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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., Competing Interests: Declaration of competing interest The authors declare no competing interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions., Methods: A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis., Results: Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001)., Conclusion: Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Abstract: Blunt injuries to the chest wall, specifically those related to rib fractures, need to be promptly identified and effectively managed to reduce patient morbidity and mortality. Furthermore, judicious use of multimodal pain management and early identification of patients who will benefit from the surgical stabilization of rib fractures are paramount to optimal outcomes., (Copyright © 2022 American Academy of Physician Associates.)

Background: To improve care for nonintubated blunt chest wall injury patients, our Level I trauma center developed a treatment protocol and a pulmonary evaluation tool named "PIC Protocol" and "PIC Score," emphasizing continual assessment of pain, incentive spirometry, and cough ability., Objective: The primary objective was to reduce unplanned intensive care unit admissions for blunt chest wall injury patients using the PIC Protocol and the PIC Score. Additional outcomes included intensive care unit length of stay, ventilator days, length of hospital stay, inhospital mortality, and discharge destination., Methods: This was a retrospective cohort study comparing outcomes of rib fracture patients treated at our facility 2 years prior to (control group) and 2 years following PIC Protocol use (PIC group). The protocol included admission screening, a power plan order set, the PIC Score patient assessment tool, in-room communication board, and patient education brochure. Outcomes were compared using independent-samples t tests for continuous variables and Pearson's χ2 for categorical variables with α set to p < .05., Results: There were 1,036 patients in the study (control = 501; PIC = 535). Demographics and injury severity were similar between groups. Unanticipated escalations of care for acute pulmonary distress were reduced from 3% (15/501) in the control group to 0.37% (2/535) in the PIC group and were predicted by a preceding fall in the PIC Score of 3 points over the previous 8-hr shift, marking pulmonary decline by an acutely falling PIC Score., Conclusions: The PIC Protocol and the PIC Score are easy-to-use, cost-effective tools for guiding care of blunt chest wall injury patients., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Society of Trauma Nurses.)

Background: Nonintubated video-assisted thoracoscopic surgery has been widely reported in the past decade, while nonintubated chest wall stabilization has not been reported previously. The aim of this study was to evaluate the safety and feasibility of nonintubated minimally invasive chest wall stabilization in patients with multiple rib fractures., Methods: We conducted a prospective, single-arm, observational study. In this prospective study, 20 consecutive patients with multiple rib fractures were treated using nonintubated minimally invasive chest wall stabilization., Results: Minimally invasive chest wall stabilization was mostly performed for lateral rib fractures in this study (n = 8). The mean operation time was 92.5 min, and the mean blood loss was 49 ml. No patient required conversion to tracheal intubation. The mean extubation time of the laryngeal mask was 8.9 min; the mean postoperative fasting time was 6.1 h; the mean postoperative hospital stay was 6.2 days; the mean amount of postoperative drainage was 97.5 ml; the mean postoperative pain score was 2.9 points at 6 h, 2.8 points at 12 h, and 3.0 points at 24 h; and the mean postoperative nausea and vomiting score was 1.9 points at 6 h, 1.8 points at 12 h, and 1.7 points at 24 h., Conclusions: Nonintubated minimally invasive chest wall stabilization is safe and feasible in carefully selected patients. Further studies with a large sample size are warranted., Trial Registration: ChiCTR1900025698 . Registered on 5 September 2019.

Introduction: A patient-relevant, focused Core Outcome Set (COS) is essential to the design of clinical trials dealing with chest wall trauma, in order to maximise quality of evidence regarding impact of interventions and to reduce research waste., Methods: Outcome measures were collated by way of systematic review and entered into a three round Delphi consensus completed anonymously online. Participants were international clinicians and allied health professionals (AHP) involved in the treatment of rib fractures as well as patients who had experienced severe chest trauma. Consensus thresholds for statements were defined a priori as a group rating of more than 70% or less than 15% for 'important' or 'not important'., Results: Sixty-five participants responded to the first round and the final round Final round consisted of five AHP, two patients and 16 clinicians from eight different countries. Twenty-three outcomes were regarded as important for the COS; eight adverse events, three mortality, five clinical or physiological outcomes, six life impact and one resource-related. Health related quality of life was rated highest of the life impact outcomes but participants thought it was also important to assess disability, physical function, quality of life, return to activities and return to work., Conclusion: Collecting serious adverse outcomes was important to all stakeholders as were life impact outcomes such as quality of life, physical function and return to activities. Resource use outcomes were considered less important. We recommend this Core Outcome Set, developed with multiple relevant stakeholders, for use in future clinical trials, following further work on the most appropriate methods and instruments for measurement., Competing Interests: Declaration of Competing Interest AR declares receiving research and educational grants from DePuy Ltd outside the submitted work. York Trials Unit receives funding from the British Orthopaedic Association (BOA) for the BOA Orthopaedic Surgery Research Centre (BOSRC)., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Rib fractures are common in ageing people after trauma and delirium is a complication often seen in acutely hospitalized elderly patients. For both conditions, elderly have an increased risk for institutionalization, morbidity, and mortality. This study is the first to investigate risk factors of delirium in elderly patients with rib fractures after trauma., Methods: A retrospective chart review was performed on patients ≥65 years admitted with rib fractures after blunt chest wall trauma to the Amphia hospital Breda, the Netherlands, between July 2013 and June 2018. Baseline patient, trauma- and treatment-related characteristics were identified. The main objectives were identification of risk factors of delirium and investigation of the effect of delirium on outcomes after rib fractures. Outcomes were additional complications, length of hospital stay, need for institutionalization and mortality within six months., Results: Forty-seven (24.6%) of 191 patients developed a delirium. Independent risk factors for delirium were increased age, physical impairment (lower KATZ-ADL score), nutritional impairment (higher SNAQ score) and the need for a urinary catheter, with odds ratios of 1.07, 0.78, 1.53 and 8.53 respectively. Overall, more complications were observed in patients with delirium. Median ICU and hospital length of stay were 4 and 7 days respectively, of which the latter was significantly longer for delirious patients (p < 0.001). Significantly more patients with delirium were discharged to a nursing home or rehabilitation institution (p < 0.001). The 6-month mortality in delirious patients was nearly twice as high as in non-delirious patients; however, differences did not reach statistical significance., Conclusion: Delirium in elderly patients with rib fractures is a serious and common complication, with a longer hospital stay and a higher risk of institutionalization as a consequence. Increased awareness for delirium is imperative, most importantly in older patients, in physically or nutritionally impaired patients and in patients in need of a urinary catheter.

Background: Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course., Methods: We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview., Results: From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB ® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49-63] with a median ISS of 21 [IQR 16-29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12-68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred., Conclusions: In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule. Trial registration number KEK BASEC Nr. 2016-01679.

Background: This study aimed to assess the outcome of patients undergoing internal fixation of complex rib fractures in a U.K. major trauma center., Methods: A retrospective analysis was performed on all patients undergoing operative fixation of rib fractures from March 2014 to May 2016. Outcome measures included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, infection, and mortality., Results: One hundred and two patients (66 male patients and 36 female patients, with a median age of 62 years) underwent rib fracture fixation during the study period. The causes of trauma were road traffic accidents in 39 patients (38%), a fall from a substantial height in 38 patients (37%), and a fall down stairs in 21 patients (21%). Thirty-eight patients (37%) had isolated chest trauma, and 64 patients (63%) had additional injuries. Fifty-three patients (52%) required ICU admission with a mean ICU stay of 4.7 days (range, 1 to 34 days). The median hospital length of stay was 10.6 days (range, 3 to 51 days). Patients with additional injuries (p = 0.01) and those requiring mechanical ventilation (p < 0.0001) stayed significantly longer. Sixty-five patients (64%) underwent rib fixation within 48 hours of the injury, and 37 patients (36%) underwent the surgical procedure after 48 hours. A surgical procedure within 48 hours resulted in a shorter ICU stay (p = 0.01), fewer cases of pneumonia (p = 0.001), reduced duration of mechanical ventilation (p = 0.03) and fewer tracheostomies (p = 0.02), and shorter hospital length of stay (11.5 compared with 17.3 days; p = 0.008)., Conclusions: Surgical stabilization of multiple rib fractures may improve the outcome in patients with multiple injuries and isolated chest wall trauma. Early surgical fixation leads to shorter length of stay and better outcomes., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Unstable chest wall injuries can result from multiple rib fractures or a flail chest, and are associated with high rates of morbidity and mortality. Traditionally such injuries have been treated non-operatively, with mechanical ventilation when required, and pain management. Surgical treatment of these fractures is technically possible, and studies suggest improved outcomes, such as lower time on mechanical ventilation and length of time in the intensive care unit, compared to non-operative treatment. However, there are many challenges and controversies regarding indications for surgical fixation, patient selection, outcomes, and fixation strategy. Further research in this area is warranted to better answer these questions., (© 2018 Elsevier Ltd. All rights reserved.)

Rib fixation has become a strategy for patients with displaced rib fractures and hemo/pneumothoraces (HTX/PTX). Rib plating improves pain control and respiratory mechanics, thereby reducing recovery times and morbidity/mortality. Current treatment consists of chest tube placement, pain control, and pulmonary toilet. The addition of rib plating should reduce time till HTX/PTX resolution and chest tube removal. The study compares chest tube stay time in rib-plated patients with those managed with current treatment. We hypothesize that patients undergoing rib plating will have a reduction in chest tube stay times. A retrospective review of a Level 1 trauma registry was performed. Rib-plated patients (n = 70) from 2013 to 2015 were compared with a randomly selected, nonoperative, injury-matched, historical (2003-2008) control group (n = 60). Demographics were obtained. Independent variables analyzed include Injury Severity Score (ISS), intensive care unit days, length of stay, and chest tube stay times. 60 control patients had an average ISS of 19 and age of 51 years, compared with ISS of 20 and age of 56 years in plated patients. Plated patients had a reduction in chest tube days, 6.5 versus 8.4 days, P value = 0.02. Plated patients had 14 intensive care unit days versus 19 days, P value = 0.09. T tests were performed to confirm significance. Reduction in chest tube days improves patient pain and allows for improved ambulation and pulmonary toilet, helping reduce respiratory complications. Our review shows that plating may prove beneficial in reducing complications associated with management of HTX/PTX in the setting of rib fractures.

Several patients suffer from rib fractures after traumas, and in severe cases it can be life-threatening. Until recently, attempts to perform surgical fixation in patients with instability have been unsuccessful. Chronic non-union causes persistent pain, disability and loss of quality of life. Implementation of surgical stabilization of rib fractures with tailored plates seems to improve pain relief, especially in cases of non-union but also in patients with instability of the chest wall after severe traumas, where advanced pain treatment (epidural catheter) is insufficient or weaning off fails.

Objective: To determine the prevalence, management and outcomes of patients with flail chest injuries, compared to patients without flail chest injuries (single rib fractures and multiple rib fractures without a flail segment)., Design: Retrospective cohort study., Setting: Ontario, Canada., Participants: Ontario residents over the age of 16 years who had been admitted to hospital with a chest wall injury from 2004 to 2015 were identified using administrative health care databases., Main Outcome Measurements: Outcomes included treatment modalities such as rate of surgical repair, days on mechanical ventilation, days in the intensive care unit, days in hospital, rate of chest tube placement; and rates of complication, including pneumonia, tracheostomy, readmission, and death., Results: In total 117,204 patients with fractures of the chest wall were identified. Of the entire cohort, 1.5% of them had a flail chest injury, 41% had multiple rib fractures, and 58% had single rib fractures. Patients with flail chest injuries had significantly worse outcomes compared to patients with multiple rib fractures in all categories (P < 0.0001). Similarly, patients with multiple rib fractures had significantly worst outcomes compared with patients with single rib fractures (P < 0.0001). Only 4.5% of patients with flail chest injuries were treated surgically, however, the number increased from 1% before 2010 to 10% after 2010 (P < 0.0001). After adjustment for potential confounders, patients with flail chest injuries treated surgically had a reduced risk of early mortality compared to those treated nonoperatively (OR 0.16, P = 0.019)., Conclusions: Surgical stabilization of flail chest injuries has increased significantly in recent years. The results of this study provide preliminary evidence that the increasing rate of surgical intervention may be warranted by reducing mortality., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Chest wall trauma is common, and contributes significantly to morbidity and mortality of trauma patients. Early identification of major chest wall and concomitant intrathoracic injuries is critical. Generalized management of multiple rib fractures and flail chest consists of adequate pain control (including locoregional modalities); management of pulmonary dysfunction by invasive and noninvasive means; and, in some cases, surgical fixation. Multiple studies have shown that patients with flail chest have substantial benefit (decreased ventilator and intensive care unit days, improved pulmonary function, and improved long-term functional outcome) when they undergo surgery compared with nonoperative management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Although thoracic trauma is common, little is known about which factors lead to poor functional outcomes. We sought to determine which characteristics of chest wall injury predict postrecovery pulmonary symptoms or health-related quality of life., Methods: We conducted a secondary analysis of data from a randomized trial involving patients with chest wall injuries at a Level I trauma center between December 2007 and July 2012. We evaluated the overall severity of the chest wall injury-characterized primarily by the number of fractured ribs-and rib fracture location (upper, middle, and lower; anterior, lateral, and posterior) as predictors of patient-reported outcomes 60 days after injury: dyspnea burden (0-40), Modified Medical Research Council Dyspnea Scale (MMRC) (0-4), St. George's Respiratory Questionnaire (SGRQ), and normalized Medical Outcomes Study Short-Form 36 (SF-36) scores., Results: Of 189 evaluable subjects, the mean (SD) number of fractured ribs was 5 (4). The number of fractured ribs was not associated with dyspnea burden, MMRC, or SGRQ scores. After adjustment for confounders, each additional fractured rib was associated with worse SF-36 Physical Functioning and Bodily Pain scores (-0.6 units [95% confidence interval (CI), -1.1 to 0.0] and -0.8 units [95% CI, -1.3 to -0.2], respectively). Lower rib fractures were associated with worse dyspnea burden (3.4 units; 95% CI, 1.0-5.9), MMRC score (0.4 units; 95% CI, 0.0-0.8), and SF-36 Physical Functioning, Role-Physical, Role-Emotional, and Physical Component Summary scores (-4 units [95% CI, -8 to 0], -5 units [95% CI, -8 to -1], -4 units [95% CI, -8 to 0], and -4 units [95% CI, -7 to -1], respectively)., Conclusion: The overall anatomic severity of chest wall injuries does not predict worse dyspnea symptoms 60 days after injury, but it does predict increased patient perceptions of pain and physical function limitations. Lower rib fractures predict both persistent respiratory symptoms and perception of decreased overall health., Level of Evidence: Prognostic/epidemiologic study, level III.

Internal fixation of the ribs has been shown in numerous studies to decrease complications following traumatic rib fractures. Anterior injuries to the chest wall causing cartilaginous fractures, although rare, can cause significant disability and can lead to a variety of complications and, therefore, pose a unique clinical problem. Here, we report the surgical technique used for four patients with internal fixation of injuries to the cartilaginous portions of the chest wall treated at our center. All patients had excellent clinical outcomes and reported improvement in symptoms, with no associated complications. Patients who have injuries to the anterior portions of the chest wall should be considered for internal fixation of the chest wall when the injuries are severe and can lead to clinical disability.

Background: Rib fractures occur in 10% of injured patients, are associated with morbidity and mortality, and frequently necessitate intensive care unit (ICU) care. A scoring system that identifies the risk for respiratory failure early in the evaluation process may allow early intervention to improve outcomes. The aim of this study was to test the hypothesis that a scoring system based on initial clinical findings can identify patients with rib fractures at greatest risk for morbidity and mortality., Methods: A simple scoring system to stratify risk was developed and applied to patients through a retrospective trauma registry review. Points were assigned as follows: age < 45 years = 1 point, age 45 to 65 years = 2 points, age > 65 years = 3 points; <3 fractures = 1 point, 3 to 5 fractures = 2 points, >5 fractures = 3 points; no pulmonary contusion = 0 points, mild pulmonary contusion = 1 point, severe pulmonary contusion = 2 points, bilateral pulmonary contusion = 3 points; and bilateral rib fracture absent = 0 points, bilateral rib fracture absent present = 2 points. A review of trauma registry patients with rib fractures (June 2008 to February 2010) at a state-designated level 1 trauma center was performed. Data reviewed included age, number of fractures, bilateral injury, presence of pulmonary contusion, classification of the contusion, length of hospital stay, mechanical ventilation, ICU admission, and length of stay. The scoring system was retrospectively applied to 649 patients to determine validity., Results: A score ≤ 7 indicated lower mortality (24 of 579 [4.2%]) compared with patients with scores > 7 (10 of 70 [14.3%]) (Fisher's 2-sided P = .0018). Patients with scores ≤ 6 were less likely to be admitted to an ICU (29.7%) compared with those with scores ≥ 7 (56.7%) (P < .0001). Patients with total scores < 7 were less likely to require intubation (20.6%) compared with those with scores ≥ 7 (40.0%) (P < .0001). Patients with scores ≤ 4 had shorter lengths of stay (36.0% <5 days) compared with those who had scores > 4 (59.7%) (P < .0001)., Conclusions: A simple scoring system predicts the likelihood that patients will require mechanical ventilation and prolonged courses of care. A score of 7 or 8 predicted increased risk for mortality, admission to the ICU, and intubation. A score > 5 predicted a longer length of stay and a longer period of ventilation. This scoring system may assist in the earlier implementation of treatment strategies such epidural anesthesia, ventilation, and operative fixation of fractures., (Copyright © 2012. Published by Elsevier Inc.)

The overview presents the current situation in the diagnostics and therapy of unstable thoracic wall injuries. The diagnostic spectrum is enlarged by multidetector computed tomography with 3D reconstruction imaging in rib fractures. The use of MDCT in routine examination of blunt thoracic injuries proved to bet the most sensitive imaging method in rib fractures detection, including their dislocations and assessment of the extent of thoracic wall deformity. MDCT improves visualization of the thoracic wall injuries, thus facilitating assessment of the potential respiratory disorder significance. Non-surgical therapy is, as a standard, indicated in patients with thoracic wall injuries. The treatment includes respiratory tract hygiene, pain management and selective ventilatory support. Relative indications for surgical stabilization of fractures include block and serial rib fractures, thoracic deformities and defects and rib fractures healing disorders combined with other limiting criteria. Surgical stabilization is technically managed using metal or absorbable plasters. Surgery with open reduction and internal rib fixation, in particular in block or serial rib fractures, is associated with reduction of ventilation support time and reduction in the risk of infection.

Most injuries to the chest wall with residual deformity do not result in long-term respiratory dysfunction unless they are associated with pulmonary contusion. Indications for operative fixation include flail chest, reduction of pain and disability, a chest wall deformity or defect, symptomatic nonunion, thoracotomy for other indications, and open fractures. Operative indications for chest wall injuries are rare.

Background: Chest wall implosion injuries secondary to side impact are unusual but devastating injuries. The purpose of this series is to describe the clinical entity, present a surgical technique to reduce and repair the thoracic cage deformity without thoracotomy, and report outcomes in nine patients., Study: Institutional review board approved retrospective case series, surgical technique., Setting: Level I Trauma Center., Methods: Twenty-two patients were admitted during 7-year period with thoracic cage implosion injuries and multiple segmental rib fractures from a side impact mechanism. All patients' required mechanical ventilation and had an implosion deformity along the posterolateral thoracic cage, pulmonary contusion, and clavicular fractures. Nine patients underwent repair of rib fractures through a paramidline posterior approach without thoracotomy using standard 2.4-mm titanium plates. Seven patients with similar fracture pattern treated nonoperatively were used as a historical control. Total intubation time, intensive care unit (ICU) length of stay (LOS), and final shoulder function using the Constant Murley scoring system were compared between the two groups., Results: Average age, male to female ratio, and injury severe score were comparable for both cohorts (p > 0.6). Average follow-up was 16 months versus 12 months for the operative and nonoperative groups, respectively, (p = 0.11). In the operative group, 8 of 9 (89%) patients were extubated within 24 hours of surgery; 3 of 9 (33%) were extubated in the operating room. In the operative group, seven patients underwent internal fixation of the clavicle and progressed to union with a mean Constant score of 93. Nine patients had nonoperative treatment of the clavicle with a mean Constant score of 75 (p = 0.04). Total intubation time (1.9 days) was significantly shorter in the operative group than the nonoperative controls at 13.3 days (p < 0.01) and length of ICU stay was also shortened at 5.7 (4-8) days versus 16.7 (10-26) days, respectively, (p < 0.01)., Conclusion: Chest wall implosion injuries with fixed deformities of the thoracic cage, multiple segmental rib fractures, and clavicular injury are a distinct clinical entity, which can be effectively managed with a posterior paramidline approach without thoracotomy. Reduction of the deformity and repair of the rib fractures led to a dramatic reduction in time to extubation, ICU LOS, and in-hospital complications including pneumonia and sepsis. Repair of the clavicular fracture appeared to be beneficial.

Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib's relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

We report a case of a young woman who was found unresponsive in a garbage dumpster beneath the balcony of her 9th floor apartment residence. Initial investigations by the police and coroner raised concerns regarding the circumstances of the death. Initial examination of the body, revealed a single penetrating injury on the chest with a wide abrasion collar--the injury pattern was similar to a gunshot entry wound or a shored exit wound. Autopsy revealed the abraded skin perforation along with major chest injuries with bruising of the chest wall, extensive comminuted rib fractures, and pleural and lung lacerations. These injuries were consistent with the effects of a fatal descent from height. The penetrating injury with the abrasion collar was due to a fractured end of a rib protruding through the skin mimicking a gunshot wound. The involvement of a firearm was further excluded by postmortem radiography (no projectile in situ), detailed external examination of the clothing, and scene investigation revealing that the decedent had descended from a balcony into the dumpster. This case underscores the concept that all round penetrating wounds with abrasion collars are not gunshot injuries.

The authors present the case of a 57-year-old man with polytrauma, who was injured in a train accident. Together with other injuries, he also sustained multiple comminuted fractures on the left half of the rib cage. These subsequently required surgical intervention because of thoracic instability and impending lung injury. Extensive damage to the thoracic skeleton was treated by removal of the damaged tissues and replacement by the HI-TEX PARP NT implant. The presented procedure is being discussed as an alternative to metallic fixation in thoracic instability in cases of devastating injury or injury resulting in bone and tissue loss.