Background: Intercostal cryoneurolysis (IC) causes axonotmesis resulting in numbness distal to the nerve lesion with eventual nerve regeneration. Reported outcomes in thoracic surgery range from the majority of patients recovering normal sensation within a few weeks to some incidences of chronic neuropathic pain. We hypothesize its use can decrease pain for rib fracture patients. Methods: Multi-institution retrospective review of 13 patients who underwent surgical stabilization of rib fractures (SSRFs) with video-assisted thoracoscopy-guided IC. Demographics included mechanism of injury, number of ribs fractured and plated, and number of intercostal nerves ablated. Outcomes include pre- and post-operative pain scores, completeness of nerve function return, and dysesthesias experienced during healing. Pre- and post-operative pain scores were compared by paired t-test. Statistical significance was attributed to P < 0.05. Results: The median age was 58 (35–77) and all injuries were caused by blunt mechanism. Median number of ribs fractured was 7 (4–11). Mean time to operation was 2.1 ± 1.2 days. Median number of ribs plated was 4 (range 3–6), and the median number of intercostal nerves ablated was 6 (3–7). Eleven patients with complete pain scores were found to have mean preoperative pain of 6.9 ± 2.3 and mean postoperative pain of 4.9 ± 2.9 (P = 0.026). The mean length of stay was 8.1 ± 2.9 days after admission and 5.9 ± 2.7 days after surgery. At an average follow-up of 21.3 ± 6.2 weeks, all patients had regained some sensation. Sensation regained ranged from 10% at 16.1 weeks to 100% as early as 15.9 weeks. One patient (7.6%) developed transient severe, lifestyle limiting, hyperesthesia present at 3 months and resolved at 6 months. 8 of 13 (61.5%) patients developed transient mild-to-moderate, nonlifestyle limiting, dysesthesias. These symptoms resolved by 6 months. Conclusion: In our patients with severe rib fractures, cryoneurolysis with SSRF resulted in significantly decreased postoperative pain and approximately 70% of patients reporting some transient dysesthesias in the recovery process. While these results are encouraging, larger, prospective studies are needed to fully characterize the indications for IC.

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Background: Surgical rib fixation in displaced rib fracture has been associated with positive patient outcomes in the literature. There is no data in the literature detailing the volume related outcomes in centres that offer surgical rib fixation in these patients. Methods: A retrospective review was conducted on surgical rib fixation cases performed from 2014 to 2018, with the early phase (EP) consisting of cases performed in the 2014-2017 period and the recent phase (RP) consisting of cases performed in 2018 to date. Variables for comparison included, indication for intervention, pain outcomes, and length of stay (LOS). Results: The five-year period yielded 37 cases. In the EP, 17 cases were performed, compared to 20 cases in the RP. The chest AIS scores were >3 for all cases with an average ISS of 21 in the EP compared to 19 in the RP. All patients underwent surgical rib fixation within 96 hours of admission. Pain was the predominant indication for intervention in the EP (65%, n = 11) compared to the RP where deformity and respiratory support (55%, n = 11) were the chief indicators. Subjective pain improvement was in favour of RP by 2.5 days. The average LOS was 546 hours days in the EP group, and 391 hours in the RP group. More anatomically difficult posterior and bilateral rib fixation cases were carried out in the RP group. Follow-up rate between the EP and RP were 75% vs 85% respectively with no hardware or pulmonary complications. Conclusion: Preliminary data analysis from the authors' institution suggests surgical rib fixation can be conducted with minimal complication. Increased case volume might improve outcomes related to subjective pain scores, length of stay, and complexity of surgical technique.

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Blunt thoracic aortic injury (BTAI) is a significant problem in cardiothoracic trauma. It is a leading cause of prehospital death from high energy motor vehicle crashes. Injuries can be classified into one of four grades: grade I – intimal tear; grade II – intra-mural hematoma; grade III – pseudoaneurysm and grade IV – uncontained rupture. Clinical symptoms and signs are often limited, especially in minor injury grades. Left sided hemothorax and a widened mediastinum on chest radiography are concerning features suggestive of BTAI. Computed scanning is now an indispensable tool used to evaluate patients and has largely replaced aortography. The aim of management is to control hemorrhage (if present) and to reduce the risk of delayed aortic rupture. Patients with pseudoaneurysm can undergo semi-elective repair, provided blood pressure can be controlled which is critical to preventing lesion progression and rupture. Patients presenting with an uncontained rupture require emergent repair. The preferred method of intervention is no longer operative repair (with bypass for distal perfusion), but thoracic endovascular aneurysm repair (TEVAR). An endovascular approach is associated with a lower morality and lower rates of spinal cord ischemia. The aim of this review is present the history of management and the supporting evidence along with an overview of current practice from a busy US trauma center.

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Introduction: Little is known about the risk of readmission after surgical stabilization of rib fractures (SSRFs). Materials and Methods: We performed a retrospective analysis of the National Readmissions Database, a representative sample of all hospitalized patients in the US, from January 2012 to December 2014. All inpatient encounters with a primary trauma diagnosis of rib fractures were included in the study. Patients who underwent SSRF were compared to those who did not. Outcomes evaluated included readmission frequency and mortality. Results: There were 411,169 patients admitted after trauma with rib fractures from 2012 to 2014; of these, 382 (<1%) underwent SSRF. Among non-SSRF patients, ≥3 rib fractures (odds ratio = 1.41, 95% confidence interval 1.23–1.62) were associated with readmission. Compared to the non-SSRF group, patients undergoing SSRF had a greater incidence of flail chest (26% vs. 2%; P < 0.0001), were more likely to have an injury severity score >15 (55% vs. 37%; P < 0.0001), and more likely to have a coexisting diagnosis of respiratory failure (35% vs. 18%, P < 0.0001). Despite the increased severity of injury among patients having SSRF, there was neither a statistically significant increase in patient deaths (<1% for SSRF vs. 4% no SSRF, P = 0.03) nor readmissions (<1% for SSRF vs. 1% for non SSRF, P = 1.0). Conclusions: Long-term readmission rates for traumatic rib fracture patients are low. If nonoperative management is pursued, the presence of ≥3 rib fractures increases the risk of readmission. Patients requiring SSRF do not have higher readmission or mortality rates despite having a higher burden of injury during their initial hospitalization, suggesting the clinical benefit of surgical fixation.

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Background: Due to increased frailty and comorbidities, surgeons may be reluctant to perform surgical stabilization of rib fractures (SSRF) in geriatric (≥65yr) and super-geriatric (≥80yr) patients. We hypothesized that elderly patients would have delayed time to operation and more complications. We aimed to determine whether advanced age was a factor in deciding to proceed with SSRF and presented a risk for mortality. Methods: Single-institution review of rib fracture (RF) patients from 8/2009-2/2017. Univariate analysis was performed for groups age ≤64yr, 65-79yr, and ≥80yr, and SSRF vs non-SSRF. Baseline injury characteristics were compared for all age groups. Results: We identified 3098 non-SSRF patients (≤64yr, n=1770; 65-79yr, n=706; ≥80yr, n= 622) and 277 SSRF (≤64yr, n=162pt; 65-79yr, n=73pt; ≥80yr, n=42pt). For SSRF, there were no differences in sex or race, time from admission to operation, number of RF, or SSRF indications between any age group. Mortality was greater for non-SSRF patients overall [155/3098 (5%) vs 4/277 (1.4%), P < 0.01], for non-SSRF patients less than 65 years old [63/1770 (3.6%) vs 0/159, P < 0.01], and between 65-79 years old [35/706 (5%) vs 0/76, P = 0.03] but similar between non-SSRF and SSRF patients in the 80 and older cohort [57/622 (9.2%) vs 4/42(9.2%), P = 0.9]. In analysis of injury characteristics, for SSRF≥80yr greater mortality was associated with GCS <14 vs GCS≥14 (1/3 vs 0/39, P < 0.01), and more RF [median 20RF in pts with mortality (IQR:5-13) vs 10RF in patients without mortality (IQR:10-29), P = 0.02). Conclusions: Age was not associated with longer time to OR nor with difference in injury pattern or severity as indication for SSRF. Although mortality increases for RF after 80yr, among appropriately selected super-geriatric patients SSRF is a safe and effective treatment. Level of Evidence: IV Study type: Therapeutic.

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Multiple rib fractures from trauma are common and nonoperative management, including pain control and aggressive pulmonary care, are the mainstay of treatment. However, patients with hindered pulmonary function despite maximal medical therapy, either from acute pain or chest wall instability (flail chest) should be considered for surgical rib stabilization. Additionally, patients with persistent pain or with rib fractures that do not heal (nonunion) should also be considered for surgery. Indications, contraindications, surgical considerations, complications, and future directions of surgical stabilization of rib fractures are reviewed here.

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Rib nonunion is a rare occurrence that requires surgical management and has a high rate of failure that may necessitate repeated intervention. We present the case of successful rescue redo repair of previously failed plating of chronic nonunion for multilevel posterior rib fractures, reinforced by wire cerclage of the osteosynthesis plate. Our objective is to illustrate the feasibility of repeated interventions, and the technique to resolve this challenging problem.

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A 36- year old male was admitted with shock following a road traffic accident. The patient had a low Glasgow Coma Scale score of 8/15 for which he was ventilated and intubated. Computed tomography scan showed pneumomediastinum and pneumopericardium along with left-sided hemopneumothorax. Hemopneumothorax was addressed with an intercostal drain. There was no further blood loss. Persisting hemodynamic compromise needing inotropic support prompted a diagnosis of tamponading effect of pneumopericardium. Pericardiocentesis was performed which resulted in immediate hemodynamic stability. The patient was discharged from intensive care unit after tracheostomy and had a complete recovery. Tension pneumopericardium is an extremely rare condition which can be fatal if left untreated. Prompt suspicion, diagnosis, and treatment of the condition in a hemodynamically unstable trauma patient can be lifesaving.

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Cardiac tamponade resulting from blunt chest trauma is an emergent and life-threatening condition. Cardiac rupture from blunt chest trauma is not a common presentation, and more so in the absence of rib or sternal fracture. We present a case of blunt chest trauma, who presented with features of cardiac tamponade. Emergency sternotomy revealed a right atrial rupture near the appendage which was surgically repaired. The patient also underwent simultaneous splenectomy for Grade 4 splenic injury. The patient recovered uneventfully. Prompt recognition of the injury based on a high index of suspicion must lead to immediate surgical intervention in order for these patients to survive, even in the absence of specialized imaging investigations.

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Objective: Contrecoup injuries are well-known lesions in the neurosurgical practice, while their existence in other medical disciplines is lacking. Another term of confusion is the contralateral lesion that is ill defined when compared to the contrecoup injury. A nomenclature, mechanism, and clinical significance of such lesions in cardiothoracic trauma patients are warranted. Patients and Methods: Only one patient with thoracic contracoup injuries was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Östra, Gothenburg, Sweden. The other four cases with contrecoup injuries were encountered in a prospective manner in different places both in Sweden and Norway. All the four prospective cases were witnessed and well documented during trauma occurrence and management. Results: All patients developed significant contralateral chest wall symptoms and signs requiring treatment. One patient developed huge contrecoup pneumothorax. Two patients developed contrecoup hemothoraces. One patient developed contrecoup cardiac injury. One patient developed contralateral chest wall rib fractures. Two patients developed contralateral sternal fractures; one of them was unstable and required surgical fixation. Conclusions: Nomenclatures to what are have called contrecoup and contralateral lesions in cardiothoracic practice are suggested. Discrepancy between the trauma side of the chest and the resulting lesions exactly on the contralateral part may make the diagnosis difficult to understand and could give a suspicion concerning the trauma site, and whether the patient was conscious or simply not telling the truth as in case of trauma with medicolegal aspects.

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Context: Flail chest is associated with significant mortality risk. Chest wall repair is associated with improved outcomes; however, the optimal fixation technique is unknown. Aims: We undertook a review to assess the optimal fixation technique required in order to successfully repair flail chest. Subjects and Methods: This is a retrospective review of consecutive patients with multiple rib fractures undergoing surgical fixation. The predictive value of ratio of fractures fixed in relation to flail segment and ratio of ribs fixed in relation to flail segment was assessed by the primary outcome measure of requirement for reoperation. Results: Thirty-one patients presenting with symptomatic rib fractures were referred to a single surgeon for primary management or a second opinion following previous fixation, between August 2011 and October 2018, and underwent repair. Twenty-two patients were male (71%), and the median age was 66 years (range: 18–81). Twenty-seven patients (87%) were diagnosed with flail segment. Twenty-four patients had a “Fracture Fixation to Flail” ratio (F_x: F_l) ≥1, and none required further rib fixation, whereas three patients had F_x: F_l<1, two of whom (67%) required further rib fixation (P = 0.0085). Twenty patients had R_x: F_l≥1, and none required further rib fixation, whereas seven patients had R_x: F_l<1, in whom five (71%) required no further intervention and two (29%) required further rib fixation (P = 0.0598). Minimum fixation number (MFN) was calculated. MFN was achieved in 22 of 27 patients. Two of the four patients with MFN did not achieve the required refixation (P = 0.0171). Conclusions: F_x:F_lmost accurately predicts the risk of underfixation and subsequent requirement for further intervention in patients undergoing operative repair of flail chest.

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Background: Surgical stabilization of rib fractures (SSRFs) is increasing in popularity. During the operation, disruption of the chest wall musculature occurs, which may affect chest wall and glenohumeral–scapular movement. Although postoperative physical therapy (PT) is widely recommended, specific, validated, protocols for SSRF patients do not exist. The purpose of this study was to evaluate the feasibility and safety of a PT protocol specifically designed for SSRF patients. Methods: This was a pilot study of all SSRF patients admitted to a single level-I trauma center between December 2017 and February 2019. Included patients received a PT evaluation within 72 h of operation. This evaluation included implementation of specific PT interventions and a written home exercise program. Objective measures included: patient reported pain scores, shoulder strength, chest expansion, spirometry, and the disabilities of the arm, shoulder, and hand (DASH) survey. These measures were obtained at initial inpatient evaluation, 1–week and 1–month post discharge in an outpatient visit, and at 3 months through telephone DASH survey. Results: Nineteen patients were analyzed. Patients were primarily male (74%), suffering from blunt trauma, with a median 8 (interquartile range [IQR]: 7–10) rib fractures and Injury Severity Score (ISS) of 17 (12–23). The median (IQR) time from SSRF to PT evaluation was 1 (1–2) day. Median chest expansion doubled from PT evaluation to 1–month follow–up (1.9 cm PT evaluation; 2.5 cm 1 week; 4.5 cm 1–month, P = 0.014). The median age-predicted spirometry improved from 29% preoperatively, to 38% at PT evaluation and to 86% at 1-month postdischarge (P ≤ 0.05 for the trend). Shoulder strength improved from PT evaluation to 1–month follow–up. The median DASH scoring improved at all follow–up intervals, with no clinically significant functional impairments at 3 months (86 on PT evaluation; 56 at 1–week, 21 at 1–month; 8 at 3–month phone interview). Conclusion: A specific, novel, PT protocol for patients after SSRF appears to be feasible and safe. Our results demonstrate a significant decrease in patient-perceived disability, improved shoulder strength, chest expansion, and spirometry compared to immediate postoperative levels. Although we cannot determine the effect of the protocol on recovery, our results provide the preliminary data on which to base a larger, randomized trial to determine if a beneficial effect of the protocol is present.

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Background: We hypothesized that obese patients undergoing rib stabilization would have a smaller ratio of ribs repaired to those fractured, increased days to operation, increased length of operation, were mechanically ventilated longer, required a longer stay in the intensive care unit (ICU) and hospital, and had an increased risk of developing pneumonia. Materials and Methods: This was a retrospective evaluation of patients who underwent surgical rib stabilization after trauma at a single institution over 9 years. Two hundred and seventy-three patients were divided according to body mass index (BMI) into three groups: group 1 (BMI: 15–29, n = 149), Group 2 (BMI: 30–35, n = 80), and Group 3 (BMI: 35–48, n = 44). Analysis of variance was performed to evaluate differences in outcomes in association with BMI. Two-tail t-tests were further utilized to compare Group 1 and Group 3. Results are reported in P values, with P < 0.05 being significant. Results: Sixty-eight percent were male, the mean age was 61, and 96% were Caucasian. Comorbidities: asthma (15%), chronic obstructive pulmonary disease (12%), smokers (22%), hypertension (40%), and type 2 diabetes mellitus (15%). Patients with a higher BMI had a longer average hospital length of stay (12.0, 13.4, and 15.6 days, P < 0.05). The incidence of postoperative pneumonia was increased in those with a higher BMI (10%, 12%, and 30%, P < 0.05). The remaining variables were not significant. Conclusion: Those with a higher BMI had a longer hospital stay and were at increased risk for developing pneumonia after rib stabilization. BMI did not have a significant effect on the ratio of ribs stabilized, time to operation, length of operation, days on mechanical ventilation, or ICU length of stay.

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Background: Increased age and number of rib fractures are known to increase the risk of mortality. The impact of comorbidities on the outcomes of patients with rib fractures has not previously been described. We hypothesized that specific medical comorbidities are associated with increased risk of morbidity and mortality following rib fracture. Methods: Patients with multiple rib fractures or flail chest were identified in the National Inpatient Sample by ICD-10 code from the 4^th quarter of 2015 through 2016. Comorbidities were categorized into Elixhauser comorbidity groups, and injury severity was estimated using the Injury Severity Score (ISS). The composite adverse outcome was defined as death, pneumonia, tracheostomy, or discharge to a short-term acute care facility. Multivariable logistic regression was performed with covariates chosen through backward selection from the univariate model to determine the relationship of outcomes to demographic variables and comorbidities with alpha set to 0.001. Results: Totally 26,289 patients met inclusion criteria. Composite adverse outcomes occurred in 5,132 (19.5%) patients. Profound ISS (OR 6.013), severe ISS (odds ratio [OR] 2.569), fluid and electrolyte disorder (OR 2.471), and paralysis (OR 2.372) were most associated with adverse outcomes. Within causes of injury, motor vehicle was associated with increased risk of adverse outcome (OR 1.322). Flail chest was also independently associated with adverse outcome (OR 1.816). Conclusion: Morbidity and mortality following rib fracture occurred in approximately one-fifth of patients, especially those with high ISS or associated medical comorbidities. This data can be used for risk stratification and identification of high-risk patients for escalation of care.

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Damage control as a management strategy for the most severely injured and metabolically depleted patients was first utilized for penetrating abdominal trauma. The principles are early hemorrhage control, limiting enteric contamination, resuscitation in the intensive care unit and, a delayed, definitive re-operation when normal physiology is restored. Since its initial use over two decades ago, the principles of damage control have been successfully utilized in the management of vascular and orthopedic injuries, and more recently in volume resuscitation. There has been a slower adoption of damage control approach to thoracic trauma, primarily due to concerns of cardiac tamponade and impaired pulmonary physiology, both the result of packing the pleural space. This review article describes philosophy, techniques and outcomes of damage control thoracic surgery.

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