Vomiting-induced costal cartilage fracture: a case report.

The use of ultrasonography as a first line imaging test in cases of possible costal cartilage fracture can be pivotal. In this case report, we present the case of a patient with a suspected atraumatic vomiting-induced costal cartilage fracture. The costal cartilage fracture was non-displaced and incomplete, thus not visible in a Computed Tomography scan. When Ultrasound imaging was employed at the area of tenderness, soft tissue edema and hematoma around the cartilage were visualized. High level of suspicion for a cartilage fracture in this case revealed a subtle osseous injury.

Biomechanics of a previously unknown thyroid cartilage fracture in fatal strangulation.

After the death of a 63-year-old woman following pressure against the neck, the injury was assessed forensically and a radiological-preparatory examination of the osseous structure of the larynx was conducted. We used fine preparation and, for further characterization of the fracture, radiological imaging in spiral CT, 3D reconstruction and fine-focus technique (mammography). While a skeletal injury with the basal fractures of the upper horns of the thyroid cartilage was clearly visible in the CT and 3D reconstruction, the radiological visualization of a 3-4mm wide wall-penetrating dehiscence in the upper part of the thyroid cartilage commissure required a higher sensitivity. Using fine-focus technology, we were able to diagnose this fracture as an avulsion of the cartilage from the medial primary ossification center of the thyroid cartilage. Not only has this type of fracture of an insertion avulsion of the median thyrohyoid ligament never been described before, but it must also be considered as the main fracture in dorsocranial traction. In this specific case, it enabled the expert to state in court that strangulation had occurred from behind.

Prevelance of the costal cartilage fracture on the computerised tomography in chest trauma.

INTRODUCTION: Radiography remains limited in costal cartilage injuries, and sonography, CT and MR imaging turns out to be more sensitive in the detection of cartilage injuries. This study aims to determine the frequency of costal cartilage fractures detected in the CT images of the patients with high energy chest trauma and to evaluate the association of costal cartilage fracture with the complications of trauma. METHODS: The CT images of 93 patients aged 18-91 years with a trauma admitted to the Emergency Department of the State Hospital between February 2019 and June 2019 were studied retrospectively. Thorax CT images of 93 patients who presented to the emergency department with blunt chest trauma with AIS > 2 were retrospectively investigated by a radiologist with a board certificate who had 15 years of experience in the field. RESULTS: Costal cartilage fracture was identified in 39 of 93 patients with severe chest trauma. Among the 93 chest trauma patients admitted to the emergency department between February and June 2019, the prevalence of costal cartilage was calculated as 41.93%. Note that the most common costal cartilage fractures in the study group were identified in the 6th, 7th, 8th and 1st costal cartilages. Another significant relationship (p = 0.007) was found between costal cartilage calcification and cartilage fracture. CONCLUSION: Costal cartilage fractures frequently occur in blunt thoracic trauma with multiple rib fractures and are of clinical importance as they lead to the instability of chest wall. The incidence of cartilage fractures increases in elderly patients with costal cartilage calcification.

Fixation of Acute Chondral Fractures in Adolescent Knees.

OBJECTIVES: Chondral fractures are focal cartilage lesions without osseous attachment, most commonly seen in adolescent knees. They have limited capacity for intrinsic healing and traditional treatment has been removal of loose fragments. However, case reports of successful healing after fixation indicate that repair of the joint surface is possible. We wanted to evaluate the outcome in a cohort of patients who underwent fixation of acute chondral fractures in the knee. DESIGN: Patients treated with fixation of a chondral fracture in the knee at our institution were invited to participate in a follow-up study. The mechanism of injury, fragment properties and complications were registered. Patients completed KOOS (Knee Injury and Osteoarthritis Outcome Score) and Lysholm questionnaires and performed a validated single leg hop test. Magnetic resonance imaging (MRI) was used to assess healing of the defect and the quality of the cartilage. RESULTS: Ten patients with a median age at surgery of 15 years (12-17 years) and median follow-up of 5 years (2-9 years) were assessed. The lesions were located on the patella (n = 7), the trochlea (n = 2), and the lateral femoral condyle (n = 1). Median lesion size was 250 mm2 (1.9-6.0 cm2) All patients were treated within 2 months of injury (4-58 days). All patients returned to preinjury level of sports and MRI showed retained fragments that integrated well with surrounding cartilage at follow-up. Mean Lysholm score at follow-up was 90 (73-100). CONCLUSION: Fixation of traumatic chondral-only fragments using bioabsorbable implants may result in successful healing in adolescent patients and should be considered a treatment option in acute injuries.

Osteochondral Fracture of Posterior Aspect of Lateral Femoral Condyle After Lateral Patella Dislocation: A Case Report.

CASE: A healthy 15-year-old girl presented with osteochondral fracture at the posterior aspect of the lateral femoral condyle (LFC) associated with a right patellar dislocation after a noncontact injury. The patient remained asymptomatic 18 months after the arthroscopically assisted reduction and internal fixation of the osteochondral fracture using bioabsorbable pins and was able to eventually resume her usual activities of daily living. CONCLUSIONS: This is the first report of an osteochondral fracture at the posterior aspect of the LFC after an acute patellar dislocation, successfully treated with arthroscopically assisted reduction and internal fixation using bioabsorbable pins. This rare injury and unique mechanism of injury have been discussed.

The added value of postmortem magnetic resonance imaging in cases of hanging compared to postmortem computed tomography and autopsy.

The purpose of this study was to evaluate the added value of postmortem magnetic resonance imaging (MRI) compared to postmortem computed tomography (CT) and autopsy in cases of fatal hanging. In addition, the study analyzed the strengths of each examination method regarding typical injuries in these cases. We investigated a cohort of 25 decedents who underwent CT, MRI and autopsy. Two radiologists assessed all MR images of the head and neck as well as the corresponding CT images. The results were compared to autopsy findings by retrospectively analyzing the autopsy reports. Postmortem MRI revealed intramuscular hemorrhages in a large number of cases, however, autopsy did not confirm all of the detected hemorrhages. CT and autopsy detected fractures in several cases, whereas MRI showed a fracture in just one single case. Other previously described vital signs and relevant findings, such as fracture-related gas bubbles, soft tissue emphysema or pneumomediastinum, were observed in only a few individual cases. MRI provided added diagnostic value in the detection of soft tissue injuries and lymph node swelling in fatal hangings. As an adjunct to autopsy, postmortem MRI may reveal additional hemorrhages, which might be missed at autopsy. Since standard MRI demonstrated low sensitivity for the detection of fractures, an additional imaging modality or autopsy is required to overcome this limitation.

Postmortem Magnetic Resonance Imaging and Postmortem Computed Tomography in Ligature and Manual Strangulation.

PURPOSE: The aim of this study was to evaluate magnetic resonance imaging (MRI) findings in cases of fatal manual or ligature strangulation. Verification of strangulation by computed tomography (CT), MRI, and at autopsy as well as its detectability in each modality was assessed. METHODS: We retrospectively analyzed 6 manual and ligature strangulation cases between 2013 and 2019 who all underwent a whole-body CT, head and neck MRI, and an autopsy. Two radiologists examined head and neck imaging data and compared the data to autopsy findings. RESULTS: Magnetic resonance imaging showed a high efficiency in verifying intramuscular hemorrhages, which were confirmed in autopsy. Moreover, in one case without a visible strangulation mark, soft tissue injuries associated with strangulation were detected. Fractures, especially thyroid cartilage fractures, were successfully diagnosed by CT. CONCLUSIONS: As MRI showed a successful detection of soft tissue lesions in relation to strangulation, it can serve as an alternative method or provide additional value to an autopsy. Intramuscular hemorrhages are a common finding in manual and ligature strangulation, providing a useful sign of applied pressure on the neck. However, to evaluate fractures, an additional CT or autopsy is recommended.

Unique presentation of cricoid cartilage fracture causing intermittent dyspnea without preceding trauma.

Cricoid cartilage fracture is generally caused by significant neck trauma and causes continuous dyspnea, neck pain, or hoarseness developing immediately after the traumatic episode. A 69-year-old woman without any history of trauma was admitted to our hospital with intermittent dyspnea. Six months before admission she had started to complain of dyspnea occurring several times a month without warning, improving spontaneously within a few hours without treatment. Her primary care doctor diagnosed asthma and she was treated with inhaled short-acting beta agonists and glucocorticoids, without improvement. On initial evaluation at our hospital, the cause of dyspnea was unclear. Laryngoscopy was performed, which excluded vocal cord dysfunction. A further attack of dyspnea occurred on the fourth admission day. Stridor was evident during the attack, and bronchoscopy revealed subglottic narrowing of the trachea on both inspiration and expiration with no mass or foreign objects. Computed tomography (CT) of the neck revealed cricoid cartilage fracture causing airway narrowing and dyspnea. She was orally intubated, and tracheostomy was performed 2 weeks later to maintain her airway, which resolved her dyspnea. This patient's presentation was unique in two aspects. First, there was no history of trauma that may cause her cricoid cartilage fracture. Second, her symptoms of dyspnea were intermittent rather than continuous. These aspects led to suspicions of other diseases such as asthma or vocal cord dysfunction, thus delaying the diagnosis. Cricoid cartilage fracture should be considered in patients with dyspnea of unknown cause, irrespective of continuous or intermittent symptoms and preceding traumatic episodes.

Trypsin Pre-Treatment Combined With Growth Factor Functionalized Self-Assembling Peptide Hydrogel Improves Cartilage Repair in Rabbit Model.

The objective of this study was to improve cartilage repair and integration using self-assembling KLD hydrogel functionalized with platelet-derived growth factor-BB and heparin-binding insulin-like growth factor-1 with associated enzymatic trypsin pre-treatment of the native cartilage. Bilateral osteochondral defects were created at the central portion of the femoral trochlear groove of 48 skeletally mature, white New Zealand rabbits. One limb received a randomly assigned treatment and the contralateral limb served as the control. Treated defects were exposed to trypsin for 2 min and filled with self-assembling KLD hydrogel only, or associated to growth factors. All control limbs received KLD hydrogel alone or received only trypsin but not hydrogel. Ninety days post-defect creation, the rabbits were euthanized and magnetic resonance imaging, radiography, macroscopic evaluation, histology, and immunohistochemistry of the joint and repaired tissue were performed. Mixed model analyses of variance were utilized to assess the outcome parameters and individual comparisons were performed using Least Square Means procedure and differences with p-value < 0.05 were considered significant. Trypsin enzymatic pre-treatment improved cellular morphology, cluster formation and subchondral bone reconstitution. Platelet-derived growth factor-BB improved subchondral bone healing and basal integration. Heparin-binding insulin-like growth factor-1 associated with platelet-derived growth factor improved tissue and cell morphology. The authors conclude that self-assembling KLD hydrogel functionalized with platelet-derived growth factor and heparin-binding insulin-like growth factor-1 with associated enzymatic pre-treatment of the native cartilage with trypsin resulted in an improvement on the cartilage repair process. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2307-2315, 2019.

Cough-induced costal cartilage fracture.

We present two cases of atraumatic costal cartilage fracture secondary to violent coughing. Although costal cartilage fractures due to trauma and bony rib fractures due to violent coughing have been described, to our knowledge there have been no prior reported cases of cough-induced costal cartilage fracture. It is important for radiologists to consider costal cartilage fractures, which are often more subtle than osseous injuries, in patients with chest pain, and understand that they may not always be preceded by direct trauma. Identifying this injury is clinically important and will prevent patients from undergoing unnecessary examinations to rule out a cardiac cause of chest pain or a pulmonary embolism.

Triradiate cartilage fracture of the acetabulum treated surgically.

Fractures of the acetabulum are rare in the pediatric age and may be complicated by the premature closure of the triradiate cartilage. We report a case of triradiate cartilage displaced fracture treated surgically. A 14 years old boy, following a high-energy road trauma, presented an hematoma in the right gluteal region with severe pain. According to radiographic Judet's projections was highlighted a diastasis of the right acetabular triradiate cartilage.  CT scan study with 2D-3D reconstructions confirmed as type 1 Salter-Harris epiphyseal fracture. Due to the huge diastasis of the triradiate cartilage, the patient was operated after 72 hours through a plating osteosynthesis. We decided during the preoperative study that the plates should not be removed. Two years after surgery, the patient is clinically asymptomatic; the radiographic evaluation shows a complete cartilage's fusion and the right acetabulum is perfectly symmetrical to the contralateral. For the treatment of acetabular fractures in pediatric age should be carefully evaluated fracture's pattern, patient's age, skeletal maturity's grade, acetabulum's volume and diameter.

Using histology to evaluate micro-CT findings of trauma in three post-mortem samples - First steps towards method validation.

Forensic imaging technology has rapidly advanced over the past several decades and is gaining increasing significance in medico-legal death investigations. Medical-grade computed tomography (CT) is now routinely used in post-mortem examinations at numerous institutions across the globe. However, the resolution of medical-grade CT is limited and unsuitable when used to depict some smaller anatomical structures or micro-trauma. High-resolution micro-CT offers up to 100× the resolution to overcome this problem but is a very recent addition to the field of forensic radiology. Few studies so far have attempted to validate the results which is an essential prerequisite for it to be used in the criminal justice process as demanded by regulatory bodies. This study directly compares micro-CT images with histology, the current gold standard. Three cases were examined: two larynges from suspected strangulations and one ribcage of a case of fatal child abuse. A strong correlation was observed between histology and micro-CT as the majority of skeletal injuries were identified correctly. This paper discusses the forensic implications of the results and how micro-CT is complementary to histology.

Relevant findings on postmortem CT and postmortem MRI in hanging, ligature strangulation and manual strangulation and their additional value compared to autopsy - a systematic review.

Several articles have described the use of postmortem computed tomography (CT) and postmortem magnetic resonance imaging (MRI) in forensic medicine. Although access to CT scanners and, particularly, access to MRI scanners, is still limited for several institutes, both modalities are being applied with increasing frequency in the forensic setting. Certainly, postmortem imaging can provide crucial information prior to autopsy, and this method has even been considered a replacement to autopsy in selected cases by some forensic institutes. However, the role of postmortem imaging has to be assessed individually according to various injury categories and causes of death. Therefore, this systematic review focuses on the role of postmortem CT and MRI in cases of hanging and ligature and manual strangulation. We assessed the most common and relevant findings on CT and MRI in cases of strangulation and compared the detectability of these findings among CT, MRI and autopsy. According to the available literature, mainly fractures of the hyoid bone or thyroid cartilage were investigated using postmortem CT. Compared to autopsy, CT demonstrated equivalent results concerning the detection of these fractures. A currently described "gas bubble sign" may even facilitate the detection of laryngeal fractures on CT. Regarding the detection of hemorrhages in the soft tissue of the neck, postmortem MRI is more suitable for the detection of this "vital sign" in strangulation. Compared to autopsy, postmortem MRI is almost equally accurate for the detection of hemorrhages in the neck. Another "vital sign", gas within the soft tissue in hanging, which is hardly detectable by conventional autopsy, can be clearly depicted by CT and MRI. The number of cases of manual and ligature strangulation that were investigated by means of postmortem CT and MRI is much smaller than the number of cases of hanging that were investigated by CT and MRI. Likewise, judicial hanging and the hangman's fracture on postmortem imaging were described in only a few cases. Based on the results of this systematic review, we discuss the additional value of CT and MRI in fatal strangulation compared to autopsy, and we reflect on where the literature is currently lacking.

Laryngeal fractures treated with titanium mesh fixation.

The larynx plays a vital role in respiration, swallowing, and vocal function. Thus, laryngeal fractures that are not appropriately managed may lead to permanent dyspnea, dysphagia, and voice disorders. In cases of laryngeal fractures, surgical repair by internal fixation has been performed with materials such as thread, steel wire, and titanium miniplates. However, thyroid and cricoid cartilage have a complicated morphology, and ossification at each site in the cartilage is not uniform; thus, in some cases it is difficult to perform internal fixation with conventional methods. In this case report, we describe two patients who underwent successful fixation of fractures in their laryngeal cartilage after trauma by using titanium mesh with thread and screws. Since optimal reduction and fixation of fractured laryngeal cartilage cannot be performed with conventional methods in patients with unossified cartilage, titanium mesh may be considered a safe and reliable alternative.

Repair of displaced thyroid cartilage fracture using miniplate osteosynthesis.

Acute laryngeal trauma is estimated to occur in approximately one patient per 14 500 to 42 500 emergency room admissions. If the larynx is injured, its vital functions are affected and can be threatened in case of severe injury. Soft cartilage offers no protective advantage, which is the reason why young as well as older individuals are at risk of thyroid cartilage fracture. Experimentation on cadaver larynx has demonstrated that virtually all laryngeal fractures are longitudinally oriented. Furthermore, muscular pull can contribute to a misalignment of the fractures. As stated by Bent and Porubsky, a fracture is considered severely rather than moderately displaced, if it is freely mobile on physical examination, has more than two fracture lines or demonstrates a displacement greater than the width of the thyroid cartilage on CT imaging. We present two cases of severely displaced thyroid cartilage fracture treated in our department by open reduction and internal fixation using miniplates. Functional and radiological outcomes were excellent.

The Role of Postmortem Computed Tomography in the Evaluation of Strangulation Deaths.

We explored the value of postmortem computed tomography (PMCT) to augment autopsy in evaluating strangulation fatalities. A literature search identified 16 studies describing autopsy findings in 576 deaths and two studies describing autopsy and PMCT findings in six deaths. Similar cases were identified from our institution, yielding 130 deaths with autopsy findings and 14 deaths with both autopsy and PMCT findings. The presence of laryngohyoid fracture and soft tissue hemorrhage was compared from autopsy and autopsy+PMCT cases. The detection rates of fractures in autopsy and autopsy+PMCT cases were not significantly different. PMCT identified all fractures observed at autopsy and five fractures not identified. While PMCT may not detect soft tissue injuries in decomposed remains or subtle internal hemorrhages in neck injury, it is equally able to detect bony injuries as autopsy and might surpass autopsy in detecting subtle fractures. We conclude PMCT is useful to supplement autopsy in strangulation cases.

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma.

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ2 and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. © RSNA, 2017.

Imaging of Folate Receptor Expressing Macrophages in the Rat Groove Model of Osteoarthritis: Using a New DOTA-Folate Conjugate.

Objective To evaluate the presence and localization of folate receptor expressing macrophages in the rat groove model of osteoarthritis and determine the suitability of a new folate conjugate with albumin-binding entity (cm09) for in vivo SPECT (single-photon emission computed tomography) analysis. Design In male Wistar rats, local cartilage damage was induced in addition to a standard ( n = 10) or high-fat diet ( n = 6). After 12 weeks, 111In labeled folate conjugates were administered, and SPECT/CT (computed tomography) imaging was performed after 24 hours. Subsequently, osteoarthritis severity and folate receptor expression were assessed using (immuno)-histological sections. Results In vivo SPECT/CT imaging of the new folate conjugate (cm09) was as useful as a folate conjugate without albumin-binding entity in the groove model of osteoarthritis with less renal accumulation. Induction of cartilage damage on a standard diet resulted in no effect on the amount of folate receptor expressing macrophages compared with the contralateral sham operated joints. In contrast, inducing cartilage damage in the high-fat diet group resulted in 28.4% increase of folate receptor expression as compared with the nondamaged control joints. Folate receptor expressing cells were predominantly present in the synovial lining and in subchondral bone as confirmed by immunohistochemistry. Conclusions Folate receptor expression, and thus macrophage activation, can clearly be demonstrated in vivo, in small animal models of osteoarthritis using the new 111In-folate conjugate with specific binding to the folate receptor. Increased macrophage activity only plays a role in the groove model of osteoarthritis when applied in a high-fat diet induced dysmetabolic condition, which is in line with the higher inflammatory state of that specific model.

[When is cartilage repair successful?] / Wann ist eine Knorpelreparatur erfolgreich?

Focal cartilage lesions are a cause of long-term disability and morbidity. After cartilage repair, it is crucial to evaluate long-term progression or failure in a reproducible, standardized manner. This article provides an overview of the different cartilage repair procedures and important characteristics to look for in cartilage repair imaging. Specifics and pitfalls are pointed out alongside general aspects. After successful cartilage repair, a complete, but not hypertrophic filling of the defect is the primary criterion of treatment success. The repair tissue should also be completely integrated to the surrounding native cartilage. After some months, the transplants signal should be isointense compared to native cartilage. Complications like osteophytes, subchondral defects, cysts, adhesion and chronic bone marrow edema or joint effusion are common and have to be observed via follow-up. Radiological evaluation and interpretation of postoperative changes should always take the repair method into account.