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We reviewed 66 cases of traumatic rib fracture by traffic accident between January 2009 and December 2011. The age of patients ranged from 18 to 88 years, with an average age of 55.6, and they were predominantly male. They met with traffic accident when driving automobiles in 30 cases, driving motorcycles in 15 cases, and walking in 9 cases. The average number of fractured ribs was 4.1±3.2.Multiple rib fractures were observed in 75.8% of patients. Injuries other than rib fractures were involved in all patients who suffered over 7 rib fractures. Except one who died of pneumonia 62 days after traffic accident, 7 of 8 patients died within 48 hours:6 in a shock state and 1 in cardiac pulmonary arrest on arrival. About 80 % of the patients with rib fractures were hospitalized. As traffic accidents could cause any type of injuries including rib fractures, it is important to examine the whole body when patients were transported to a hospital.

The paper presents two case reports of living victims, in which imaging studies of the chest conducted at a medical facility were an essential part of the medico-legal opinion. The first case was that of a young male hospitalized due to CT evidence of bilateral rib fractions, who claimed to have been assaulted by police officers. The other case was that of a six week old baby hospitalized due to chest X-ray evidence of right hand side rib fractions. The chest X-ray was performed due to one bruise found on the baby's forehead and two small bruises on the back, which gave rise to suspicions of child abuse. In both cases, expert witnesses in radiology definitively excluded the presence of any fractures. These cases indicate that a new assessment of imaging studies contained in medical records is needed. Expert opinions based solely on the description of imaging studies may result in grave consequences.

The incidence of a fractured humeral head penetrating into the thoracic cavity is extremely rare. A 46-year-old woman presented with moderate respiratory distress at the emergency department after being involved in a motor vehicle accident. Radiographic examinations revealed fractures of the second to fifth ribs on the left side along with hemopneumothorax and fracture-dislocation of the humeral head into the thoracic cavity. After initial stabilization, video-assisted thoracic surgery (VATS) was performed to remove the fractured humeral head, and this was followed by a hemiarthroplasty. In this case report, we have discussed significant aspects of this uncommon finding in order to alert surgeons of the potential risks associated with intrathoracic displacement of the fractured humeral bone in trauma patients.

Blunt chest trauma frequently leads to various complications such as pneumothorax, hemothorax, and lung contusion. Since neighboring organ injury caused by a rib fracture with chest trauma could be fatal when a great vessel is involved, immediate diagnosis and treatment including surgery are important. Here, we present a case of chest trauma, in which we performed video-assisted thoracoscopic rib resection to prevent injury to the descending aorta by the fractured rib tip.

This article summarizes the evaluation and treatment of musculoskeletal causes of chest pain. Conditions such as costochondritis, rib pain caused by stress fractures, slipping rib syndrome, chest wall muscle injuries, fibromyalgia, and herpes zoster are discussed, with emphasis on evaluation and treatment of these and other disorders. Many of these conditions can be diagnosed by the primary care clinician in the office by history and physical examination. Treatment is also discussed, including description of manual therapy and exercises as needed for some of the conditions., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma., Method: A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray., Outcomes: Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures., Conclusion: The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

Elderly patients are highly susceptible to rib fractures after trauma. The use of a clinical pathway to determine resource allocation for patients with rib fractures has resulted in positive treatment outcomes. This retrospective study assessed the efficacy of a triage protocol involving trauma services on hospital length of stay in elderly patients with fractured ribs. Patients who had 3 or more ribs fractured experienced a statistically significant reduction in hospital length of stay after protocol implementation. We conclude that elderly patients with 3 or more rib fractures should be systematically referred to a trauma specialist.

Stress fractures are common troublesome injuries in athletes and non-athletes. Historically, stress fractures have been thought to predominate in the lower extremities secondary to the repetitive stresses of impact loading. Stress injuries of the ribs and upper extremities are much less common and often unrecognized. Consequently, these injuries are often omitted from the differential diagnosis of rib or upper extremity pain. Given the infrequency of this diagnosis, few case reports or case series have reported on their precipitating activities and common locations. Appropriate evaluation for these injuries requires a thorough history and physical examination. Radiographs may be negative early, requiring bone scintigraphy or MRI to confirm the diagnosis. Nonoperative and operative treatment recommendations are made based on location, injury classification, and causative activity. An understanding of the most common locations of upper extremity stress fractures and their associated causative activities is essential for prompt diagnosis and optimal treatment.

A 79-year-old man underwent coronary artery bypass grafting and ascending aorta prosthetic replacement for aneurysm at our Institution. His postoperative course was characterized by rapid onset of hypotension and anemia. Re-exploration found no surgical source of bleeding. A chest computed tomography showed a huge extrapleural hematoma caused by rib fractures. Percutaneous chest drainage was effective, and the patient recovered quickly. Follow-up computed tomography confirmed a good result.

Purpose: To retrospectively identify the incidence and probable risk factors for rib fractures after percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) of neoplasms in the lung and to identify complications related to these fractures., Materials and Methods: Institutional review board approval was obtained for this HIPAA-compliant retrospective study. Study population was 163 patients treated with MWA and/or RFA for 195 lung neoplasms between February 2004 and April 2010. Follow-up computed tomographic images of at least 3 months were retrospectively reviewed by board-certified radiologists to determine the presence of rib fractures. Generalized estimating equations were performed to assess the effect that patient demographics, tumor characteristics, treatment parameters, and ablation zone characteristics had on development of rib fractures. Kaplan-Meier curve was used to estimate patients' probability of rib fracture after ablation as a function of time. Clinical parameters (ie, pain in ribs or chest, organ damage caused by fractured rib) were evaluated for patients with confirmed fracture., Results: Rib fractures in proximity to the ablation zone were found in 13.5% (22 of 163) of patients. Estimated probability of fracture was 9% at 1 year and 22% at 3 years. Women were more likely than were men to develop fracture after ablation (P = .041). Patients with tumors closer to the chest wall were more likely to develop fracture (P = .0009), as were patients with ablation zones that involved visceral pleura (P = .039). No patients with rib fractures that were apparently induced by RFA and MWA had organ injury or damage related to fracture, and 9.1% (2 of 22) of patients reported mild pain., Conclusion: Rib fractures were present in 13.5% of patients after percutaneous RFA and MWA of lung neoplasms. Patients who had ablations performed close to the chest wall should be monitored for rib fractures.

Aim: Computed tomography (CT) has been suggested as an aid or even a replacement for autopsy. The aim of this trial was to study the conformity of the two methods in finding injuries in non-surviving patients after unsuccessful cardiopulmonary resuscitation., Methods: In this prospective study, 31 patients were submitted to a CT prior to autopsy after unsuccessful resuscitation attempts. Pathological findings were noted by both the radiologist and the pathologists in a specified protocol. The pathologists and radiologist were blinded from each other's results., Results: CT and autopsy revealed rib fractures in 22 and 24 patients respectively (kappa=0.83). In 8 patients, CT revealed more rib fractures than autopsy; and in 12 patients, autopsy revealed more rib fractures than CT. In 7 patients, neither method showed any rib fractures. The mean difference between the two methods in detecting rib fractures was 0.16 (S.D.: ± 3.174, limits of agreement: -6.19 to 6.51). The kappa value for sternal fractures was 0.49. A total of 260 pathological findings were noted by CT and 244 by autopsy. The average patient showed a median of 9 injuries (every fracture counted as one injury), independent of the method used in detecting the injuries., Conclusions: There was a strong concordance between the two methods in finding rib fractures but not sternal fractures and these results support the concept of CT as a valuable complement to autopsy in detecting rib fractures after unsuccessful cardiopulmonary resuscitation but not as a replacement. Other injuries did not show the same concordance., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Increasing age and number of rib fractures are thought to portend a worse outcome with blunt chest trauma, although this is not clearly substantiated in the literature. We hypothesized that these parameters have a significant and synergistic effect, worsening patient outcome. Using the National Trauma Data Bank, we evaluated patients from 2002 to 2006. Patients with a rib fracture International Classification of Diseases, 9th Revision code were included; those with sternal fractures were excluded. Data on demographics, injury, comorbidity, complications, intensive care unit duration, ventilator duration, length of stay, and death were collected. Significant univariate predictors were included in the multivariate logistic regression analysis to adjust for any potential confounders. We identified 35,467 patients who met the inclusion. The mean age was 45.5 years with a mean Injury Severity Score of 19.3. There were 2.1 per cent open rib fractures. Using univariate analysis, rib fracture number was significant. However, once multivariate analyses were applied, the number of rib fractures was not found to be an independent predictor of outcome. The number of rib fractures is not an independent predictor of outcome. Age and overall trauma burden are more powerful predictors of poor outcomes. Treatment focus should shift from the chest to the broader scope of injuries and comorbidities.

According to medical literature, fracture of the first rib is quite rare and the bilateral condition is especially rare. This type of fracture is usually associated with severe intrathoracic trauma and other bony or neurovascular injuries, thus can be considered as a harbinger of major trauma. However here we present three cases of low velocity first rib fractures without any major trauma or multisystem injuries. All the three patients were treated conservatively and did well on simple analgesics and rest and had no early or late complications. It can be seen that not all the first rib fractures are associated with major trauma or multisystem injuries. There is a variant of first rib fracture with low velocity injuries which is not associated with any major complications in contrast to majority of first rib fractures associated with high velocity injuries. Causative factor of such injuries may be violent muscular contraction of scalenus anterior or serratus anterior, but not direct trauma.

Objective: Blunt chest wall trauma is a common injury treated in the Emergency Departments and has a high reported morbidity and mortality. No national guidelines exist for the management of this patient group unless the patient has severe immediate life-threatening injuries. The aim of this study was to investigate current management of blunt chest wall trauma patients in the UK and to gather expert opinion of the risk factors for morbidity and mortality., Methodology: A sample of 100 physicians working in Emergency Departments in the UK were purposively selected and sent a postal questionnaire to complete. Non-responder analysis was undertaken in order to assess bias. The completed questionnaires were analysed with descriptive statistics., Results: A response rate of 90% was achieved. The different type of hospital providing emergency care was well represented in the results. The general surgical team was the most frequently used ward-based team when the patient required admission to hospital (51%). Inconsistencies exist regarding the use of guidelines for the management of the blunt chest wall patient. The risk factors for morbidity and mortality suggested by the sample concurred with current literature including patient age, pre-existing conditions and number of ribs fractured and areas for further research were highlighted., Conclusion: Variation exists in the management of blunt chest wall trauma patients in the UK. This study provides the expert opinion of a sample of 90 physicians working in Emergency Departments in the UK regarding the risk factors for morbidity and mortality in blunt chest wall trauma patients., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

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.)

Background: The purpose of this study was to identify clinical and dosimetric factors associated with radiotherapy induced bone injury (RIBI) following stereotactic lung radiotherapy., Methods: Inoperable patients with early stage non-small cell lung cancer, treated with SBRT, who received 54 or 60 Gy in 3 fractions, and had a minimum of 6 months follow up were reviewed. Archived treatment plans were retrieved, ribs delineated individually and treatment plans re-computed using heterogeneity correction. Clinical and dosimetric factors were evaluated for their association with rib fracture using logistic regression analysis; a dose-event curve and nomogram were created., Results: 46 consecutive patients treated between Oct 2004 and Dec 2008 with median follow-up 25 months (m) (range 6 - 51 m) were eligible. 41 fractured ribs were detected in 17 patients; median time to fracture was 21 m (range 7 - 40 m). The mean maximum point dose in non-fractured ribs (n=1054) was 10.5 Gy ± 10.2 Gy, this was higher in fractured ribs (n=41) 48.5 Gy ± 24.3 Gy (p<0.0001). On univariate analysis, age, dose to 0.5 cc of the ribs (D0.5), and the volume of the rib receiving at least 25 Gy (V25), were significantly associated with RIBI. As D0.5 and V25 were cross-correlated (Spearman correlation coefficient: 0.57, p<0.001), we selected D0.5 as a representative dose parameter. On multivariate analysis, age (odds ratio: 1.121, 95% CI: 1.04 - 1.21, p=0.003), female gender (odds ratio: 4.43, 95% CI: 1.68 - 11.68, p=0.003), and rib D0.5 (odds ratio: 1.0009, 95% CI: 1.0007 - 1.001, p<0.0001) were significantly associated with rib fracture.Using D0.5, a dose-event curve was constructed estimating risk of fracture from dose at the median follow up of 25 months after treatment. In our cohort, a 50% risk of rib fracture was associated with a D0.5 of 60 Gy., Conclusions: Dosimetric and clinical factors contribute to risk of RIBI and both should be included when modeling risk of toxicity. A nomogram is presented using D0.5, age, and female gender to estimate risk of RIBI following SBRT. This requires validation.

This report describes an uncommon variant of humpy-back syndrome associated with multiple rib fractures and multisystemic vasculitis in several nursing piglets and, for the first time, a skin disease in swine consistent with alopecia areata. Both conditions were observed concurrently on the farm and occasionally in the same piglets.

Tricuspid valve (TV) injury is a rare complication of blunt chest trauma, most commonly as a result of a traffic collision. The authors describe a case of massive TV regurgitation due to a rupture of the chorde tendinae to the anterior and septal leaflets in a 21-year-old man, the victim of a car crash. Concomitant organ injuries included, among others, multiple rib fractures, pulmonary contusion, open femoral fracture. TV annuloplasty with Medtronic Duran ring implantation was performed one year after the accident because of right ventricular function worsening and occurrence of right heart failure symptoms. Three years after surgery only trivial TV regurgitation is detectable. The patient manifest good physical efficiency and continues occupational activity.

Pleurobiliary fistula after blunt abdominal trauma is rare. We report a case managed with tube thoracostomy alone, without the need for biliary system drainage., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The authors describe 4 first rib fractures in 3 infants, highlighting the difficulty in detecting first rib fractures on skeletal survey. All 4 fractures were the result of physical abuse. A literature search does not find a case of first rib fracture in a healthy infant that is not the result of child abuse. The diagnosis of first rib fracture in an infant should prompt a thorough medical and social evaluation for child abuse.

Background: Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this study, we present our 11-year experience in the management and clinical outcome of 888 chest trauma cases as a result of blunt and penetrating injuries in our university hospital in Damascus, Syria., Methods: We reviewed files of 888 consequent cases of chest trauma between January 2000 and January 2011. The mean age of our patients was 31 ± 17 years mostly males with blunt injuries. Patients were evaluated and compared according to age, gender, etiology of trauma, thoracic and extra-thoracic injuries, complications, and mortality., Results: The leading cause of the trauma was violence (41%) followed by traffic accidents (33%). Pneumothorax (51%), Hemothorax (38%), rib fractures (34%), and lung contusion (15%) were the most common types of injury. Associated injuries were documented in 36% of patients (extremities 19%, abdomen 13%, head 8%). A minority of the patients required thoracotomy (5.7%), and tube thoracostomy (56%) was sufficient to manage the majority of cases. Mean hospital LOS was 4.5 ± 4.6 days. The overall mortoality rate was 1.8%, and morbidity (n = 78, 8.7%)., Conclusions: New traffic laws (including seat belt enforcement) reduced incidence and severity of chest trauma in Syria. Violence was the most common cause of chest trauma rather than road traffic accidents in this series, this necessitates epidemiologic or multi-institutional studies to know to which degree violence contributes to chest trauma in Syria. The number of fractured ribs can be used as simple indicator of the severity of trauma. And we believe that significant neurotrauma, traffic accidents, hemodynamic status and GCS upon arrival, ICU admission, ventilator use, and complication of therapy are predictors of dismal prognosis.

A case of a 33 year-old female with continuous murmur was admitted to the hospital for diagnostic purposes. TEE was inconclusive. Coronary angiography revealed an aneurysm of left anterior descending with the fistula to the right ventricle. The patient underwent implantation of inset of left internal mammary artery graft and ligation of fistula during open heart surgery.

Background: The risk factors for mortality following blunt chest wall trauma have neither been well established or summarised., Objective: To summarise the risk factors for mortality in blunt chest wall trauma patients based on available evidence in the literature., Data Sources: A systematic review of English and non-English articles using MEDLINE, EMBASE and the Cochrane Library from their introduction until May 2010. Additional studies were identified by hand-searching bibliographies and contacting relevant clinical experts. Grey literature was sought by searching abstracts from all Emergency Medicine conferences. Broad search terms and inclusion criteria were used to reduce the number of missed studies., Study Selection: A two step study selection process was used. All published and unpublished observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients., Data Extraction: A two step data extraction process using pre-defined data fields, including study quality indicators., Study Appraisal and Synthesis: Each study was appraised using a previously designed quality assessment tool and the STROBE checklist. Where sufficient data were available, odds ratios with 95% confidence intervals were calculated using Mantel-Haenszel method for the risk factors investigated. The I(2) statistic was calculated for combined studies in order to assess heterogeneity., Results: Age, number of rib fractures, presence of pre-existing disease and pneumonia were found to be related to mortality in 29 identified studies. Combined odds ratio of 1.98 (1.86-2.11, 95% CI), 2.02 (1.89-2.15, 95% CI), 2.43 (1.03-5.72, 95% CI) and 5.24 (3.51-7.82) for mortality were calculated for blunt chest wall trauma patients aged 65 years or more, with three or more rib fractures, pre-existing conditions and pneumonia respectively., Conclusions: The risk factors for mortality in patients sustaining blunt chest wall trauma were a patient age of 65 years or more, three or more rib fractures and the presence of pre-existing disease especially cardiopulmonary disease. The development of pneumonia post injury was also a significant risk factor for mortality. As a result of the variable quality in the studies, the results of the selected studies should be interpreted with caution., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Abusive head trauma (AHT) affects one in 4000-5000 infants every year and is one of the most serious forms of physical child abuse that has a high associated mortality and morbidity. Differentiating this form of abuse from another potential cause of brain injury is of utmost importance to the welfare of the child concerned and it is essential that the condition is correctly diagnosed. This article describes the evidence base behind the associated historical, clinical and neuroradiological features of AHT and spinal injury in physical abuse and sets out an algorithm of essential investigations that should be performed in any infant or young child where AHT is suspected.

We describe a fatal case, in which a horse suffered a fall and as a consequence, rib fractures. Diagnosis was made postmortem and the horse died without showing clear signs of respiratory dysfunction. The retrospective reports of injuries can be important to reduce these traumatic events and to avoid fatalities.

After operative correction of a clavicle fracture using an elastic stable intramedullary nail the patient presented signs of delayed fracture healing after 2 months. During the sixth postoperative month the 28-year-old obviously pain-ridden female patient showed dystonia of the shoulder girdle and allodynia surrounding the operation field. Upon these findings, we decided - as a result of the complex regional pain syndrome that had not been previously described in this location - to treat the patient by administering bisphosphonates, multimodal analgetic therapy, physiotherapy and occupational therapy. Fourteen months after surgery, the patient showed no remaining symptoms, and the fracture had consolidated at that time.

Background: Abuse of children is abhorrent in Western society and, yet, is not uncommon. Nonaccidental trauma (NAT) is the result of a complex sociopathology. Not all of the causative factors of NAT are known, many are incompletely described, not all function in each case, and many are secondary to preexisting pathology in other areas., Questions/purposes: We therefore addressed the following questions in this review: (1) what is the general incidence of NAT; (2) what factors are intrinsic to the abused child, family, and society; and (3) what orthopaedic injuries are common in NAT?, Methods: We searched Medline, Medline In Process & Other Non-Indexed Citations, and Embase using OVID. Only one article fit our inclusion criteria; therefore, this is a descriptive generalized review of the epidemiology of NAT., Results: The general incidence of NAT ranges from 0.47 per 100,000 to 2000 per 100,000. Younger children are at greater risk of NAT than older children. Parents are often the perpetrators of the abuse. Rib fractures are highly indicative of NAT in young children., Conclusions: It is important to consider child, family, and societal factors when confronted with suspicions of child abuse. Our review demonstrates the currently limited information on the true incidence of NAT. To determine a much more accurate incidence of NAT, there needs to be a population-based surveillance program conducted through primary care providers.

Background: Cronkhite-Canada syndrome (CCS) is a rare multiple gastrointestinal polyposis. Up till now, many complications of CCS have been reported in the literature, but rib fracture is not included., Case Presentation: We report a case of a 58-year-old man who was admitted to our hospital with a 6-month history of frequent diarrhea, intermittent hematochezia and a weight loss of 13 kg. On admission, physical examination revealed alopecia of the scalp, hyperpigmentation of the hands and soles, and dystrophy of the fingernails. Laboratory data revealed hypocalcaemia and hypoproteinemia. Esophagogastroduodenoscopy, video capsule endoscopy and colonoscopy revealed various sizes of generalized gastrointestinal polyps. Histological examination of the biopsy specimens obtained from the stomach and the colon showed adenomatous polyp and inflammatory polyp respectively. Thus, a diagnosis of CCS was made. After treatment with corticosteroids for 24 days and nutritional support for two months, his clinical condition improved. Two months later, he was admitted to our hospital for the second time with frequent diarrhea and weight loss. The chest radiography revealed fractures of the left sixth and seventh ribs. Examinations, including emission computed tomography, bone densitometry test, and other serum parameters, were performed, but could not identify the definite etiology of the rib fractures. One month later, the patient suffered from aggravating multiple rib fractures due to the ineffective treatment, persistent hypocalcaemia and malnutrition., Conclusions: This is the first case of a CCS patient with multiple rib fractures. Although the association between CCS and multiple rib fractures in this case remains uncertain, we presume that persistent hypocalcaemia and malnutrition contribute to this situation, or at least aggravate this rare complication. Besides, since prolonged corticosteroid therapy will result in an increased risk of osteoporotic fracture, CCS patients who accept corticosteroid therapy could be potential victims of rib fracture.

A 57-year-old patient suffered head and chest trauma following a bicycle accident. After 12 days in hospital with early mobilization the patient developed a deep vein thrombosis 5 days after being discharged and the family physician diagnosed a non-displaced clavicle fracture. The patient complained that no thrombosis prophylaxis had been carried out during the stay in hospital and the clavicle fracture had been overlooked. The expert opinion from the arbitration board determined that no health limitations had occurred as a result of the missed clavicle fracture. There were no indications for anticoagulation in accordance with the guidelines due to a lack of risk factors and the event was deemed unpreventable.

Motor vehicle accidents contribute widely to population morbidity and mortality around the world, and cardiac injuries are a major factor determining outcome. Autopsy reports from 380 motor vehicle occupants who died in motor vehicle crashes in Adelaide, Australia, and Hamburg, Germany, over a 6-year period were reviewed, analysing the presence and type of cardiac injuries and their correlation with factors such as crash type, presence of seatbelt/airbag and vehicle speed as well as with the presence of other injuries which might predict the presence of cardiac injuries in a clinical setting. 21.1% had cardiac injuries identified macroscopically autopsy or histology. Cardiac injuries were the only cause of death or contributed to a fatal outcome in 76% of these cases. Sternal fractures and left-sided serial rib fractures were predictive of cardiac injury., (Copyright 2010 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Isolated fracture of a cervical rib is a very rare entity. Cervical rib fracture due to heavy backpack usage is a new occupational hazard for students. Cervical rib fracture usually presents as a painless swelling or as thoracic outlet syndrome. We report two patients with cervical rib fractures, one of them secondary to backpack usage, and review the available literature., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In the previous part of this four part series on thoracic trauma the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis were discussed. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. Sections 3 and 4 will examine other types of thoracic injuries and their management, such as trauma to the diaphragm and heart. The final part provides a brief but concise overview of neck anatomy, trauma and management., (Crown Copyright 2010. Published by Elsevier Ltd. All rights reserved.)

Nonoperative management (NOM) of blunt liver or spleen injuries (LSI) is widely accepted, but diaphragmatic injuries (DI) can be elusive. We hypothesize that rib fractures and minor LSI (RF+ minor LSI) are associated with DI. Patients with blunt injury undergoing exploratory laparotomy between January 1, 2000, and December 31, 2007, were identified from our registry. The association between injury variables and DI was examined with logistic regression. Organ Injury Scores of the liver and spleen of Grade I/II were defined as "minor." A potentially nonoperative (PNO) patient had a rib fracture and minor LSI but no bowel injury or hypotension (systolic blood pressure less than 90 mmHg). The incidence of DI was 7.5 per cent (53 of 705) overall but 20 per cent (seven of 35) in patients with RF + minor LSI. Nineteen PNO patients had four (21.1%) DIs. RF + LSI (3.26 [1.74-6.12], P < 0.001) and motor vehicle collisions (4.93 [2.36-10.32], P < 0.001) were independently associated with DI. The incidence of laparotomy in all critically ill blunt injury patients (n = 2177) decreased significantly (P = 0.003). RF + minor LSI are associated with DI even when there are no other operative injuries. Because NOM is increasingly accepted, the potential for missed DI exists. When high-quality imaging is not available or is equivocal, further studies should be considered.

Objective: To review the management and follow-up of patients with minor thoracic injuries (MTI) treated by emergency or primary care physicians., Design: A multicentre, retrospective study., Setting: Three university-affiliated emergency departments of the metropolitan region of Quebec city, Que., Participants: Patients older than 16 years of age with suspected or proven rib fractures following traumatic events., Main Outcome Measures: Differences in admission and discharge proportions and disposition management following MTI., Results: Four hundred and forty-seven charts were analyzed. Only 23 patients (5.2%) were admitted during the study period. Admission and discharge proportions were significantly different among the 3 surveyed hospitals, ranging from 1.3% to 15.2% (P < or = .001). There were no recommendations of follow-up noted in most (53.5%) of the charts and there were no differences after hospital stratification. Planned follow-up visits were scheduled for 5.7% of discharged patients. Being older than 65 years of age or having multiple rib fractures had no influence on management and follow-up recommendations. Eighty-two patients (18.6%) had unplanned follow-up visits in the emergency department, with inadequate pain relief as the principal reason for consultation (56.1%). There was no significant difference after stratification for age and type of analgesia. Other clinically significant delayed complications were recorded in 8.3% of all MTI patients., Conclusion: The proportion of patients admitted for rib fractures was lower than the expected 25%, based on previous publications, and varied across surveyed hospitals. A very low proportion of patients was offered planned follow-up visits or even any follow-up recommendations in view of possible delayed complications and disabilities. Further studies are needed to identify predictors of delayed MTI complications and enhance appropriate use of follow-up resources.

Background: The lidocaine patch 5% was developed to treat postherpetic neuralgia. Anecdotal experience at our institution suggests the lidocaine patch 5% decreases narcotic usage in patients with traumatic rib fractures. This trial was developed to define the patch's efficacy., Study Design: Patients with rib fractures admitted to the trauma service at our Level I trauma center were enrolled and randomized in a 1 to 1 double-blind manner to receive a lidocaine patch 5% or placebo patch. Fifty-eight patients who met the inclusion criteria were enrolled from January 2007 to August 2008. Demographic and clinical information were recorded. The primary outcomes variable was total narcotic use, analyzed using the 1-tailed Mann-Whitney test. The secondary outcomes variables included non-narcotic pain medication, average pain score, pulmonary complications, and length of stay. Significance was defined based on a 1-sided test for the primary outcome and 2-sided tests for other comparisons, at p < 0.05., Results: Thirty-three patients received the lidocaine patch 5% and 25 received the placebo patch. There were no significant differences in age, number of rib fractures, gender, trauma mechanism, preinjury lung disease, smoking history, percent of current smokers, and need for placement of chest tube between the lidocaine patch 5% and placebo groups. There was no difference between the lidocaine patch 5% and placebo groups, respectively, with regard to total IV narcotic usage: median, 0.23 units versus 0.26 units; total oral narcotics: median, 4 units versus 7 units; pain score: 5.6 +/- 0.4 versus 6.0 +/- 0.3 (mean +/- SEM); length of stay: 7.8 +/- 1.1 versus 6.2 +/- 0.7; or percentage of patients with pulmonary complications: 72.7% versus 72.0%., Conclusions: The lidocaine patch 5% does not significantly improve pain control in polytrauma patients with traumatic rib fractures.

Aim: A systematic review of the scientific literature to define clinical indicators distinguishing inflicted (iBI) from non-inflicted brain injury (niBI)., Methods: An all language literature search of 20 electronic databases, websites, references and bibliographies from 1970-2008 was carried out. Relevant studies were independently reviewed by two trained reviewers, with a third review where required. Inclusion criteria included primary comparative studies of iBI and niBI in children aged <18 years, with high surety of diagnosis describing key clinical features. Multilevel logistic regression analysis was conducted, determining the positive predictive value (PPV) and odds ratios (OR) with p values for retinal haemorrhage, rib/long bone/skull fractures, apnoea, seizures and bruising to head/neck., Results: 8151 studies were identified, 320 were reviewed and 14 included, representing 1655 children, 779 with iBI. Gender was not a discriminatory feature. In a child with intracranial injury, apnoea (PPV 93%, OR 17.06, p<0.001) and retinal haemorrhage (PPV 71%, OR 3.504, p = 0.03) were the features most predictive of iBI. Rib fractures (PPV 73%, OR 3.03, p = 0.13) had a similar PPV to retinal haemorrhages, but there were less data for analysis. Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI, although not significantly so., Conclusions: This systematic review shows that apnoea and retinal haemorrhage have a high odds ratio for association with iBI. This review identifies key features that should be recorded in the assessment of children where iBI is suspected and may help clinicians to define the likelihood of iBI.

Introduction: Pseudoarthrosis of the first rib is a rare condition that may occur in athletes as a result of repetitive activities, mainly overhead. The usual clinical presentation is pain in the neck or the ipsilateral shoulder., Case Report: This is the case of a 19-year-old female patient who had sudden pain of the base of the neck while doing yoga. Pseudoarthrosis of the first rib was diagnosed with X-rays and CAT scan. Treatment consisted of a rehabilitation and physical therapy program that was successful despite the persistence of the pseudoarthrosis., Discussion: Cases of first rib fractures have been reported in athletes practicing multiple activities; however, pseudoarthrosis cases are rare since most of them progress to bone healing. This is the first reported case of a fracture or pseudoarthrosis in a patient practicing yoga. As in most reported cases, conservative treatment was successful., Conclusion: Fractures and pseudoarthrosis of the first rib are rare in athletes and should be included in the differential diagnosis of athletes presenting with shoulder and neck pain. Conservative treatment is successful in most cases.

Alveolar haemosiderin-laden macrophages (HLMs) in histological sections of the lung represent evidence of previous pulmonary haemorrhage and in infants may be associated with features of non-accidental injury (NAI). The aim of this study is to establish the frequency of alveolar HLMs detected at post-mortem in a large series of sudden unexpected infant deaths, and to determine their clinical significance with particular regard to a possible association with NAI. A search was performed of a database of 1516 anonymised paediatric autopsies to identify all infants (<1 year of age) that died suddenly and unexpectedly in whom HLMs were demonstrated on routine histological examination of lung sections using special iron (Perls') stains. Clinical details and other post-mortem findings were then reviewed. During the study period (1996-2005 inclusive), there were 601 sudden unexpected infant deaths. Of the 536 autopsies in whom histological data regarding HLMs were recorded and slides were available for review, 29 (5%) demonstrated alveolar HLMs in lung sections. In 9 (31%) infants there were additional features of NAI; in 11 (38%) infants, there were features in the clinical history and/or on pathological examination of natural disease sufficient to potentially explain the presence of HLMs, and 9 (31%) represented otherwise unexplained infant deaths with no significant clinical history or other abnormalities. HLMs were present in 9 of the 27 (33%) total infant deaths with other features indicative of NAI, compared to only 9 of the 242 (4%) unexplained infant deaths without any other features of NAI or other contributory pathology (difference 29.6%, 95% CI 14.6-48.6%, p<0.0001; positive likelihood ratio 9.0, 95% CI 3.9-19.8). This association remained even if cases with rib fractures were excluded. Alveolar HLMs may be identified in a significant minority of sudden infant deaths following routine histological examination of the lungs with special stains for iron pigment. In most, there will be features in the clinical history or findings at post-mortem to indicate underlying natural disease which may account for their presence. However, in the absence of such features, alveolar HLMs, whilst not diagnostic, are associated with a significantly increased risk for the detection of other features of NAI; the presence of otherwise unexplained alveolar HLMs at autopsy should therefore prompt a careful exclusion of inflicted injury.