Combined disruption of the thoracic spine and costal arch fracture: An indicator of a severe chest trauma

Background Blunt high-energy trauma increase the risk of associated thoracic and accompanying abdominal organ injuries in chest trauma. A higher overall injury severity has been shown for sternovertebral injuries caused by a flexion-compression mechanism. Literature for a hyperextension-distraction mechanism equivalent to a costal arch fracture combined with a thoracic spinal fracture is sparse. Therefore, we want to show the clinical significance of this entity. Methods A retrospective analysis of our level-one trauma center collective of severely injured patients was performed. Patients from 2013 to 2019 that involved an Injury Severity Score (ISS) ≥16 were screened for the combined thoracovertebral injury entity and analyzed concerning its accident mechanism, the injury spectrum, and the clinical course. Results The thoracovertebral injury entity is rare. Three male patients (50–65 years old) with ISS of 57, 41, and 20 could be observed from over 1000 severely injured. All patients suffered from high-energy trauma and from tearing of the thoracic vertebrae regions 7–9. The costal arch was torn in the anterior area. All cases showed a posterolateral serial rib fracture, a traumatic intercostal pulmonary hernia, and an avulsion of the diaphragm. Two patients sustained further life-threatening injuries, such as severely bleeding avulsion to the azygos vein and a rupture of the spleen. The physicians performed exploratory thoracotomy, closure of the pulmonary hernia, re-fixation of the diaphragm and angle-stable plate osteosynthesis of the fractured ribs, including the costal arch. The spine was fixed dorsally using a screw-rod system. The patients were discharged home with independent mobility and without neurological damage. Conclusions This thoracovertebral injury entity is associated with high overall injury severity and life-threatening thoracoabdominal injuries. Injuries to the costal arch can act as an indicator of severe trauma. They should be detected thorough clinical examination and assessment of the trauma CT in the soft tissue window.

Abdominal intercostal hernia and costal arch repair

A 70-year-old asthmatic man presented with a history of chronic intermittent left-sided chest pains and a bulge-like deformity of his chest which became more prominent with expiration. He sustained a traumatic fall 2 years prior whereby he fractured his right humerus at the surgical neck, requiring total arthroplasty. Examination and CT imaging of the thorax revealed a left costal arch fracture with hemidiaphragm rupture and associated transperitoneal fat herniation. He underwent left thoracolaparotomy with costal arch and diaphragmatic hernia repair. He was discharged 48 hours postoperatively and is satisfied with good outcomes under initial follow-up. This case report highlights the surgical management of a condition that usually presents late after significant trauma and may progress to visceral strangulation if untreated.

An ECG method for positioning the tip of a PICC in “mirror people” with dextrocardia: A case report

Intracavitary electrocardiogram (ECG) has been widely used for PICC tip positioning in patients with a normal left heart. However, there is little information about using ECG for PICC insertion in patients with mirror dextrocardia. We report a 70-year-old stomach cancer patient with mirror dextrocardia admitted to our vascular access center for four Fr silicon Groshong PICC insertion. We successfully performed an ultrasound-guided modified Seldinger technique for insertion. First, the usual standardized ECG technique was used for tip positioning, and it failed. Then, we changed the procedure slightly, using the opposite electrode connections (RA: the first intercostal space of the midline of the left clavicle; LA: the first intercostal space of the midline of the right clavicle; and LL: the inferior margin of the right costal arch) to obtain an evident P-wave change to guide catheter placement in this case. We confirm that we can use the opposite electrodes to obtain an apparent P-wave for locating the catheter tip in patients with mirror dextrocardia.

Combined caudal retrocostal and lateral ultrasound-guided approach for transversus abdominis plane injection: A descriptive pilot study in pig cadavers

Transversus abdominis plane (TAP) block is a regional anesthetic technique used to desensitize the abdominal wall in several species. This study aimed to describe the anatomical characteristics of the abdominal wall and to identify a feasible approach for an US-guided TAP injection that would result in adequate staining of the relevant nerves in the abdominal wall in pig cadavers. Fresh cadavers from five Landrace pigs (age, 12 weeks; body weight, 35.5 ± 1.6 kg) were used. One pig (n = 1) was anatomically dissected, and four pigs (n = 4; i.e., 8 hemiabdomens) were used for TAP injections and evaluation of dye spread. The volume of 0.3 mL/kg/injection point of methylene blue was injected bilaterally. In the caudal retrocostal approach, the injection was performed ventral to the most caudal part of the costal arch. In the lateral approach, the injection was performed between the last rib and iliac crest. A needle was inserted in plane for the caudal retrocostal and the lateral approach caudocranially and craniocaudally, respectively. Successful staining was defined as presence of dye on the nerve for a length of >1 cm in its entire circumference. The TAP was found between different muscle layers in the described anatomical regions. In the caudal retrocostal approach the TAP was found between the external abdominal oblique and transversus abdominis muscle bellies. In the lateral approach the TAP was found between the internal abdominal oblique and transversus abdominis muscles. The approach combining lateral and caudal retrocostal injections at the studied volume stained a median of 5 (3–6) target nerves from the fourth-last thoracic nerve to L2 (six nerves). Combined caudal retrocostal and lateral TAP injections of 0.3 mL/kg/injection point, resulted in staining of target nerve branches which supply the periumbilical and caudal abdominal wall in pig cadavers.

VERIFICAÇÃO DO EFEITO AGUDO DA MOBILIZAÇÃO ARTICULAR NA FUNÇÃO PULMONAR DE INDIVÍDUOS COM DOENÇA PULMONAR OBSTRUTIVA CRÔNICA (DPOC)

Chronic Obstructive Pulmonary Disease (COPD) is characterized by airflow obstruction and consequent alteration in lung function, compromising respiratory muscle strength and rib cage mobility. Joint mobilization aims to restore arthrokinetic mobility of the rib cage joints; however, there are few studies investigating the efficacy of this approach in patients with COPD. The objective was to evaluate the acute effects of joint mobilization on pulmonary function in individuals with COPD. The sample consisted of six participants with a mean age of 56.33±12.27 years of both sexes, with COPD. Pulmonary function was assessed by spirometry, manuvacuometry and pulse oximetry at two times, before and after treatment. The therapeutic intervention consisted of thoracic spine mobilization, sternal mobilization, and costal arch mobilization techniques, respectively. For the analysis of the results was used the Shapiro Wilk Test and paired Student T test, considering p<0.05. It was observed that there were no statistically significant variations after the application of the techniques in any of the evaluated parameters. Further studies are needed to investigate the effects of mobilization techniques on these patients.

Improved simple T-cannula technique to facilitate surgery and daily skin care of growing pigs

In order to further increase the stability of the cannula behind the ribs and to facilitate cannula exteriorization in growing pigs, the present study aimed to evaluate whether elongation of the cannula flange could increase the stability of the cannula behind the ribs and to develop a tool to improve the exteriorization of the cannula through the ribs. Moreover, it was assessed whether a special skin protection paste and soft polyurethane foam material used in daily skin care could prevent erythema around the fistula. The feasibility of both, the modified simple T-cannula and daily skin care procedure, was evaluated in a digestibility experiment. Simple T-cannulae were made of high-molecular-weight polyethylene and inserted into the distal ileum of eight growing pigs (average body weight at surgery 30 kg). Modifications in the cannula design included a longer flange (11 cm) that was narrowed from the center to the ends and a bending of the flange to adapt it to the curve of the costal arch. In order to reduce the damage to the thread on the outer cannula barrel during surgery, a special surgical plug in conjunction with a screw thread on the inside of the barrel was developed. With respect to the daily cleaning of the fistula, a special skin protection paste was applied on the skin around the fistula to create a waterproof film that entirely sealed the skin. Additionally, foam material was inserted between the retaining ring and the skin to absorb the leaking digesta. Monitoring of the pigs throughout the trial showed that modifications in cannula design proved to be useful as they facilitated exteriorization of the cannula through the ribs and stability of the cannula behind the ribs. Moreover, the use of the skin protection paste and foam material during postsurgical treatment of growing pigs effectively prevented skin irritation around the flank area.

Ossifying Lipoma in Costal Arches That Suggest Extensive Pulmonary Involvement: Case Report

Background: Lipomas are the most common benign soft tissue tumors in the general population. These lesions can appear on any part of the body and usually develop in the subcutaneous superficial tissue. Lipomas that show ossifying changes are very rare, representing less than 1% of the reported lipomas. They usually manifest as hard nodular lesions in the head and neck, the extremities, the sternoclavicular region, and the subcutaneous tissue in general; they are rare in the costal arches. Case presentation: We report the case of a patient with a history of multiple diseases and 2 tumor-like lesions with internal lytic areas detected in the fourth right costal arch and in the eighth left costal arc; we describe his clinical manifestations, radiological and laboratory findings as well as the pathological results and outcome. Conclusions: Ossifying lipomas are rare benign tumors with asymptomatic clinical presentation. It is important to perform an adequate radiological differentiation from other more aggressive lesions such as liposarcomas.

Precise Application of the Xiao-Chai-Hu-Tang in 98 Cases of Patients with the Major Syndrome of Feeling Pain and Tenderness under the Right Costal Arch

Xiao-Chai-Hu-Tang (XCHT), a representative of previous edition of Formulas of Traditional Chinese Medicine and harmonizing formulas, has multiple pharmacological functions. However, a variety of side effects could be caused by misuse or abuse, ignoring the theory of diagnosis and treatment based on the combination of syndrome and disease differentiation. Therefore, we conducted a retrospective study to evaluate the efficacy of XCHT, depending upon the individual patient’s condition. Among 98 patients treated with XCHT, most of the patients of syndromes could be cured after about two course. The therapeutic effect rate of prescribed XCHT in our 98 cases of treatment is 91.84% (90/98). In addition, the high frequently syndromes are consistent with Shanhanlun. With multiple years of experience, we believe that: patient feel pain and tenderness under the right costal arch is one of the symptoms of patients who fit for the treatment with XCHT.