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Background: There is a lack of studies focusing on long-term chest function after chest wall injury due to cardiopulmonary resuscitation (CPR). The purpose of this cross-sectional study was to investigate long-term pain, lung function, physical function, and fracture healing after manual or mechanical CPR and in patients with and without flail chest., Methods: Patients experiencing out-of-hospital cardiac arrest between 2013 and 2020 and transported to Sahlgrenska University Hospital were identified. Survivors who had undergone a computed tomography (CT) showing chest wall injury were contacted. Thirty-five patients answered a questionnaire regarding pain, physical function, and quality of life and 25 also attended a clinical examination to measure the respiratory and physical functions 3.9 (SD 1.7, min 2-max 8) years after the CPR. In addition, 22 patients underwent an additional CT scan to evaluate fracture healing., Results: The initial CT showed bilateral rib fractures in all but one patient and sternum fracture in 69 %. At the time of the follow-up none of the patients had persistent pain, however, two patients were experiencing local discomfort in the chest wall. Lung function and thoracic expansion were significantly lower compared to reference values (FVC 14 %, FEV1 18 %, PEF 10 % and thoracic expansion 63 %) (p < 0.05). Three of the patients had remaining unhealed injuries. Patients who had received mechanical CPR in additional to manual CPR had a lower peak expiratory flow (80 vs 98 % of predicted values) (p=0.030) =0.030) and those having flail chest had less range of motion in the thoracic spine (84 vs 127 % of predicted) (p = 0.019) otherwise the results were similar between the groups., Conclusion: None of the survivors had long-term pain after CPR-related chest wall injuries. Despite decreased lower lung function and thoracic expansion, most patients had no limitations in physical mobility. Only minor differences were seen after manual vs. mechanical CPR or with and without flail chest., Competing Interests: Declaration of competing interest The authors declare no competing interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Competing interests: None declared.

Rib fractures are highly predictive of non-accidental trauma in children under 3 years old. Rib fracture detection in pediatric radiographs is challenging because fractures can be obliquely oriented to the imaging detector, obfuscated by other structures, incomplete, and non-displaced. Prior studies have shown up to two-thirds of rib fractures may be missed during initial interpretation. In this paper, we implemented methods for improving the sensitivity (i.e. recall) performance for detecting and localizing rib fractures in pediatric chest radiographs to help augment performance of radiology interpretation. These methods adapted two convolutional neural network (CNN) architectures, RetinaNet and YOLOv5, and our previously proposed decision scheme, "avalanche decision", that dynamically reduces the acceptance threshold for proposed regions in each image. Additionally, we present contributions of using multiple image pre-processing and model ensembling techniques. Using a custom dataset of 1109 pediatric chest radiographs manually labeled by seven pediatric radiologists, we performed 10-fold cross-validation and reported detection performance using several metrics, including F2 score which summarizes precision and recall for high-sensitivity tasks. Our best performing model used three ensembled YOLOv5 models with varied input processing and an avalanche decision scheme, achieving an F2 score of 0.725 ± 0.012. Expert inter-reader performance yielded an F2 score of 0.732. Results demonstrate that our combination of sensitivity-driving methods provides object detector performance approaching the capabilities of expert human readers, suggesting that these methods may provide a viable approach to identify all rib fractures., (© 2024. The Author(s).)

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: Blunt trauma acting against the human body presents the fundamental cause of pulmonary fat embolism (PFE) and fat embolism syndrome. The aim of the present study was to investigate PFE in non-survivors after cardiopulmonary resuscitation (CPR)., Methods: This was a prospective cohort study conducted in University Hospital Ostrava, Czech Republic. Within a 4-year study period, all non-survivors after CPR because of out-of-hospital cardiac arrest were assessed for the study eligibility. The presence/seriousness of PFE was determined by microscopic examination of cryo-sections of lung tissue (staining with Oil Red O)., Results: In total, 106 persons after unsuccessful CPR were enrolled in the study. The most frequent cause of death in the study population (63.2% of cases) was cardiac disease (ischemic heart disease); PFE was not determined as the cause of death in any of our study cases. Sternal fractures were identified 66.9%, rib fractures (usually multiple) in 80.2% of study cases; the median number of rib fractures was 10.2 fractures per person. Serious intra-thoracic injuries were found in 34.9% of cases. Microscopic examination of lung cryo-sections revealed PFE in 40 (37.7%) study cases; PFE was most frequently evaluated as grade I or II. Occurrence of sternal and rib fractures was significantly higher in persons with PFE than between persons without PFE (p = 0.033 and p = <0.001). Number of rib fractures was also significantly higher in persons with PFE. The occurrence of serious intra-thoracic injuries was comparable in both our study groups (p = 0.089)., Conclusions: PFE presents a common resuscitation injury which can be found in more than 30% of persons after CPR. Persons with resuscitation skeletal chest fractures have significantly higher risk of PFE development. During autopsy of persons after unsuccessful CPR, it is necessary to distinguish CPR-associated injuries including PFE from injuries that arise from other mechanisms., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Predicting and understanding thorax injury is fundamental for the assessment and development of safety systems to mitigate injury risk to the increasing and vulnerable aged population. While computational human models have contributed to the understanding of injury biomechanics, contemporary human body models have struggled to predict rib fractures and explain the increased incidence of injury in the aged population. The present study enhanced young and aged human body models (HBMs) by integrating a biofidelic cortical bone constitutive model and population-based bone material properties. The HBMs were evaluated using side impact sled tests assessed using chest compression and number of rib fractures. The increase in thoracic kyphosis and the associated change in rib angle with increasing age, led to increased rib torsional moment increasing the rib shear stress. Coupled with and improved cortical bone constitutive model and aged material properties, the higher resulting shear stress led to an increased number of rib fractures in the aged model. The importance of shear stress resulting from torsional load was further investigated using an isolated rib model. In contrast, HBM chest compression, a common thorax injury-associated metric, was insensitive to the aging factors studied. This study proposes an explanation for the increased incidence of thorax injury with increasing age reported in epidemiological data, and provides an enhanced understanding of human rib mechanics that will benefit assessment and design of future safety systems., Competing Interests: BP was employed by Autoliv Research. CM was employed by Honda Development & Manufacturing of America. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Corrales, Bolte, Pipkorn, Markusic and Cronin.)

This study examines the pattern of rib injuries occurring in cases of fatal torso stab wounds in Ireland between 2011 and 2018. It has been suggested by previous studies that rib fractures are not commonly sustained in stab wounds to the torso. We wanted to ascertain whether this was the case, as our data suggested that rib fractures were frequent, and where a rib is fractured there is a higher chance of organ injury and death, making this an important area of study. One hundred and forty seven cases of fatal stab wounds from an eight-year period were retrospectively reviewed. Fatal stab wounds to other body areas, were excluded; leaving a total of 104 cases with stab wounds to the torso. We found that 69.2% of cases had rib injuries, a figure significantly higher than previously reported. Our data suggests that stab wounds to the torso often fracture ribs, putting the underlying organs at increased risk of injury and perhaps contributing to fatality. The amount of force needed to cause a rib fracture can be difficult to quantify and indeed from the high percentage of rib fractures sustained in our data it appears that the ribs may be fractured regardless of the amount of force used; this is borne out by the finding that self-inflicted injuries also caused rib fractures. Our study shows that other factors, such as anatomical positioning and wound depth may have a greater bearing than force in terms of whether a rib fracture is sustained., (© 2023 The Authors. Journal of Forensic Sciences published by Wiley Periodicals LLC on behalf of American Academy of Forensic Sciences.)

Objective: Most car occupant fatalities occur in frontal crashes and the thorax is the most frequently injured body region. The objectives of the study were, firstly, to quantify the relation between risk factors (such as speed and occupant age) and rib and sternum fracture injury probability in frontal car crashes, and, secondly, to evaluate whether rib fracture occurrence can predict sternum fractures., Methods: Weighted German data from 1999-2021 were used to create the injury risk curves to predict both, at least moderate and at least serious, rib and sternum fracture risks. A contingency table for rib and sternum fractures allowed the calculation of sensitivity, specificity, and precision, as well as testing for the association., Results: Elderly occupants (≥65 years old) had increased rib and sternum fracture risk compared to mid aged occupants (18-64 years old). Besides occupant age, delta-V was always and sex sometimes a significant predictor for skeletal thoracic injury. Sternum fractures were more common than rib fractures and more likely to occur at any given delta-V. Sternum fractures occurred often in isolation. Female occupants were at higher risk than males to sustain at least moderate rib and sternum fractures together and sternum fractures in isolation. Rib and sternum fractures were associated, but low sensitivity and precision show that rib fractures do not predict sternum fractures well., Conclusions: Elderly and female occupants were at the highest risk and should be targeted by thoracic injury criteria and thresholds for frontal crash occupant protection. Rib and sternum fractures were not associated. Therefore, sternum fractures need to be predicted and evaluated separately from rib fractures.

Background: Cardiopulmonary resuscitation (CPR), although lifesaving may cause chest wall injury (CWI) because of the physical force exerted on the thorax. The impact of CWI on clinical outcome in this patient group is unclear. The primary aim of this study was to investigate the incidence of CPR-related CWI and the secondary aim to study injury pattern, length of stay (LOS), and mortality in patients with and without CWI., Methods: This is a retrospective study of adult patients who were admitted to our hospital due to cardiac arrest (CA) during 2012 to 2020. Patients were identified in the Swedish CPR Registry and those undergoing CT of the thorax within 2 weeks after CPR were included. Patients with traumatic CA, chest wall surgery prior or after CA were excluded. Demographic data, type and length of CPR, type of CWI, LOS on mechanical ventilator (MV), in intensive care unit (ICU) and in hospital (H), and mortality were studied., Results: Of 1,715 CA patients, 245 met the criteria for inclusion. The majority (79%) of the patients suffered from CWI. Chondral injuries and rib fractures were more common than sternum fractures (95% vs. 57%), and 14% had a radiological flail segment. Patients with CWI were older (66.5 ± 15.4 vs. 52.5 ± 15.2, p < 0.001). No difference was seen in MV-LOS (3 [0-43] vs. 3 [0-22]; p = 0.430), ICU-LOS (3 [0-48] vs. 3 [0-24]; p = 0.427), and H-LOS (5.5 [0-85] vs. 9.0 [1-53]; p = 0.306) in patients with or without CWI. Overall mortality within 30 days was higher with CWI (68% vs. 47%, p = 0.007)., Conclusion: Chest wall injuries are common after CPR and 14% of patients had a flail segment on CT. Elderly patients have an increased risk of CWI, and a higher overall mortality is seen in patients with CWI., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives : Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods : This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results : We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions : Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.

Background: Internal fixation for rib fractures has been widely carried out worldwide, and its surgical efficacy has been recognized. However, there is still controversy about whether implant materials need to be removed. At present, the research on this topic is still lacking at home and abroad. Therefore, in this study, the patients undergoing removal of internal fixation for rib fractures in our department within one year were followed up, to statistically analyze implant-related complications, postoperative complications and postoperative remission rate., Methods: A retrospective analysis was conducted on 143 patients undergoing removal of internal fixation for rib fractures from 2020 to 2021 in our center. The implant-related complications, postoperative complications and postoperative remission rate of patients with internal fixation were analyzed., Results: In this study, a total of 143 patients underwent removal of internal fixation, among which 73 suffered from preoperative implant-related complications (foreign-body sensation, pain, wound numbness, sense of tightness, screw slippage, chest tightness, implant rejection), and 70 had no post operative discomfort but asked for removal of internal fixation. The average interval between rib fixation and removal was 17 ± 9.00 (months), and the average number of removed materials was 5.29 ± 2.42. Postoperative complications included wound infection (n = 1) and pulmonary embolism (n = 1). of the 73 patients with preoperative implant-related complications, the mean postoperative remission rate was 82%. Among the 70 patients without preoperative discomfort, the proportion of discomforts after removal was 10%. No perioperative death occurred., Conclusion: For patients with internal fixation for rib fractures, removal of internal fixation can be considered in the case of implant-related complications after surgery. The corresponding symptoms can be relieved after removal. The removal presents low complication rate, and high safety and reliability. For patients without obvious symptoms, it is safe to retain the internal fixation in the body. For the asymptomatic patients who ask for removal of internal fixation, the possible risk of complications should be fully informed before removal., (© 2023. The Author(s).)

Background: The utilization of stereotactic body radiation therapy (SBRT) is increasing for primary and secondary lung neoplasms. Despite encouraging results, SBRT is associated with an increased risk of osteoradionecrosis-induced rib fracture. We aimed to (1) evaluate potential clinical, demographic, and procedure-related risk factors for rib fractures and (2) describe the radiographic features of post-SBRT rib fractures., Methods: We retrospectively identified 106 patients who received SBRT between 2015 and 2018 for a primary or metastatic lung tumor with at least 12 months of follow up. Exclusion criteria were incomplete records, previous ipsilateral thoracic radiation, or relevant prior trauma. Computed tomography (CT) images were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was employed to determine clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location)., Results: A total of 106 patients with 111 treated tumors met the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total fractured ribs). The highest number of fractured ribs per patient was five. Multivariate regression identified posterolateral tumor location as the only independent risk factor for rib fracture. On CT, fractures showed discontinuity between healing edges in 77% of affected patients., Conclusions: Nearly one third of patients receiving SBRT for lung tumors experienced rib fractures, 34% of whom experienced pain. Many patients developed multiple fractures. Post-SBRT fractures demonstrated a unique discontinuity between the healing edges of the rib, a distinct feature of post-SBRT rib fractures. The only independent predictor of rib fracture was tumor location along the posterolateral chest wall. Given its increasing frequency of use, describing the risk profile of SBRT is vital to ensure patient safety and adequately inform patient expectations., (© 2023. The Author(s).)

Purpose: This study aimed to compare the adverse reactions of conventional-dose and hypofractionated dose of proton therapy for breast cancer., Materials and Methods: Breast cancer patients treated with proton radiotherapy in conventional-dose or hypofractionated dose were studied retrospectively., Result: From January 2017 to December 2019, our center treated 50 patients following lumpectomy with proton radiotherapy. According to the AJCC 8th Edition standard, there were stage I in 26 patients, stage II in 22 patients, and stage III in 2 patients. A total of 14 patients received intensity-modulated proton therapy at a dose of 50 Gy in 25 fractions, followed by a 10 Gy 4 fractionated boost to the lumpectomy cavity, while 36 received 40.05 Gy in 15 fractions, simultaneous integrated boost (SIB) 48 Gy to the lumpectomy cavity. Median follow-up time for 40.05 Gy group was 35.6 months (15-43 months). Median follow-up time for 50 Gy group was 46.8 months (36-68 months). For acute toxicity, the grade 1 and 2 radiodermatitis in conventional-dose group were 35.7% and 57.1%, respectively. In hypofractionated dose group, the grade 1 and 2 radiodermatitis were 91.7% and 8.3%, respectively. The radiodermatitis is hypofractionneted dose better than conventional-dose significantly. Grade 1 radiation-induced esophagitis in conventional-dose group and hypofractionated dose group were 85.71% and 60%, respectively. For late toxicity, no patients developed radiation-induced pneumonitis and rib fracture in conventional-dose group. Three patients presented grade 1 pneumonitis; one patient presented graded 2 pneumonitides and two patients presented rib fracture in hypofractionated dose group. One presented hypothyroidism in hypofractionated dose group. All patients were satisfied with breast shape. The one- and two-year OS and DFS for conventional-dose group were 100 and 100; 100 and 92.9%, respectively. The one- and two-year OS and DFS for hypofractionated dose group were 100 and 100; 100 and 100%, respectively., Conclusion: Proton radiation therapy can significantly reduce the normal tissue dose in breast cancer patients' hearts, lungs, and other organs. Hypofractionated proton therapy shortens the treatment course with mild radiation-related adverse effects, and has a better effect on addressing the acute adverse reactions than conventional proton radiotherapy., (© 2023. The Author(s).)

Objectives: Sternal retractors utilized during open-heart surgeries through median sternotomy can cause upper rib fractures which sometimes further leads to brachial plexus injury. We aimed to investigate the incidence of brachial plexus injury and upper rib fractures in open-heart surgeries and how these injuries are associated with each other., Methods: We investigated 1050 cases during the past five years. The incidence of brachial plexus injury and upper rib fractures after median sternotomy was assessed in all patients and the patients who sustained were evaluated for the affected side, the level of paralysis., Results: Ten cases (0.95%) exhibited brachial plexus injury after median sternotomy. Nine cases developed paralysis on left upper extremity. In all ten cases, sensory and motor nerve impairment were exhibited in the lower plexus. Rib fractures were observed in 35.0% of cases after median sternotomy and the usage of asymmetric sternal retractors to harvest left internal thoracic artery (LITA) significantly affected the side of fracture., Conclusion: Sternal retractors utilized during open-heart surgeries through median sternotomy may cause rib fractures and brachial plexus injury, so operators should be aware of these complications., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Objective: One potential nonstandard seating configuration for vehicles with automated driving systems (ADS) is a reclined seat that is rear-facing when in a frontal collision. There are limited biomechanical response and injury data for this seating configuration during high-speed collisions. The main objective of this study was to investigate thoracic biomechanical responses and injuries to male postmortem human subjects (PMHS) in a rear-facing scenario with varying boundary conditions. Method: Fourteen rear-facing male PMHS tests (10 previously published and 4 newly tested) were conducted at two different recline angles (25-degree and 45-degree) in 56 km/h frontal impacts. PMHS were seated in two different seats; one used a Fixed D-Ring (FDR) seat belt assembly and one used an All Belts To Seat (ABTS) restraint. For thoracic instrumentation, strain gages were attached to ribs to quantify strain and fracture timing. A chestband was installed at the mid-sternum level to quantify anterior-posterior (AP) chest deflections. Data from the thorax instrumentation were analyzed to investigate injury mechanisms. Results: The PMHS sustained a greater number of rib fractures (NRF) in the 45-degree recline condition (12 ± 7 NRF for ABTS45 and 25 ± 18 NRF for FDR45) than the 25-degree condition (6 ± 4 NRF for ABTS25 and 12 ± 8 NRF for FDR25), despite AP chest compressions in the 45-degree condition (-23.7 ± 9.4 mm for ABTS45 and -39.6 ± 11.9 mm for FDR45) being smaller than the 25-degree condition (-38.9 ± 16.9 mm for ABTS25 and -55.0 ± 4.4 mm for FDR25). The rib fractures from the ABTS condition were not as symmetric as the FDR condition in the 25-degree recline angle due to a belt retractor structure located at one side of the seatback frame. Average peak AP chest compression occurred at 45.7 ± 3.4 ms for ABTS45, 45.6 ± 3.1 ms for FDR45, 46.7 ± 1.9 ms for ABTS25, and 46.9 ± 2.3 ms for FDR25. Average peak seatback resultant force occurred at 43.9 ± 0.9 ms for ABTS45, 44.6 ± 0.8 ms for FDR45, 42.5 ± 0.2 ms for ABTS25, and 41.5 ± 0.5 ms for FDR25. The majority of rib fractures occurred after peak AP chest compression and peak seatback resultant force likely due to the ramping motion of the PMHS, which might create a combined loading (e.g., AP deflection and upward deflection) to the thorax. Although NRF in the 45-degree reclined condition was greater than the 25-degree recline condition, similar magnitudes of rib strains were observed regardless of seat and restraint types, while strain modes varied. Conclusions: The majority of rib fractures occurred after peak AP chest compression and peak seatback force, especially in FDR25, ABTS45, and FDR45, while the PMHS ramped up along the seatback. AP chest compression, seatback load, and strain measured along the rib could not explain the greater NRF in the 45-degree recline conditions. A complex combination of AP chest deflection with upward deflection was discovered as a possible mechanism for rib fractures in PMHS subjected to rear-facing frontal impacts in this study.

Background: Rib fractures in adult horses are poorly documented., Objectives: To describe the presenting signs, diagnosis, treatment and outcome of horses diagnosed with rib fracture., Study Design: Retrospective case series., Method: The clinical records and diagnostic images of all adult horses diagnosed with a rib fracture at three referral centres over a 15-year period were reviewed., Results: Seventy-three horses met the inclusion criteria. Horses presented due to either resistance to ridden work and poor performance (n = 41), lameness (n = 21) or trauma (n = 7). In four horses, the presenting complaint was not recorded. Clinical assessment and palpation localised the site of injury in 18/47 cases where recorded. Nuclear scintigraphic examination identified all fracture sites in which it was performed (59/59). In 10/24 horses, radiographic examination confirmed rib fracture. Ultrasonographic examination confirmed rib fracture in 58/59 horses (98%; 95% CI 92-100). Six horses underwent surgery due to ongoing clinical signs and non-healing fracture; all other horses were managed conservatively. Fifty-five horses were available for long-term follow up (>1 year), of which 28 (51%; 95% CI 38-64) returned to their previous level of exercise. Twelve horses did not return to their previous level of exercise due to lameness unrelated to the rib fracture and seven horses were subjected to euthanasia, of which three were as a result of the rib fracture. Eight horses did not return to their previous level of exercise for other reasons., Main Limitations: Incomplete data set due to retrospective case series., Conclusions: Although uncommon, rib fractures should be considered in cases of reduced performance or resistance during ridden exercise. Palpation may be unrewarding. Scintigraphy and ultrasonography are useful in identifying the fracture site. Rib fractures in horses carry a fair prognosis and can be managed conservatively in most cases., (© 2022 EVJ Ltd.)

Purpose: Spontaneous rib fracture (SRF) is a common late complication in treated breast cancer patients. This study evaluated the incidence and risk factors of ipsilateral SRF after radiotherapy (RT) in breast cancer patients. In addition, we identified dosimetric parameters that were significantly associated with ipsilateral SRF., Methods: We retrospectively reviewed 2204 patients with breast cancer who underwent RT between 2014 and 2016, and were followed up with bone scans. We evaluated clinical risk factors for ipsilateral SRF. Dose-volume histogram analysis was also performed for patients (n = 538) whose dosimetric data were available. All ipsilateral ribs were manually delineated, and dosimetric parameters of the ribs were converted into the equivalent dose in 2 Gy fractions (EQD2)., Results: Most of the patients with SRF (87.3%) were asymptomatic, and the remaining symptomatic patients complained of mild tenderness or chest wall discomfort; these symptoms all resolved within 6 months without any treatment. Ipsilateral SRF occurred in 14.5% of patients 3 years after RT. The median time to develop ipsilateral SRF was 15 months. In dosimetric analysis, near-maximum rib dose (D2cc) best predicted ipsilateral SRF. The cut-off value of D2cc was EQD2 52 Gy, as determined by receiver operating characteristic analysis. In multivariate analysis including dosimetric variables, D2cc EQD2 ≥ 52 Gy was the only significant risk factor for ipsilateral SRF., Conclusion: Our data demonstrated that near-maximum rib dose was the best dosimetric parameter to predict ipsilateral SRF in RT-treated breast cancer patients. In addition, our results suggest that patients who received RT with exceeding rib dose cut-off value and had ipsilateral SRF on bone scan be recommended routine follow-up without additional imaging tests., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objective: In 2020, 17% of all crash fatalities were individuals aged 65 years or older. Crash data also revealed that for older occupants, thoracic related injuries are among the leading causes of fatality. Historically, the majority of near-side impact postmortem human subjects (PMHS) studies used a generic load wall to capture external loads that were applied to PMHS. While these data were helpful in documenting biofidelity, they did not represent a realistic response an occupant would undergo in a near-side crash. The objective of this research was to test small, elderly female PMHS in a repeatable, realistic near-side impact crash scenario to investigate current injury criteria as they relate to this vulnerable population., Method: Ten small, elderly PMHS were subjected to a realistic near-side impact loading condition. The PMHS were targeted to be elderly females age 60+, approximately 5 th percentile in height and weight, with osteopenic areal bone mineral density. Each subject was seated on a mass-production seat, equipped with a side airbag and standard three-point restraint with a pretensioner. Other boundary conditions included an intruding driver's side door. PMHS instrumentation included strain gages on ribs 3-10 bilaterally to identify fracture timing. Two chestbands were used to measure chest deflection, one at the level of the axilla and one at the level of the xiphoid process., Results: Injuries observed included rib fractures, particularly on the struck side, and in multiple cases a flail chest was observed. Eight of ten subjects resulted in AIS3+ thoracic injuries, despite previously tested ATDs predicting less than a 10% chance of AIS3+ injury. Subjects crossed the threshold for AIS3 injury in the range of only 1% - 9% chest compression. Additionally, mechanisms of injury varied, as some injuries were incurred by door interactions while others came during airbag interactions., Conclusions: This research points to two areas of concern that likely require further analysis: (1) the appropriateness of potentially oversimplified PMHS testing to establish injury thresholds and define injury criteria for complicated crash scenarios; (2) the importance of identifying the precise timing of injuries to better understand the effect of current passive restraint systems.

Introduction: Cardiopulmonary resuscitation (CPR)-related injuries have not been assessed since the 2015 Resuscitation Guidelines were established., Aim: To describe the incidence and severity of CPR-related injuries, and to evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on the objective assessment of injuries., Methods: This multicenter, retrospective study analyzed autopsy reports of patients who underwent CPR. The most severe injuries were objectively assessed using the Abbreviated Injury Scale (AIS) and all injuries were summarized according to the New Injury Severity Score (NISS)., Results: Among 628 autopsy reports analyzed, patient characteristics and case details were distributed as follows: male sex, 71.1%; median age, 67 years; out-of-hospital cardiac arrest, 89.2%; bystander CPR, 56.8%. CPR-related injuries included: rib(s) 94.6%; lung(s), 9.9%; sternum, 62.4%; liver, 2.5%; and spleen, 1.8%. The incidence of bystander-provided CPR and severity of injury were similar to CPR provided only by professionals. There were no difference between mechanical and manual compressions. Females were older (p = 0.0001) and, although the frequency of their injuries was similar to males, they were significantly more severe (p = 0.01). Patients with life-threatening injury exhibited a baseline profile similar to those without injury . The median score (according to AIS) of the most severe injury was 3 and the median of summary of injuries was 13 according to the NISS-low risk of fatal injury., Conclusion: CPR-related injuries occurred frequently, although those that were life-threatening accounted for only 3% of cases. There were no differences between patients who were resuscitated by bystander(s) or by professionals and no differences between mechanical chest devices or manual resuscitation. Compared with a study based on the 2010 guidelines, similar injuries were found, but with more rib fractures, less visceral organ damage, and fewer life-threatening injuries., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interests with this manuscript., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: This paper is aimed at investigating the efficacy of combining internal fixation using prefabricated rib-locking titanium plate with ultrasound-guided thoracic paravertebral nerve blockade in treating multiple rib fractures among the elderly., Methods: Retrospective analysis of 221 elderly patients with multiple rib fractures treated from February 2016 to November 2020. According to whether surgery was performed, they were divided into the plate-blockage combination group (surgical group, 102 cases) and conservative treatment group (non-surgical group, 119 cases). The surgical group consisted of 58 males and 44 females aged from 60 to 85 years old, with an average of (67.2±3.6 ) years old, who suffered from 3 to 12 rib fractures with an average of (5.3±2.1) fractures. The non-surgical group consisted of 66 males and 53 females aged from 60 to 84 years old with an average of (66.8±3.2) years old, who suffered from 2 to 11 rib fractures with an average of(6.1±2.3) fractures. The clinical data, efficacies observed, and complications associated with both groups were compared and analyzed., Results: There was no significant difference in preoperative clinical data between two groups ( P >0.05), and all patients were discharged smoothly. Pulmonary infection ( P =0.028), atelectasis ( P =0.032), respiratory failure ( P =0.026), time to get out of bed ( P =0.040), time to fracture healing ( P =0.035), length of hospital stay in the operation group ( P =0.043), visual analogue scale (VAS) at 3 days ( P =0.028), 5 days( P =0.032), and 7 days( P =0.019), maximal voluntary ventilation (MVV) at 3 months after surgery ( P =0.042), forced expiratory volume in one second (FEV1)( P =0.035), and maximal voluntary ventilation at 6 months, the maximal voluntary ventilation(MVV)( P =0.021) and forced FEV1( P =0.026) were all significantly better than those in non-surgical treatment group., Conclusion: For elderly patients with severe multiple rib fractures, the proposed plate-blockade combination can timely and effectively relieve pain, restore thoracic stability, shorten hospital stay, and reduce the incidence of complications such as pulmonary infections and acute respiratory distress syndrome(ARDS) compared with non-surgical treatments. Prefabricated rib-locking titanium plates have proved to demonstrate high clinical efficacy in treating multiple rib fractures among the elderly.

The following study was undertaken to determine if any specific occupant characteristics, crash factors, or associated injuries identified at autopsy could predict the occurrence or number of fractured ribs in adults. Data were accrued from the Traffic Accident Reporting System (TARS) and coronial autopsy reports from Forensic Science SA, Adelaide, South Australia, from January 2000 to December 2020. A total of 1475 motor vehicle fatalities were recorded in TARS between January 2000 and December 2020, and 1082 coronial autopsy reports were identified that corresponded to TARS fatal crash data. After applying exclusion criteria involving missing data, 874 cases were included in the analysis. Of the 874 cases, 685 cases had one or more rib fractures. The leading cause of death for those with rib fractures was multiple trauma (54%), followed by head injury (17%) and chest injuries (10%). The strongest predictor of one or more rib fractures was increasing age (p < 0.001). Other factors found in the regression to be predictive of the number of rib fractures were the presence of a variety of other injuries including thoracic spinal fracture, lower right extremity fracture, splenic injury, liver injury, pelvic fracture, aortic injury, lung laceration, and hemothorax. Age is most likely associated with increasing rib fractures due to reduced tolerance to chest deflection with greater injuries occurring at lower magnitudes of impact. The association of other injuries with rib fractures may be a marker of higher impact severity crashes., (© 2022. The Author(s).)

Introduction: Large-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS., Methods: Overall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared., Results: All patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171-10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109-4.888, P = 0.027)., Conclusion: After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS., (© 2022. The Author(s).)

Objectives: Blunt chest trauma after mechanical resuscitation manoeuvres appears to have a significant impact on the often complicated course. Due to a lack of data in the literature, the purpose of this study was to investigate the feasibility and immediate outcome of chest wall stabilization for flail chest in this vulnerable patient population., Methods: We retrospectively reviewed the medical records of patients after cardiopulmonary resuscitation between January 2014 and December 2018 who were diagnosed with flail chest. We attempted to compare patients after surgery with those after conservative treatment., Results: Of a total of 56 patients with blunt chest trauma after mechanical resuscitation and after coronary angiography, 25 were diagnosed with flail chest. After the exclusion of 2 patients because of an initial decision to palliate, 13 patients after surgical stabilization could be compared with 10 patients after conservative therapy. Although there was no significant difference in the total duration of ventilatory support, there was a significant advantage when the time after stabilization to extubation was compared with the duration of ventilation in the conservative group. The presence of pulmonary contusion, poor Glasgow Coma Scale score or the development of pneumonia negatively affected the outcome, but additional sternal fracture did not., Conclusions: Surgical stabilization for chest wall instability is well tolerated even by this vulnerable patient population. Our results should be used for further randomized controlled approaches. It is necessary to evaluate the situation with all parameters in an interdisciplinary manner and to decide on a possible surgical therapy at an early stage if possible., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Competing Interests: Disclosure: The authors declare no conflict of interest.

Background: Current studies focus primarily on skeletal injuries following cardiopulmonary resuscitation (CPR). Few studies report on intrathoracic injuries (ITI) and none, to our knowledge, focus exclusively on cardiovascular injuries related to cardiac massage. This study was based on autopsy findings and assessed the incidence of non-skeletal CPR related injuries related to chest compression., Methods: This was a retrospective forensic autopsy cohort study conducted in a single institution after resuscitation. Pathologists recorded autopsy data using standardized protocol contained information from external and internal examination of the body., Results: Thirty-eight autopsy reports (21 males and 17 females), post- CPR-failure were studied. Heart lesions were reported in 19 patients (group A). The average age was 65.7 years (69.05 group A and 66.5 group B). Median weight was 75.2 Kg and was significantly higher in group B ( p = 0.01). Pericardial lesions were identified in 6 patients in group A and 2 in group B ( p = 0.2 ns). No significant difference was observed among the two groups (Table 4) with the exception of the average number of rib fractures which was higher in group A ( p = 0.04). Autopsy findings revealed heart injuries in 50% of patients with a high prevalence (52.6%) of left ventricle injuries., Conclusion: Cardiac lesions represent frequent and serious complications of unsuccessful CPR. Correct performance of chest compressions according to guidelines is the best way to avoid these complications., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s). Published by IMR Press.)

Background: Motor vehicle collisions (MVCs) are a leading cause of morbidity and mortality. However, there is limited evidence examining the effects seatbelt use has on MVC-related injuries and outcomes in patients with rib fractures. We aim to assess how seatbelt use affects associated injuries and outcomes in adult MVC patients with ≥2 rib fractures., Methods: This retrospective study utilized the American College of Surgeons (ACS) Trauma Quality Programs (TQP) Participant Use File (PUF) Database. Drivers/passengers who sustained ≥2 rib fractures following an MVC and had an AIS ≤2 for extra-thoracic body regions were analyzed. Patients were then subdivided by presence of flail chest into two cohorts, which were subdivided according to injury severity score (ISS) and seatbelt use. Logistic and linear regression was used to assess the impact of seatbelt use on outcomes., Results: Among both low and intermediate ISS classifications, restrained patients in the non-flail chest cohort had decreased incidence of pneumothorax, pulmonary contusion, and liver injury (P < 0.001). After adjusting for confounders, restrained patients (versus unrestrained) had decreased odds of pneumothorax (aOR = 0.91, P = <0.001) and acute respiratory distress syndrome (aOR=0.65, P = 0.02), while having increased odds of splenic laceration (aOR = 1.18, P = 0.003) (intermediate ISS group). Compared to unrestrained patients, restrained non-flail chest patients had a significantly decreased hospital length of stay (LOS) and intensive care unit LOS (P < 0.05)., Conclusions: Seatbelt use may be protective against serious injuries in patients with ≥2 rib fractures, resulting in improved outcomes. Education programs should be developed to bolster seatbelt compliance., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures., Methods: Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression., Results: 34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings., Conclusion: IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity., (© 2021. Springer-Verlag GmbH, DE part of Springer Nature.)

Background: Video-assisted thoracoscopic surgery (VATS) for internal fixation of rib fractures is a promising approach for treating rib fractures and flail chest. Currently the standard practice is to make 1 or several incisions on the chest wall, which will inevitably aggravate the original trauma., Methods: We retrospectively analyzed the data of patients with rib fractures who were treated with memory alloy for internal fixation by complete VATS using a thoracoscopic transthoracic memory alloy rib coaptation board and an implantation tool through the clip applier method or the puncture, traction, and suspension method at our hospital from October 2016 to June 2019., Results: Of 35 patients, 12 had traumatic flail chest injury and 23 had simple multiple rib fractures. Of the 23 patients with multiple rib fractures, 9 had fracture ends in the scapular or paravertebral region and 14 in the anterior or lateral chest walls. All surgeries were performed with complete VATS, which showed quick recovery and good thoracic appearance and function, with no complications for all patients. Follow-up for 6 to 24 months revealed no detachment of the internal fixation device., Conclusions: Internal memory alloy fixation with complete VATS for the treatment of rib fractures is a simple and minimally invasive method that enables fixing fractured ribs internally while treating thoracic trauma with a thoracoscope., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Case: A 74-year-old woman presented with multiple rib fractures, hemothorax, spleen rupture, and right shoulder dislocation. Shoulder joint reduction was performed using the traction-countertraction method. An injury to the descending aorta, caused by the seventh rib, was confirmed., Conclusion: The authors encountered an aortic injury, a rare complication of shoulder joint reduction, in a patient with a posterior rib fracture. When managing patients with posterior fractures of the fourth to ninth ribs on the left side, the reduction method should be carefully selected depending on the status of the patient to avoid aortic injuries., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B761)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Guidelines for depth of chest compressions in pediatric cardiopulmonary resuscitation (CPR) are based on sparse evidence., Objective: We sought to evaluate the performance of the two most widely recommended chest compression depth levels for pediatric CPR (1.5 in. and 1/3 the anterior-posterior diameter- APd) in a controlled swine model of asphyxial cardiac arrest., Methods: We executed a 2-group, randomized laboratory study with an adaptive design allowing early termination for overwhelming injury or benefit. Forty mixed-breed domestic swine (mean weight = 26 kg) were sedated, anesthetized and paralyzed along with endotracheal intubation and mechanical ventilation. Asphyxial cardiac arrest was induced with fentanyl overdose. Animals were untreated for 9 min followed by mechanical CPR with a target depth of 1.5 in. or 1/3 the APd. Advanced life support drugs were administered IV after 4 min of basic resuscitation followed by defibrillation at 14 min. The primary outcomes were return of spontaneous circulation (ROSC), hemodynamics and CPR-related injury severity., Results: Enrollment in the 1/3 APd group was stopped early due to overwhelming differences in injury. Twenty-three animals were assigned to the 1.5 in. group and 15 assigned to the 1/3 APd group, per an adaptive group design. The 1/3 APd group had increased frequency of rib fracture (6.7 vs 1.7, p < 0.001) and higher proportions of several anatomic injury markers than the 1.5 in. group, including sternal fracture, hemothorax and blood in the endotracheal tube (p < 0.001). ROSC and hemodynamic measures were similar between groups., Conclusion: In this pediatric model of cardiac arrest, chest compressions to 1/3APd were more harmful without a concurrent benefit for resuscitation outcomes compared to the 1.5 in. compression group., Competing Interests: Declaration of Competing Interest Dr. Salcido performs fee-for-service work for ZOLL Medical. Drs. Salcido and Menegazzi hold a patent on a system for cardiopulmonary resuscitation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We report the first case of a patient with myxofibrosarcoma (MFS) who presented acutely with a rib fracture and developed a rapidly expanding loculated hemothorax after chest trauma. The patient was taken to the operating room for evacuation of hemothorax, and samples and biopsy specimens were taken for cytologic and pathologic examination. Final report with immunohistochemical staining showed a high-grade MFS. After the procedure, there was clinical and radiological improvement, and the patient was followed up as an outpatient. Myxofibrosarcoma is a very rare and aggressive connective tissue neoplasm with variable presentations. Surgical resection is the preferred treatment. Prompt diagnosis and adequate management of these tumors are important to reduce their high local recurrence and distant metastasis rates. Therefore, it is important to be aware of its common and uncommon presentations., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR., Methods: A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able., Results: Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home., Conclusion: Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed., Level of Evidence: Therapeutic, Level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The primary objective of this study was to determine the prevalence of (a) additional injuries, (b) abuse as determined by a standardized scale, and (c) reports to child protective services (CPS) among children younger than 5 years in whom a rib fracture was the first presenting injury concerning for abuse., Methods: A retrospective study of children younger than 5 years diagnosed with rib fractures at a tertiary pediatric hospital between 2007 and 2018 was performed. Children in motor vehicle crashes, hospitalized after birth, or with previously diagnosed metabolic bone disease were excluded. We included only those children whose rib fractures were the first presenting injury. Demographic and clinical information was abstracted from the records. Prevalence of additional injuries, a diagnosis of abuse, and a report to CPS were calculated. Associations between patient demographic and clinical characteristics and the outcomes of interest were examined., Results: Of the 67 cases included, additional injuries concerning for abuse were identified in 40 (60%), and 58% were deemed likely or definite abuse. Reports to CPS were filed in 72% of cases. Posterior rib fractures, multiple rib fractures, and presence of rib fractures of multiple ages were all associated with presence of additional injuries and classification as definite or likely abuse (all P ≤ 0.05)., Conclusions: The presence of a rib fracture in young children is associated with a high likelihood of additional concerning injuries and should prompt a thorough evaluation for child abuse., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The objective of this study was to determine the prevalence of rib fractures (RFs) identified by chest x-ray (CXR) among children younger than 2 years who sustained accidental versus nonaccidental injuries. It is hypothesized that RFs are uncommon among all accidental pediatric trauma mechanisms (eg, falls, motor vehicle crashes) as compared with the prevalence of RFs in the setting of nonaccidental trauma (NAT)., Methods: A retrospective chart review of sequential CXRs of children younger than 2 years evaluated at a pediatric level 1 trauma center for accidental trauma and possible NAT was conducted from January 1, 2011, to October 31, 2016. Data collected included demographics, CXR indication and findings, history of cardiopulmonary resuscitation, trauma mechanism, associated injuries, final diagnoses, and outcomes., Results: Two (<1%) of 226 CXRs obtained to evaluate accidental trauma demonstrated acute RFs. Ten (19.6%) of 51 CXRs obtained in the setting of concern for NAT revealed RFs (9/10 identified only healing RFs and 1/10 identified acute RFs). Among patients with a final diagnosis of NAT (ie, not neglect, accidental trauma, etc; n = 38), the overall prevalence increased to 26.3%., Conclusions: The presence of RFs in pediatric accidental trauma is uncommon even in the setting of high-force mechanisms, and when identified, these RFs are acute. Comparatively, the overall prevalence of RFs identified on CXR among cases with a final diagnosis of NAT was much higher and almost exclusively healing RFs. These data provide support that identification of RFs is highly concerning for NAT even if an accidental mechanism is provided. When RFs are identified, a full NAT work-up should be considered., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data., Methods: Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up., Results: Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months., Conclusion: Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma., Level of Evidence: Collected case series, level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study aimed to assess the prevalence of chest wall injuries due to cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA) and to compare in-hospital outcomes in patients with versus without chest wall injuries., Methods: A retrospective cohort study of all intensive care unit (ICU)-admitted patients who underwent cardiopulmonary resuscitation for OHCA between January 1, 2007, and December 2019 was performed. The primary outcome was the occurrence of chest wall injuries, as diagnosed on chest computed tomography. Chest wall injury characteristics such as rib fracture location, type, and dislocation were collected. Secondary outcomes were in-hospital outcomes and subgroup analysis of patients with good neurological recovery to identify those who could possibly benefit from the surgical stabilization of rib fractures., Results: Three hundred forty-four patients were included, of which 291 (85%) sustained chest wall injury. Patients with chest wall injury had a median of 8 fractured ribs (P25-P75, 4-10 ribs), which were most often undisplaced (on chest computed tomography) (n = 1,574 [72.1%]), simple (n = 1,948 [89.2%]), and anterior (n = 1,785 [77.6%]) rib fractures of ribs 2 to 7. Eight patients (2.3%) had a flail segment, and 136 patients (39.5%) had an anterior flail segment. Patients with chest wall injury had fewer ventilator-free days (0 days [P25-P75, 0-16 days] vs. 13 days [P25-P75, 2-22 days]; p = 0.006) and a higher mortality rate (n = 102 [54.0%] vs. n = 8 [22.2%]; p < 0.001) than those without chest wall injury. For the subgroup of patients with good neurological recovery, the presence of six or more rib fractures or a single displaced rib fracture was associated with longer hospital and ICU length of stay, respectively., Conclusion: Cardiopulmonary resuscitation-related chest wall injuries in survivors of OHCA and especially rib fractures are common. Patients with chest wall injury had fewer ventilator-free days and a higher mortality rate. Patients with good neurological recovery might represent a subgroup of patients who could benefit from surgical stabilization of rib fractures., Level of Evidence: Therapeutic, level IV; Epidemiological, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: In patients with a cardiac pacemaker, pocket-related complications such as nerve impairment or bone fractures are infrequent. We present a man with a fracture of the 4th rib several months after pacemaker implantation., Case Presentation: A 74-year-old man, with a left prepectoral pacemaker implanted 13 months ago, presented complaining of chest pain. The pain started after a sudden trunk rotation and right arm flexion movement with a crack. There was tenderness to palpation and crepitation over the left upper ribs. Computed tomography identified a non-displaced fracture line in the anterior aspect of the left 4th rib. After kinesiotaping and activity restriction, pain alleviated., Conclusion: Pacemaker implantation might have caused shoulder dysfunction and pectoral tightness resulting in reduced flexibility of the trunk. Consequently, a reaching motion of the arm with a trunk rotation might have directed rotational force vectors towards the osteopenic left 4th rib causing a fragility fracture. In elderly with a pacemaker, osteopenia and concomitant sarcopenia may create a predisposition to this atypical complication., (© 2021. International Osteoporosis Foundation and National Osteoporosis Foundation.)

Background and Purpose: Anatomical changes during the stereotactic body radiation therapy (SBRT) of early stage non-small cell lung cancer (NSCLC) may cause the delivered dose to deviate from the planned dose. We investigate if normal tissue complication probability (NTCP) models based on the delivered dose predict radiation-induced rib fractures better than models based on the planned dose., Material and Methods: 437 NSCLC patients treated to a median dose of 3x18 Gy were included. Delivered dose was estimated by accumulating EQD2-corrected fraction doses after being deformed with daily CBCT-to-planning CT deformable image registration. Dosimetric parameters D x (dose to a relative volume x) were extracted for each rib included in the CBCTs field-of-view. An NTCP model was constructed for both planned and delivered dose, optimizing the parameters TD 50 (dose with 50% toxicity risk), m (steepness of the curve) and x, using maximum likelihood estimation. Best NTCP model was determined using Akaike weights (Aw). Differences between the models were tested for significance using the Vuong's test., Results: Median time to fracture of 110 fractured ribs was 22.5 months. The maximum rib dose, D 0 , best predicted fractures for both planned and delivered dose. The average delivered D 0 was significantly lower than planned (p < 0.001). NTCP model based on the delivered D 0 was the best, with Aw = 0.95. The models were not significantly different., Conclusion: Delivered maximum dose to the ribs was significantly lower than planned. The NTCP model based on delivered dose improved predictions of radiation-induced rib fractures but did not reach statistical significance., (Copyright © 2021 Elsevier B.V. All rights reserved.)

At the end of the nineteenth century, recurrent cases of rib fractures were recorded in psychiatric asylums, opening a long chapter of discussions about the application of the 'non-restraint' system. Here we present a brief discussion of an article written by Enrico Morselli about five cases of rib fractures in the mental asylum of Reggio Emilia, in 1874-5. Morselli, a supporter of the ideas of 'non-restraint', suggested a common pathological cause. His analysis proposed the osteomalacic condition as the possible cause of fractured ribs, rejecting the accusations of violence by asylum attendants. The discussion also examines similar cases of the same period, making rib fractures the means through which the issue of management of the insane was addressed.

Background: Road traffic crashes related (RTCR) chest traumas remain important global public health challenge. The impact of boosting market of automobile vehicles in China during last decade on thoracic injury needs to be defined. This study aimed to review and analyze the demographic and clinical characteristics of RTCR thoracic injuries in China., Methods: Clinical records of patients with thoracic trauma admitted to thoracic surgery department between January 2003 and June 2020 were retrospectively retrieved and reviewed. Patients' profiles and clinical characteristics were comparatively analyzed between road traffic crashes caused injury and other injury mechanisms, and in RTCR chest trauma patients before January 2011 (2003 group), and after January 2011 (2011 group), when is considered as the beginning year of Chinese household vehicle era., Results: The study included 5095 thoracic trauma patients with mean age of 50.2 years, of whom 79.4% were male. Most of the patients (70.3%, n = 3583) had rib fractures. Associated injuries were present in 52.0% of the patients, of them 78.5% (n = 2080) were extremity fractures. Road traffic crashes accounted for 41.4% (n = 2108) of the injuries, most of them (98.0%) were related to motor vehicles. In comparison with other chest trauma mechanisms, RTCR chest injuries affected females and older males more frequently, with a higher incidence of rib fractures and sternum fractures, and higher injury severity scores (ISS) (all p < 0.05). Surgeries were required in 1495 (70.9%) patients of the RRTCR chest traumas, while the majority of non-RTCR thoracic injuries were managed conservatively or with tube thoracostomy (30.2%, n = 901). RTCR chest traumas caused longer hospital stay (13.0 ± 9.6 days vs. 11.8 ± 7.4 days, p = 0.001), higher ICU usage (30.7% vs. 19.6%, p = 0.001), higher rate of ventilator support (12.9% vs. 7.5%, p = 0.001), and higher mortalities (3.8% vs. 1.6%, p = 0.005) than that of non-RTRA chest injuries. For RTCR patients, when compared with 2003 group, 2011 group had similar patterns in terms of accident category, associated injury and treatment. However, 2011 group had more females (38.5% vs. 18.0%, p = 0.001) and older males (50.6 ± 9.7 vs. 47.9 ± 17.2, p = 0.001), with a higher ISS (18.3 ± 10.2 vs. 17.1 ± 8.9, p = 0.004), and fewer were managed with chest tubes (25.0% vs. 29.2%, p = 0.031). Clinical outcomes were not significantly different between the groups in terms of hospital length of stay, intensive care unit (ICU) usage, ICU length of stay, duration of ventilator hours and mortality. However, the 2011 group had more patients requiring ventilator support (14.4% vs. 10.6%, p = 0.011)., Conclusions: Road traffic crashes remain to be the major etiology of thoracic injuries in China, which usually affects middle-aged males, causing rib fractures with concomitant injuries frequently occurring to other organ systems. Treatments mainly include tube thoracotomy and surgical procedures. Although the clinical characteristics and outcomes of traffic accident related chest traumas are largely unchanged in spite of the rapid increasing numbers of motor vehicles, variations in the pattern of injuries by gender, age, injury severity and ventilator usage may still provide important information for targeted management., (© 2021. The Author(s).)

Rib fractures represent a common injury type due to blunt chest trauma, affecting hospital stay and mortality especially in elderly patients. Factors promoting rib fragility, however, are little investigated. The purpose of this in vitro study was to explore potential determinants of human rib fragility in the elderly. 89 ribs from 13 human donors (55-99 years) were loaded in antero-posterior compression until fracture using a material testing machine, while surface strains were captured using a digital image correlation system. The effects of age, sex, bone mineral density, rib level and side, four global morphological factors (e.g. rib length), and seven rib cross-sectional morphological factors (e.g. cortical thickness, determined by μCT), on fracture load were statistically examined using Pearson correlation coefficients, Mann-Whitney U test as well as Kruskal-Wallis test with Dunn-Bonferroni post hoc correction. Fracture load showed significant dependencies (p < 0.05) from bone mineral density, age, antero-posterior rib length, cortical thickness, bone volume/tissue volume ratio, trabecular number, trabecular separation, and both cross-sectional area moments of inertia and was significantly higher at rib levels 7 and 8 compared to level 4 (p = 0.001/0.013), whereas side had no significant effect (p = 0.989). Cortical thickness exhibited the highest correlation with fracture load (r = 0.722), followed by the high correlation of fracture load with the area moment of inertia around the longitudinal rib cross-sectional axis (r = 0.687). High correlations with maximum external rib surface strain were detected for bone volume/tissue volume ratio (r = 0.631) and trabecular number (r = 0.648), which both also showed high correlations with the minimum internal rib surface strain (r =  - 0.644/ - 0.559). Together with rib level, the determinants cortical thickness, area moment of inertia around the longitudinal rib cross-sectional axis, as well as bone mineral density exhibited the largest effects on human rib fragility with regard to the fracture load. Sex, rib cage side, and global morphology, in contrast, did not affect rib fragility in this study. When checking elderly patients for rib fractures due to blunt chest trauma, patients with low bone mineral density and the mid-thoracic area should be carefully examined.

Introduction: Trauma to the chest wall is one of the most common injuries suffered. Knowing whether there are regular and reproducible changes in frequency or severity of certain injury types may help resource allocation and improve prevention efforts or outcomes; however, no prior studies have evaluated seasonal variation in chest wall injuries (CWIs). We aimed to determine if CWIs vary annually in a consistent distinct temporal variation., Methods: Using an established traumatic blunt CWI database at a single urban level 1 trauma center, patients with a moderate-to-severe (chest wall Abbreviated Injury Score (AIS) ≥2) CWI were reviewed. A subpopulation of predominant chest wall injury (pCWI) was defined as those with a chest wall AIS ≥3 and no other anatomic region having a higher AIS. Demographics, injury patterns, mechanisms of injury, and AIS were collected in addition to date of injury over a 4-y period. Data were analyzed using descriptive statistics as well as Poisson time-series regression for periodicity. Seasonal comparison of populations was performed using Student's t-tests and Analysis of Variance (ANOVA) with significance assessed at a level of P < 0.05., Results: Over a 4-y period nearly 16,000 patients presented with injury, of which 3042 patients were found to have a blunt CWI. Total CWI patients per year from 2014 to 2017 ranged from 571 to 947. Over this period, August had the highest incidence for patients with any CWI, moderate-to-severe injuries, and pCWI. February had the lowest overall injury incidence as well as lowest moderate-to-severe injury incidence. January had the lowest pCWI incidence. Yearly changes followed a quadratic sinusoid model that predicted a peak between incidence, between June and October, and the low season. A low season was found to be December-April. Comparing low to high seasons of injured patient monthly means revealed significant differences: total injuries (69.94 versus 85.56, P = 0.04), moderate to severe (62.25 versus 78.19, P = 0.06), and pCWI (25.25 versus 34.44, P = 0.01). Analysis of injuries by mechanism revealed a concomitant increase in motorcycle collisions during this period., Conclusions: There appears to be a significant seasonal variation in the overall incidence of CWI as well as severe pCWI, with a high-volume injury season in summer months (June-October) and low-volume season in winter (December-April). Motorcycle accidents were the major blunt injury mechanism that changed with this seasonality. These findings may help guide resource utilization and injury prevention., (Copyright © 2020 Elsevier Inc. All rights reserved.)