Feasibility of Dark-Field Radiography to Enhance Detection of Nondisplaced Fractures.

Background Many clinically relevant fractures are occult on conventional radiographs and therefore challenging to diagnose reliably. X-ray dark-field radiography is a developing method that uses x-ray scattering as an additional signal source. Purpose To investigate whether x-ray dark-field radiography enhances the depiction of radiographically occult fractures in an experimental model compared with attenuation-based radiography alone and whether the directional dependence of dark-field signal impacts observer ratings. Materials and Methods Four porcine loin ribs had nondisplaced fractures experimentally introduced. Microstructural changes were visually verified using high-spatial-resolution three-dimensional micro-CT. X-ray dark-field radiographs were obtained before and after fracture, with the before-fracture scans serving as control images. The presence of a fracture was scored by three observers using a six-point scale (6, surely; 5, very likely; 4, likely; 3, unlikely; 2, very unlikely; and 1, certainly not). Differences between scores based on attenuation radiographs alone (n = 96) and based on combined attenuation and dark-field radiographs (n = 96) were evaluated by using the DeLong method to compare areas under the receiver operating characteristic curve. The impact of the dark-field signal directional sensitivity on observer ratings was evaluated using the Wilcoxon test. The dark-field data were split into four groups (24 images per group) according to their sensitivity orientation and tested against each other. Musculoskeletal dark-field radiography was further demonstrated on human finger and foot specimens. Results The addition of dark-field radiographs was found to increase the area under the receiver operating characteristic curve to 1 compared with an area under the receiver operating characteristic curve of 0.87 (95% CI: 0.80, 0.94) using attenuation-based radiographs alone (P < .001). There were similar observer ratings for the four different dark-field sensitivity orientations (P = .16-.65 between the groups). Conclusion These results suggested that the inclusion of dark-field radiography has the potential to help enhance the detection of nondisplaced fractures compared with attenuation-based radiography alone. © RSNA, 2024 See also the editorial by Rubin in this issue.

Micro-CT in a forensic examination of a fatal child abuse case: A case report.

Child abuse is a serious concern that can cause the death of a child. In such cases the medico-legal evidence is often pivotal but complex, drawing across multiple medical disciplines and techniques. One key specialism is histopathology, which is considered the gold standard for estimating the age of individual fractures. Another is micro-CT imaging, which can visualise the location of trauma across the body. This case report demonstrates how micro-CT was used to contextualise the histological evidence in the Criminal Justice Proceedings of a fatal child abuse case. This was achieved by overlaying the aged fracture evidence from histopathology onto the visuals rendered from micro-CT imaging. The case was a suspected child abuse of a deceased 1-month old infant who was reported unresponsive by their parents. The child was taken to hospital where they were pronounced dead. Suspicion was raised and post-mortem imaging confirmed head trauma and rib fractures, and the case was escalated for a forensic investigation. This case report details how the micro-CT imaging was merged with the gold standard of histopathology for visualisation of trauma, and how the court presentation was planned alongside Senior Investigating Officers and various medical experts. The presentation was used in court by the histopathologist to present the evidence. The resulting presentation provided additional clarity to jury members regarding the location, severity, frequency, and timings of the injuries. From the perspective of the investigating police force, the resulting presentation was crucial in ensuring understanding of the medico-legal evidence of how the infant died. The prosecuting lawyer noted that combining the histological and micro-CT evidence in this way allowed the evidence to be presented in a sensitive, clear, and impactful manner.

Return to work and activity after rib-fixation for acute chest trauma: first application of a validated patient-reported outcomes assessment tool.

OBJECTIVES: Rib fractures present a heavy pain and functional burden in trauma. Our primary aim was to determine return to work in patients with acute rib fractures requiring surgical stabilization of rib fractures. Our secondary outcomes were pain and quality of life. We also document the first application of the Work Productivity and Activity Impairment Instrument, a validated injury-specific patient-reported outcome measure, for chest wall injury in the literature. METHODS: A retrospective review was conducted on patients with rib fractures requiring surgical fixation in a single centre between 2008 and 2020. After applying inclusion and exclusion criteria to ensure relevance, all eligible patients were asked to complete patient-reported outcome measure questionnaires. RESULTS: Of 1841 trauma patients with rib fractures, 66 underwent surgical fixation. Thirty-nine patients were eligible and 31 completed the questionnaires. Pre-injury and post-injury answers were compared. The number of patients in employment decreased postoperatively from 22 to 16 (P = 0.006). For those who returned to work, there was no difference in hours missed but reduced weekly hours and productivity scores. There were significantly more patients with pain and on pain relief. There was a lower quality of life score postoperatively. CONCLUSIONS: Approximately 1 in 5 patients who require surgical fixation for rib fractures will not return to work. This is the first chest wall trauma study that uses the Work Productivity and Activity Impairment Instrument, a validated tool for work productivity outcomes. We recommend this instrument as a reliable tool for investigating return-to-work outcomes in trauma patients.

Management of non-union of rib fractures secondary to trauma: A scoping review.

OBJECTIVE: Rib fracture non-union is an uncommon complication of traumatic rib fractures. Our objective was to perform a scoping review of the literature for the management of rib fracture non-union. This included analysis of the variations in surgical technique, complications experienced, and reported outcomes. METHODS: We conducted a scoping review and searched databases (MEDLINE, CINAHL, and Embase). We performed abstract and full-text screening, and abstracted data related to pre-operative assessment, surgical technique, complications, and reported outcome measures. RESULTS: We included 29 articles of which 19 were case reports and 10 were case series. The data quality was generally heterogeneous. The studies included 229 patients and the commonest symptoms of rib fracture non-union included chest pain, clicking, dyspnea and deformities. The patients underwent surgical management of rib fracture non-union (excluding first rib fractures) using various techniques. The majority used surgical stabilization of rib fracture with or without a graft. The reported outcomes were inconsistent between studies, but showed high rates of union (>94 %), reduction in reported VAS scores, and improved return to work when included. Implant failure occurred in 10 % of the 229 total patients reported in our studies, the re-operation rate was 13 %, and the overall complication rate was 27 %. CONCLUSION: Surgical management of rib fracture non-union often involving locking plates and screws with or without a graft has been shown in several case reports and series as an effective treatment with acceptable implant failure and complication rates. Surgical management is therefore a viable option for symptomatic patients. Further research is required to determine optimal management strategies that further reduce surgical complications for these patients.

Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity matched analysis.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) improves outcomes in chest wall trauma. Geriatric patients are particularly vulnerable to poor outcomes; yet, this population is often excluded from SSRF studies. Further delineating patient outcomes by age is necessary to optimize care for the aging trauma population. METHODS: A retrospective cohort study was conducted examining outcomes among patients aged 40+ for whom an SSRF consult was placed between 2017 and 2022 at a level 1 trauma center. Patients were categorized into geriatric (65+) and adult (40-64), as well as 80 years and older (80+) and 79 and younger (40-79). Patient outcomes were assessed comparing non-operative and operative management of chest wall trauma. Propensity matched analysis was performed to evaluate mortality differences between adult and geriatric patients who did and did not undergo SSRF. RESULTS: A total of 543 patients had an SSRF consult. Of these, 227 were 65+, and 73 were 80+. A total of 129 patients underwent SSRF (24 %). The percentage of patients undergoing SSRF did not vary between 40 and 64 and 65+ (23.7 % and 23.6 %, respectively, p = 0.97) or 40-79 and 80+ (24.0 vs 21.9, p = 0.69). Patients undergoing SSRF had higher chest injury burden and were more likely to require mechanical ventilation and ICU level care on admission. Overall, in-hospital mortality rate was 4.6 %. Among patients who underwent SSRF, mortality rate did not significantly differ between 65+ and 40-64 (7.8% vs 2.7 %, p = 0.18) or 80+ and 40-79 (6.3% vs 4.6 %, p = 0.77). This remained true in propensity matched analysis. CONCLUSION: Geriatric and octogenarian patients with rib fractures underwent SSRF at similar rates and achieved equivalent outcomes to their younger counterparts. SSRF did not differentially affect mortality outcomes based on age group in propensity matched analysis. SSRF is safe for geriatric patients including octogenarians.

Favourable outcome in survivors of CPR-related chest wall injuries.

BACKGROUND: There is a lack of studies focusing on long-term chest function after chest wall injury due to cardiopulmonary resuscitation (CPR). The purpose of this cross-sectional study was to investigate long-term pain, lung function, physical function, and fracture healing after manual or mechanical CPR and in patients with and without flail chest. METHODS: Patients experiencing out-of-hospital cardiac arrest between 2013 and 2020 and transported to Sahlgrenska University Hospital were identified. Survivors who had undergone a computed tomography (CT) showing chest wall injury were contacted. Thirty-five patients answered a questionnaire regarding pain, physical function, and quality of life and 25 also attended a clinical examination to measure the respiratory and physical functions 3.9 (SD 1.7, min 2-max 8) years after the CPR. In addition, 22 patients underwent an additional CT scan to evaluate fracture healing. RESULTS: The initial CT showed bilateral rib fractures in all but one patient and sternum fracture in 69 %. At the time of the follow-up none of the patients had persistent pain, however, two patients were experiencing local discomfort in the chest wall. Lung function and thoracic expansion were significantly lower compared to reference values (FVC 14 %, FEV1 18 %, PEF 10 % and thoracic expansion 63 %) (p < 0.05). Three of the patients had remaining unhealed injuries. Patients who had received mechanical CPR in additional to manual CPR had a lower peak expiratory flow (80 vs 98 % of predicted values) (p=0.030) =0.030) and those having flail chest had less range of motion in the thoracic spine (84 vs 127 % of predicted) (p = 0.019) otherwise the results were similar between the groups. CONCLUSION: None of the survivors had long-term pain after CPR-related chest wall injuries. Despite decreased lower lung function and thoracic expansion, most patients had no limitations in physical mobility. Only minor differences were seen after manual vs. mechanical CPR or with and without flail chest.

[A Review of 70 Cases of Thoracic Trauma with Rib Fixation:Indications and Practical Innovations of the Procedure].

We summarized the experience of surgical stabilization of rib fractures (SSRF) at a core hospital in eastern Hiroshima, which is a primary center for tertiary emergency medical care, especially for high-energy trauma cases including chest injuries. The study focuses on patients who underwent SSRF from January 2016 to September 2023, analyzing patient characteristics, injury mechanisms, associated injuries, fracture locations, time from injury to surgery, fixation devices used, and postoperative outcomes. Our hospital primarily treats elderly patients, and falls are the most common cause of injury, followed by traffic accidents. The criteria for SSRF in our hospital were clinical manifestations of flail chest, need for lung repair, persistent pain, or improvement of thoracic deformity. We had a high rate of fixation of fractures of the 4th-10th ribs, which have a significant impact on respiratory mechanics; although KANI plates were primarily used, the introduction of MatrixRIB plates offers advantages in certain scenarios. The study also identified challenges with the KANI plate, including cases of plate dislodgement, particularly in patients with multiple fractures and severe thoracic deformities. The combination of video-assisted thoracoscopic surgery and SSRF allows for more effective rib fixation and reduces surgical wound size and muscle damage.

[Surgical Stabilization of Traumatic Multiple Rib Fractures Using Absorbable Osteosynthesis Agent(u-HA/PLLA Composite Material)].

In case that met several indication criteria with 4 or more rib fractures, we performed surgical stabilization of multiple fractured ribs using a plate and screw system( Super FIXORB MX) that was made of uncalcined hydroxyapatite (u-HA)/poly-L-lactic acid (PLLA) composite material with excellent bioactivity and absorbability. We report our clinical experience of 7 cases in which this device was used. Although there is still room for further consideration of the technique and the strength of the device itself, computed tomography( CT) images taken 9 months after surgery showed that the fixative device was almost assimilated with the bone at the fracture repair site in cases where fixation was successful.

[The Surgical Indication of Multiple Rib Fractures of Patients by Traumas and Timing of the Surgical Stabilization of Rib Fractures].

It's reported that 10% of the inpatients by traumas have fractured ribs. It's easy to judge if it's the case of flail chest, or respiratory failure due to airway injury or pulmonary contusion. There is no guideline for treatments of a patient who has multiple ribs fractures without respiratory failure. We did the surgical stabilization of rib fractures for 10 cases from 2020 to October 2023. As a result, we find out useful surgical indication for treatment of rib fractures.

[Outcomes of Surgical Treatment for Chest Trauma].

BACKGROUND: Intra-thoracic organ bleeding and chest wall injury following chest trauma can easily lead to life-threatening emergencies and a delay in treatment may lead to fatal outcomes. Interestingly, the optimal timing, indications, and surgical techniques have not been standardized. METHOD: We retrospectively analyzed 35 patients who underwent surgical treatment for chest trauma. RESULTS: All patients with penetrating trauma (n=4) underwent emergency surgery for a hemothorax. There were no postoperative complications or hospital deaths. All patients with blunt trauma( n= 31) had multiple rib fractures;rib fixation was performed in 29 patients( 94%). Eight patients( 26%) had flail chest. The duration from injury to surgery averaged 7.5 days. The prognosis was generally favorable with no postoperative complications, but two patients died in the hospital due to multiple organ failure caused by high-energy trauma. Patients with flail chest or multiple organ injury had prolonged postoperative hospital stays. CONCLUSIONS: Patients who sustain chest trauma follow various clinical courses. Appropriate timing of surgical intervention at an early stage after injury can be life saving and hasten a functional recovery.

High sensitivity methods for automated rib fracture detection in pediatric radiographs.

Rib fractures are highly predictive of non-accidental trauma in children under 3 years old. Rib fracture detection in pediatric radiographs is challenging because fractures can be obliquely oriented to the imaging detector, obfuscated by other structures, incomplete, and non-displaced. Prior studies have shown up to two-thirds of rib fractures may be missed during initial interpretation. In this paper, we implemented methods for improving the sensitivity (i.e. recall) performance for detecting and localizing rib fractures in pediatric chest radiographs to help augment performance of radiology interpretation. These methods adapted two convolutional neural network (CNN) architectures, RetinaNet and YOLOv5, and our previously proposed decision scheme, "avalanche decision", that dynamically reduces the acceptance threshold for proposed regions in each image. Additionally, we present contributions of using multiple image pre-processing and model ensembling techniques. Using a custom dataset of 1109 pediatric chest radiographs manually labeled by seven pediatric radiologists, we performed 10-fold cross-validation and reported detection performance using several metrics, including F2 score which summarizes precision and recall for high-sensitivity tasks. Our best performing model used three ensembled YOLOv5 models with varied input processing and an avalanche decision scheme, achieving an F2 score of 0.725 ± 0.012. Expert inter-reader performance yielded an F2 score of 0.732. Results demonstrate that our combination of sensitivity-driving methods provides object detector performance approaching the capabilities of expert human readers, suggesting that these methods may provide a viable approach to identify all rib fractures.

The application of electrical impedance tomography and surgical outcomes of thoracoscope-assisted surgical stabilization of rib fractures in severe chest trauma.

Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fractures. More studies have claimed that early video-assisted thoracoscopic surgery with surgical stabilization of rib fractures (SSRF) results in a good prognosis in patients with major trauma. This study aimed to verify the outcomes in patients with chest trauma whether SSRF was performed. Consecutive patients who were treated in a medical center in Taiwan, for traumatic events between January 2015 and June 2020, were retrospectively reviewed. This study focused on patients with major trauma and thoracic injuries, and they were divided into groups based on whether they received SSRF. We used electrical impedance tomography (EIT) to evaluate the change of ventilation conditions. Different scores used for the evaluation of trauma severity were also compared in this study. Among the 8396 patients who were included, 1529 (18.21%) had major trauma with injury severity score > 16 and were admitted to the intensive care unit initially. A total of 596 patients with chest trauma were admitted, of whom 519 (87%) survived. Younger age and a lower trauma score (including injury severity scale, new injury severity score, trauma and injury severity score, and revised trauma score) account for better survival rates. Moreover, 74 patients received SSRF. They had a shorter intensive care unit (ICU) stay (5.24, p = 0.045) and better performance in electrical impedance tomography (23.46, p < 0.001). In patients with major thoracic injury, older age and higher injury survival scale account for higher mortality rate. Effective surgical stabilization of rib fractures shortened the ICU stay and helped achieve better performance in EIT. Thoracoscope-assisted rib fixation is suggested in severe trauma cases.

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.

[Experience with Surgical Stabilization for Traumatic Rib Fractures and Sternal Fractures].

The treatment of traumatic rib fractures and sternal fractures have focused on pain and respiratory management, and conservative treatment has been recommended. Recently, however, a number of case series from abroad have been reported and demonstrated the usefulness of surgical stabilization of rib fractures (SSRF) and sternal fractures (SSSF). We have experienced seven cases of SSRF and two cases of SSSF at International University Health and Welfare Narita Hospital and Atami Hospital. Based on our experienced cases, we have outlined the preoperative evaluation, indication for surgery, timing of surgery, surgical techniques, and postoperative course. Of these nine cases, the clinical course of two cases of SSRF and one case of SSSF were detailly presented. The surgical indications and techniques for traumatic rib fractures and sternal fractures vary from institution to institution, and there is no single optimal treatment. We hope that the accumulation of cases, and discussions will help to build a higher quality evidence for surgical treatment of thoracic trauma in Japan.

Together is better - RibScore and SCARF in the prediction of pulmonary complications and association with SSRF.

BACKGROUND: Optimal treatment of patients with rib fractures requires identification of those patients at risk of pulmonary complications. It is also important to determine which patients would benefit from Surgical Stabilisation of Rib Fractures (SSRF). This study aims to validate two scoring systems (RibScore and SCARF score) in predicting complications and association with SSRF in an Australian trauma population. Clinical observation suggests that complications and criteria for SSRF is associated with anatomical and physiological factors. Therefore it is hypothesized that utilisation of an anatomical (RibScore) and physiological (SCARF) in conjunction will have improved predictive ability. METHOD: Retrospective cohort study of rib fracture patients admitted to an Australian Level I trauma centre from Jan 2017 to Jan 2021. RibScore and SCARF score were calculated. Multivariate logistic regression was performed to determine risk factors associated with complications and SSRF, as well the scoring systems' ability via ROC AUC. RESULTS: 1157 patients were included. Higher median RibScore (1vs0; p < 0.001) and SCARF score (3vs1, p < 0.001) was associated with development of complications. Similarly for SSRF, RibScore (3vs0; p < 0.001), SCARF score (3vs1; p < 0.001) were higher. On multivariate analysis, increasing RibScore and SCARF score were associated with an increased risk of respiratory failure, pneumonia, death, and SSRF. The sensitivity for a patient with a high risk score in either RibScore or SCARF increased to 96.3 % in identifying pulmonary complications (from 66.7 % in RibScore and 88 % in SCARF, when used individually) and 91.9 % in identifying association with SSRF (from 86.5 % in RibScore and 70.3 % in SCARF). CONCLUSION: RibScore and SCARF score demonstrate predictive ability for complications and SSRF in an Australian trauma rib fracture population. Combining a radiological score with a clinical scoring system demonstrates improved sensitivity over each score individually for identifying patients at risk of complications from rib fractures, those who may require SSRF, and those who are low risk. STUDY TYPE: Retrospective Cohort Study LEVEL OF EVIDENCE: Level III.

Rib and sternum fracture risks for restrained occupants in frontal car crashes.

OBJECTIVE: Most car occupant fatalities occur in frontal crashes and the thorax is the most frequently injured body region. The objectives of the study were, firstly, to quantify the relation between risk factors (such as speed and occupant age) and rib and sternum fracture injury probability in frontal car crashes, and, secondly, to evaluate whether rib fracture occurrence can predict sternum fractures. METHODS: Weighted German data from 1999-2021 were used to create the injury risk curves to predict both, at least moderate and at least serious, rib and sternum fracture risks. A contingency table for rib and sternum fractures allowed the calculation of sensitivity, specificity, and precision, as well as testing for the association. RESULTS: Elderly occupants (≥65 years old) had increased rib and sternum fracture risk compared to mid aged occupants (18-64 years old). Besides occupant age, delta-V was always and sex sometimes a significant predictor for skeletal thoracic injury. Sternum fractures were more common than rib fractures and more likely to occur at any given delta-V. Sternum fractures occurred often in isolation. Female occupants were at higher risk than males to sustain at least moderate rib and sternum fractures together and sternum fractures in isolation. Rib and sternum fractures were associated, but low sensitivity and precision show that rib fractures do not predict sternum fractures well. CONCLUSIONS: Elderly and female occupants were at the highest risk and should be targeted by thoracic injury criteria and thresholds for frontal crash occupant protection. Rib and sternum fractures were not associated. Therefore, sternum fractures need to be predicted and evaluated separately from rib fractures.

Very long-term effects of conservatively treated blunt thoracic trauma: A retrospective analysis.

INTRODUCTION: Despite the high incidence of blunt thoracic trauma and frequently performed conservative treatment, studies on very long-term consequences for these patients remain sparse in current literature. In this study, we identify prevalence of long-term morbidity such as chronic chest pain, shortness of breath, and analyze the effect on overall quality of life and health-related quality of life. METHODS: Questionnaires were send to patients admitted for blunt thoracic trauma at our institution and who were conservatively treated between 1997 and 2019. We evaluated the presences of currently existing chest pain, persistence of shortness of breath after their trauma, the perceived overall quality of life, and health-related quality of life. Furthermore, we analyzed the effect of pain and shortness of breath on overall quality of life and health-related quality of life. RESULTS: The study population consisted of 185 trauma patients with blunt thoracic trauma who were admitted between 1997 and 2019, with a median long term follow up of 11 years. 60 percent still experienced chronic pain all these years after trauma, with 40,7 percent reporting mild pain, 12,1 percent reporting moderate pain, and with 7,7 percent showing severe pain. 18 percent still experienced shortness of breath during exercise. Both pain and shortness of breath showed no improvement in this period. Pain and shortness of breath due to thoracic trauma were associated with a lower overall quality of life and health-related quality of life. CONCLUSION: Chronic pain and shortness of breath may be relatively common long after blunt thoracic trauma, and are of influence on quality of life and health-related quality of life in patients with conservatively treated blunt thoracic trauma.

Management of Blunt Chest Trauma.

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.