The introduction of Multidetector-row CT (MDCT) has revolutionized the diagnostic strategy of multitrauma patients. The rapid acquisition of a large scanning volume with a thin slice collimation allows for motion-free images of high spatial resolution, and this enables the application of the multiplanar reformat (MPR) and 3D volume-rendering (VR) images. The MPR images more accurately demonstrate aortic rupture or dissection, diaphragmatic injuries and fracture of vertebrae, sternum and costal cartilages. Diagnosing vascular injuries can be aided by using the MIP images. Rib fracture, trachea and bronchial laceration are more easily detected by the 3D images, while airway and vascular injuries can be detected from performing virtual endoscopy. We introduce our current CT imaging protocol and we present our clinical experience with using MDCT in the assessment of patients with blunt thoracic trauma
Aortic Rupture ; Cartilage ; Endoscopy ; Humans ; Lacerations ; Rib Fractures ; Spine ; Sternum ; Thoracic Injuries* ; Trachea ; Vascular System Injuries

BACKGROUND: The aims of this study are to determine the predicting factors related with cardiovascular injuries in sternal fractures and to suggest the indication of emergency echocardiography. MATERIAL AND METHOD: A retrospective review of the Ewha Womans University Mok-Dong Hospital trauma registry revealed 40 patients, that visited the hospital with a sternal fracture a over 5-year period. We analyzed 4 factors as predicting factors; 1) presence of restraint, 2) presence of associated injuries, 3) presence of a past medical history involving cardiovascular system, and 4) Revised Trauma Score(RTS). We, also, assessed the utility of conventional study methods involving cardiovascular injuries, such as ECG, chest X-ray, and enzyme level. Based on the methods, we inferred an indication for emergency echocardiography in sternal fractures. RESULT: Statistically significant predicting factors were the presence of a past medical history involving cardiovascular system and abnormal RTS on admission. Usage of emergency echocardiography depended upon the predicting factors and the results from conventional evaluations. We can now suggest the indications of emergency echocardiography in sternal fractures as 1) if more than two studies reveal abnormality without any significant predicting factors, and 2) if more than one study reveals abnormality with any significant predicting factors. CONCLUSION: The past medical history involving cardiovascular system and initial vital signs imply the presence of cardiovascular injuries in sternal fractures. And if needed, emergency echocardiography should be performed.
Cardiovascular System ; Echocardiography ; Electrocardiography ; Emergencies ; Female ; Humans ; Retrospective Studies ; Sternum ; Thoracic Injuries ; Thorax ; Vital Signs

Infected median sternotomy wounds represents one of major complication of cardiothoracic surgery. Although the incidence is less than 1%, its associated morbidity, mortality, and "cost" remain unacceptably high. For the treatment of this recalcitrant wound infections, most patient underwent radical debridement with sternectomy and reconstructed by muscle flaps. The most common combination of flaps being the omentum and bilateral pectoralis major musculocutaneous flaps. In our case, 2 patients who had extensive mediastinal infection at sternotomy wound underwent omental transposition flap pedicled on the right gastroepiploic artery and pectoralis major muscle flap. Omentum has rich lymphatics and high vascularity enough to revascularize the ischemic tissues. Using the greater omentum for infected median sternotomy wound combined with other muscle flap is an useful method for reconstruction of large defects invading lower 1/3 of sternum or retrosternal dead space.
Debridement ; Gastroepiploic Artery ; Humans ; Incidence ; Mortality ; Myocutaneous Flap ; Omentum ; Sternotomy ; Sternum ; Wound Infection ; Wounds and Injuries

We report a case of insufficiency fracture of the sternum in a 70-year-old female patient with a review of the literature. She complained of sudden onset chest pain and aggravating dyspnea. She has been managed with corticosteroid due to chronic obstructive pulmonary disease for 15 years. Diagnosis of sternal insufficiency fracture presented with thoracic kyphosis was made on the basis of absence of trauma history, radiologic findings of lateral chest radiograph, bone scintigraphy and chest computed tomography. Thoracic kyphosis and osteoporosis secondary to menopause, corticosteroid therapy and limited mobility due to chronic obstructive pulmonary disease were considered as predisposing factors of the sternal insufficiency fracture in this patient.
Aged ; Case Report ; Female ; Fractures, Spontaneous/radiography ; Fractures, Spontaneous/diagnosis* ; Fractures, Spontaneous/complications ; Human ; Kyphosis/complications ; Lung Diseases, Obstructive/complications ; Osteoporosis, Postmenopausal/complications ; Sternum/radiography ; Sternum/injuries*

Fracture of the sternum has been considered as a serious iniury and also associated with major complications such as myocardial, major thoracic vascular, and spinal injury. Retrospective datas from blunt trauma victims admitted to our hospital were analyzed to determine significance of sternal fractures and possible associated injures. 101 sternal fractures by blunt trauma were admitted from january, 1986 to december, 1995. Frequency was about 3.51% of the nonpenetrating chest trauma. The ratio of male to female was 1.82 versus 1. Most common cause in the sternal fracture was high decelerating injury(73 cases). Most common fracture site was sternal body(75 cases). Average days of admission were 26 days. Abnormal ECG findings were sinus bradycardia(7cases), complete or incomplete RBBB(6 cases), sinus tachycardia(4 cases), specific S-T change(3 cases), 1st degree A-V block(2 cases), LVH(1 case), PVC(1 case), and Low voltage(1 case). CPK-MB was increased about 32.1% of sternal fractures. Except of expired 2 patients, patients were treated with conservative treatment(94 cases) and open reductions and steel wire fixations(5 cases). Complication after operation was wound infection(1 case). Causes of death were 1 hypovolemia and 1 acute respiratory distress syndrome. In conclusion, although sternal fracture is less frequent, and mostly treats with conservative treatment, it shoud be carefully observed because of critical associated injuries.
Cause of Death ; Electrocardiography ; Female ; Humans ; Hypovolemia ; Male ; Respiratory Distress Syndrome, Adult ; Retrospective Studies ; Spinal Injuries ; Steel ; Sternum ; Thorax ; Wounds and Injuries

OBJECTIVETo assess clinical effectiveness of using bilateral pectoralis major or plus rectus abdominis muscle flaps in treating deep sternal wound infection (DSWI) following median sternotomy.

METHODSBetween January 2009 and December 2013, 19 patients with DSWI after median sternotomy for cardiac surgery were admitted to our hospital, including 14 males (73.7%) and 5 females (26.3%), aged 55±13 (18-78) years. According to the Pairolero classification of infected median sternotomies, 3 (15.8%) patients were type II, and the other 16 (84.2%) were type III. Surgical procedure consisted of adequate debridement of infected sternum, costal cartilage, granulation, steel wires, suture residues and other foreign substances. Sternal reconstruction used the bilateral pectoralis major or plus rectus abdominis muscle flaps to obliterate dead space. The drainage tubes were placed and connected to a negative pressure generator for adequate drainage.

RESULTSThere were no intraoperative deaths. In 15 patients (78.9%), bilateral pectoral muscle flaps were mobilized sufficiently to cover and stabilize the defect created by wound debridement. 4 patients (21.0%) needed bilateral pectoral muscle flaps plus rectus abdominis muscle flaps because their pectoralis major muscle flaps could not reach the lowest portion of the wound. 2 patients (10.5%) presented with subcutaneous infection, and 3 patients (15.8%) had hematoma. They recovered following local debridement and medication. 17 patients (89.5%) were examined at follow-up 12 months later, all healed and having stable sternum. No patients showed infection recurrence during the follow-up period over 12 months.

CONCLUSIONDSWI following median sternotomy may be effectively managed with adequate debridement of infected tissues and reconstruction with bilateral pectoralis major muscle or plus rectus abdominis muscle flap transposition.

Adolescent ; Adult ; Aged ; Female ; Humans ; Male ; Middle Aged ; Sternum ; injuries ; Surgical Flaps ; Wounds and Injuries ; surgery ; Young Adult

Type 2 manubriosternal dislocations with concomitant spinal fracture are rare and may be associated with thoracic visceral injuries. The complication of delayed haemothorax has not been reported yet. We report a case of a young male who suffered manubriosternal dislocation with chance type thoracic spine fracture due to fall of a tree branch over his back. The haemothorax presented late on day three. The possible injury mechanism is discussed along with review of literature. We conclude that a lateral chest radiograph is indicated in spinal fracture patients complaining of midsternal pain. Computerized axial tomography scan of chest with contrast is indicated to rule out visceral injuries and a chest radiograph should be repeated before the patient is discharged to look for delayed haemothorax.
Adult ; Hemothorax ; etiology ; Humans ; Joint Dislocations ; complications ; diagnostic imaging ; Male ; Manubrium ; injuries ; Radiography, Thoracic ; Spinal Fractures ; complications ; diagnostic imaging ; Sternum ; injuries ; Thoracic Vertebrae ; injuries

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.
Length of Stay ; Mortality ; Plastics ; Reconstructive Surgical Procedures ; Software Design ; Standard of Care ; Sternotomy ; Sternum ; Surgeons ; Thoracic Surgery ; Wound Infection ; Wounds and Injuries

BACKGROUND: The aim of the study was to test the hypothesis that in patients with chronic complex sternum dehiscence, the use of muscle flap repair minimizes the occurrence of paradoxical motion of the chest wall (CWPM) when compared to sternal rewiring, eventually leading to better respiratory function and clinical outcomes during follow-up. METHODS: In a propensity score matching analysis, out of 94 patients who underwent sternal reconstruction, 20 patients were selected: 10 patients underwent sternal reconstruction with bilateral pectoralis muscle flaps (group 1) and 10 underwent sternal rewiring (group 2). Eligibility criteria included the presence of hemisternum diastases associated with multiple (≥3) bone fractures and radiologic evidence of synchronous chest wall motion (CWSM). We compared radiologically assessed (volumetric computed tomography) ventilatory mechanic indices such as single lung and global vital capacity (VC), diaphragm excursion, synchronous and paradoxical chest wall motion. RESULTS: Follow-up was 100% complete (mean 85±24 months). CWPM was inversely correlated with single lung VC (Spearman R=−0.72, p=0.0003), global VC (R=−0.51, p=0.02) and diaphragm excursion (R=−0.80, p=0.0003), whereas it proved directly correlated with dyspnea grade (Spearman R=0.51, p=0.02) and pain (R=0.59, p=0.005). Mean CWPM and single lung VC were both better in group 1, whereas there was no difference in CWSM, diaphragm excursion and global VC. CONCLUSION: Our study suggests that in patients with complex chronic sternal dehiscence, pectoralis muscle flap reconstruction guarantees lower CWPM and greater single-lung VC when compared with sternal rewiring and it is associated with better clinical outcomes with less pain and dyspnea.
Diaphragm ; Dyspnea ; Follow-Up Studies ; Fractures, Bone ; Humans ; Lung ; Pectoralis Muscles* ; Propensity Score ; Sternum ; Thoracic Wall* ; Thorax* ; Vital Capacity ; Wounds and Injuries*

BACKGROUND: Sternal fractures are relatively rare, and caused mainly by blunt anterior chest wall trauma. In most cases, sternal fractures are treated conservatively. However, if the patient exhibits problematic symptoms such as intractable chest wall pain or bony crepitus due to sternal instability, surgical correction is indicated. But no consensus exists regarding the most appropriate surgical method. We analyzed the results of surgical fixation in cases of sternal fracture in order to identify which surgical method led to the best outcomes. METHODS: We retrospectively reviewed the medical records of patients with sternal fractures from December 2008 to December 2011, and found 19 patients who underwent open reduction and internal fixation of the sternum with a longitudinal plate (L-group) or a T-shaped plate (T-group). We investigated patients' characteristics, clinical details regarding each case of chest trauma, the presence of other associated injuries, the type of open reduction and fixation, whether a combined operation was performed, and postoperative complications. RESULTS: Of the 19 patients, 10 patients (52.6%) were male, and their average age was 56.8 years (range, 32 to 82 years). Seven patients (36.8%) had isolated sternal fractures, while 12 (63.2%) had other associated injuries. Seven patients (36.8%) were in the L-group and 12 patients (63.2%) were in the T-group. Three patients in the L-group (42.9%) showed a loosening of the fixation. In all patients in the T-group, the fracture exhibited stable alignment. CONCLUSION: Open reduction and internal fixation with a T-shaped plate in sternal fractures is a safer and more efficient treatment method than treatment with a longitudinal plate, especially in patients with a severely displaced sternum or anterior flail chest, than a longitudinal plate.
Bone Plates ; Consensus ; Flail Chest ; Fracture Fixation ; Humans ; Male ; Medical Records ; Methods ; Postoperative Complications ; Retrospective Studies ; Sensitivity Training Groups ; Sternum ; Thoracic Injuries ; Thoracic Wall ; Thorax