54 research outputs found
Operative treatment of multiple costochondral dislocations in a patient with severe rib fractures and a flail chest following trauma
Get PDFA 73-year-old male patient underwent operative treatment for dislocation of multiple costochondral junctions alongside multiple bony rib fractures and a flail chest following high-energy trauma. During the operative fixation of the flail chest, the costochondral lesions were surgically stabilised with plates and screws, which were fixated on the osseous anterior rib, sternum or the rib cartilage. The patient experienced no pulmonary complications during the primary admission. At 7 months after the trauma, the chest CT scan showed full consolidation of all fixated rib fractures, including the costochondral lesions, without hardware dislocation or complications. The patient did not require any pain medication and had no pain during daily activities, at rest or at night. Although being a biomechanically demanding region, which is often not defined in current rib fracture classification, operative treatment of costochondral lesions is feasible with outcome similar to the treatment of bony rib fractures
Abdominal flank bulge following intercostal neurectomy for symptomatic rib fracture nonunion
Get PDFThe gold standard for rib fracture nonunion management remains a matter of debate. Operative treatment of rib fracture nonunion has become increasingly popular. A 69-year-old man was operatively treated with intercostal neurectomy of the left eighth rib to resolve chronic thoracic pain following a rib fracture nonunion. After the intervention, the patient developed a flank bulge which was most likely due to the intercostal neurectomy, causing partial denervation of the abdominal musculature. Although the pain at the nonunion site decreased after the operative intervention, the patient still experienced severe pain during daily activities and reported poor quality of life due to the flank bulge. Physiotherapy and an abdominal belt did not improve this flank bulge. When considering operative neurectomy of the intercostal nerves of ribs 7-12 to resolve chronic pain due to rib fracture nonunion, the treating surgeon should be aware of this debilitating complication
Surgical strategy for treating multiple symptomatic rib fracture malunions with bridging heterotopic ossifications:A case report
Get PDFRib fractures are common and serious injuries, which can negatively impact long-term quality of life. Here we present a woman in her early twenties who was referred to our trauma surgery outpatient clinic five years after a motor vehicle collision in which she sustained upper extremity injury and multiple displaced rib fractures. The rib fractures were initially managed non-operatively. At the time of the outpatient consultation, she endured persistent severe pain located between the left scapula and the thoracic spine. The pain worsened on repetitive motion and deep respiration. A new chest CT revealed left-sided posterior rib fracture malunions of ribs 4 to 8 with heterotopic ossifications (HO) that formed an osseous bridge between these ribs. Surgical excision of the bridging HO and remodeling of the angulated rib malunions resulted in significant alleviation of symptoms, which allowed her to return to work and other activities. Given the dramatic improvement after surgery, we suggest considering surgical remodeling and excision for rib fracture malunions and associated HO that cause local mechanical symptoms.</p
Traditional radiography versus computed tomography to assess reduced distal radius fractures
Get PDFIntroduction: This study compares computed tomography (CT) with plain radiography in its ability to assess distal radius fracture (DRF) malalignment after closed reduction and cast immobilization. Methods: Malalignment is defined as radiographic fracture alignment beyond threshold values according to the Dutch guideline encompassing angulation, inclination, positive ulnar variance and intra-articular step-off or gap. After identifying 96 patients with correct alignment on initial post-reduction radiographs, we re-assessed alignment on post-reduction CT scans. Results: Significant discrepancies were found between radiographs and CT scans in all measurement parameters. Notably, intra-articular step-off and gap variations on CT scans led to the reclassification of the majority of cases from correct alignment to malalignment. CT scans showed malalignment in 53% of cases, of which 73% underwent surgery. Conclusion: When there is doubt about post-reduction alignment based on radiograph imaging, additional CT scanning often reveals malalignment, primarily due to intra-articular incongruency.</p
Surgical management of costal margin rupture associated with intercostal hernia:Evolution of techniques
Get PDFINTRODUCTION: Costal margin rupture (CMR) injuries in association with intercostal hernia (IH) are rare and symptomatic and provide a significant surgical challenge. Surgical failure rates up to 60% are reported, and optimal techniques are unclear. We have characterized these injuries and describe the evolution of our surgical management techniques. METHODS:Patients characterized by the Sheffield Classification where CMR and IH were both present, either CMR-IH or transdiaphragmatic intercostal hernia (TDIH), were identified prospectively, and injury characteristics, patient management, and follow-up data were recorded. Surgical techniques evolved according to patient outcomes from suture repair without and then with extrathoracic mesh, to three iterations of double-layer mesh repair (DLMR). The third iteration involved DLMR with biologic mesh, titanium buttress plates applied to the ribs adjacent to the IH with intercostal nerve-sparing suture placement. Associated surgical stabilization of rib fractures, or surgical stabilization of nonunited rib fractures, was performed when required, with costal margin plate fixation where possible.RESULTS: Of 25 patients with CMR-IH and 11 with TDIH, 25 patients underwent surgery, with 6 reoperations in 5 patients. There were 8 suture repairs and 3 extrathoracic mesh repairs: DLMR was performed in 14 patients (3 Mark [Mk] 1, 5 Mk 2, and 6 Mk 3) with 2, 1, and 0 reoperations, respectively. Costal margin stabilization with titanium plates was successful twice at the level of the seventh but failed twice out of three times at the ninth costal cartilage. Reoperation after a failed mesh repair is particularly challenging and may require the placement of titanium buttress plates, surgical stabilization of rib fractures, and the use of stainless steel wire sutures. CONCLUSION: Repair of CMR-IH/TDIH is challenging, but experience-based evolution of techniques has led to a durable and reproducible Mk 3 repair.LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.</p
Biomechanical characteristics of rib fracture fixation systems
Get PDFBackground: The primary aim of this study was to determine and compare the biomechanical properties of a fractured or intact rib after implant fixation on an embalmed thorax. Methods: Five systems were fixated on the bilateral fractured or intact (randomly allocated) 6th to 10th rib of five post-mortem embalmed human specimens. Each rib underwent a four-point bending test to determine the bending structural stiffness (Newton per m2), load to failure (Newton), failure mode, and the relative difference in bending structural stiffness and load to failure as compared to a non-fixated intact rib. Findings: As compared to a non-fixated intact rib, the relative difference in stiffness of a fixated intact rib ranged from −0.14 (standard deviation [SD], 0.10) to 0.53 (SD 0.35) and for a fixated fractured rib from −0.88 (SD 0.08) to 0.17 (SD 0.50). The most common failure mode was a new fracture at the most anterior drill hole for the plate and screw systems and a new fracture within the anterior portion of the implant for the clamping systems. Interpretation: The current fixation systems differ in their design, mode of action, and biomechanical properties. Differences in biomechanical properties such as stiffness and load to failure especially apply to fractured ribs. Insight in the differences between the systems might guide more specific implant selection and increase the surgeon's awareness for localizing hardware complaints or failure.</p
Artificial intelligence fracture recognition on computed tomography: review of literature and recommendations
Get PDFPurpose: The use of computed tomography (CT) in fractures is time consuming, challenging and suffers from poor inter-surgeon reliability. Convolutional neural networks (CNNs), a subset of artificial intelligence (AI), may overcome shortcomings and reduce clinical burdens to detect and classify fractures. The aim of this review was to summarize literature on CNNs for the detection and classification of fractures on CT scans, focusing on its accuracy and to evaluate the beneficial role in daily practice. Methods: Literature search was performed according to the PRISMA statement, and Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched. Studies were eligible when the use of AI for the detection of fractures on CT scans was described. Quality assessment was done with a modified version of the methodologic index for nonrandomized studies (MINORS), with a seven-item checklist. Performance of AI was defined as accuracy, F1-score and area under the curve (AUC). Results: Of the 1140 identified studies, 17 were included. Accuracy ranged from 69 to 99%, the F1-score ranged from 0.35 to 0.94 and the AUC, ranging from 0.77 to 0.95. Based on ten studies, CNN showed a similar or improved diagnostic accuracy in addition to clinical evaluation only. Conclusions: CNNs are applicable for the detection and classification fractures on CT scans. This can improve automated and clinician-aided diagnostics. Further research should focus on the additional value of CNN used for CT scans in daily clinics
Surgical Site Infection after Surgical Stabilization of Rib Fractures: Rare but Morbid
Get PDFBackground: Although surgical stabilization for rib fractures (SSRF) has been adopted widely over the past decade, little information is available regarding the prevalence and outcomes of post-operative surgical site infection (SSI). We hypothesized that SSI after SSRF is uncommon but morbid. Patients and Methods: Patients undergoing SSRF at a level 1 trauma center from 2010-2020 were reviewed. The primary outcome was the prevalence of SSI, documented by clinical examination, radiography, systemic markers of infection, and microbiology. Results: Of 228 patients undergoing SSRF, 167 (73.2%) were male, the median age was 53 years (P25-P75; 41-63 years), injury severity score (ISS) was 19 (P25-P75, 13-26), with a median of eight fractured ribs (P25-P75, 6-11). All stabilization plates were titanium. SSRF was typically performed on post-injury day one (P25-P75, 0-2 days) after trauma. All patients received antibiotic agents within 30 minutes of incision, and a median of four ribs (P25-P75, 3-6) were repaired. Four (1.8%) patients developed an SSI and all underwent implant removal. Two patients required implant removal within 30 days (on post-operative day seven and 17) and two for chronic infection at seven and 17 months after SSRF. The causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) bacteria in all patients. After implant removal, three patients received intravenous and oral antibiotic agents, ranging from two to six weeks, without recurrent infection. No patient required additional SSRF. Conclusions: Surgical site infection after SSRF is rare but morbid and can become symptomatic within one week to 17 months. Implant removal results in complete recovery
AI for detection, classification and prediction of loss of alignment of distal radius fractures:a systematic review
Get PDFPurpose: Early and accurate assessment of distal radius fractures (DRFs) is crucial for optimal prognosis. Identifying fractures likely to lose threshold alignment (instability) in a cast is vital for treatment decisions, yet prediction tools’ accuracy and reliability remain challenging. Artificial intelligence (AI), particularly Convolutional Neural Networks (CNNs), can evaluate radiographic images with high performance. This systematic review aims to summarize studies utilizing CNNs to detect, classify, or predict loss of threshold alignment of DRFs. Methods: A literature search was performed according to the PRISMA. Studies were eligible when the use of AI for the detection, classification, or prediction of loss of threshold alignment was analyzed. Quality assessment was done with a modified version of the methodologic index for non-randomized studies (MINORS). Results: Of the 576 identified studies, 15 were included. On fracture detection, studies reported sensitivity and specificity ranging from 80 to 99% and 73–100%, respectively; the AUC ranged from 0.87 to 0.99; the accuracy varied from 82 to 99%. The accuracy of fracture classification ranged from 60 to 81% and the AUC from 0.59 to 0.84. No studies focused on predicting loss of thresholds alignement of DRFs. Conclusion: AI models for DRF detection show promising performance, indicating the potential of algorithms to assist clinicians in the assessment of radiographs. In addition, AI models showed similar performance compared to clinicians. No algorithms for predicting the loss of threshold alignment were identified in our literature search despite the clinical relevance of such algorithms.</p
An open source convolutional neural network to detect and localize distal radius fractures on plain radiographs
Get PDFPURPOSE: Distal radius fractures (DRFs) are often initially assessed by junior doctors under time constraints, with limited supervision, risking significant consequences if missed. Convolutional Neural Networks (CNNs) can aid in diagnosing fractures. This study aims to internally and externally validate an open source algorithm for the detection and localization of DRFs. METHODS: Patients from a level 1 trauma center from Adelaide, Australia that presented between 2016 and 2020 with wrist trauma were retrospectively included. Radiographs were reviewed confirming the presence or absence of a fracture, as well as annotating radius, ulna, and fracture location. An internal validation dataset from the same hospital was created. An external validation set was created with two other level 1 trauma centers, from Groningen and Rotterdam, the Netherlands. Three surgeons reviewed both sets for DRFs. RESULTS: The algorithm was trained on 659 radiographs. The internal validation set included 190 patients, showing an accuracy of 87% and an AUC of 0.93 for DRF detection. The external validation set consisted of 188 patients, with an accuracy and AUC were 82% and 0.88 respectively. Radial and ulnar bone segmentation on the internal validation was excellent with an AP50 of 99 and 98, but moderate for fracture segmentation with an AP50 of 29. For external validation the AP50 was 92, 89 and 25 for radius, ulna, and fracture respectively. CONCLUSION: This open-source algorithm effectively detects DRFs with high accuracy and localizes them with moderate accuracy. It can assist clinicians in diagnosing suspected DRFs and is the first radiograph-based CNN externally validated on patients from multiple hospitals.</p
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