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Sternum fracture with involvement of the upper manubrium: oblique fracture-the higher lap belt injury. (A) Often caused by a lap belt injury in smaller car occupants the unstable fractures show severe dislocation with a gap in front of the upper mediastinum and instability of the shoulder girdle (Case 3). Often series of ribs are broken following the direction of the lap belt. (B) The oblique fracture had been stabilized by a transversal plate on the 1st pair of ribs, the adjacent ribs had been treated by costosternal plate (2nd rib) and plating (3rd rib). The second sternal fracture which involved the upper corpus sterni received a longitudinal plate. (C) the sagittal profile has been restored. (D) dislocated oblique manubrium fracture (Case 2). (E) reduction using compression wires (DePuySynthes, Switzerland) (F) fixation with the first of two transverse plates.
Source publication
Background:
Flail Chest Injuries (FCI) are one of the most severe thoracic injuries. Moreover, an additional sternal fracture (SF) even worsens the outcome, such as the duration of mechanical ventilation, therefore an surgical fixation of the fractures could be considered in certain cases to improve the weaning from the ventilator. This paper aims...
Contexts in source publication
Context 1
... feature of these fractures was the rotatory instability of the shoulder girdle resulting in a fracture gap and the loss of protection of the upper mediastinum. In addition to this, rib fractures were found, which showed an oblique series course from proximal nearby the sternum to distal in a more lateral position, usually caused by a seatbelt (Fig. ...
Context 2
... occurred by a reduction of the main fragments by bilateral compression. This could be obtained either by means of a pointed forceps or by means of special compression wires (DePuySynthes, Oberdorf, Switzerland) ( Fig. 1 D-F). The osteosynthesis is then performed to neutralize the load vector by a transverse plate osteosynthesis on the first pair of ribs, including the manubrium sterni, and in the case of an additional transverse fracture of the manubrium in 2 cases by a specially shaped plate (T or I form, Fig. 2) or with another longitudinal sternum plate (Fig. 1 B,C). ...
Context 3
... 1 D-F). The osteosynthesis is then performed to neutralize the load vector by a transverse plate osteosynthesis on the first pair of ribs, including the manubrium sterni, and in the case of an additional transverse fracture of the manubrium in 2 cases by a specially shaped plate (T or I form, Fig. 2) or with another longitudinal sternum plate (Fig. 1 B,C). Accompanying unstable rib fractures were stabilized costosternal in the sternum near area and in the sternum remote area on the rib itself by locking plate osteosynthesis ( In the case of a centrally located sternum frac- ture, extending from the lower manubrium to the lower corpus third, we found 5 transverse fractures, 2 oblique ...
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Introduction: Flail chest is a severe life threatening injury with mortality
rates reaching up to 33%, traditionally treated with mechanical
ventilation (“internal fixation”). Recently, some authors recommend a
surgical approach for highly unstable flail chest. Several rib fixation
techniques have been described although none are considered gold
st...
Simple rib fractures are the most common injury sustained following blunt chest trauma, accounting for more than half of thoracic injuries from non-penetrating trauma. Severe blunt injury to the chest continues to be one of the leading causes of morbidity and mortality in both young and old trauma victims. We conducted the current meta-analysis usi...
Introduction:
In contrast to the emerging evidence on the operative treatment of flail chest, there is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe our standardized approach and report the outcome (e.g. patient satisfaction, pain and complications) after surgical treatment of...
Purpose
Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms of injury (MOI), injury patterns, and associated injuries in patients who undergo surgery for chest wall trauma.
Methods
This was a retrospective study of trauma patients...
Citations
... The displacement of sternal fractures was described for 350 patients; 196 (56%) were displaced, 5,[8][9][10][13][14][15]19,[24][25][26]28,29,31,32,41,42,48,51,53,54 and 154 (44%) were nondisplaced (p=0.833). 8,11,[14][15][16]18,27,37,39,48,50,55,58 Sternal fracture locations were reported for 499 patients: sternal body in 408 (81.8%), 5,8,9,11,12,14,[16][17][18][19][20][24][25][26][27][28][29]32,35,37,39,41,44,[46][47][48][52][53][54][55]57,58 manubrium in 60 (12.0%), 20,31,44,47 manubriosternal joint dislocation in 23 (4.6%), 9,13,28,42,48,50 manubrium and body in 7 (1.4%), 13,14,35,51 and xyphoid process in 1 (0.2%). ...
... The displacement of sternal fractures was described for 350 patients; 196 (56%) were displaced, 5,[8][9][10][13][14][15]19,[24][25][26]28,29,31,32,41,42,48,51,53,54 and 154 (44%) were nondisplaced (p=0.833). 8,11,[14][15][16]18,27,37,39,48,50,55,58 Sternal fracture locations were reported for 499 patients: sternal body in 408 (81.8%), 5,8,9,11,12,14,[16][17][18][19][20][24][25][26][27][28][29]32,35,37,39,41,44,[46][47][48][52][53][54][55]57,58 manubrium in 60 (12.0%), 20,31,44,47 manubriosternal joint dislocation in 23 (4.6%), 9,13,28,42,48,50 manubrium and body in 7 (1.4%), 13,14,35,51 and xyphoid process in 1 (0.2%). ...
... Motor vehicle accident [6, 7, 10, 13, 14, 17-20, 23, 24, 27, 28, 32-36, 38, 40, 42-44, 47, 49, 53-55, 58, 59] 20,464 (86.6) Motorcycle [14,34,36,47] 1,925 (8.1) Bicycle [30,34,40] 373 (1.6) Sled crash [47] 1 (0.0) Pedestrian-struck [7,34] 820 (3.4) Road traffic accident, unspecified [21] 37 (0.2) Fall [7, 8, 13, 14, 21, 25, 29, 33-36, 40, 41, 44, 47-50, 56] 2,334 (9.0) Assault [7,8,33,39] 64 (0.3) Heavy object strike [12,26,27,59] 11 (0.0) Gymnastic exercises 4 (0.0) Broad jump [48] 1 (25) Elbowed [16] 1 (25) Gymnastic exercises, unspecified [37] 1 (25) Surfing accident [28] 1 (25) Others 10 (0.0) Animal bumps [14] 5 (50) Burying [47] 1 (10) Soil bank collapse [31] 1 (10) Industrial accident [5] 1 (10) Cardiopulmonary resuscitation [52] 1 (10) Sustaining blunt trauma [51] 1 (10) For unstable or significantly displaced sternal fractures, especially those with severe combined injuries, patients should be hospitalised, operative fixation may be necessary. The indications for sternal fractures were unstable anterior chest wall, fracture displacement, nonunion and sustained chest pain unresponsive to analgesia management. ...
The present article aimed to give an overview of sternal fractures and discuss their management and prognoses. The retrieved pertinent publications of 2011-2021 constituted the materials of the present study. The misdiagnosis rate of X-ray was 5.5% and that of sonography was 6.3% for diagnosing the sternal fractures. There were more patients with complicated than with isolated sternal fractures (98.8% vs. 1.2%, p<0.001). Sternal fractures were treated surgically in 59.5%, conservatively in 39.7%, and staged conservatively and surgically in 0.8% of patients. Extremity fractures, brain injury, lung contusion, and intraabdominal/intraperitoneal injuries were the most common associated injuries to sternal fractures. A small number of patients with sternal fractures have fracture-related delayed complications, most of which require surgical treatments with good outcomes. For solitary sternal fractures, short-term pain relief is sufficient. Most complicated sternal fractures require surgical treatment by sternal fixation. Intrathoracic injuries, especially life-threatening cardiopulmonary injuries that are complicated to sternal fractures warrant resuscitation and corresponding active treatment. The causes of patients' death with sternal fractures were usually not related to the sternum fracture itself, but mostly to the associated injuries. Key Words: Fracture, Sternum, Trauma.
... 2,3 A sternal fracture, in addition to flail chest, worsens the instability of the chest wall, making surgical repair essential. 4 In a previous case, we experienced a transverse sternal fracture accompanied by a unilateral flail chest. 2 We performed a wire fixation for the sternal fracture first. However, the stability of the chest wall was inadequate. ...
... Moreover, in cases such as the present case, a more complex instability may develop. 4 There are several reports on external fixation methods 4 in which each rib in the injured thoracic cage is repaired individually. However, in our case, where multiple ribs had to be repaired at the same time, more invasive and complicated surgical procedures would have been required. ...
Sternal bone fractures with bilateral multiple rib fractures cause serious instability of the anterior chest wall, and prolonged mechanical ventilation may be required. A 45-year-old man was injured in a motor vehicle collision. He suffered from a bilateral flail chest injury accompanied by a transverse sternal fracture. Minimally invasive surgical stabilisation of the anterior chest wall was performed using two bars as per the Nuss procedure. Two days after surgery, he was extubated from artificial respiration and was ultimately discharged without any complications.
... Sternal fractures are a rare form of chest injury and are mainly due to a violent force applied to the thorax's sternum area or crush injury (1). Traffic accidents, high fall injuries, and spinal hyperflexion injuries are the main causes, and severe sternal fractures are often associated with lung injury or heart trauma, leading to respiratory failure and shock (2)(3)(4). Sternal fractures are usually not difficult to diagnose through a detailed medical history, CT scan, and clinical symptoms (5,6), and the most common fracture site is the gladiolus or gladiomanurical junction (7). ...
Background:
Sternal fracture can result from multiple types of severe chest trauma and carries significant risk. Surgical fixation is an effective method for sternal fracture.
Methods:
The clinical data of patients with sternal fractures who presented to our hospital between August 2016 and July 2019 were collected. The 42 patients were divided into three groups, with 15 patients treated by internal fixation with NI-TI memory alloy embracing fixator, 10 patients receiving steel wire fixation, and 17 who received non-surgical treatment and who was designated as a control (conservative) group. Differences in clinical indices included the duration of surgery, blood loss, hospitalization, wound healing, hospitalization expenses, VAS scores, and patient satisfaction scores between the three groups was compared. The analysis of variance and t-test were used for quantitative variables, which were approximately normally distributed. Dichotomous data were compared used Pearson χ2 or Fisher's exact test, and a P value less than 0.05 was considered as statistically significant.
Results:
All patients were cured, and there were no significant differences in general clinical features between the three groups (P>0.05). Thoracic deformity in the surgical groups was corrected anatomically and received better pain scores, while patients in the NI-TI memory alloy embracing fixator group showed advantages of bleeding and patient satisfaction (P<0.05).
Conclusions:
Operative treatment for a sternal fracture is safe, effective and can quickly restore the stability of the thorax. Memory alloy embracing fixator is markedly superior to other fixator materials.
... Furthermore, several studies have reported that surgical reconstruction can improve long-term pulmonary function and decrease pain compared to non-operative management [22]. Numerous surgical methods for rib fractures have been described in the literature [22,23]. In our case, we used titanium alloy fixators and a nickel-titanium memory alloy embracing fixators. ...
... In our case, we used titanium alloy fixators and a nickel-titanium memory alloy embracing fixators. Osteosynthesis with plates has improved to be the most extensive security option for the surgical treatment of rib fractures [23]. The clinical implication of the flail segment can vary based on the size and the anatomical location. ...
Background:
Development of multiple rib fractures leading to bilateral flail chest in Cronkhite-Canada Syndrome (CCS) has not been reported.
Case presentation:
A 59-year-old man presented with complaints of fatigue, chest pain, respiratory distress and orthopnea requiring ventilatory support to maintain oxygenation. CCS with bilateral anterior and posterior flail chest due to multiple rib fractures (2nd-10th on the right side and 2nd-11th on the left side). He underwent open reduction and anterior and posterior internal fixation using a titanium alloy fixator and a nickel-titanium memory alloy embracing fixator for chest wall reconstruction. He recovered gradually from the ventilator and showed improvement in his symptoms. He gained about 20 kg of weight in the follow up period (6 months after discharge from the hospital).
Conclusion:
CCS is a rare, complex disease that increases the risk of developing multiple rib fractures, which can be successfully treated with open reduction and internal fixation.
... The evidence regarding the surgical approach in treatment of flail chest with concomitant sternal fracture is low, predominantly due to a low number of cases. The approach might even be different depending on which region on sternum that is fractured and the type and numbers of fractures resulting in flail chest [9]. The treatment of these patients is demanding, both in regards of classification, timing and the surgical set-up. ...
... The treatment of patients with flail chest and concomitant sternal fracture is even less evident, due to the very low number of cases. The published cases indicate that such injuries should be treated surgically in order to stabilize thoracic movement, as in patients with flail chest without sternal fracture [9]. ...
... However, the surgical procedure demands correct timing and experience in surgical stabilization of the thoracic wall [9] and requires accurate planning with the involved surgeons and anesthesiologists before surgery. ...
Introduction:
Flail chest is diagnosed clinically by the presence of paradox movement of a segment of the thoracic wall during spontaneous breathing. Radiographic finding confirming a clinical flail chest are fractures of three or more consecutive ribs or costal cartilages in two or more places. Surgical stabilization is associated with a reduced length of hospital stay, time with mechanical ventilation and risk of respiratory complications.
Presentation of case:
A trauma patient had a Computed Tomography (CT) scan showing multiple costa fractures, sternal fracture, manubrium fracture, sternal displacement and dehiscence of the sternal-costal attachment. The severity of the trauma was visualized after performing a cartilage reconstruction of the trauma CT scan. The patient underwent surgery, using fixation plates to stabilize the thoracic cage, and was then weaned quickly from mechanical ventilation.
Discussion:
This case indicates, that if a patient has a severe flail chest recognized clinically, but not radiologically, a reconstruction of cartilage can reveal the true severity of the trauma. Indeed, the patient in this case experienced a positive outcome from surgery. However, such a procedure demands correct timing and experience in surgical stabilization of the thoracic wall. Furthermore, the injury required accurate planning with the involved personal before surgery.
Conclusion:
Surgical stabilization of advanced flail chest with concomitant sternal fracture, seems to be a safe procedure, that might reduce the need of mechanical ventilation and the length of stay at the Intensive Care Unit (ICU). Furthermore, cartilage reconstruction of the trauma CT scan can potentially identify a severe flail chest, that might be missed on regular 3D bone reconstruction.
... The study confirms that whether it is a severe flail chest, a sternum fracture, or even multiple rib fractures, surgical treatment can effectively reduce the hospital stay and the duration of intensive care unit stay [1,2]. In addition, the curative effect in a patient with pulmonary infection and thoracic deformity is obvious. ...
There are studies confirmed that for severe flail chest or sternal fractures, even multiple rib fractures, surgery can effectively reduce hospital stay and relieve chest wall pain. But it is a challenge to fix too many costal cartilage fractures in such a small area if we just put internal fixator directly on the sternum. Through this case report we want to share our method of fixation of multiple costal cartilage and sternal fractures at the same time through a small incision, and it is also appropriate for multiple costal cartilage fractures without sternal fracture.
... In flail chest, with mediastinal flutter related to the paradoxical movement of the chest wall, related to the pressure on SVC and IVC, hemodynamics can be disturbed and the patient can undergo cardiac arrest [6]. Although in most of the cases of chest wall traumas surgical reconstruction is not needed [4][5][6][7][8], surgical stabilization was shown to be useful in certain subgroup of patients [5]. Specific guidelines are deficient for the management of certain combinations of chest wall injuries, because of their low incidence. ...
... The most frequent treatment modality for flail chest is mechanic ventilation today [4][5][6][7][8]. However, in the literature, it's reported that surgical rib stabilization demonstrated coherent results compared to conservative management, regarding duration of mechanical ventilation, duration of hospitalization in intensive care unit and total duration of hospitalization, incidence of pneumonia, and need for tracheostomy in flail chest patients [1]. ...
... In addition to locked plates, other osteosynthesis materials like rib clamp systems can be used or an internal bracing of the chest wall can also be performed by the way of bars [8]. However, clemp systems have significant risk of implant failure and bars have the risk of sternum fracture [8]. ...
Introduction:
Multiple rib fractures exposes serious respiratory disorders and they are generally treated with non surgical methods. Nevertheless, in cases of long term pain despite medical treatment, parenchymal injury, hematoma, posture disorder and flail chest, surgery is needed. Flail chest, as the most critical form of blunt chest trauma, can disturb the hemodynamic of patient significantly and threaten life. This work has been reported in line with the SCARE criteria.
Presentation of case:
A 32 year old male patient referred to our hospital with flail chest in intubated status due to industrial accident. In physical examination, there was displaced dissociation in lower 1/3 of sternum and pericardium was palpated in the subcutaneus tissue. In thorax CT, there was fracture both in the right 7-8. costochondral and in the left 8. costochondral joints. Additionally, crepitation was palpated in these joints. There was flail chest in the right anterior hemithorax and in the lower sternum. Patient was treated with chest wall reconstruction with titanium plaques.
Discussion:
In cases of flail chest, after a few days mechanical ventilation, implementing stabilization provides a rapid healing.
Conclusions:
We believe there is significant place of surgery for stabilization in proper cases.
Objective
Anterior flail chest frequency represents a significant case of ventilator insufficiency. Surgical stabilization of acute phase of trauma is considered to effectively shorten the period of ventilation compared to conservative treatment using mechanical ventilation. We have applied minimally invasive surgery to stabilize the injured chest wall.Methods
Surgical stabilization of predominantly anterior flail chest segments was performed using one or two bars as per the Nuss procedure, during the acute phase of chest trauma. Data from all patients were examined.ResultsTen patients received surgical stabilization using the Nuss method between 1999 and 2021. All patients had already been mechanically ventilated prior to surgery. The mean period from trauma to surgery was 4.2 days (range, 1–8 days). The number of bars used was one for 7 patients, and two for 3 patients. The mean operation time was 60 min (range, 25–107 min). All patients were extubated from artificial respiration without surgical complications or mortality. Mean total ventilation period was 6.5 days (range, 2–15 days). All bars were removed in a subsequent surgery. No collapses or fracture recurrences were observed.Conclusion
This method is simple and effective for fixed anterior dominant frail segment.
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.
Die histopathologische Einteilung des Lungenkarzinoms hat in den letzten Jahren eine zunehmend hohe Differenzierung erfahren und wird heute nach der WHO-Klassifikation von 2009 vorgenommen. Ziel der pratherapeutischen Diagnostik ist neben der Tumorsicherung die Einordnung der jeweiligen Tumorausdehnung in eine der 4 Tumorstadien der UICC in der aktuellen 7. Version von 2007. Neben der bildgebenden Diagnostik hat sich vor allem die Bronchoskopie weiter entwickelt. Dies betrifft zum einen die Moglichkeiten, mit verschiedenen Navigationstechniken, wie z. B. dem endobronchialen Utraschall mit der sog. Minisonde kleine, weit peripher liegende Tumore zu biopsieren. Zum anderen hat sich die diagnostische Sicherheit transbronchialer Feinnadelpunktionen von Lymphknoten mit der Nutzung von Ultraschallbronchoskopen deutlich erhoht, sodass zum Nachweis und Ausmas einer bestehenden Lymphknotenmetastasierung heute nur noch ausnahmsweise die Mediastinoskopie herangezogen werden muss. Im nachfolgenden Artikel werden die verschiedenen Tumorstadien mit ihren Unterstadien vorgestellt, der Ablauf und die verschiedenen Verfahren des Stagings beschrieben sowie stadienadaptiert Prognoseparameter definiert. Abschliesend wird auf die Moglichkeiten der interventionellen bronchoskopischen Behandlung in palliativen Situationen bei Tumorstenose, Blutung oder Fistel hingewiesen.
