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Large open chest wall wounds can be difficult to manage due to full-thickness tissue loss with underlying rib fractures and exposed lung parenchyma. Historically, the use of synthetic material has been discouraged in the traumatic setting with the concern that it may be associated with an increased risk of infection. We present 4 patients with large open injuries to the thorax-one from blunt and three from penetrating trauma. We describe our initial management followed by prompt surgical repair using biologic mesh, titanium rib spanning plates, and rotational tissue flaps with Z-plasty of the skin for definite closure. All patients did well post-operatively without complications or wound infections. With the appropriate management, we suspect there may be an advantage in performing immediate reconstruction and closure in large open thoracic injuries utilizing biologic mesh and titanium rib spanning plates with a lower risk of infection than previously believed., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Sarcopenia has been shown to portend worse outcomes in injured patients; however, little is known about the impact of thoracic muscle wasting on outcomes of patients with chest wall injury. We hypothesized that reduced pectoralis muscle mass is associated with poor outcomes in patients with severe blunt chest wall injury., Methods: All patients admitted to the intensive care unit between 2014 and 2019 with blunt chest wall injury requiring mechanical ventilation were retrospectively identified. Blunt chest wall injury was defined as the presence of one or more rib fractures as a result of blunt injury mechanism. Exclusion criteria included lack of admission computed tomography imaging, penetrating trauma, <18 y of age, and primary neurologic injury. Thoracic musculature was assessed by measuring pectoralis muscle cross-sectional area (cm 2 ) that was obtained at the fourth thoracic vertebral level using Slice-O-Matic software. The area was then divided by the patient height in meters 2 to calculate pectoralis muscle index (PMI) (cm 2 /m 2 ). Patients were divided into two groups, 1) the lowest gender-specific quartile of PMI and 2) second-fourth gender-specific PMI quartiles for comparative analysis., Results: One hundred fifty-three patients met the inclusion criteria with a median (interquartile range) age 48 y (34-60), body mass index of 30.1 kg/m 2 (24.9-34.6), and rib score of 3.0 (2.0-4.0). Seventy-five percent of patients (116/153) were male. Fourteen patients (8%) had prior history of chronic lung disease. Median (IQR) intensive care unit length-of-stay and duration of mechanical ventilation (MV) was 18.0 d (13.0-25.0) and 15.0 d (10.0-21.0), respectively. Seventy-three patients (48%) underwent tracheostomy and nine patients (6%) expired during hospitalization. On multivariate linear regression, reduced pectoralis muscle mass was associated with increased MV duration when adjusting for rib score and injury severity score (β 5.98, 95% confidence interval 1.28-10.68, P = 0.013)., Conclusions: Reduced pectoralis muscle mass is associated with increased duration of MV in patients with severe blunt chest wall injury. Knowledge of this can help guide future research and risk stratification of critically ill chest wall injury patients., (Published by Elsevier Inc.)

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.)

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: Blunt thoracic trauma is responsible for 35% of trauma-related deaths in the United States and significantly contributes to morbidity and healthcare-related financial strain. The goal of this study was to evaluate factors influencing mortality in patients emergently admitted with the primary diagnosis of blunt chest wall trauma. Methods: Adults emergently admitted for blunt chest trauma were assessed using the National Inpatient Sample Database, 2004-2014. Data regarding demographics, comorbidities, and outcomes were collected. Relationships were determined using univariable and multivariable logistic regression models. Results: In total, 1120 adult and 1038 elderly patients emergently admitted with blunt chest trauma were assessed; 46.3% were female, and 53.6% were male. The average ages of adult and elderly patients were 46.6 and 78.9 years, respectively. Elderly and adult patients both displayed mortality rates of 1%. The regression model showed HLOS and several comorbidities as the main risk factors of mortality Every additional day of hospitalization increased the odds of mortality by 9% (OR = 1.09, 95% CI = 1.01-1.18, p = 0.033). Mortality and liver disease were significantly associated (OR = 8.36, 95% CI = 2.23-31.37, p = 0.002). Respiratory disease and mortality rates demonstrated robust correlations (OR = 7.46, 95% CI = 1.63-34.11, p = 0.010). Trauma, burns, and poisons were associated with increased mortality (OR = 3.72, 95% CI = 1.18-11.71, p = 0.025). The presence of platelet/white blood cell disease correlated to higher mortality. (OR = 4.42, 95% CI = 1.09-17.91, p = 0.038).

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: The aim was to complete a feasibility study that would test the methods of the main trial, that will investigate whether early thoracic and shoulder girdle exercises reduce chronic pain in patients with blunt chest wall trauma, when compared with normal care., Methods: A single centre, parallel, feasibility randomised controlled trial was completed at a University Teaching Hospital in Wales between June and September 2019. Adult patients with blunt chest wall trauma, admitted to hospital for greater than 24 hours, with no concurrent, immediately life-threatening injuries, were included. The intervention was a simple physiotherapy programme comprising thoracic and shoulder girdle exercises. Feasibility outcome measures included: primary outcomes: (1) 80% or more of identified eligible patients were approached for potential recruitment to the trial (2) 30% or less of approached, eligible patients dissented to participate in the trial; secondary outcomes: (3) follow-up data for patient secondary outcomes can be collected for 80% or more of patients, (4) there should be no greater than 10% increase in serious adverse events in the intervention group compared with the control group., Results: A total of 19/19 (100%) patients were deemed eligible for the trial and were approached for participation, 5/19 (26%) eligible patients declined to participate in the trial, follow-up data were collected for n=10/14 (71%) patients and there were no serious adverse events reported in either group., Conclusions: We have demonstrated that a fully powered randomised clinical trial of the EarLy Exercise in blunt Chest wall Trauma Trial is feasible., Trial Registration Number: ISRCTN16197429., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches., Competing Interests: Declaration of competing Interest The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Author WBL holds several patents related to rib fixation and receives royalties from DePuy Synthes Inc. The remaining authors report no conflict of interest., (Published by Elsevier Inc.)

Introduction: Trauma to the chest wall is one of the most common injuries suffered. Knowing whether there are regular and reproducible changes in frequency or severity of certain injury types may help resource allocation and improve prevention efforts or outcomes; however, no prior studies have evaluated seasonal variation in chest wall injuries (CWIs). We aimed to determine if CWIs vary annually in a consistent distinct temporal variation., Methods: Using an established traumatic blunt CWI database at a single urban level 1 trauma center, patients with a moderate-to-severe (chest wall Abbreviated Injury Score (AIS) ≥2) CWI were reviewed. A subpopulation of predominant chest wall injury (pCWI) was defined as those with a chest wall AIS ≥3 and no other anatomic region having a higher AIS. Demographics, injury patterns, mechanisms of injury, and AIS were collected in addition to date of injury over a 4-y period. Data were analyzed using descriptive statistics as well as Poisson time-series regression for periodicity. Seasonal comparison of populations was performed using Student's t-tests and Analysis of Variance (ANOVA) with significance assessed at a level of P < 0.05., Results: Over a 4-y period nearly 16,000 patients presented with injury, of which 3042 patients were found to have a blunt CWI. Total CWI patients per year from 2014 to 2017 ranged from 571 to 947. Over this period, August had the highest incidence for patients with any CWI, moderate-to-severe injuries, and pCWI. February had the lowest overall injury incidence as well as lowest moderate-to-severe injury incidence. January had the lowest pCWI incidence. Yearly changes followed a quadratic sinusoid model that predicted a peak between incidence, between June and October, and the low season. A low season was found to be December-April. Comparing low to high seasons of injured patient monthly means revealed significant differences: total injuries (69.94 versus 85.56, P = 0.04), moderate to severe (62.25 versus 78.19, P = 0.06), and pCWI (25.25 versus 34.44, P = 0.01). Analysis of injuries by mechanism revealed a concomitant increase in motorcycle collisions during this period., Conclusions: There appears to be a significant seasonal variation in the overall incidence of CWI as well as severe pCWI, with a high-volume injury season in summer months (June-October) and low-volume season in winter (December-April). Motorcycle accidents were the major blunt injury mechanism that changed with this seasonality. These findings may help guide resource utilization and injury prevention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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.

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods., (Copyright © 2020 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

Background: In recent years, researchers and clinicians have been developing prognostic prediction tools (PPTs) as a way of identifying patients at risk of deterioration. The use of PPTs in the clinical environment not only impacts the risk of adverse outcomes for patients, but the use of these tools also effect clinical practice. Much attention has been paid to the clinical performance of PPTs. But more insight is needed on how the use of PPTs impacts clinical practice. The objective of this study was to map some of the ways in which PPTs effect clinical practice. The STUMBL (STUdy evaluating the impact of a prognostic model for Management of BLunt chest wall trauma patients) feasibility trial evaluated the use of a new prognostic prediction tool (PPT) to guide the management blunt chest wall trauma patients in the emergency departments (ED). The trial was undertaken between October 2016 and September 2018 and conducted at four sites in England and Wales. Nested within the feasibility trial was a qualitative study aimed at understanding how ED clinicians experienced and used the PPT. The qualitative methods included a focus group and telephone interviews with 9 ED clinicians. This study focused on participant perceptions of the feasibility and use of the STUMBL tool on clinical practice in the ED., Results: Clinical practice is reshaped as a result of the introduction of the STUMBL PPT into the clinical environment. The PPT enhanced reflexive awareness of prognostic practice; facilitated communication between patients and professionals; helps to guide patient outcomes; and provides a common ground for clinician discussion on prognostication., Conclusions: The qualitative data collected offered useful insights into the ways in which the tool changes clinical practice. This was a small study of the effect of one kind of PPT on clinical practice. Nevertheless, this study maps areas in which clinical practice is affected by the introduction of a PPT into the clinical environment. More research is needed to better understand these effects, and to understand how these tools become embedded in clinical practice over the longer term.

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.)

Most diaphragmatic ruptures are due to the traumatic or penetrating injury, while the spontaneous diaphragmatic rupture is considered uncommon. The spontaneous transdiaphragmatic hernia is a consequence of violent coughing, vomiting that increase the thoracoabdominal pressure causing the diaphragmatic rupture. Even rarer is the concomitant prolapse of abdominal viscera into the thoracic subcutis through the chest wall, a condition known as spontaneous transdiaphragmatic intercostal hernia. Herein, we present a rare case of spontaneous transdiaphragmatic intercostal hernia presenting as a thoracoabdominal emergency.

Trauma affecting the chest wall, even in isolation, can carry a significant morbidity and mortality and thus appropriate management is vital. Consequences of chest wall trauma may include significant pain, altered chest wall mechanics, hypoventilation, infection and respiratory failure. In order to best determine the appropriate management, risk stratification tools have been developed to identify patients at highest risk of complications who would most benefit from more invasive management strategies. Early optimization of analgesia is vital both for patient experience and to reduce the risk of pulmonary complications. The analgesic options range from multimodal oral analgesia to invasive regional anaesthetic techniques such as thoracic epidurals, paravertebral catheters, intercostal nerve blocks and fascial plane blocks. Other important considerations include provision of appropriate oxygen therapy, ventilation support and physiotherapy. For a selected group of patients with the most significant injuries, surgical rib fixation may be appropriate if chest wall mechanics are sufficiently impaired.

Thoracic and thoraco-abdominal aortic repair remains a challenging issue in vascular surgery, and long-term complications are well described. We report 2 cases of octogenarians with unusual long-term complications after open and endovascular thoracic aortic repair of chest wall pressure injury from the vascular prosthesis. In the first case, a computed tomographic scan of an 80-year-old man showed a pressure injury of the chest wall and rib erosion caused by a Dacron graft. The second case was an 81-year-old woman who presented with external bleeding from the left posterior chest wall. A computed tomographic scan showed a type IA endoleak and chest wall damage with rib erosion and thoracic cutaneous fistulae from the endovascular graft. Both patients were treated by relining the endovascular graft; debriding the surgical fistula was done only in the second case. In our experience, endovascular repair is a good option to avoid a complete open surgical repair., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Tricuspid valve (TV) avulsion is rare and ordinarily does not require emergent intervention. We present the case of a polytrauma patient with traumatic TV avulsion who ultimately required urgent TV replacement in the setting of hemodynamic instability. Urgent TV replacement may be warranted after careful consideration of patient risk factors and clinical context.

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.

Tubercular infection of the chest wall is rare and typically progresses to abscess formation. Treatment of these abscesses combines medical therapy with surgical debridement, which can cause defects of various sizes. This case report describes reconstruction of relatively small chest wall defects caused by tubercular abscesses with the use of two different flaps: a lateral intercostal artery perforator flap and a split pectoralis major muscle flap. The use of these flap techniques may provide a novel approach to cover small chest wall defects caused by tubercular abscesses., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Fractures of the anterior chest wall are rare among the total number of fractures. They include sternal fractures (SF) and the adjacent cartilaginous structures of the ribs. The accident mechanism can allow conclusions to be drawn about which further accompanying injuries may be present, e.g. rib and spinal fractures., Objective: The present work is intended to give an overview of injuries of the anterior chest wall. It includes clinical aspects as well as imaging and popular literature., Material and Methods: Included are injury constellations of the anterolateral chest wall, in particular of the sternum in combination with injuries of the spinal column in the sense of a sternovertebral injury (SVI). Possible treatment strategies were reviewed and the corresponding advantages and disadvantages are presented., Results: In symptomatic fractures of the anterior chest wall, their operative stabilization should be considered in order to restore the stability of the trunk. In addition, rib fractures in direct trauma and spinal injuries in indirect trauma are often included in the treatment., Conclusion: In the case of injuries of the thoracic trunk, this must always be regarded as a unit and must therefore be clarified in the context of the clinical examination and diagnostic apparatus. The possible accident mechanism can allow conclusions to be drawn about possible injury patterns, e.g. in the sense of SVIs.

Background: Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed., Objective: A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options., Material and Methods: Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed., Results and Discussion: Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.

Background: Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show a high incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to a loss of function of the shoulder and a pronounced deformation of the chest wall., Objective: This article shows the origin and clinical importance of FCI. What importance does a concomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively?, Material and Methods: After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in a corpse study and then put into practice., Results and Conclusion: This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the 2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and a marked deformation of the thoracic wall are present. Remaining misalignments are associated with a simultaneous loss of function of the chest wall and shoulder.

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.

Background: Open reduction and internal fixation of rib fractures is recommended to decrease mortality, shorten the duration of mechanical ventilation, and lower hospital length of stay. Prosthetic titanium plates are frequently used to repair chest wall trauma, and are typically contoured to the patient's anatomy at the time of implant in the operating room. We describe the use of 3-dimensional (3D) digitally corrected rapid prototyping to generate a model of a patient's skeletal anatomy for the purposes of preoperative customization of standard titanium plates for fixation of rib fractures., Methods: A computed tomography imaging Digital Imaging and Communication in Medicine data set was segmented. Rib fractures were virtually realigned using the mirrored normal anatomy as a guide. The model was printed and used to customize titanium rib fixation plates prior to the procedure., Results: Preoperative shaping of 5 titanium plates using the final 3D model required a total of 5.65 minutes. Surgical fixation of 4 of the patient's 5 fractures was accomplished using the titanium plates that were preoperatively shaped using our 3D model., Discussion: We demonstrate successful use of a digitally rendered model to preoperatively customize standard titanium rib fixation plates. Compared with intraoperative contouring of rib fixation plates, we believe that this approach facilitates repair of complex rib fractures, saving time in the operating room. We believe this technique can improve the accuracy of reductions, increase the ease and efficiency of these procedures, and afford benefits in reducing surgical stress on patients who have already suffered significant trauma.

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.

Objective: The objective of our study was to retrospectively determine the anatomic distribution of chest wall ectopic gas resembling pneumoperitoneum (i.e., pseudopneumoperitoneum) and its relationship with trauma mechanisms and clinical outcomes using CT., Materials and Methods: Investigators from two separate trauma referral centers screened 492 chest, abdomen, and pelvis CT examinations of patients who had sustained any form of trauma between 2010 and 2015. After excluding 186 patients with recognized causes of ectopic gas, 306 patients (211 men and 95 women; mean age, 44.5 years; range, 6-95 years) remained for analysis by two radiology residents in center 1 and a radiology resident in center 2. Positive cases were reviewed by all investigators, including an experienced fellowship-trained abdominal radiologist. The anatomic location of the pseudopneumoperitoneum, injury severity score, trauma velocity (high speed vs low or unknown speed), trauma mechanism, clinical findings on follow-up, and exploratory laparotomy data were collected for patients with pseudopneumoperitoneum. Two hundred consecutive nontrauma CT examinations from 2015 were selected as control cases by a resident in center 1. The t test and chi-square test were used for determining associations., Results: Pseudopneumoperitoneum was identified in 5.2% of patients, occurring bilaterally adjacent to the lower six costochondral junctions, and was significantly more common with high-velocity trauma than with low-velocity trauma (p = 0.010). None of the patients with pseudopneumoperitoneum had evidence of perforated hollow viscus at surgery (n = 2) or on clinical follow-up (n = 14). No patients had unnecessary surgery due to pseudopneumoperitoneum., Conclusion: Pseudopneumoperitoneum is a posttraumatic phenomenon centered near the lower six costochondral junctions. Recognizing these findings may help prevent unnecessary laparotomy in the trauma setting.

Background: Uncontrollable chest wall bleeding secondary to thoracic trauma has been a challenging problem faced by surgeons. Thoracic packing has been described as a good alternative although most thoracic surgeons avoid it because of the potential deleterious effects on cardiopulmonary function., Methods: We describe a selective gauze packing technique of the thoracic wall preserving cardiopulmonary function in 3 patients with uncontrollable bleeding, where gauze packs were placed on bleeding areas holding them in a "sandwich-like" arrangement between the skin and the pleura and tightly fixed with coated wire stitches using internal and external-thoracic Ventrofil® devices., Results: Successful hemostasis and cardio-respiratory stability were achieved in all cases after selective packing. X-ray showed acceptable lung expansion and no heart compression., Conclusions: This selective packing technique is simple, feasible and highly effective in managing uncontrollable post-traumatic or even post-operative chest wall hemorrhages when the life of patients is in danger., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This report describes a paediatric patient presenting with haemodynamically stable non-sustained ventricular tachycardia 1 day after minor blunt chest trauma. Initial laboratory studies, chest X-ray and echocardiography were normal; however, cardiac MRI revealed precordial haematoma, myocardial contusion and small pericardial effusion. Throughout her hospital course, she remained asymptomatic aside from frequent couplets and triplets of premature ventricular contractions. Ectopy was controlled with oral verapamil. This case highlights how significant cardiac injury may be missed with standard diagnostic algorithms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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.)

Traumatic injury to the tricuspid valve can result from severe nonpenetrating chest wall trauma. We present the case of an initially asymptomatic 11-year-old girl who was kicked in the chest by a horse. The trauma resulted in avulsed papillary muscles, ruptured chordae, and right heart failure. She underwent early tricuspid valve reconstruction and annuloplasty. We advocate for routine use of echocardiography to assess for traumatic injury to intracardiac structures. In addition, we believe that early surgical intervention may prevent right-sided heart dysfunction, atrial arrhythmias, and the need for valve replacement., (Copyright © 2016 The Society of Thoracic Surgeons. Published by 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.

The thoracic wall protects the heart, great vessels, lungs, trachea, and bronchus, which are organs important for maintaining respiration/circulation, against external forces. Therefore, injury of the thoracic wall may necessitate emergency treatment. Such injury primarily consists of rib and sternal fractures. In particular, fractures of 2 or more consecutive ribs with each rib being fractured at 2 or more sites and serial rib fracture with sternal fracture lead to reverse thoracic movement involving contraction on inhalation and expansion on expiration. Such thoracic injury is termed flail chest. Injury of the thoracic wall, such as flail chest, markedly influences the prognosis. Therefore, it is necessary to promptly evaluate the general condition, involving respiratory/circulatory kinetics, confirm the presence or absence of concomitant injury, such as bruises of the lungs/heart, and accurately select therapeutic strategies, including artificial respiration and surgical intervention.

A 23-year-old man presented with a chronic anterior chest wall wound. Previously he had a split thickness skin graft in the area in where the wound bed had become infected, developing a thick purulent drainage. The infected skin graft was excised. Histologic examination of the failed graft revealed skin with surface ulceration, focal abscess formation, deep penetrating acute and chronic inflammation with numerous eosinophils, and granulomatous changes demonstrating a foreign body-type reaction to fungal hyphae (highlighted by periodic acid-Schiff staining, Figures 1A-E). The patient's past medical history included scoliosis, acute lower back pain, right shoulder degenerative joint disease, atopic dermatitis, lymphadenitis, rhonchi, insomnia, depression, and a long history of recurrent infections, particularly cutaneous staphylococcal and candida albicans infections, often accompanied by a purulent drainage. Review of the patient's laboratory studies revealed chronically elevated alkaline phosphatase, with highly elevated serum IgE (2,922 IU/ml) and eosinophilia (925/μL3) since childhood. Other lab studies were unremarkable, except for episodic elevations of the white blood cell count. The patient's family history was largely unremarkable and the patient's parents and siblings had no histories of unusual infections.

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.