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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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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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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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: 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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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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