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Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Antibiotic agents have been shown to improve outcomes in open extremity fractures. The first-generation cephalosporins, which are used most often, are often under-dosed based on weight and recommended frequency. Ceftriaxone offers a broader coverage and a decreased frequency of administration. Our institution began utilizing ceftriaxone for open fracture management in 2017 to address those concerns. Objective: To examine the efficacy of cefazolin versus ceftriaxone for open fracture management of extremity trauma. Patients and Methods: Retrospective study from 2015-2019 of patients who sustained open extremity fractures. Patients were stratified by antibiotic administered and Gustilo-Anderson grade. Outcomes included non-union/malunion, superficial surgical site infection (SSI), deep SSI, osteomyelitis, re-operation after index hospital visit, re-admission due to prior injury, limb loss, and death. Subgroup analysis stratified each antibiotic group by Gustilo-Anderson grade 1 or 2 and grade 3. Results: Data was collected from 2015 to 2019. Of the 1,149 patients, 619 patients met inclusion criteria. Three hundred fifty-five patients received cefazolin and 264 patients received ceftriaxone. There were no statistically significant differences between groups on specified outcomes. No statistically significant differences existed during subgroup analysis for the specified outcomes. Multivariable analysis demonstrated increased Gustilo-Anderson grade increased risk of infectious outcome. Conclusions: Ceftriaxone is a safe and effective alternative for open fracture extremity management that offers the advantage of 24-hour dosing and single antibiotic coverage for grade 3 open fractures. It does not increase infectious complications and offers benefits of resource efficiency.

Splenic injuries are mostly treated with nonoperative management (NOM) with observation to monitor for continued hemorrhage and holding early chemical DVT prophylaxis to reduce the risk of NOM failure. Eberle et al demonstrated chemoprophylaxis prior to 72 hours didn't increase failure rate of NOM. We chose to extrapolate this finding and compare outcomes in high-grade splenic injuries (HGSI) with chemoprophylaxis before and after 48 hours. From January 2013 to December 2017, 104 patients with HGSI received chemoprophylaxis with unfractionated heparin (UH) or low molecular weight heparin (LMWH) within 72 hours of diagnosis. Of these, 8 patients received chemoprophylaxis within 24 hours, 46 between 24 and 48 hours, and 50 patients between 48 and 72 hours. This population consisted of 70 males and 34 females, with an average age of 40.1 years. The average ISS was 23 and the majority (77%) were grade 3 injuries. We observed 6 failures of NOM: 1 in the <24 hour group, 3 in the 24-48 hour group, and 2 in the 48-72 hour group. There was no statistically significant difference between the <24 hour and >24 groups or between the <48 hour and 48-72 hour groups. A linear regression analysis created a model describing the time to initiation of DVT prophylaxis using age, sex, splenic injury grade, and ISS; the failure rate decreased by 0.00002% for each hour prior to giving DVT prophylaxis, with a P value of .111. We conclude a noninferiority statement that DVT prophylaxis prior to 48 hours does not increase the risk of NOM failure.

Background: Rib fractures are associated with significant morbidity and mortality in polytraumatized patients. There is considerable variability in the management (operative vs. non-operative) and timing of operative intervention. Although Eastern Association for the Surgery of Trauma (EAST) guidelines recommend early operative intervention in patients with flail chest, there are no strong recommendations regarding operative fixation in patients with a non-flail chest rib fracture pattern., Methods: We reviewed our Trauma Quality Improvement Program database for patients aged 18 to 99 who underwent operative intervention of ribs from January 2016 to July 2019. We examined hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, Injury Severity Score, age, discharge disposition and packed red blood cell transfusions. Similarly, we collected data from patients aged 18 to 99 who had one or more rib fractures in this time frame. We compared results in a 4:1 ratio of patients managed non-operatively to patients managed operatively. The patient groups were matched based on age, number of rib fractures and presence of bilateral rib fractures., Results: Between January 2016 and July 2019, 33 of 4189 total patients diagnosed with rib fractures underwent operative fixation; the matched non-operative group consisted of 132 patients. The statistically significant differences included presence of bilateral rib fractures, displaced rib fractures and flail chest segments. The median ICU days were longer in the operative group (6.0 vs. 3.5 days). A subgroup analysis of patients without flail segments demonstrated a significant presence of displaced rib fractures.Our single-institution matched comparison of outcomes in operative intervention versus Non-operative Management (NOM) of rib fractures found an increased median number of ICU days. Patients who underwent operative intervention often stayed in the ICU preoperatively and postoperatively for aggressive pulmonary hygiene and pain control, suggesting observer bias. The increased incidence of displaced rib fractures and the presence of a flail segment in the operative group demonstrate congruence with EAST guidelines. A subgroup analysis of patients without flail segment did not demonstrate differences in outcomes nor shoulder girdle injury characteristics., Level of Evidence: This article presents level III evidence that can be used by other clinicians to analyze eligibility for patients to undergo surgical stabilization of rib fracture (SSRF) and to provide counterarguments for performing SSRF in a heterogenous group of patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Spinal column injuries are very commonly diagnosed in the multitrauma population, and extensive distraction injuries are often fatal due to cerebrovascular injuries or spinal cord injuries. We present a 62-year-old female who presented after an MVC with a 2-cm vertical distraction injury of C5-6 with a right vertebral artery transection and left vertebral artery dissection. She received multidisciplinary treatment which resulted in her survival, albeit with severe neurologic deficits. We challenge the current literature that suggests a blunt vertebral artery transection is 100% fatal.