Delayed hemothorax following blunt thoracic trauma: a case report.

BACKGROUND: Late hemothorax is a rare complication of blunt chest trauma. The longest reported time interval between the traumatic event and the development of hemothorax is 44 days. CASE PRESENTATION: An elderly patient with right-sided rib fractures from chest trauma, managed initially with closed thoracostomy, presented with a delayed hemothorax that occurred 60 days after initial management, necessitating conservative and then surgical intervention due to the patient's frail condition and associated complications. CONCLUSIONS: This case emphasizes the clinical challenge and significance of delayed hemothorax in chest trauma, highlighting the need for vigilance and potential surgical correction in complex presentations, especially in the elderly.

Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials.

PURPOSE: Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment. METHODS: Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics. RESULTS: Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD - 4.34, 95% CI - 6.98, - 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI - 13.51, 4.84); length of intensive care unit stay (WMD - 4.62, 95% CI - 7.19, - 2.05; p < 0.01; I2 = 78%; GRADE: low; PI - 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD - 5.39, 95% CI - 11.38, - 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI - 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found. CONCLUSIONS: Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.

Eficacia y seguridad de la estabilización quirúrgica con sistema de clips y barras en pacientes adultos con tórax inestable debido a fractura costal múltiple / Efficacy and safety of surgical stabilization with clips and rods system in adult patients with flail chest due to multiple rib fracture

INTRODUCCIÓN: El presente documento de evaluación de tecnología sanitaria (ETS) expone la evaluación de la eficacia y seguridad del procedimiento de estabilización quirúrgica haciendo uso del sistema de clips y barras de titanio (SCBT), en comparación con la estabilización neumática con ventilación mecánica (ENVM) en pacientes adultos con tórax inestable debido a fractura costal múltiple. El tórax inestable es una condición potencialmente mortal que se produce como consecuencia de traumatismo generalmente cerrado de tórax. La condición está definida como presencia de tres o más costillas fracturadas en dos o más lugares en cada costilla que se presenta de forma concomitante con respiración paradójica (depresión de los fragmentos costales fracturados en la inspiración y protrusión hacia el exterior de los mismos en la expiración). La presencia de tórax inestable puede ocasionar desestabilización en la función respiratoria del paciente, que cursa con ventilación inefectiva e hipercapnia, asimismo, puede causar complicaciones como consecuencia de una estancia prolongada en hospitalización, y en casos severos, la muerte del paciente. El tratamiento de la condición casi siempre requiere de oxigenación median

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

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

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

Rib fracture in buffalo with ruminal cannula

Background: Buffalos are very rustic animals that are adapted to adverse conditions, but the lack of adequate managementcan increase the susceptibility of these animals to several diseases. Rib fracture in this species is usually related to mineraldeficiency and complications resulting from unappropriated management. Rib fractures in ruminants are rarely diagnosedand usually present conservative treatment; however, cases with presence of contaminated wounds require extra attention.The objective of this work was to report an atypical case of open fracture of the last rib in a buffalo with ruminal cannula,describing the case from diagnosis to surgical treatment.Case: An adult female water buffalo (Bubalus bubalis) that was well fed and receiving minerals, with implantation ofa ruminal cannula, presented a lesion around the ruminal cannula, with increasing volume, exudation, and myiasis. Thegeneral parameters and behavior of the animal were apparently normal. The animal presented normal appetite and respiration and good physical condition and nutritional state, with pain reaction to the touch in the region of the lesion andtheir adjacencies; it presented no claudication and reluctance to remain in left lateral decubitus, and no discomfort. Theclinical inspection of the cutaneous lesion showed an oblique-type fracture in the body of the last left rib, with exposedbone in the lumbar region and extremity exposed to the ruminal cannula, already presenting necrosis. The region wascleaned, removing larvae (myiasis) for better exposition of the fracture; in the following day...(AU)

Rib fracture in buffalo with ruminal cannula

Background: Buffalos are very rustic animals that are adapted to adverse conditions, but the lack of adequate managementcan increase the susceptibility of these animals to several diseases. Rib fracture in this species is usually related to mineraldeficiency and complications resulting from unappropriated management. Rib fractures in ruminants are rarely diagnosedand usually present conservative treatment; however, cases with presence of contaminated wounds require extra attention.The objective of this work was to report an atypical case of open fracture of the last rib in a buffalo with ruminal cannula,describing the case from diagnosis to surgical treatment.Case: An adult female water buffalo (Bubalus bubalis) that was well fed and receiving minerals, with implantation ofa ruminal cannula, presented a lesion around the ruminal cannula, with increasing volume, exudation, and myiasis. Thegeneral parameters and behavior of the animal were apparently normal. The animal presented normal appetite and respiration and good physical condition and nutritional state, with pain reaction to the touch in the region of the lesion andtheir adjacencies; it presented no claudication and reluctance to remain in left lateral decubitus, and no discomfort. Theclinical inspection of the cutaneous lesion showed an oblique-type fracture in the body of the last left rib, with exposedbone in the lumbar region and extremity exposed to the ruminal cannula, already presenting necrosis. The region wascleaned, removing larvae (myiasis) for better exposition of the fracture; in the following day...

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

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

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

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

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

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

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

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

Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis.

OBJECTIVES: Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis. METHODS: This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis. RESULTS: Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY. CONCLUSIONS: Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Rib cage ostheosynthesis. Literature review and case reports]. / Osteosintesis de reja costal. Revisión de la bibliografía y reporte de casos.

BACKGROUND: Fractures of the chest wall include sternum and rib fractures. Traditionally they are managed conservatively due to the anatomy of the rib cage that allows most of them to remain stable and to form a callus that unites the fractured segments. In spite of this management, some patients present with chronic pain or instability of the wall which makes them require some type of fixation. The present article performs a literature review based on 4 cases. CLINICAL CASES: The first case was a 61 year-old man with blunt chest trauma, with a great deformity of the chest wall associated with subcutaneous emphysema, and pneumothorax. The second case was a 51 year-old man with blunt chest trauma, initially managed at another institution, who despite treatment, had persistent pain and dyspnoea. The third case was a 30 year-old man that suffered a motor vehicle accident, with resulting pain and crepitation of the rib cage and with diagnostic images showing multiple rib fractures. The last case is a 62 year-old man that fell down the stairs, with blunt chest trauma with high intensity pain, dyspnoea and basal ipsilateral hypoventilation. CONCLUSION: Rib fracture fixation offers a good alternative in selected patients to decrease associated morbidity, leading to a patient's fast return to his or her working life.

[Unstable thorax fixation with bioabsorbable plates and screws. Presentation of some cases]. / Fijación de tórax inestable con placas y tornillos bioabsorbibles. Presentación de serie de casos.

BACKGROUND: Flail chest is managed with mechanical ventilation or inhalation therapy, and analgesia. Mechanical ventilations carry risks by themselves and disengage with the external fixators so they must be operated to improve lung ventilatory mechanics and cleaning. Little has been published on the use of bioabsorbable material and its evolution in the setting of flail chest. MATERIAL AND METHODS: A material that did had to be retired, that presented the malleability of titanium and its inflammatory reaction was minimal and could be handled in both adults and children was investigated. Here is shown a descriptive study of patients with flail chest under rib fixation with plates and bioabsorbable screws. RESULTS: 18 cases are presented, aged 33-74 years, three with bilateral flail chest; fixation was performed between days 1-21 of the accident. In cases that showed no fractures pelvic limbs, gait next day restarted fi ng in all cases improved mechanical ventilation, pain decreased, none has so far presented reaction material. CONCLUSIONS: Flail chest has a high (16.3%) mortality when no management provides the pathophysiology of the condition (pain, poor mechanical ventilation, alveolar edema-pulmonary contusion). The use of bioabsorbable material has no side effects attributable to material which is another option for rib fixation.

Fijación quirúrgica de fracturas costales con placas de titanio: reporte de dos casos / Surgical repair of rib fractures using titanium plates: report of two cases

Rib fractures are common lesions in blunt chest trauma. Disregarding the severity of other high energy associated lesions, chest wall trauma characteristically causes intense pain, respiratory complications and long-term disability. Pain relief and chest wall function restoration are obtained by surgical stabilization of rib fractures. In nowdays still there is a considerable variability in surgical techniques and devices, as well as in their results and clinical indications. We report two cases of chest wall trauma and rib fractures repaired with osteosynthesis (Synthes® system MatrixRIB. Solothurn, Switzerland) and we discuss their new clinical indications and results.

Las fracturas costales son lesiones frecuentes en los traumatismos torácicos contusos. Sin contar aquellas lesiones asociadas con la alta absorción de energía, las fracturas costales causan característicamente dolor intenso, complicaciones respiratorias y ausentismo laboral significativo. Una de las estrategias terapéuticas es la estabilización quirúrgica del foco de fractura, la cual tiene múltiples ventajas teóricas como la disminución del dolor y la restauración de la función de la pared costal. Existen múltiples formas de fijación costal, pero su indicación, técnica quirúrgica y resultados son muy disímiles. Presentamos dos casos de reparación de pared torácica con material de osteosíntesis especialmente diseñado para este efecto (Synthes® MatrixRIB, Solothurn, Suiza), y se discuten sus alcances en las indicaciones y resultados clínicos.

Fijación quirúrgica de las fracturas costales con placas de osteosíntesis. Experiencia inicial / Surgical fixatiion of fractures of the rib with osteosynthesis plates

Las fracturas costales son muy frecuentes en los traumatismos torácicos cerrados. La mayoría de estos pacientes tienen un dolor importante con los movimientos y con la tos. Los pacientes politraumatizados con tórax inestable presentan una alta morbimortalidad, el principal enfoque del tratamiento se centra en la terapia del dolor y la ventilación con presión positiva. Actualmente existen estudios que demuestran la mejoría en el tratamiento al utilizar la estabilización quirúrgica. Material y métodos: en el período comprendido entre diciembre de 2010 y diciembre de 2011, en nuestro hospital y en la práctica privada, se realizó la comparación prospectiva, de la evolución de 5 pacientes en los que se fijaron las fracturas costales con osteosíntesis con placa "U", con 8 pacientes a los que no se les realizó fijación quirúrgica de las fracturas costales. La edad promedio de cada grupo fue similar (34 y 39 años respectivamente). Solo se tuvieron en cuenta a aquellos pacientes que sufrieron al menos 2 fracturas en costillas diferentes. La placa en U posee entre 4-6 tornillos, orificios con rosca en la cara profunda de la placa y un puente que separa ambos segmentos estabilizadores. Para la valoración del dolor se utilizó la escala lineal analógica subjetiva asociada a la demanda de analgesia endovenosa en las primeras 24 horas y oral posteriormente. Esquema protocolizado (Diclofenac EV. 2 mg/kg, ibuprofeno 5,33 mg/kg VO., paracetamo 6,33 mg/kg VO). Analgesia adicional: primeras 24 hs se utilizó D-propoxifenos 1,52 mg/kg EV y luego de las 24 hs D-propoxifeno 2,6 mg/kg VO. Resultados: sobre el grupo control se observó que con el tratamiento farmacológico se logró controlar el dolor en el 37,5 % de los casos (3 pacientes), mientras que el 62,5 % restante requirió analgesia adicional. En el grupo con fijación quirúrgica solo un paciente (20%) requirió analgésicos sobre el grupo control. Todos los pacientes con dolor o inestabilidad mostraron mejoría subjetiva ...

Trauma to the chest wall frequently results in fracture of the ribs which provides its stability. As an injury it ranges from one which causes little but discomfort to one which is immediately life threatening. Most of these patients show important pain during movements and with cough. Politraumatized patients with unstable thorax present a high morbimortality, and the mainstay approach of treatment focuses in pain management and ventilation. Fixation of fractured ribs may be indicated if the injured chest wall requires a chest wall fixation with osteosynthesis plates. An initial experience presented by the authors, is discussed

[Chest granuloma secondary to methyl methacrylate. Case report]. / Granuloma de tórax secundario a metilmetacrilato. Reporte de caso.

We present the case of a patient with a history of a massive left hemithorax crushing injury in 1985; the exact management of the lesion is unknown. Twenty years later he had a thoracic fistula with a culture that was reported as positive for Enteroccocus faecalis and Staphyloccocus epidermidis. The patient was referred by the chest surgery service with the diagnosis of rib osteomyelitis once complementary imaging tests were performed (plain X-rays, CAT scan and MRI). The patient underwent surgery at our service; a granulomatous reaction secondary to a foreign body (methyl methacrylate and Ethibon) was reported. Chest reconstruction for massive lesions is possible with methyl methacrylate. Imaging studies involve the well-known difficulty to identify this material, given that it may produce signals and densities that are difficult to interpret by specialized physicians.

[Treatment in unstable thorax. Case report]. / Tratamiento de tórax flotante. Presentación de caso.

We present 45 years-old male patient with bilateral luxation of all costochondral joints due to a compression mechanism while he was working beneath a car and the support was lost. He presented with floating sternum and ventilatory compromise among other injuries. Initially he was intubated and the costochondral joints were temporary fixated with dexon suture while making counter balance with 2 kg. As he was on positive pressure ventilation, lungs reexpanded we decided to place three anchors in each side of the sternum, fixated to an external aluminum support. After 10 days out of the intensive care unit, he was discharged and seen every 2 weeks. The anchors were retired in week number four and after 3 months he reintegrated to normal labor and daily activities, with limitation on flexo-extension of the left elbow by arthrogryposis.

Trauma-related thoracoplasty: case report.

Trauma primarily affects young people and is the leading cause of death in the first three decades of life. Flail chest is observed in approximately 10% of all patients with severe chest trauma, and the mortality rate among such patients is 10-15%. We report herein the case of a car accident victim with chest trauma causing hemopneumothorax and multiple rib fractures, intense pain and deformity of the chest wall. Surgical stabilization was performed, with good results. Therapeutic options are also discussed.