the personalized probability of the flail motion. A novel nomogram was developed in patients with flail segments of traumatic RFX to predict paradoxical chest wall motion. The number of RFX, Grade III segmental RFX, and the location of the RFX were significant risk factors.

Comparing machine learning and logistic regression for acute kidney injury prediction in trauma patients: A retrospective observational study at a single tertiary medical center.

Acute kidney injury (AKI) is common in patients with trauma and is associated with poor outcomes. Therefore, early prediction of AKI in patients with trauma is important for risk stratification and the provision of optimal intensive care unit treatment. This study aimed to compare 2 models, machine learning (ML) techniques and logistic regression, in predicting AKI in patients with trauma. We retrospectively reviewed the charts of 400 patients who sustained torso injuries between January 2016 and June 2020. Patients were included if they were aged > 15 years, admitted to the intensive care unit, survived for > 48 hours, had thoracic and/or abdominal injuries, had no end-stage renal disease, and had no missing data. AKI was defined in accordance with the Kidney Disease Improving Global Outcomes definition and staging system. The patients were divided into 2 groups: AKI (n = 78) and non-AKI (n = 322). We divided the original dataset into a training (80%) and a test set (20%), and the logistic regression with stepwise selection and ML (decision tree with hyperparameter optimization using grid search and cross-validation) was used to build a model for predicting AKI. The models established using the training dataset were evaluated using a confusion matrix receiver operating characteristic curve with the test dataset. We included 400 patients with torso injury, of whom 78 (19.5%) progressed to AKI. Age, intestinal injury, cumulative fluid balance within 24 hours, and the use of vasopressors were independent risk factors for AKI in the logistic regression model. In the ML model, vasopressors were the most important feature, followed by cumulative fluid balance within 24 hours and packed red blood cell transfusion within 4 hours. The accuracy score showed no differences between the 2 groups; however, the recall and F1 score were significantly higher in the ML model (.94 vs 56 and.75 vs 64, respectively). The ML model performed better than the logistic regression model in predicting AKI in patients with trauma. ML techniques can aid in risk stratification and the provision of optimal care.

Novel nomogram for predicting pulmonary complications in patients with blunt chest trauma with rib fractures: a retrospective cohort study.

The direct consequences of chest trauma may cause adverse outcomes. Therefore, the early detection of high-risk patients and appropriate interventions can improve patient outcomes. This study aimed to investigate the risk factor for overall pulmonary complications in patients with blunt traumatic rib fractures. Prospectively recorded data of patients with blunt chest trauma in a level 1 trauma center between January 2019 and October 2022 were retrospectively analyzed. The primary outcomes were one or more pulmonary complications. To minimize the overfitting of the prediction model, we used the least absolute shrinkage and selection operator (LASSO) logistic regression. We input selected features using LASSO regression into the multivariable logistic regression model (MLR). We also constructed a nomogram to calculate approximate individual probability. Altogether, 542 patients were included. The LASSO regression model identified age, injury severity score (ISS), and flail motion of the chest wall as significant risk factors. In the MLR analysis, age (adjusted OR [aOR] 1.06; 95% confidence interval [CI] 1.03-1.08; p < 0.001), ISS (aOR 1.10; 95% CI 1.05-1.16; p < 0.001), and flail motion (aOR 8.82; 95% CI 4.13-18.83; p < 0.001) were significant. An MLR-based nomogram predicted the individual risk, and the area under the receiver operating characteristic curve was 0.826. We suggest a novel nomogram with good performance for predicting adverse pulmonary outcomes. The flail motion of the chest wall may be the most significant risk factor for pulmonary complications.

Postoperative submuscular emphysema due to air leakage from the residual screw holes after plate removal in a patient who had undergone surgical stabilization of flail chest.

Many studies have reported indications and complications of surgical stabilization of rib fractures. However, data about the postoperative complications after the removal of the plates are still lacking. The author reports a rare complication after plate removal, postoperative submuscular emphysema, due to air leakage from the residual screw hole. A 68-year-old male with a flail chest was successfully treated by surgical rib fixation. A few months later, the patient wanted his implants removed due to chest irritation. The removal operation was completed, and postoperative courses were not unusual. However, a large amount of submuscular emphysema was found in the follow-up period. The patient was successfully managed by applying a submuscular thoracic drainage catheter. Although postoperative subcutaneous emphysema due to residual screw holes after plate removal is rare, we need to pay more attention when selecting the proper length of screws during surgical rib fixation.

Intestinal obstruction caused by small bowel entrapment within a lumbar fracture: A case report.

INTRODUCTION: Intestinal obstruction associated with traumatic vertebral fracture is extremely rare. We report a case of obstructive small bowel injury caused by entrapment of the small intestine at the fracture site of the 5th lumbar vertebra due to trauma. CASE PRESENTATION: A 55-year-old man fell from a height of 4 m and visited the emergency room of a local hospital with complain of back pain. During the examination, a 5th lumbar vertebral body fracture and left psoas muscle hematoma were observed, and the patient was admitted to the neurosurgery department for conservative treatment. The patient received conservative treatment for 2 days, but new symptoms of intestinal obstruction and fever occurred. A neurosurgeon at the hospital suspected duodenal perforation and transferred the patient to the regional trauma center for treatment. Our medical staff reviewed the patient's symptoms and imaging data and decided to perform an emergency operation because of small bowel entrapment in the 5th lumbar vertebrae fracture and perforation of the small intestine. We found that the small bowel, approximately 160 cm below the ligament of Treitz, was incarcerated at the 5th lumbar vertebral fracture site. After careful manual reduction of the entrapment of the small intestine, a small bowel resection of 25 cm, including the injury site, was performed with anastomosis. CONCLUSION: If symptoms of intestinal obstruction are observed in patients with traumatic spinal injury, medical staff must consider the exceedingly rare possibility of bowel entrapment.

Undetected traumatic cardiac herniation like playing hide-and-seek-delayed incidental findings during surgical stabilization of flail chest: A case report.

BACKGROUND: Post-traumatic blunt pericardial injury is a rare condition with only a few reported cases which were generally diagnosed during initial examinations upon admission. However, pericardial injuries not bad enough to dislocate the heart may only cause intermittent electrocardiogram (ECG) changes or be asymptomatic. CASE SUMMARY: In this case, we report a blunt pericardial injury undetected on preoperative transthoracic echocardiography and chest computed tomography. We misjudged intermittent ECG changes and blood pressure fluctuations as minor symptoms resulting from cardiac contusion and did not provide intensive treatment. The pericardial injury was found incidentally during surgical stabilization of rib fractures and was successfully repaired. CONCLUSION: Post-traumatic blunt pericardial ruptures should be considered in patients with blunt chest trauma showing abnormal vital signs and ECG changes.

Acupuncture combined with multidisciplinary care for recovery after traumatic multiple rib fractures: a prospective feasibility cohort study.

INTRODUCTION: Acute pain significantly delays early physiological recovery and results in chronic functional disability in patients with traumatic multiple rib fractures (MRFs). This prospective cohort study aimed to investigate the feasibility of acupuncture combined with multidisciplinary care during recovery in patients with traumatic MRFs. METHODS: Twenty patients with traumatic MRFs who were admitted to a regional trauma centre in South Korea were enrolled. A combination of acupuncture and multidisciplinary inpatient ward management was provided at the trauma ward. Patients were permitted to continue acupuncture treatments at outpatient clinics for 3 months after the traumatic events. Clinical outcomes, including pain, acute physiological recovery, quality of life, patient satisfaction with the care provided, respiratory function and use of opioids, were evaluated up to 6 months after trauma. RESULTS: Seventeen (85%) participants completed the 6-month follow-up. One patient withdrew consent during admission due to discomfort after three sessions of acupuncture. The proportion of patients with above-moderate level of pain decreased from 95% at baseline to 41% at 6 months. Quality of life appeared to deteriorate consistently throughout the study period. Around 80% of respondents expressed satisfaction with the acupuncture treatments and stated that they found acupuncture to be acceptable. Over 94% of respondents reported slight or considerable improvement. CONCLUSION: The provision of acupuncture combined with multidisciplinary care for recovery in patients with traumatic MRFs was feasible in a regional trauma centre in South Korea. Randomised trials are needed to investigate the role of acupuncture combined with multidisciplinary care in the future. TRIAL REGISTRATION NUMBER: KCT0002911 (Clinical Research Information Service).

Prevalence of chronic post-thoracotomy pain in patients with traumatic multiple rib fractures in South Korea: a cross-sectional study.

Chronic post-thoracotomy pain is a debilitating condition after traumatic multiple rib fractures and surgery. We aimed to estimate the prevalence of chronic post-thoracotomy pain after traumatic multiple rib fractures in South Korea and explore factors associated with it. From October 2017 to June 2019, a cross-sectional survey of 100 adults, who had undergone thoracotomy due to traumatic fractures of two or more ribs 2 years to 3 months prior to the survey, was conducted in the regional trauma center in South Korea. In total, 80% and 65% patients reported any level and above moderate chronic pain, respectively. Quality of life was mostly below the normative value of the US general population. Forty-six percent patients had restrictive respiratory dysfunction, and 47% and 59% patients were classified as being at risk of above mild-level anxiety and depression, respectively. More than 70% of patients had a current opioid prescription. Multivariable logistic regression analysis showed weak evidence of association between acute, severe postoperative pain and chronic postsurgical pain (adjusted odds ratio 2.4, 95% confidence intervals 0.9 to 6.4). Collectively, chronic post-thoracotomy pain and associated incomplete recovery regarding respiratory, functional, and psychological outcomes were prevalent in patients with traumatic multiple rib fractures in South Korea.

Prognostic Accuracy of Massive Transfusion, Critical Administration Threshold, and Resuscitation Intensity in Assessing Mortality in Traumatic Patients with Severe Hemorrhage: a Meta-Analysis.

BACKGROUND: The aim of this study was to assess the prognostic value of massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI) for the mortality of trauma patients with severe hemorrhage. METHODS: Seventeen relevant articles were obtained by searching the PubMed databases through February 15, 2019. The estimated mortality rates and injury severity scores were obtained through a meta-analysis. In addition, diagnostic test accuracy (DTA) reviews were conducted to obtain the sensitivity, specificity, diagnostic odds ratio, and the summary receiver operating characteristic curve. RESULTS: At 24 hours, the estimated mortality rates were 0.194, 0.126, and 0.168 in assessments using MT, CAT, and RI, respectively. In addition, the pooled sensitivity of CAT (0.89; 95% confidence interval [CI], 0.82-0.94) was significantly higher than that of MT (0.63; 95% CI, 0.57-0.68) and RI (0.69; 95% CI, 0.63-0.75). Overall, the pooled specificity of MT and CAT was 0.82 (95% CI, 0.80-0.83) and 0.85 (95% CI, 0.83-0.88), respectively, while the pooled sensitivity was 0.49 (95% CI, 0.44-0.54) and 0.50 (95% CI, 0.38-0.62), respectively. CONCLUSION: CAT may be a more sensitive predictor for 24-hour mortality than other predictors. Furthermore, RI also appears to be a useful predictor for 24-hour mortality. Both MT and CAT showed high specificity for overall mortality.

Chest Trauma Scoring Systems for Predicting Respiratory Complications in Isolated Rib Fracture.

BACKGROUND: We retrospectively compared chest trauma scoring systems in patients with rib fractures without major extrathoracic injury for predicting respiratory complications. We also evaluated the predictive power according to the presence or absence of pulmonary contusion. MATERIALS AND METHODS: Data from 177 patients with isolated rib fractures were included (December 2013 to April 2018). The primary outcome was respiratory complications (pneumonia, respiratory failure, or empyema). The Abbreviated Injury Scale (AIS), Thoracic Trauma Severity Score (TTSS), Chest Trauma Score (CTS), Rib Fracture Score (RFS), and RibScore were evaluated using univariate and receiver operating characteristic (ROC) analyses to determine their predictive value for pulmonary complications. We divided patients into two groups according to the presence or absence of pulmonary contusion, and constructed ROC curves for both groups. RESULTS: Twenty-eight patients (15.8%) had ≥1 respiratory complication, with significantly higher numbers of standard, segmental, and displaced rib fractures as well as significantly higher TTSS, CTS, RFS, and AIS scores. In all patients, the TTSS (0.723, 95% confidence interval [CI] 0.651-0.788) showed the highest area under the ROC curve (AUROC), followed by the CTS, RFS, AIS, and RibScore. In patients with pulmonary contusion, TTSS also showed the highest AUROC (0.704, 95% CI 0.613-0.784). In patients without pulmonary contusion, RFS showed the highest AUROC (0.759, 95% CI 0.630-0.861). CONCLUSIONS: TTSS was the most useful system for predicting respiratory complications in isolated rib fracture patients with pulmonary contusion. By contrast, RFS was the most useful in patients without pulmonary contusion.

Life-threatening massive empyema: A novel complication of intrathoracic omental herniation.

Intrathoracic omental herniation (ITOH) is the herniation of the omentum through the esophageal hiatus without herniation of the stomach. It is a rare disease and serious complications due to ITOH have not been reported in the literature. Here, we reported the case of 47-year old man who presented to the emergency department with dyspnea and chest pain. Enhanced computed tomography (CT) demonstrated a large retrocardiac mass and ITOH was suspected. During the observation period in the emergency department, the patient's condition rapidly deteriorated. Follow-up CT showed large parapneumonic effusion and empyema. Emergency surgery was performed and the omental sac was removed. The patient's vital signs were restored and his symptoms were relieved. He was discharged on hospital day 15 without complications. Emergency physicians should be aware that severe complications of ITOH could develop and that if the patient's symptoms and vital signs worsen, emergency surgery should be considered.

Surgical treatment of thoracic menigocele associated with neurofibromatosis and kyphoscoliosis.

A 46-year-old man presented with a lateral thoracic meningocele associated with cutaneous neurofibromatosis type I and kyphoscoliosis of the thoracic spine upon medical examination. In the majority of such cases, these meningoceles remain asymptomatic, but surgery is indicated when giant or symptomatic cysts are present. The large thoracic meningocele was successfully extirpated through the transthoracic approach in combination with lumbar puncture and cerebrospinal drainage for decompression of the cyst.