Search Results (117)

Background: Rib fractures are among the most common thoracic injuries following blunt trauma and are associated with significant morbidity, particularly in elderly and polytrauma populations. Historically managed non-operatively, recent advances have redefined the role of surgical stabilization of rib fractures (SSRF) in improving patient outcomes. The objective of this narrative review is to evaluate current evidence surrounding the management of rib fractures, with a focus on indications for SSRF, surgical techniques, special populations, and future directions in care. Methods: A narrative review of the literature was conducted, incorporating relevant randomized controlled trials, cohort studies, clinical guidelines, and expert consensus statements. Emphasis was placed on patient selection criteria, surgical strategies, multimodal analgesia, and emerging technologies. Results: SSRF has demonstrated benefits in short- and long-term outcomes, including improved pain control, reduced ventilator dependence, shorter ICU and hospital stays, and better functional recovery. These outcomes are most evident in patients with flail chest, severe displacement, or failure of conservative therapy. Minimally invasive techniques and 3D-printed implants represent promising innovations. Despite growing evidence, SSRF remains underutilized due to variability in institutional protocols and access to trained personnel. Conclusions: The management of rib fractures continues to evolve with increasing support for surgical intervention in select patients. Wider implementation of SSRF, guided by standardized protocols and advanced technologies, may improve outcomes and reduce complications in this high-risk trauma population. Full article

Thoracic injuries account for a high percentage of combat casualty mortalities, with 80% of preventable deaths resulting from abdominal or thoracic hemorrhage. An effective method for detecting and triaging thoracic injuries is point-of-care ultrasound (POCUS), as it is a cheap and portable noninvasive imaging method. POCUS image interpretation of pneumothorax (PTX) or hemothorax (HTX) injuries requires a skilled radiologist, which will likely not be available in austere situations where injury detection and triage are most critical. With the recent growth in artificial intelligence (AI) for healthcare, the hypothesis for this study is that deep learning (DL) models for classifying images as showing HTX or PTX injury, or being negative for injury can be developed for lowering the skill threshold for POCUS diagnostics on the future battlefield. Three-class deep learning classification AI models were developed using a motion-mode ultrasound dataset captured in animal study experiments from more than 25 swine subjects. Cluster analysis was used to define the “population” based on brightness, contrast, and kurtosis properties. A MobileNetV3 DL model architecture was tuned across a variety of hyperparameters, with the results ultimately being evaluated using images captured in real-time. Different hyperparameter configurations were blind-tested, resulting in models trained on filtered data having a real-time accuracy from 89 to 96%, as opposed to 78–95% when trained without filtering and optimization. The best model achieved a blind accuracy of 85% when inferencing on data collected in real-time, surpassing previous YOLOv8 models by 17%. AI models can be developed that are suitable for high performance in real-time for thoracic injury determination and are suitable for potentially addressing challenges with responding to emergency casualty situations and reducing the skill threshold for using and interpreting POCUS. Full article

Background: Lateral lumbar or thoracic interbody fusion (LLIF) is increasingly considered for anterior column reconstruction and restoring segmental lordosis in degenerative, infectious, or deformity conditions. Reports about using LLIF with expandable interbody spacers for spine trauma are scarce. Methods: In this retrospective, single-center observational cohort study, we reviewed all patients treated by an expandable LLIF interbody spacer (ELSA^® Expandable Integrated LLIF Spacer, Globus Medical Inc) for trauma indication at our spine center between September 2018 and January 2024. The primary outcome measures were fusion rate at 12 months, change in segmental sagittal Cobb angle, and clinical outcome according to the MacNab criteria. Secondary outcomes included adverse events and complications. Results: We identified n = 21 patients with a mean age of 48.3 (standard deviation (SD) 15.7), 47.6% were female. LLIF was mostly performed at T11/12 (n = 4; 19.1%) and T12/L1 (n = 10; 47.5%). Indications were AO Spine type A2 (n = 4, 19.1%), A3 (n = 14; 66.7%) or A4 fractures (n = 3; 14.3%) with ligamentous (B2-type) in eight (38.1%) and hyperextension (B3-type) injury in one patient (4.8%). Surgery included the release of the anterior longitudinal ligament in four cases (19.1%). Intraoperative AEs were noted in n = 1 (4.8%), postoperative AEs in n = 3 (14.3%) at discharge, n = 4 (19.1%) at three, and n = 2 (9.5%) at twelve months. Segmental sagittal Cobb angle changed from 1.3° (preoperative) to 13.3° at twelve months (p < 0.001). Functional outcome was excellent/good in n = 15 (71.4%; four missing) at 12 months. The fusion rate at the LLIF level was 100% at the 12-month follow-up. Conclusions: LLIF with expandable interbody spacers for spine trauma (off-label use) is safe, promotes solid fusion (100% fusion rate at 12 months), and enables correction of sagittal segmental Cobb angle (mean improvement of 12°), with good or excellent clinical outcomes in most patients (71.4%). Full article

This report examines the successful recovery of a feline that presented with multiple complex fractures and dislocations involving the facial and cranial structures resulting from a traffic accident. Diagnostic CT imaging identified significant injuries, including luxation of the left temporomandibular joint (TMJ), a mandibular symphyseal fracture, a hard palate fracture, and a left orbital fracture accompanied by severe exudate within the nasal cavity, compressing the left orbit and nasal passages. Importantly, no additional injuries were detected in the thoracic or abdominal regions, facilitating a more targeted treatment plan. The management of this case required extensive surgical intervention, including open reduction of the TMJ, stabilization of the mandibular symphysis, repair of the bony palate, and partial maxillectomy. After 20 days of ICU hospitalization, the feline fully recovered. This outcome is particularly noteworthy as the combination of severe injuries observed in this case is unprecedented in the veterinary literature. Consequently, it offers critical insights into both surgical techniques and postoperative management strategies applicable to similarly complex trauma cases. The feline’s full recovery, characterized by the restoration of normal daily functions, highlights the clinical significance of pursuing multiple, complex surgical procedures in cases of severe trauma. It serves as a valuable reference for advancing the understanding and management of severe facial trauma in veterinary practice. Full article

Background: Autologous breast reconstruction has undergone a remarkable evolution, driven by the pursuit of addressing past concerns primarily related to donor site morbidity and complication risks. Improved techniques now prioritize minimizing invasiveness, complications, and recovery time while achieving aesthetically pleasing and durable results. Methods: Recent advancements in autologous breast reconstruction have been examined, focusing on enhancements in surgical techniques, imaging technologies, minimally invasive approaches, and postoperative care. Results: To reduce donor site morbidity, attention has recently shifted back to abdominal flaps vascularized by subcutaneous vessels. Specifically, the superficial circumflex iliac artery perforator (SCIP) flap has emerged as a promising option. Additionally, robotic-assisted flap harvest serves as another method to reduce the invasiveness. At the recipient site, rib-sparing internal mammary vessel isolation and perforator-to-perforator anastomosis have been suggested to lessen trauma and maintain thoracic integrity. The use of thorough preoperative imaging and intraoperative assessment of real-time perfusion with indocyanine green angiography (ICG) has enhanced the success of the procedure. Beyond aesthetic restoration, contemporary breast reconstructive surgeons are increasingly aware of both short-term and long-term complications, particularly lymphatic sequelae. The LYMPHA technique (lymphatic microsurgical preventive healing approach) promotes immediate restoration of the lymphatic system and has shown the potential to reduce the risk of breast cancer-related lymphedema (BCRL). Furthermore, the integration of enhanced recovery after surgery (ERAS) protocols has transformed perioperative care by optimizing pain management, minimizing hospitalization duration, and allowing a quicker return to daily activities. Conclusions: Recent advancements in autologous breast reconstruction have significantly improved patient outcomes. With innovations in flap design, technology, lymphatic preservation, and recovery protocols, it has been possible to usher in a new era of less invasive procedures and fewer complications while achieving high aesthetic results and allowing patients to return to their daily lives as quickly as possible. Full article

Background: Facial features are the first basic sign of medical knowledge of children and adults with congenital malformations. Children born with multiple contractures almost always receive the misdiagnosis of arthrogryposis multiplex. Larsen syndrome can easily be diagnosed at birth via the proper interpretations of its characteristic facial features and multiple dislocations. Comprehensive clinical diagnosis can facilitate an orthopedic strategy for early treatment and can enhance the recognition of unreported craniocervical malformation complexes. Material and Methods: Six children (four boys and two girls, with ages ranging from a few months to 7 years old) were referred to our department for diagnosis and treatment. All children received their first misdiagnosis by the pediatricians as manifesting arthrogryposis multiplex congenita. The clinical phenotype was our first decisive tool for diagnosis. All children exhibited the classical phenotype of dish-like facies associated with multiple joint dislocations. Radiological phenotypic characteristics confirmed our clinical diagnosis of Larsen syndrome. Three children out of six showed unpleasant cervical spine deformities. The first child, a 2-year-old, became tetraplegic after minor trauma. One child presented with progressive rigid cervical kyphosis. The third child was a product of a first-relative marriage and was born with congenital tetraplegia. A genotype was carried out for confirmation. Results: Three children underwent open reduction for congenital hip and knee dislocations. One child underwent spinal fusion CO-C7 because of tetraplegia. A 3D-reformatted and reconstruction CT scan of the craniocervical junction showed two forms of unusual dys-segmentation, firstly along C2-3 effectively causing the development of acute-angle cervical kyphosis. Secondly, an infant with congenital tetraplegia showed a serious previously undescribed atlanto–axial malformation complex. Namely, atlanto–axial maldevelopment (dys-segmentation) of (C1/C2) was associated with hypoplasia of the anterior and the posterior rings of the atlas. Genetic tests of these children were compatible with the autosomal dominant type of Larsen syndrome and manifested a heterozygous mutation in FLNB mapped 3p14.3, encoding an actin-binding protein, filamin B. The child with congenital tetraplegia showed no mutations in FLNB, though his clinical and radiological phenotype and his family history of first-relative marriage were totally compatible with the diagnosis of the autosomal recessive type of Larsen syndrome. Conclusions: Our strategy was and still is based on a coherent clinical and radiological diagnosis, which is based on comprehensive clinical and radiological phenotypic characterizations. We implemented a 3D-reformatted CT scan to further understand the craniocervical junction pathology in three children. Strikingly, prenatal onset of lethal maldevelopment (dys-segmentation) of the atlanto–axial spine segments has been diagnosed in an infant with congenital tetraplagia. A less serious cervical spine malformation was detected in two children who presented with progressive acute-angle cervico and cervico-thoracic kyphosis. Our clinical strategy can form the basis for a thorough clinical assessment for infants and children born with multiple malformation complexes and can lead to recognition of novel understandings. Full article

Road accidents are one of the leading causes of death worldwide, with significant repercussions on public health and the global economy. Fatal accidents can cause injuries in various anatomical areas with different dynamics. The thorax is one of the main sites involved in fatal accidents, due to the presence of vital organs such as the heart and lungs. Protective devices, such as seatbelts and airbags, also play a fundamental role in preventing chest injuries. However, external examination is often insufficient to determine the extent of internal trauma, resulting in significant difficulties in reconstructing the accident dynamics. In particular, in the absence of an autopsy, it is difficult to determine whether the driver or passengers were wearing protective devices, such as seatbelts, at the time of the accident. Diagnosing injuries secondary to protective devices, such as airbags, can also be complex without this assessment. Through a review of the literature, this work analyzes the different types of thoracic trauma that can be found at autopsy, providing indications to the forensic pathologist for the examination of these injuries. This review highlights the importance of the autopsy examination as a gold-standard investigation in the analysis of thoracic trauma from road accidents, in order to evaluate with certainty the injuries that caused death, and to facilitate the reconstruction of the dynamics for judicial purposes. Finally, an analysis of postmortem radiological investigations and of the role of protective measures in these events, such as the seatbelt and airbag, is provided. Full article

Background: The present study aims to investigate the influence of systematic radiological screening for silent vertebral fractures (VFs) on osteoporosis diagnosis, treatment decisions, and long-term clinical outcomes compared to standard care without routine screening in elderly patients hospitalised primarily for fractures requiring surgical treatment at sites other than the spine. Material/Methods: In a level 1 trauma centre, patients with fractures requiring surgical treatment after low-energy trauma were prospectively examined over a period of 12 months. Using radiographs of the thoracic and lumbar spine in two planes, previously unknown VFs were identified and categorised according to the classification for osteoporotic fractures (OFs) of the thoracolumbar spine. Results: A total of 106 patients with a mean age of 79.4 years participated in this study, and 112 previously unknown vertebral compression fractures were diagnosed in 57% (60/106) of the patients. In this group, lumbar vertebra 2 was the most frequently affected, and the majority of these VFs were classified as OF 2, which corresponds to an isolated endplate fracture with minimal involvement of the posterior wall. Furthermore, 26% (28/106) of the patients in the evaluation showed VFs at multiple levels. This study revealed no statistically significant difference in the prevalence of silent VFs between male and female patients (p = 0.055). Additionally, the analysis revealed that nearly 75% of patients exhibited vitamin D insufficiency. Conclusions: The high prevalence of silent VFs in elderly patients emphasises the necessity for systematic radiological investigations, irrespective of gender. Full article

Background/Objectives: Effective pain management in polytrauma patients with rib fractures is essential, particularly in the critical care setting. While epidural analgesia is considered the gold standard, it is not always feasible, necessitating alternative locoregional approaches. We present the case of a polytrauma patient with multiple, bilateral rib fractures and severe chest pain that hindered weaning from mechanical ventilation. A bilateral Serratus Anterior Plane Block (SAPB) was performed, with catheters placed for continuous administration of local anesthetics. Pain relief was immediate, enabling a rapid weaning from mechanical ventilation, safe extubation, and subsequent discharge to rehabilitation. A review of the literature on this technique in critically ill patients with thoracic trauma and multiple rib fractures is also presented. Methods: We conducted a literature search up to November 2024, identifying studies evaluating the use of SAPB in critically ill patients with chest trauma and rib fractures. Results: Eight studies were identified, including a total of 197 cases, of which only 3 involved a bilateral SAPB. Studies and published case reports demonstrated significant variability in analgesic protocols and reported outcomes. Notably, only two papers addressed specifically its role in facilitating weaning from mechanical ventilation. Conclusions: Pain control is fundamental in managing severe chest trauma. This case and the reviewed literature suggest that the SAPB is a promising option when epidural analgesia is contraindicated or impractical. However, further studies are needed to define its place in clinical practice and optimize its use in critically ill patients. Full article

Background: The non-robotic endoscopic harvest of the internal mammary artery (IMA) facilitates minimally invasive bypass grafting while minimizing chest wall trauma. The technique was pioneered in the early 1990s and has recently regained popularity due to its accessibility and reproducibility. This review aims to provide an overview of endoscopic IMA harvest from its inception to the present. Methods: In August 2024, a literature search was performed using the electronic databases of the Cochrane Controlled Trials Register (CCTR) and PubMed. To obtain optimal search results, the keywords “thoracoscopic”, “endoscopic”, “minimally invasive”, “video-assisted”, “video-assisted thoracoscopic surgery VATS”, and “internal mammary artery” or “internal thoracic artery” were used, excluding the term “robotic”. References from the extracted articles were also reviewed to identify additional studies on endoscopic IMA harvest. Results: A total of 17 articles were included in the final analysis. Left internal mammary artery (LIMA) harvest times of between 17 and 164 min were reported, with an injury to LIMA rates between 0.7 and 2.2%. Conclusions: After a 15-year period without scientific publications, interest in the endoscopic-assisted approach has rekindled in recent years due to the reduction in chest trauma compared to direct vision harvest and the widespread availability of conventional endoscopic tools. This renewed focus underscores the potential to make minimally invasive coronary surgery available in all centers. Full article

Background: Grade I-II blunt traumatic aortic injuries (BTAIs) are typically managed conservatively, but their long-term progression is poorly understood. Chronic pseudoaneurysms may develop years after the injury, often remaining asymptomatic and being incidentally diagnosed. Methods: Two cases of post-traumatic aortic pseudoaneurysms, detected 20 and 25 years following conservatively managed BTAIs, are reported. Additionally, a comprehensive review of all post-traumatic pseudoaneurysms reported in the MedLine (PubMed.gov, U.S. National Library of Medicine, National Institute of Health) database between January 1984 and December 2024 was performed. Results: Both our patients underwent successful hybrid procedures, with no complications at the 1- and 4-year follow-ups. Our literature review identified 37 patients across 22 studies, with 32.4% presenting asymptomatically or incidentally diagnosed through routine imaging, between 1 month and 50 years after the initial trauma. In 37.8% of cases, the patients underwent open or endovascular repair. Conclusions: This case series and literature review emphasize the importance of long-term follow-up for patients with conservatively managed BTAIs, as chronic complications such as aortic pseudoaneurysms can arise decades later. Continuous surveillance is critical to ensure early detection and management. Full article

Introduction: Detection of blunt traumatic diaphragm injury (TDI) can be challenging in the absence of surgical exploration. Our objective is to study the mechanisms of injury and detection modes for patients with blunt TDI. Methods: This is a single-center, retrospective review conducted in a level 1 trauma center from 2016 to 2023, inclusive. We identified seven patients with blunt TDI using the primary mechanisms and trauma type. Results: Out of seven patients, two were associated with motor vehicle collisions, four were pedestrians struck, and one fell down the stairs. The mean ISS was 48.4 (29–75). Of the seven patients with blunt TDI, four died in the trauma bay–two from traumatic arrest and two died spontaneously. Multiple rib fractures were one of the common injury patterns in six cases, whereas in the remaining case, blunt TDI was confirmed at laparotomy and repaired. One patient died two days after admission. Of the two patients who survived, one had a TDI identified during video-assisted thoracic surgery (VATS) for retained hemothorax, and one patient had a TDI repaired during emergent exploratory laparotomy for other injuries. In the remaining four patients, blunt TDI was confirmed based on their autopsy reports. Conclusions: Injuries in all seven cases were sustained with a high-energy injury mechanism. Multiple rib fractures were reported in six cases. Based on our findings, we recommend that clinicians maintain a high level of suspicion for blunt TDI in patients with thoracoabdominal trauma, especially in cases with rib fractures or high-impact trauma. Full article

Background: Spinal cord injury (SCI) frequently leads to pain, leading to significant disability. Pain sensitization, a key feature of SCI, is commonly assessed via quantitative sensory testing like the Pressure Pain Threshold (PPT), though the factors influencing PPT changes remain unclear. This study hypothesizes that specific clinical and neurophysiological factors modulate PPT in SCI patients. The primary objective is to identify predictors of PPT in SCI patients. Methods: We conducted a cross-sectional analysis of neurophysiological, clinical, and demographic data from 102 SCI patients in an ongoing prospective cohort study called “Deficit of Inhibition as a Marker of Neuroplasticity” (DEFINE study). Multivariable regression analyses were used to evaluate demographic, clinical, and functional variables associated with PPT, the primary outcome measure. Results: The sample comprised 87.9% males with an average age of 41. Trauma was the leading cause of SCI (77.45%), predominantly affecting the cervical and thoracic levels. Pain was reported by 44% of participants, and the mean PPT was 8.3 kPa, measured bilaterally. Multivariate analysis of PPT in the left, right, and bilateral thenar regions revealed consistent trends. Significant negative associations were found between bilateral PPT and low beta EEG frequency in the central area (β = −14.94, p = 0.017), traumatic lesion etiology (β = −1.99, p = 0.038), and incomplete lesions by the American Spinal Injury Association classification (β = −1.68, p = 0.012). In contrast, positive associations were observed with age (β = 0.08, p < 0.001). Conclusions: Our findings show that increased beta oscillations and traumatic brain injury having a lower PPT indicate that factors associated with maladaptive plasticity are associated with decreased and likely less functional PPT. On the other hand, increased motor function may help to regulate PPT in a more functional status. Full article

Background: Blunt traumatic aortic injury (BTAI) is the second most common cause of death following blunt trauma, and it can affect people of all ages. The aim of this study was to evaluate age-related differences in outcomes among patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI. Methods: All patients treated with TEVAR for BTAI at a tertiary care center in Europe between 2005 and 2023 were included in this study. All clinical and imaging data were collected and analyzed retrospectively. Results: A total of 70 patients with a median age of 43 years were included, and 89% were male. Older patients had significantly higher American Society of Anesthesiologists (ASA) physical status classification scores (p < 0.001) compared to younger patients. All age groups (<18, 18–40, 41–65, and >65) exhibited low to borderline low initial hemoglobin levels with a further decline over time (p = 0.063, p < 0.001, p < 0.001, and p = 0.018, respectively). Age groups were comparable regarding injury mechanism, Injury Severity Score (ISS), concomitant injuries and postoperative complications. The age-independent ISS showed a moderate to strong correlation to the length of intensive care unit stay (r = 0.594, p < 0.001). Total in-hospital mortality was 6% and none was from aortic-related complications. There was a generally high rate of loss of follow-up (59%). Conclusions: Although older patients presented worse ASA scores in comparison to younger patients, no significant differences regarding postoperative morbidity/mortality were noted. These findings imply that patient age and preinjury physical status might not substantially influence outcomes when treating BTAI with TEVAR. Full article

Extracorporeal membrane oxygenation (ECMO), an advanced life support method, was developed to treat severe cardiac and pulmonary failure in critically ill patients. ECMO was previously used to treat ARDS, cardiogenic shock, and after heart or lung transplant. It has since become a versatile therapeutic and surgical tool. When conventional methods fail, this technique works well for high-risk procedures such as tracheal resections, ventricular tachycardia ablations, and complicated percutaneous coronary interventions. These uses demonstrate ECMO’s ability to oxygenate and stabilize the hemodynamics in challenging clinical circumstances. Clinical studies report survival rates exceeding 60% in ECMO-assisted thoracic surgeries, underscoring its efficacy in these settings. Recent advancements, such as portable ECMO systems and artificial intelligence-driven management tools, have further enhanced the safety and effectiveness of ECMO, enabling its use in diverse clinical environments. However, challenges remain, particularly in patient selection, resource allocation, and addressing ethical dilemmas. The integration of standardized protocols and technological innovations has mitigated complications such as vascular injury and infection, contributing to improved patient outcomes. This review examines ECMO applications and integration into multidisciplinary care, its configurations, and its growing role outside the intensive care unit in elective thoracic and cardiac surgery, trauma, and non-cardiac high-risk procedures. Full article