Background: This investigation aimed to describe factors associated with early complications of surgical management due to penetrating laryngotracheal trauma in Colombia. Materials and Methods: A descriptive and retrospective cohort study was carried out; bivariate analysis using Pearson's Chi-square and Fisher's exact test was utilized to find associations with morbidity outcomes. Results: Between 2005 and 2019, 50 patients with penetrating laryngotracheal injuries underwent surgery; the median age was 29.5 years (interquartile ranges = 24.0–39.7), wherein 92% were male. The trachea was the most affected organ in 74% of patients, and lesions associated with laryngotracheal trauma were reported in 50% of patients. Cervicotomy was the surgical approach in 92% of patients. The 30-day overall morbidity was 24%, and mortality was 6%; dehiscence of the primary repair, or anastomosis, was present in 10% of the patients: 2% partial and 8% complete. Dehiscence was associated with infection (P = 0.002). Early stenosis was described in 10% of the patients; association was found between stenosis and dehiscence (P = 0.001), infection (P = 0.001), and reoperation (P = 0.001). Finally, infection was present in 8% of the patients and was indeed associated to the requirement of postoperative intensive care unit (ICU) hospitalization (P = 0.003). Conclusions: Limited information is available about factors related to early complications in laryngotracheal trauma. Nonetheless, in this series, a statistically significant association was found between early dehiscence of the primary repair, or anastomosis, and infection. Moreover, early stenosis was associated with dehiscence, infection, and reoperation. Finally, early infection was associated with the requirement of postoperative ICU hospitalization.
Objectives: Surgical stabilization of rib fractures (SSRF) improves outcomes in patients with flail chest and displaced fractures with impaired pulmonary function. Elderly and frail patients with such injuries are at risk for significant morbidity and may benefit from SSRF. The 5-factor modified frailty index (mFI-5) is a validated predictor of postoperative outcomes. The purpose of this study is to evaluate the relationship between frailty and outcomes following SSRF at a tertiary care trauma center. Methods: A retrospective review of patients undergoing SSRF from 2015 to 2019. Patients over 18 years old with two or more displaced fractures were included in the study. Exclusion criteria were isolated fracture, traumatic brain injury, and pulmonary contusion. Frail patients were defined by an mFI-5 score 2 or greater. Chi-square analysis, Fischer's exact test, and Student's t-test were used for comparative analysis as appropriate. P < 0.05 was considered statistically significant. Results: One hundred and fifty-four patients met inclusion criteria. Forty-eight patients were designated frail and 106 nonfrail. The mean number of fractures was similar between frail and nonfrail groups (7.0 vs. 7.3, P = 0.685). Injury Severity Score was lower in the frail group (14.5 vs. 17.8, P = 0.02). Inpatient mortality (P = 0.312), rates of pneumonia, end-organ dysfunction, and surgical site infections were similar (P > 0.05). Intensive care unit admission (47.9% vs. 29.2%, P = 0.025) and tracheostomy rates (P = 0.009) were increased in the frail group. Frailty also increased the risk of prolonged mechanical ventilation >48 h on multivariate analysis. Conclusion: Frail patients, stratified using mFI 5 score, experienced similar rates of multiple postoperative outcomes, including mortality, but had increased rates of prolonged ventilation and tracheostomy. Despite observed but expected increased morbidity in these patients, the similar complication and mortality rates suggest a role for surgical stabilization of severe rib fractures in frail patients.
Background: Current pathologies and the concepts applied for chest trauma, both for revision of thoracic cavity and to solve same traumatisms, have allowed to develop minimal surgery approach techniques for the resolution of multiple nosologies, thanks to their various benefits, currently this has been classified as a vanguard surgical technique worldwide. Material and Methods: Patients undergoing ribs fixation with minimal invasive technique, at ISSEMYM Medical Center, Thoracic Surgery Service, were analyzed according to age, gender, number of ribs fixed, days of hospital stay, days with endopleural tube, type of anesthesia, and complications. We present a series of cases with retrospective, descriptive design in a period of 72 months. Results: This is the largest case series reported for fixing ribs by minimal invasive approach, a final sample n = 103 was used, and favorable results and description of the same technique were described. The analyzed number of fixed ribs presented an average of 3.8 ribs fixed per patient. The average of hospital stay days was 5.08 days, after the procedure. Moreover, the oldest patient undergoing this procedure was 89 years old and the youngest was 23 years old. Conclusions: The technique of fixing ribs by minimal invasive approach continues to be a choice technique to reduce postoperative complications and reduce days of hospital stay, it is a reproducible, safe and pioneering technique for chest surgery, even in geriatric patients.
Operative stabilization of both flail and nonflail rib fractures has become very common, with a 76% increase in community hospitals over the past 10 years. This review will explain the rationale and evidence for improved outcomes with operative management of rib fractures, describe the contemporary strategy, and give an algorithm to follow for the management of critical patients in the intensive care unit (ICU) setting with rib fractures. A PubMed and Medline literature search was conducted with the search terms of rib fractures, rib stabilization, rib plating, chest trauma, chest wall, flail chest, nonflail, and ribs. The level of evidence supporting an intervention was evaluated based on the available prospective, randomized trials, nonrandomized trials, retrospective studies, meta-analyses, cohort studies, and reviews. Selected publications of interest on both rib plating and conservative treatment were retrieved and their bibliographies were also reviewed to identify relevant publications. Data from the relevant publications were reviewed, summarized, and the information synthesized. Rib plating has shown improved outcomes in both flail and nonflail rib fractures. Both prospective and retrospective data document a decreased duration of mechanical ventilation, decreased mortality, less pain, decreased incidence of pneumonia, decreased need for tracheostomy, decreased length of ICU and hospital stay, faster return to work, less overall cost, and better pulmonary function at 6 months. The proposed algorithm based on the presented data allows the physician to easily determine which patients are appropriate for rib plating.
Introduction: Increased interests in surgical approaches for multiple rib fractures in trauma patients have emerged lately. A novel strategy based on intraoperative ultrasound (US) assessment to locate these fractures has been proposed to perform smaller incisions for thoracic wall reconstructions. We aimed to describe variations of site, size, and direction of surgical incisions before and after US use intraoperatively for localization of rib fractures. Materials and Methods: In this pilot study, ten trauma patients with multiple rib fractures requiring thoracic wall reconstruction were prospectively included during a 9-month period. Computer tomography of the thorax was used for determining surgical incisions. Before surgical incision, US was used for the identification of rib fractures and for marking a different surgical incision. In each patient, qualitative comparisons of surgical incision marks before and after US were performed. Results: The qualitative analysis demonstrated that five patients (5/10) had a change in the direction of the incision and also in five patients (5/10) there was a change in the size of the incision. In those five patients in whom the length and size of the incision changed, there was a median length reduction of the incision of 3 cm (interquartile range 2–3). Conclusions: In this pilot study, we observed that trauma patients with multiple rib fractures requiring thoracic wall reconstruction may benefit from intraoperative assessment of US for targeted surgical planning. US might offer advantages for surgical planning before defining the final surgical approach.
Background: Increased age and number of rib fractures are known to increase the risk of mortality. The impact of comorbidities on the outcomes of patients with rib fractures has not previously been described. We hypothesized that specific medical comorbidities are associated with increased risk of morbidity and mortality following rib fracture. Methods: Patients with multiple rib fractures or flail chest were identified in the National Inpatient Sample by ICD-10 code from the 4th quarter of 2015 through 2016. Comorbidities were categorized into Elixhauser comorbidity groups, and injury severity was estimated using the Injury Severity Score (ISS). The composite adverse outcome was defined as death, pneumonia, tracheostomy, or discharge to a short-term acute care facility. Multivariable logistic regression was performed with covariates chosen through backward selection from the univariate model to determine the relationship of outcomes to demographic variables and comorbidities with alpha set to 0.001. Results: Totally 26,289 patients met inclusion criteria. Composite adverse outcomes occurred in 5,132 (19.5%) patients. Profound ISS (OR 6.013), severe ISS (odds ratio [OR] 2.569), fluid and electrolyte disorder (OR 2.471), and paralysis (OR 2.372) were most associated with adverse outcomes. Within causes of injury, motor vehicle was associated with increased risk of adverse outcome (OR 1.322). Flail chest was also independently associated with adverse outcome (OR 1.816). Conclusion: Morbidity and mortality following rib fracture occurred in approximately one-fifth of patients, especially those with high ISS or associated medical comorbidities. This data can be used for risk stratification and identification of high-risk patients for escalation of care.
Trauma represents a significant portion of the world's morbidity and mortality. Chest trauma accounts for approximately 25% of mortality in trauma patients, and this rate is much higher in patients with polytraumatic injuries. The thoracic cavity contains three major anatomical systems: the airway, lungs, and the cardiovascular system including the thoracic duct. Blunt or penetrating trauma can cause significant disruption to each of these systems that can quickly prove to be life threatening unless rapidly identified and treated. In the present article, the authors present a review of the thoracic duct injury evaluation and treatment.
Impalement injuries are rare. We present here a case of impalement injury of chest and its management. A 10-year-old boy fell from a tree and landed on pointed bamboo object. He was diagnosed as a case of impalement injury with right-sided pneumothorax. A right anterolateral thoracotomy with removal of foreign body and repair of lung laceration was done. The patient in the postoperative period remained stable. He was discharged on day 10. Thoracic impalement injuries are dangerous injuries because of close proximity of the impaled objects to the heart and major vessel. The impaled object should be left as such and an urgent transfer to a facility dealing with such type of injury is required. A thoracotomy incision based on the tract should be employed. Postoperative patient should be put on broad-spectrum antibiotic along with chest physiotherapy.
Background: We hypothesized that obese patients undergoing rib stabilization would have a smaller ratio of ribs repaired to those fractured, increased days to operation, increased length of operation, were mechanically ventilated longer, required a longer stay in the intensive care unit (ICU) and hospital, and had an increased risk of developing pneumonia. Materials and Methods: This was a retrospective evaluation of patients who underwent surgical rib stabilization after trauma at a single institution over 9 years. Two hundred and seventy-three patients were divided according to body mass index (BMI) into three groups: group 1 (BMI: 15–29, n = 149), Group 2 (BMI: 30–35, n = 80), and Group 3 (BMI: 35–48, n = 44). Analysis of variance was performed to evaluate differences in outcomes in association with BMI. Two-tail t-tests were further utilized to compare Group 1 and Group 3. Results are reported in P values, with P < 0.05 being significant. Results: Sixty-eight percent were male, the mean age was 61, and 96% were Caucasian. Comorbidities: asthma (15%), chronic obstructive pulmonary disease (12%), smokers (22%), hypertension (40%), and type 2 diabetes mellitus (15%). Patients with a higher BMI had a longer average hospital length of stay (12.0, 13.4, and 15.6 days, P < 0.05). The incidence of postoperative pneumonia was increased in those with a higher BMI (10%, 12%, and 30%, P < 0.05). The remaining variables were not significant. Conclusion: Those with a higher BMI had a longer hospital stay and were at increased risk for developing pneumonia after rib stabilization. BMI did not have a significant effect on the ratio of ribs stabilized, time to operation, length of operation, days on mechanical ventilation, or ICU length of stay.
Introduction: Surgical stabilization of rib fractures (SSRF) has emerged as an acceptable modality to manage chest wall injuries in select patients after blunt thoracic injury; however, its use in penetrating trauma has not been described. Materials and Methods: An international, retrospective study was carried out in two centers who reported experience with SSRF following penetrating chest wall trauma. All adult patients (≥18 years) who underwent SSRF after penetrating thoracic trauma between January 1, 2008, and December 13, 2017 were included. Results: Thirteen patients were enrolled in the study. The entire cohort was male with a median age of 28 years (interquartile range [IQR] 22, 33). Chest wall injury was due to firearm and impalement injuries in 10 (77%) and 3 (23%) patients, respectively. Indications for SSRF included chest wall instability (n = 8), mechanical ventilation or impending respiratory failure (n = 7), and pain (n = 4). Median time to SSRF was 24 h (IQR 20, 48). A median of 3 rib fracture lines (IQR 2, 4) were identified on imaging, and a median of 3 plates (IQR 2, 4) were placed in each patient. Six patients (46%) were extubated immediately after SSRF and the remainder required 3 (IQR 2, 6) days of mechanical ventilation. No patient required a tracheostomy. There were no cases of hardware failure, empyema, hemothorax, or death during hospitalization. Conclusion: In this series, 13 patients with penetrating thoracic injuries underwent SSRF with improved clinical outcomes. These data demonstrate that SSRF can be safely and effectively utilized in patients with penetrating chest wall injuries.
Bear attacks on humans are rare and are even more rarely reported in medical literature. Each year people have numerous accidental interactions with bears around the world. In India, bear attack incidences have been reported in and around Kashmir and in Central India. A very small fraction of these bear attacks result in human injury. Injuries due to bear attacks include skin lacerations, bites etc. The most common areas of injury are the face, legs and hands. Thoracic injuries due to a bear attack hasn't been reported earlier. We present the case of a 55 year old with bear attack, suffered among other injuries, a right Hemo-Pneumothorax. A flail segment was also noted on the right anterolateral region. The patient did not need any invasive ventilation. Right Inter-costal Drain tube inserted ICD drain was discontinued on day 4 of admission. Post drain removal a subcutaneous collection was noted on the back with suspicious pleural tear near the 12th rib detected on MRI. ICD was re-inserted and the patient, conservatively managed. Bear attacks are rare in India, and thoracic injuries causing a flail segment, pleural tear and a hemo-pneumothorax hasn't yet been reported. This case report hence, highlights the fact that bear attacks, like a blunt/penetrating trauma can provide with a challenging scenario in the emergency room. Right knowledge and stepwise management of these cases can therefore ensure complete and wholesome treatment, even in cases with thoracic injuries.
Background: Surgical stabilization of rib fractures (SSRFs) is increasing in popularity. During the operation, disruption of the chest wall musculature occurs, which may affect chest wall and glenohumeral–scapular movement. Although postoperative physical therapy (PT) is widely recommended, specific, validated, protocols for SSRF patients do not exist. The purpose of this study was to evaluate the feasibility and safety of a PT protocol specifically designed for SSRF patients. Methods: This was a pilot study of all SSRF patients admitted to a single level-I trauma center between December 2017 and February 2019. Included patients received a PT evaluation within 72 h of operation. This evaluation included implementation of specific PT interventions and a written home exercise program. Objective measures included: patient reported pain scores, shoulder strength, chest expansion, spirometry, and the disabilities of the arm, shoulder, and hand (DASH) survey. These measures were obtained at initial inpatient evaluation, 1–week and 1–month post discharge in an outpatient visit, and at 3 months through telephone DASH survey. Results: Nineteen patients were analyzed. Patients were primarily male (74%), suffering from blunt trauma, with a median 8 (interquartile range [IQR]: 7–10) rib fractures and Injury Severity Score (ISS) of 17 (12–23). The median (IQR) time from SSRF to PT evaluation was 1 (1–2) day. Median chest expansion doubled from PT evaluation to 1–month follow–up (1.9 cm PT evaluation; 2.5 cm 1 week; 4.5 cm 1–month, P = 0.014). The median age-predicted spirometry improved from 29% preoperatively, to 38% at PT evaluation and to 86% at 1-month postdischarge (P ≤ 0.05 for the trend). Shoulder strength improved from PT evaluation to 1–month follow–up. The median DASH scoring improved at all follow–up intervals, with no clinically significant functional impairments at 3 months (86 on PT evaluation; 56 at 1–week, 21 at 1–month; 8 at 3–month phone interview). Conclusion: A specific, novel, PT protocol for patients after SSRF appears to be feasible and safe. Our results demonstrate a significant decrease in patient-perceived disability, improved shoulder strength, chest expansion, and spirometry compared to immediate postoperative levels. Although we cannot determine the effect of the protocol on recovery, our results provide the preliminary data on which to base a larger, randomized trial to determine if a beneficial effect of the protocol is present.
