[Surgical Therapy of Slipping Rib Syndrome]

We have operated on two cases of slipped ribs syndrome( SRS). Both patients were men in their 40s with a history of right thoracic trauma who were referred to us because of unexplained lower thoracic pain. The left rib was positive for hooking maneuver (lift test), and dynamic ultrasonography showed narrowing of the intercostal space, which led to the diagnosis of SRS. in the first case, the tip of the ninth rib cartilage was excised, and the ninth and tenth rib cartilages were sutured and fixed with No.2 fiber wire in two places with Z sutures. In the second case, the tip of the ninth rib cartilage was excised, the eighth and ninth ribs and the ninth and tenth ribs were fixed with No.2 fiber wire with Z sutures as in the first case, and a 0.7 mm thick poly-L-lactide (PLLA) plate was added between the eighth and tenth rib cartilages. In both cases, the postoperative course was good and the pain disappeared. SRS should be recognized as a disease and surgical treatment should be used as therapy.

Stereomicroscopic analysis of cut marks inflicted by a knife with blade damage

Skeletal cut mark analysis provides relevant information on the general class characteristics of suspect knife. However, there is a lack of research on the influence of blade damage on cut mark analysis. This study aimed to thoroughly investigate the effects of damaged knife blades on cut marks' morphological and morphometrical characteristics. Fifteen undamaged, non-serrated knives were used to cut human ribs to make control cut marks. The knife blades were then damaged by a series of cuts on the bones. A comparison was made between the control cuts and 3 groups of cut marks inflicted by blades that had been damaged to different degrees. The results showed that the damaged blades created wider cut marks than undamaged one. Kerf morphology was likely to imitate the cuts made by the serrated blades such as an elliptical shape, a V-shaped cross-section and the presence of coarse striations. Wear-related features can affect cut mark analysis as the marks left behind by blades damaged to different degrees showed dissimilar dimensions and morphologies. The findings of this study can be applied to a forensic investigation when cut marks were caused by a knife with a damaged blade.

Pediatric Ribs at Chest Radiography: Normal Variants and Abnormalities

Normal variants and abnormalities of the ribs are frequently encountered on chest radiographs. Accurate identification of normal variants is crucial to avoid unnecessary investigations. A meticulous evaluation of rib abnormalities can provide valuable insights into the patient's symptoms, and even when no osseous condition is suspected, rib abnormalities may offer critical clues to underlying conditions. Rib abnormalities are associated with various conditions, including benign tumors, malignant tumors, infectious and inflammatory conditions, vascular abnormalities, metabolic disorders, nonaccidental injuries, malformation syndromes, and bone dysplasias. Abnormalities of the ribs are classified into three groups based on their radiographic patterns: focal, multifocal, and diffuse changes. Focal lesions are further subdivided into nonaggressive lesions, aggressive lesions, and infectious and inflammatory disorders. Radiologists should be aware of individual disorders of the pediatric ribs, including their imaging findings, relevant clinical information, and underlying pathogenesis. Differential diagnoses are addressed as appropriate. Since chest radiographs can suffice for diagnosis in certain cases, the authors emphasize a pattern recognition approach to radiographic interpretation. However, additional cross-sectional imaging may be necessary for focal lesions such as tumors or inflammatory conditions. Awareness of disease-specific imaging findings helps ascertain the nature of the lesion and directs appropriate management. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

A probabilistic model for murder weapon identification using stab-marks in human ribs

The aim of this article is to provide a scientific and statistical basis to identify the murder weapon in stabbing cases from the geometric characteristics of the stab-marks left on human ribs. For this purpose, a quantitative predictive model is developed, based on geometric measurements of the stab-mark and its location along the rib. A general method based on Bayesian inference and probabilities is used for the model development, rather than a deterministic model given its inability in certain occasions to identify the murder weapon. Following the process explained in this article to collect the stab-mark information required, the complete probabilistic model exposed attained a high accuracy in the identification of the murder weapon between two macroscopically identical blades with a microscopic alteration in one of them (more than 90% of correct identification is achieved).

Open Reduction and Internal Fixation of a Chronic Precordial Flail Chest Segment: A Case Report

CASE

We report on a 35-year-old man presenting with disabling pain secondary to multiple rib nonunions and a costochondral dislocation 5 months after sustaining a chest wall crush injury. He underwent surgical reconstruction of the chest and was followed for 2 years. Surgical exposure to the heart was necessary during open reduction of the flail segment, followed by costochondral joint fixation with plates and screws. Although he was a workers' compensation patient, he returned to full gainful employment.

CONCLUSION

Open reduction and internal fixation of a symptomatic, chronically displaced, precordial, flail segment can relieve pain and promote return to baseline function.

Knife cut marks inflicted by different blade types and the changes induced by heat: a dimensional and morphological study

Detailed information on skeletal trauma analysis of burned bone is important to ascertain the manner and cause of death in forensic casework. This research used three different knife types, one with a non-serrated blade, one a fine-serrated blade, and one a coarse-serrated blade, to inflict trauma to manually macerated Sus scrofa ribs (n = 240), and these ribs were later exposed to heat. Qualitative and quantitative analyses were conducted using macroscopic and microscopic techniques to assess specific characteristics of the cut marks. Differences in cut mark dimension and morphology of the ribs were investigated. After heat exposure, the cut marks on the rib samples remained recognisable and did not alter considerably. A level of dimensional and morphological preservation was reliant on the cutting action and the features of the knife blade as well as surrounding bone injury. The cut marks inflicted by the non-serrated blade remained recognisable despite exposure to the burning process. However, the cut marks inflicted by the coarse-serrated blade were likely to change significantly when exposed to heat. This study leads to two important results: (1) identification of pre-existing cut marks prior to heat exposure is possible in reconstructed burned bone fragments, and (2) cut marks from different types of knife blades showed dissimilar responses to heat. The outcomes obtained in this study stressed the need to adopt great care with the effects of heat on skeletal trauma analysis.

Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation

Background

Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury—respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel.

Methods

This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality.

Results

There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18–0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04–0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61–9.45), physiotherapy OR 2.17 (95% CI 1.52–3.11), ICU doctor OR 6.13 (95% CI 3.94–9.55), ICU liaison OR 55.75 (95% CI 17.48–177.75), pain team OR 8.15 (95% CI 5.52 –-12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64–3.94) and regional analgesia OR 8.8 (95% CI 3.39–22.79), incentive spirometry OR 8.3 (95% CI 4.49–15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43–39.2) in the intervention group compared to the control group in the post- period.

Conclusion

The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement.

Trial registration

ANZCTR: ACTRN12618001548224, approved 17/09/2018

A study into the viability of Synbone® as a proxy for Sus scrofa (domesticus) ribs for use with 7.62 × 51 mm Full Metal Jacket ammunition in ballistic testing

Forensic reconstructions and ballistic testing requires the use of consistent and repeatable simulants. Synthetic bone has been developed to be mechanically similar to human bone; however, it does not have the same viscoelastic properties. Bone acts as brittle and stiff material and fails instantly under high-energy events such as ballistic impacts. Consequently, bone simulants for use in ballistic testing should show comparable energy deposition to mammalian bones. This study aims to determine if Synbone® flat plates could be a viable proxy for Sus scrofa (domesticus) ribs in ballistic testing with 7.62 × 51 mm Full Metal Jacket ammunition. 5 mm, 6 mm and 12 mm quartered Synbone® plates were embedded into 10% ballistic gelatin and shot using 7.62 mm ammunition. The models were then analysed to compare the Synbone® to a previous Sus Scrofa (domesticus) rib study and focused on energy deposition, the number of fragments within the block, angle of deviation, onset of yaw, the temporary cavity, and the permanent wound channel. No significant difference was seen between the Sus Scrofa (domesticus) and the 5 mm Sybone®. There were significant differences observed between Sus Scrofa (domesticus) ribs and 6 mm Synbone® for the number of fragments, energy deposition and projectile tract diameter, and significant differences seen between Sus scrofa (domesticus) ribs and 12 mm Synbone® for the depth of onset of yaw, energy deposition and projectile tract diameter. This study indicates that the 5 mm Synbone® plate is a suitable proxy for Sus scrofa (domesticus) ribs for use with 7.62 × 51 mm FMJ ammunition in ballistic testing.

Trunk Injuries in Athletes

ABSTRACT

Trunk pain is a common cause of performance limitation and time away from sport in athletes. However, atraumatic trunk injuries are underrepresented in medical literature and underrecognized clinically. Delays in diagnosis and initiation of appropriate treatment can increase injury morbidity and return-to-play time. Currently, evidence-based guidelines for diagnosis and treatment of trunk pain in athletes are limited. Thus, we provide an overview of atraumatic sport-related injuries to the thoracic spine (disc herniation, scoliosis, kyphosis), ribcage (bone stress injury, costochondritis, Tietze syndrome, slipping rib syndrome, costovertebral or costotransverse joint dysfunction), and chest and abdominal wall musculature (intercostal, serratus anterior, oblique strains, regional myofascial pain), highlighting sport-specific biomechanical considerations. We aim to increase awareness of these causes of trunk pain among sports medicine providers in an effort to guide diagnostic and treatment recommendations that will ultimately improve overall musculoskeletal health in athletes.

A study into the viability of Synbone® as a proxy for Sus scrofa (domesticus) ribs for use with 5.56-mm open tip match ammunition in ballistic testing

BACKGROUND

In ballistic testing and forensic reconstruction, there is a need to use repeatable and consistent simulants. While synthetic bone is mechanically similar to human bone, it does not have the same viscoelastic properties. In high-energy impact such as ballistic impacts, bone acts as a stiff, brittle material and fails instantaneously. Therefore, a suitable simulant for use in ballistic testing should have comparable energy deposition to mammalian bones. This preliminary study aims to determine if Synbone® could be a viable proxy for Sus scrofa (domesticus) ribs in ballistic testing.

METHODOLOGY

Three thickness of Synbone® were embedded into 10% ballistic gelatin and shot using 5.56-mm ammunition. The models were then analysed to compare the Synbone® to a previous Sus scrofa (domesticus) rib study and focused on the number of fragments within the block, energy deposition, onset of yaw, angle of deviation, the temporary cavity as a percentage of the block and the depth to the temporary cavity centre, depth to maximum gelatin disruption and the permanent wound channel, including shear planes and wound tract diameter.

RESULTS

There was no significant difference in the metrics that were compared between Sus scrofa (domesticus) ribs and the three thicknesses of Synbone®, except for a significant difference in the depth to maximum gelatin disruption between the 6 mm (p = 0.009) and 12 mm plate (p = 0.007) and the Sus scrofa (domesticus) ribs.

CONCLUSION

This study indicates that the 5-mm Synbone® plate is a suitable proxy for Sus scrofa (domesticus) ribs for use with 5.56-mm OTM ammunition in ballistic testing.

Slipping rib syndrome in an adolescent wrestler

Slipping rib syndrome is a commonly missed diagnosis of upper abdominal pain. It results from hypermobility of the anterior rib due to the disruption of the interchondral ligaments, most likely secondary to repetitive motions or some inciting event. The hypermobility leads to impingement of the intercostal nerves resulting in significant pain.A 10-year-old adolescent male child was evaluated for 4 months of intermittent, left-sided, upper abdominal pain following a wrestling injury. His paediatrician referred him for further evaluation after a negative workup given the patient was still having intermittent bouts of short-lasting pain that would spontaneously resolve. Physical examination demonstrated a positive hooking manoeuvre with associated swelling and prominence over the lower left ribs.In conclusion, a broad differential diagnosis, thorough clinical examination, and knowledge of slipping rib syndrome are important to appropriately diagnose and treat patients symptoms.

Development and commissioning of an instrumented pneumatic device to simulate blunt- and sharp-force trauma

Forensic investigators commonly interpret bone fracture patterns to estimate the force required to generate that trauma. Unfortunately, these estimates are limited to qualitative values such as "mild", "moderate" or "extreme" force. This work presents a new experimental forensic device developed to simulate blunt- and sharp-force trauma injuries, while recording the forces and velocities involved, so that a more quantitative relationship between force and trauma can be established. The machine design is described in some detail, its capabilities are outlined, and the results of the commissioning and validation tests are presented. Preliminary results for both blunt- and sharp-force testing of porcine ribs, conducted at 3.8m/s, indicate the average peak force (733±95N versus 392±73N), average force (334±49N versus 101±24N), and work (2.34±0.26J versus 0.68±0.09J) are significantly higher in the blunt case. The experimental data generated by this instrumented device will allow forensic investigators to create a better quantitative link between incident conditions (velocity, force, work) and the resulting fracture patterns.

Anatomy of the Ribs and Management of their Fractures as Viewed by Avicenna (980-1037 Ad)

INTRODUCTION

Avicenna statedinteresting points on the symptoms of rib bone fractures, their physical examination, and also treatment and management of the complications in his master piece Canon in Tibb.

METHOD

We reviewed Avicenna's Canon and his viewpoints on the anatomy of the rib bones and their fractures and compared it with conventional medicine.

RESULT

He described the ana omy of the ribs; he explained the effectiveness of their structure in the prote tion of vital organs. He also suggested some methods for the management of rib fractures, such as using vacuum at the fracture site or open surgery in case of complications.

CONCLUSION

Avicenna's point of view on the approach toward rib fractures had some similarities and differences with conventional practice. Some of his suggestions could be taken into account.

Serious injuries secondary to cardiopulmonary resuscitation: incidence and associated factors

OBJECTIVES

To determine the incidence of serious rib cage damage (SRD) and serious visceral damage (SVD) secondary to cardiopulmonary resuscitation (CPR) and to explore associated factors.

MATERIAL AND METHODS

We analyzed data from the prospective registry of cases of sudden death in Tarragona, Spain (the ReCaPTa study). Cases were collected from multiple surveillance sources. In this study we included the cases of autopsied nonsurvivors after attempted manual CPR between April 2014 and May 2016. A specific protocol to detect injuries secondary to CPR was used during the autopsies.

RESULTS

We analyzed 109 cases. The mean age at death was 63 years and 32.1% were women. SRD were found in 63.3% and SVD in 14.7%. The group with SRD were significantly older (63 vs 59 years, P=.031) and included higher percentages of persons with a chest circumference over 101 cm (56.5 vs 30%, P=.016) and a waist circumference over 100 cm (62.3 vs 37.5%, P=.017). A multivariable analysis confirmed chest circumference over 101 cm as the only risk factor for SRD (odds ratio [OR], 2.45; 95% CI, 1.03-5.84) and female sex as the only risk factor for SVD (OR, 5.02; 95% CI, 1.18-21.25).

CONCLUSION

Women and any patient with a chest circumference greater than 101 cm are at greater risk for serious injuries related to CPR.

Damage control orthopedics applied in an 8-year-old child with life-threatening multiple injuries: A CARE-compliant case report

RATIONALE

Damage control is a staged surgical approach to manage polytraumatized patients. The damage control approach comprises three steps. First, bleeding is controlled and fractures are stabilized temporarily; second, vital parameters are stabilized and the child is rewarmed in the intensive care unit; and third, the child is reoperated for definitive repair of injuries. We aimed to describe the feasibility of the damage control orthopedic approach in a child.

PATIENT CONCERNS

An 8-year-old girl fell from the balcony of the 5th floor onto concrete pavement and was admitted to our accident and emergency ward in a stable cardiorespiratory state, but with gross deformity of the lower limbs, left thigh, and forearm.

DIAGNOSES

The child had sustained multiple injuries with severe bilateral lung contusion, pneumothorax, fracture of first rib, liver laceration, stable spine fractures, transforaminal fracture of sacrum, pelvic ring fracture, displaced baso-cervical femoral neck fracture, displaced bilateral multifragmental growth plate fractures of both tibiae, fractures of both fibulae, displaced fracture of left forearm, and displaced supracondylar fracture of the humerus.

INTERVENTION

In the initial operation, we performed closed reduction and K-wire fixation of the right tibia, closed reduction and external fixation of the left tibia, open reduction and screw osteosynthesis of the femoral neck fracture, closed reduction and K-wire fixation of the radius, and closed reduction of the supracondylar fracture. Subsequently, we transferred the girl to the pediatric intensive care unit for hemodynamic stabilization, respiratory therapy, rewarming, and treatment of crush syndrome. In a third step, 10 days after the injury, we managed the supracondylar fracture of the humerus by closed reduction and K-wire fixation.

OUTCOMES

Growth arrest of the left distal tibial growth plate and osteonecrosis of the femoral head and neck, slipped capital femoris epiphysis (SCFE), and coxa vara of the right femur led to balanced leg length inequality 2 years after the injury. The lesion of the left sciatic nerve improved over time and the girl walked without walking aids and took part in school sports but avoided jumping exercises.

LESSONS

We emphasize the importance of damage control principles when managing polytraumatized children.

[Thoracic Endovascular Aortic Repair for Traumatic Aortic Injury with Internal Iliac Approach;Report of a Case]

A 40-year-old female was injured in a car accident while driving. Computed tomography confirmed a dissection localized to the distal aortic arch and hematoma around the area. Severe liver damage with surrounding extravasation was also confirmed. Furthermore, multiple rib fractures and lumbar spine fracture were apparent. Thoracic endovascular aortic repair( TEVAR) was performed after transcatheter arterial embolization to treat the liver injury. As both the iliac and femoral arteries were narrow, the internal iliac artery was transected peripherally and used as an access route. This method does not require complex procedures such as artificial vascular anastomosis for vascular repair in the event of injury. Therefore, it may be considered as an option when access from the femoral artery is difficult.

Metabolic bone disease risk factors strongly contributing to long bone and rib fractures during early infancy: A population register study

Background

The aim of this study was to assess the incidence of fractures in infancy, overall and by type of fracture, its association with accidents, metabolic bone disease risk factors, and abuse diagnosis.

Methods

The design was a population-based register study in Sweden. Participants: Children born 1997–2014, 0–1 years of age diagnosed with fracture-diagnosis according to International Classification of Diseases (ICD10) were retrieved from the National Patient Register and linked to the Swedish Medical Birth Register and the Death Cause Register. Main outcome measures were fractures of the skull, long bone, clavicle and ribs, categorized by age (younger or older than 6 months), and accident or not.

Findings

The incidence of fractures during infancy was 251 per 100 000 infants (n = 4663). Major fracture localisations were long bone (44·9%), skull (31·7%), and clavicle (18·6%), while rib fractures were few (1·4%). Fall accidents were reported among 71·4%. One-third occurred during the first 6 months. Metabolic bone disease risk factors, such as maternal obesity, preterm birth, vitamin D deficiency, rickets, and calcium metabolic disturbances, had increased odds of fractures of long bones and ribs in early infancy (0–6 months): birth 32–36 weeks and long bone fracture [AOR 2·13 (95%CI 1·67–2·93)] and rib fracture [AOR 4·24 (95%CI 1·40–12·8)]. Diagnosis of vitamin D deficiency/rickets/disorders of calcium metabolism had increased odds of long bone fracture [AOR 49·5 (95%CI 18·3–134)] and rib fracture [AOR 617 (95%CI 162–2506)]. Fractures without a reported accident had higher odds of metabolic risk factors than those with reported accidents. Abuse diagnosis was registered in 105 infants, with overrepresentation of preterm births, multiple births and small-for-gestational age.

Interpretation

Metabolic bone disease risk factors are strongly associated with fractures of long bone and ribs in early infancy. Fracture cases with abuse diagnosis had a metabolic bone risk factor profile.

Sources of Variability in Structural Bending Response of Pediatric and Adult Human Ribs in Dynamic Frontal Impacts

Despite safety advances, thoracic injuries in motor vehicle crashes remain a significant source of morbidity and mortality, and rib fractures are the most prevalent of thoracic injuries. The objective of this study was to explore sources of variation in rib structural properties in order to identify sources of differential risk of rib fracture between vehicle occupants. A hierarchical model was employed to quantify the effects of demographic differences and rib geometry on structural properties including stiffness, force, displacement, and energy at failure and yield. Three-hundred forty-seven mid-level ribs from 182 individual anatomical donors were dynamically (~2 m/s) tested to failure in a simplified bending scenario mimicking a frontal thoracic impact. Individuals ranged in age from 4 - 108 years (mean 53 ± 23 years) and included 59 females and 123 males of diverse body sizes. Age, sex, body size, aBMD, whole rib geometry and cross-sectional geometry were explored as predictors of rib structural properties. Measures of cross-sectional rib size (Tt.Ar), bone quantity (Ct.Ar), and bone distribution (Z) generally explained more variation than any other predictors, and were further improved when normalized by rib length (e.g., robustness and WBSI). Cortical thickness (Ct.Th) was not found to be a useful predictor. Rib level predictors performed better than individual level predictors. These findings moderately explain differential risk for rib fracture and with additional exploration of the rib's role in thoracic response, may be able contribute to ATD and HBM development and alterations in addition to improvements to thoracic injury criteria and scaling methods.

Hepatitis E Virus Infection after Platelet Transfusion in an Immunocompetent Trauma Patient

Hepatitis E virus (HEV) infection causes acute liver disease, but severe infections are rare in immunocompetent patients. We describe a case of HEV infection in a previously healthy male trauma patient in France who received massive transfusions. Genotyping confirmed HEV in a transfused platelet pool and the donor.

Arterial Thoracic Outlet Syndrome and Cerebellar Infarction Following a Stress Fracture of the First Rib and Extensive Callus Formation: A Case Report

CASE

Stress fractures of the first rib rarely have been reported in association with sports activities. We report a case of a cerebellar infarction that possibly was associated with arterial thoracic outlet syndrome (aTOS) that developed as a result of extensive callus formation in a young baseball player with a stress fracture of the first rib.

CONCLUSION

According to the literature, almost all cases of stress fracture in the first rib have a relatively good prognosis, and there are only a few reports of TOS occurring as a rare late complication. To our knowledge, there have been no prior reports of cerebellar infarction associated with aTOS following a stress fracture of the first rib.

Comparison of rabbit rib defect regeneration with and without graft

Rib segment, as one of the most widely used autologous boneresources for bone repair, is commonly isolated with an empty left in the defect. Although defective rib repair is thought to be unnecessary traditionally, it's of vital importance actually to promote rib regeneration for patients with better postoperative recovery and higher life quality. Comparative investigations on rabbit rib bone regeneration with and without graft were reported in this article. A segmental defect was performed on the 8th rib of 4-month-old male New Zealand rabbits. The mineralized collagen bone graft (MC) was implanted into the defect and evaluated for up to 12 weeks. The rib bone repair was investigated by using X-ray at 4, 8 and 12 weeks and histological examinations at 12 weeks after surgery, which showed a higher bone remodeling activity in the groups with MC implantation in comparison with blank control group, especially at the early stage of remodeling.

Rib stress fractures among rowers: a systematic review on return to sports, risk factors and prevention

INTRODUCTION

Rib stress fractures (RSFs) are injuries frequently sustained by elite rowers with an injury rate of 8-16% over the course of a rowing career, resulting in negative effects on training and performance. For clinical management, the aim of this review was to describe time to return to sports, summarize potentially preventive measures and appraise the evidence on risk factors.

EVIDENCE ACQUISITION

A search strategy was performed in PubMed, SportDiscus, Web of Science and Embase till June 1st 2015. All studies were graded on their quality.

EVIDENCE SYNTHESIS

The search resulted in 124 studies, of which 17 were included: Ten reported on return to sports, 17 reported on risk factors and nine on preventive measures. For return to sports, nine studies mentioned a loss of training of 4-6 weeks. The shortest period was one week and the longest 16 weeks. For risk factors, insufficient or conflicting evidence was found for changes in the training program, incorrect rowing technique, female gender, low bone mineral density, inadequate equipment, and training type. For prevention, gradual changes in the training program, alertness on the part of coaches and clinicians, and supplementation of diet and hormones are suggested as effective measures. However, no effect studies have been found.

CONCLUSIONS

The main outcome of this review on RSFs is that little evidence is available on return to sports, risk factors and preventive measures. Coaches and clinicians should carefully guide and assist rowers suffering from RSFs in off training and in the subsequent training period to regain their pre-injury level.

Surgical versus nonsurgical interventions for flail chest

BACKGROUND

Thoracic trauma (TT) is common among people with multiple traumatic injuries. One of the injuries caused by TT is the loss of thoracic stability resulting from multiple fractures of the rib cage, otherwise known as flail chest (FC). A person with FC can be treated conservatively with orotracheal intubation and mechanical ventilation (internal pneumatic stabilization) but may also undergo surgery to fix the costal fractures.

OBJECTIVES

To evaluate the effectiveness and safety of surgical stabilization compared with clinical management for people with FC.

SEARCH METHODS

We ran the search on the 12 May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), EMBASE Classic and EMBASE (OvidSP), CINAHL Plus (EBSCO), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), and clinical trials registers. We also screened reference lists and contacted experts.

SELECTION CRITERIA

Randomized controlled trials of surgical versus nonsurgical treatment for people diagnosed with FC.

DATA COLLECTION AND ANALYSIS

Two review authors selected relevant trials, assessed their risk of bias, and extracted data.

MAIN RESULTS

We included three studies that involved 123 people. The methods used for blinding the participants and researchers to the treatment group were not reported, but as the comparison is surgical treatment with medical treatment this bias is hard to avoid. There was no description of concealment of the randomization sequence in two studies.All three studies reported on mortality, and deaths occurred in two studies. There was no clear evidence of a difference in mortality between treatment groups (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.13 to 2.42); however, the analysis was underpowered to detect a difference between groups. Out of the 123 people randomized and treated, six people died; the causes of death were pneumonia, pulmonary embolism, mediastinitis, and septic shock.Among people randomized to surgery, there were reductions in pneumonia (RR 0.36, 95% 0.15 to 0.85; three studies, 123 participants), chest deformity (RR 0.13, 95% CI 0.03 to 0.67; two studies, 86 participants), and tracheostomy (RR 0.38, 95% CI 0.14 to 1.02; two studies, 83 participants). Duration of mechanical ventilation, length of intensive care unit stay (ICU), and length of hospital stay were measured in the three studies. Due to differences in reporting, we could not combine the results and have listed them separately. Chest pain, chest tightness, bodily pain, and adverse effects were each measured in one study.

AUTHORS' CONCLUSIONS

There was some evidence from three small studies that showed surgical treatment was preferable to nonsurgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical ventilation, and length of ICU stay. Further well-designed studies with a sufficient sample size are required to confirm these results and to detect possible surgical effects on mortality.

Particle therapy for clinically diagnosed stage I lung cancer: comparison with pathologically proven non-small cell lung cancer

BACKGROUND

The purpose of the present study was to present the treatment outcomes of particle therapy for indeterminate pulmonary nodules (IPNs) diagnosed as stage I non-small cell lung cancer, including a comparative analysis involving pathologically proven lung cancer (PPLC).

MATERIAL AND METHODS

A total of 54 patients (57 lesions) who underwent particle therapy for IPNs were enrolled in this study. Median patient age was 76 (range 52-87) years. T-classification was: T1a, 30; T1b, 16; and T2a, 11. Particle therapy using protons or carbon ions was delivered at total doses of 52.8-80 Gy equivalent in 4-26 fractions. The PPLC cohort included 111 patients.

RESULTS

The median follow-up time was 41 (range 7-90) months. For all IPN patients, the three-year overall survival, progression-free survival, local control and distant progression-free survival rates were 90%, 72%, 94% and 79%, respectively. Grade 2 toxicities were radiation pneumonitis (19%), dermatitis (9%), rib fracture (2%), chest wall pain (2%) and neuropathy (2%). No ≥grade 3 toxicities were observed. In univariate analysis, the IPN group showed significantly better survival relative to the PPLC group. However, after adjustment for baseline imbalances between these two groups in multivariate analysis, pathological confirmation did not correlate with survival.

CONCLUSIONS

Particle therapy for IPNs provided favorable outcomes with minimal toxicities, which may be comparable to those for PPLC patients. Further studies are needed to clarify the optimal management of IPN patients.

[Avulsion fracture of the serratus anterior muscle in a golfer]

Golf is a sport with much repetitive actions often causing overuse injuries. We report a case of a left side avulsion fracture of the anterior serratus at the insertion on costa 4-6. A professionel golfer experienced sudden onset of pain of the chest during a golfswing. Clinically the patient had winging of the scapula and pain at the lateral side of costa 4-6. Ultrasonography showed an avulsion fracture of costa 5 at the insertion of the anterior serratus. The patient was referred to scapula-stabilising rehabilitation and fully recovered.

Perimortem trauma in King Richard III: a skeletal analysis

BACKGROUND

Richard III was the last king of England to die in battle, but how he died is unknown. On Sept 4, 2012, a skeleton was excavated in Leicester that was identified as Richard. We investigated the trauma to the skeleton with modern forensic techniques, such as conventional CT and micro-CT scanning, to characterise the injuries and establish the probable cause of death.

METHODS

We assessed age and sex through direct analysis of the skeleton and from CT images. All bones were examined under direct light and multi-spectral illumination. We then scanned the skeleton with whole-body post-mortem CT. We subsequently examined bones with identified injuries with micro-CT. We deemed that trauma was perimortem when we recorded no evidence of healing and when breakage characteristics were typical of fresh bone. We used previous data to identify the weapons responsible for the recorded injuries.

FINDINGS

The skeleton was that of an adult man with a gracile build and severe scoliosis of the thoracic spine. Standard anthropological age estimation techniques based on dry bone analysis gave an age range between 20s and 30s. Standard post-mortem CT methods were used to assess rib end morphology, auricular surfaces, pubic symphyseal face, and cranial sutures, to produce a multifactorial narrower age range estimation of 30-34 years. We identified nine perimortem injuries to the skull and two to the postcranial skeleton. We identified no healed injuries. The injuries were consistent with those created by weapons from the later medieval period. We could not identify the specific order of the injuries, because they were all distinct, with no overlapping wounds. Three of the injuries-two to the inferior cranium and one to the pelvis-could have been fatal.

INTERPRETATION

The wounds to the skull suggest that Richard was not wearing a helmet, although the absence of defensive wounds on his arms and hands suggests he was still otherwise armoured. Therefore, the potentially fatal pelvis injury was probably received post mortem, meaning that the most likely injuries to have caused his death are the two to the inferior cranium.

FUNDING

The University of Leicester.

[Surgical Stabilisation of Flail Chest Injury: Indications, Technique and Results]

PURPOSE OF THE STUDY

Multiple rib fractures with segmental chest wall instability are caused by high-energy chest trauma and are associated with significant morbidity and mortality. Flail chest injuries are mostly combined with lung injury (contusion, rupture, laceration) and subsequent pneumothorax or haemothorax. Early mechanical ventilation with internal pneumatic splinting is a conservative treatment for flail chest in patients with respiratory insufficiency. The surgical stabilisation of a flail chest is an effective method of treatment and is beneficial for selected patients. It shortens the duration of mechanical ventilation and thus reduces morbidity associated with prolonged ventilatory support. In addition, it decreases long-term pain and the inability of a flail chest to heal due to malunion, non-union or progressive collapse of the flail segment. Surgical stabilisation of a flail chest is indicated when the clinical examination shows progressive respiratory dysfunction confirmed by the results of multiple detector computer tomography (MDCT) of the thorax.

MATERIAL AND METHODS

Thirty-three consecutive patients who underwent surgical stabilisation of a flail chest at the Trauma Centre between 2010 and 2014 were retrospectively evaluated. This included patient demographics, chest injury extent, results of pre-operative chest imaging (MDCT), surgical stabilisation technique and post-operative outcome. In addition to providing a radiographic finding of respiratory failure, the result of MDCT chest examination was considered an important criterion for surgical intervention. Surgical stabilisation of the chest wall was performed at an interval ranging from 2 hours to 11 days after injury. Intra-thoracic procedures were indicated in patients with lung injury (pulmonary laceration). The surgical procedure was completed by chest tube placement.

RESULTS

Surgical stabilisation was carried out using 3 to 8 plates for flail segment fixation involving 3 to 4 ribs. The duration of post- operative mechanical ventilation was 5 days on the average. It was longer in patients with associated injuries such as craniocerebral trauma or severe pulmonary contusion. Tracheostomy was performed in seven patients requiring prolonged mechanical ventilation. Two patients had superficial surgical site infection. No death was recorded in the follow-up period.

CONCLUSIONS

Surgical stabilisation of the flail chest segment is considered an effective procedure in selected patients, leading to improvement of respiratory function. By allowing for a shorter period of time on mechanical ventilation, it reduces the occurrence of complications due to ventilatory support. The result of MDCT chest examination in patients with fail chest is an important indication criterion for surgical fixation.

Rectal impalement injury: from cruelty to salvage endeavour

Massive penetrating trauma by rectal impalement is a very rare form of injury, complicated and potentially lethal. It is even rarer for such injury to result in pelvic, abdominal and thoracic internal damages. We report the case of a 62 year-old man who was admitted in emergency after an aggression with a sharp wooden stake inserted forcibly into his rectum. Clinical examination revealed the blunt extremity of the stake outside the anus and the prominent sharp end reaching his right supraclavicular fossa. Radiographic examination showed the stake extending from the rectum to the right side of the neck.Surgery disclosed penetration through the rectum, retroperitoneum,large bowel mesentery, liver, diaphragm, right lung and right 2nd rib. The patient survived following management by a multidisciplinary surgical team. As similar reported cases are scarce, knowledge of the management of the few cases that have been successfully treated is likely to prepare the emergency teams to act rationally and efficiently in such exceptionally grave circumstances.

The evaluation of procedure and treatment outcome in patients with tension pneumothorax

INTRODUCTION

Tension pneumothorax is a directly criti- cal illness condition. The aim of this study was to evaluate the outcome of tension pneumothorax treatment in trauma patients.

MATERIAL AND METHODS

We assessed the results of treat- ment of 22 patients hospitalized for trauma in 2000-2010, in whom at the time of admission tension pneumothorax symptoms were found. This constituted 18% of trauma patients who at the time of admission to the hospital, during the initial examination, were diagnosed with pneumothorax. In the study group there were 17 men and 5 women. The patients' ages ranged from 21 to 85 years (mean 48.8). In 19 cases tension pneumothorax was associated with polytrauma. Traffic accidents were the cause of most cases. Injury to one or both lungs was observed in 16 patients. Typical paradoxi- cal breathing occurred in 2 patients. The number of frac- tured ribs averaged 6.3 per patient. In each of the patients, immediately on admission, after diagnosis based on clini- cal symptoms, tension pneumothorax decompression was performed by pleural drainage. Lung decompression and improvement of the clinical condition of the patient were obtained in a few minutes after pleural drainage. Then, fur- ther diagnostic and therapeutic procedures were continued. Full time of hospitalization due to polytrauma injury was on average 58.6 days. Two patients died during treatment for polytrauma. Pneumothorax was not the cause of death in either of the patients.

CONCLUSION

In summary, the therapeutic standard ordering of tension pneumothorax decompression, directly on admission to the hospital, allows the patient to survive in spite of the grave nature of the injury.

[Anesthesiological support of surgical intervention on clavicular osteosynthesis in patients with multiple rib fractures]

In 162 patients, operated on for isolated or combined thoracic trauma with multiple fractures of ribs and clavicle, the results of treatment were compared, depending on the anesthesiological support applied. In 18 (11.1%) patients nosocomial pneumonia have had occurred, in 64 (40.0%)--a respiratory support was applied, in 84 (51.8%)--bronchofibroscopy. Application of regional anesthesia have permitted to reduce the respiratory complications rate as well as the necessity for respiratory support and the patients stay in the intensive care unit.

Complex suicide by self-stabbing with subsequent drowning in the sea

The paper presents a unique case of a complex suicide committed by a young man, mostly probably triggered by a disappointment in love. The uniqueness of the suicide lies in the fact that the victim inflicted several deep stab wounds on himself, in the chest and abdomen, while standing partly submerged in the sea and, having done so, he dropped and disappeared in the water. The postmortem examination showed, apart from deep wounds in the trunk, characteristics of drowning that manifested itself in the form of aqueous emphysema of the lungs. Suicide was clearly determined on the basis of the circumstances preceding death, the location, and arrangement of the trunk wounds and the testimony given by a witness of the incident. The circumstances preceding the suicidal act clearly suggest an underlying undiagnosed mental disorder.

[Methodological paradoxes on paradigm changes of surgical tactics in traumatic instability of sternocostal frame]

Scientific literature about the surgical tactics in traumatic instability sternocostal frame was conduct. Studies have shown that this type of trauma expediently are useful minimal invasive osteosynthesis. The original method of osteosynthesis ribs and sternum external fixation apparatus were proposed, its application promoted to significantly improved the results of treatment.

Successful treatment of flail chest with chondrosternal disruption and traumatic parasternal lung hernia with titanium rib bridges

The surgical principles for the treatment of flail chest have yet to be fully established. Furthermore, the relationship between flail chest and lung hernias is unclear. We report here a rare case of chondrosternal traumatic disruption and lung hernia that was treated with a novel technique using titanium rib bridges and clips, which successfully reduced the hernia defect and provided stability to the chest wall. This procedure was beneficial in minimising the patient's ventilation time and time away from work.

Blunt liver injury with intact ribs under impacts on the abdomen: a biomechanical investigation

Abdominal trauma accounts for nearly 20% of all severe traffic injuries and can often result from intentional physical violence, from which blunt liver injury is regarded as the most common result and is associated with a high mortality rate. Liver injury may be caused by a direct impact with a certain velocity and energy on the abdomen, which may result in a lacerated liver by penetration of fractured ribs. However, liver ruptures without rib cage fractures were found in autopsies in a series of cases. All the victims sustained punches on the abdomen by fist. Many studies have been dedicated to determining the mechanism underlying hepatic injury following abdominal trauma, but most have been empirical. The actual process and biomechanism of liver injury induced by blunt impact on the abdomen, especially with intact ribs remained, are still inexhaustive. In order to investigate this, finite element methods and numerical simulation technology were used. A finite element human torso model was developed from high resolution CT data. The model consists of geometrically-detailed liver and rib cage models and simplified models of soft tissues, thoracic and abdominal organs. Then, the torso model was used in simulations in which the right hypochondrium was punched by a fist from the frontal, lateral, and rear directions, and in each direction with several impact velocities. Overall, the results showed that liver rupture was primarily caused by a direct strike of the ribs induced by blunt impact to the abdomen. Among three impact directions, a lateral impact was most likely to cause liver injury with a minimum punch speed of 5 m/s (the momentum was about 2.447 kg.m/s). Liver injuries could occur in isolation and were not accompanied by rib fractures due to different material characteristics and injury tolerance.

Investigation of pulmonary contusion extent and its correlation to crash, occupant, and injury characteristics in motor vehicle crashes

BACKGROUND

Pulmonary contusion (PC) is a leading injury in blunt chest trauma and is most commonly caused by motor vehicle crashes (MVC). To improve understanding of the relationship between insult and outcome, this study relates PC severity to crash, occupant, and injury parameters in MVCs.

METHODS

Twenty-nine subjects with PC were selected from the Crash Injury Research and Engineering Network (CIREN) database, which contains detailed crash and medical information on MVC occupants. Computed tomography scans of these subjects were segmented using a semi-automated protocol to quantify the volumetric percentage of injured tissue in each lung. Techniques were used to quantify the geometry and location of PC, as well as the location of rib fractures. Injury extent including percent PC volume and the number of rib fractures was analyzed and its relation to crash and occupant characteristics was explored.

RESULTS

Frontal and near-side crashes composed 72% of the dataset and the near-side door was the component most often associated with PC causation. The number of rib fractures increased with age and fracture patterns varied with crash type. In near-side crashes, occupant weight and BMI were positively correlated with percent PC volume and the number of rib fractures, and the impact severity was positively correlated with percent PC volume in the lung nearest the impact.

CONCLUSIONS

This study quantified PC morphology in 29 MVC occupants and examined the relationship between injury severity and crash and occupant parameters to better characterize the mechanism of injury. The results of this study may contribute to the prevention, mitigation, and treatment of PC.

The evaluation of the treatment results in patients with a small closed pneumothorax

INTRODUCTION

The aim of this study was to analyze the methods and results of the treatment of patients with a small closed pneumothorax.

MATERIAL AND METHODS

The results of the treatment of 34 patients hospitalized for trauma in 2000-2010 due to a small closed pneumothorax were assessed. There were 23 men and 11 women. The age of the patients ranged from 20-84 years (av. 48.5). 15 patients had trauma affecting the right side, and 19 had left side trauma. In 10 cases the pneumothorax was associated with multiple trauma. In 24 cases fracture of the ribs (av. 3.4) was revealed in radiological examination. In 10 patients radiographs did not show fracture of the ribs (in 5 of these patients, a clinical trial indicated a fracture of one rib, not visible on x-ray). The size of the pneumothorax in chest radiographic anterior-posterior projection ranged from 0.5-2 cm (av. 1.2). Conservative treatment was monitored through radiological examination.

RESULTS

In 33 patients spontaneous pneumothorax resorption was observed. In one patient it was necessary to apply pleural drainage due to the enlargement of the pneumothorax and the appearance of symptoms of respiratory failure. In one case it was necessary to puncture the pleural cavity to remove a hematoma occurring along with the pneumothorax. Good results of treatment were achieved in all cases.

CONCLUSIONS

In conclusion, the conservative treatment of a small closed pneumothorax is effective in most cases.

Oblique axis body fracture--pitfalls in management

BACKGROUND

Transverse fractures through the body of the axis, rather than at the base of the odontoid are uncommon and management with an external orthosis is usually recommended. Oblique fractures through the body of the axis accompanying a hangman's fracture have not been reported and are not described as part of any classification system. Such fractures may be at high risk for treatment failure in an external orthosis.

CASE DESCRIPTION

We report on a case of an oblique axis fracture that failed treatment with external orthosis. Posterior instrumented fusion was employed successfully using a C1-C3 and C4 poly axial screw rod construct. Frameless stereotaxy and a biomodel were useful surgical adjuncts. Twelve month follow up revealed bony union in an asymptomatic patient.

CONCLUSIONS

Oblique fractures of the body of the axis can displace in a halo-thoracic orthosis. Serial radiological review is required to detect displacement prior to fracture union. Oblique fractures of the body of the axis can be managed surgically with preservation of atlanto-occipital motion, resulting in satisfactory clinical and radiological outcomes.

Lesion generation through ribs using histotripsy therapy without aberration correction

This study investigates the feasibility of using high-intensity pulsed therapeutic ultrasound, or histotripsy, to non-invasively generate lesions through the ribs. Histotripsy therapy mechanically ablates tissue through the generation of a cavitation bubble cloud, which occurs when the focal pressure exceeds a certain threshold. We hypothesize that histotripsy can generate precise lesions through the ribs without aberration correction if the main lobe retains its shape and exceeds the cavitation initiation threshold and the secondary lobes remain below the threshold. To test this hypothesis, a 750-kHz focused transducer was used to generate lesions in tissue-mimicking phantoms with and without the presence of rib aberrators. In all cases, 8000 pulses with 16 to 18 MPa peak rarefactional pressure at a repetition frequency of 100 Hz were applied without aberration correction. Despite the high secondary lobes introduced by the aberrators, high-speed imaging showed that bubble clouds were generated exclusively at the focus, resulting in well-confined lesions with comparable dimensions. Collateral damage from secondary lobes was negligible, caused by single bubbles that failed to form a cloud. These results support our hypothesis, suggesting that histotripsy has a high tolerance for aberrated fields and can generate confined focal lesions through rib obstacles without aberration correction.

Biomechanical response of ribs under quasistatic frontal loading

OBJECTIVE

The goal of the present study was to identify rib-level differences in fracture characteristics for individual ribs subjected to anterior-posterior loading.

METHODS

Twenty-seven individual ribs were extracted from levels 2 to 10 from 3 postmortem human subjects (2 females and one male) and subjected to anterior-posterior loading at a quasistatic (2 mm/s) loading rate. The ribs were placed in a fixture that provided a pinned boundary condition at each extremity, and each specimen was loaded to failure. Reaction force and strains on the internal and external cortical surfaces of the ribs were measured.

RESULTS

Rib 2 was found to be 3 to 4 times stiffer than rib 3, whereas all other ribs were comparable in stiffness to rib 3. Fracture forces, fracture displacement, and work to fracture showed no clear rib-level trends, although the young male subject consistently exhibited higher fracture force and work values than the elderly female subjects for a given rib level. The cortical strains on the external surface of the rib remained in tension during the loading, whereas the internal surface strains were in compression. The data from the present study were compared to a similar study performed at dynamic loading rates (1.43-1.85 m/s). The quasistatic tests exhibited lower peak force and greater normalized fracture displacement than the dynamic tests, though the work was comparable between the 2 studies.

CONCLUSIONS

The present study is one of the few that focuses on testing the rib as an entire structure and can contribute to understanding of how the structural behavior of an individual rib contributes to the fracture tolerance of the overall thorax when undergoing frontal loading.

Sensitivity of the WorldSID 50th and ES-2re Thoraces to Loading Configuration

An ideal injury criterion should be predictive of the risk of injury across the range of loading conditions where it may be applied. The injury risk curve associated with this criterion should be applicable to all loading conditions. With respect to side impact, the injury risk curve should apply to pure lateral or oblique loading by rigid and padded walls, as well as airbags. Trosseille et al. (2009) reported that the number of fractured ribs was higher in pure lateral impact than in forward oblique interaction with an airbag. A good dummy criterion should be able to account for this difference. To evaluate various injury criteria with the WorldSID 50 th and ES-2re dummies, the dummies were exposed to the same airbag loadings as the PMHS. The criteria measured in the dummy tests were paired with the rib fractures from the PMHS tests. Regarding the effect of configuration, results of sled tests with the 50 th percentile WorldSID (Petitjean, 2009) and ES-2re (Kuppa, 2003) have been paired with injuries found in the PMHS tested in the same conditions. The relationships obtained were compared with the relationships established in the same way for the subjects loaded in the airbag tests. Comparing the lateral and oblique lateral loading conditions, both the WorldSID and the ES-2re exhibited differences in peak lateral deflection of their ribs that were consistent with the different number of rib fractures for PMHS subjected to these loading conditions. For each dummy, the risk of rib fractures could be assessed from one injury risk curve, regardless of the loading angle. Furthermore, the same injury risk curve can be used to assess the risk of rib fractures from sled tests and airbag loading. However, because the WorldSID deflection measurements differed in the rigid and padded sled tests, it is recommended that the dummy's sensitivity to padding be further assessed prior to adopting injury risk curves for WorldSID. Rib deflections of the ES- 2re were not sensitive to padding. Finally, VC should not be considered as a valid criterion to assess the risk of rib fractures.

[Role of chest physician in the management of patient with thoracic trauma]

Thoracic traumas are frequent and potentially fatal, because of the associated neurological and abdominal lesions. They are observed in car crashes, combat environments and urban terrorist bombings. The mechanisms of the traumatic injury are complex and account for the diversity of the lesions. The management of a chest trauma patient is a model of multidisciplinary collaboration where the chest physician can make a significant contribution.

Evaluation of thoracic deflection as an injury criterion for side impact using a finite elements thorax model

This study aims to investigate the relationship between the number of rib fractures and the thoracic deflection in side impact, and in particular its variability with respect to various loading configurations. The relevance of thoracic deflection as an injury criterion depends on the existence or not of this variability. Few studies were dedicated to this issue in the literature. First, a validation database was established, which covers different impact directions (frontal, lateral and oblique), different loading types (impactor, belt and airbag), and different injury levels (from the absence of, to presence of numerous ribs fractured). The HUMOS human body model was then modified and validated versus the database. Besides the typical validation in terms of global response, particular attention was paid to validate the model with respect to the ribcage strain profile, the occurrence of rib fractures and their locations. Some key features relative to the thorax modeling (such as the connection between the ribcage and the surrounding tissues) were also investigated. Using this model, the relationship between the rib fracture and thoracic deflection was studied versus loading type. It was demonstrated that this relationship does not change significantly from one loading type to another, supporting the thoracic deflection as a relevant indicator of ribcage injury level. In addition, the relationship between the thoracic response and the test severity (such as impact velocity or distance between airbag and subject), was also established for each kind of loading. These relationships, obtained over a unique subject, are free of uncertainty relative to cadaver scattering, measurement and autopsy. They provide a consistent characterization of thoracic injuries under various test conditions and therefore, can be used to guide cadaver test protocol development and result analysis.

Optimal sensor positioning to track rib deflections from an optical system in the Hybrid III dummy

OBJECTIVES

The objective of the study was to determine the optimal use of a new optical device, the RibEye system, intended to obtain internal ribcage deflections from tests using anthropomorphic test dummies. Specifically, the study was designed to determine the most efficacious mounting location of light emitting diodes (LEDs) on the ribs and sternum in the 50th percentile male Hybrid III dummy.

METHODS

Optical signal drop-out and accuracy assessment tests were conducted. In the former series, symmetric antero-posterior chest compressive loading was accomplished using cylindrical and square indenters, and asymmetrical compressive loading was accomplished using unilateral offset and diagonal belt-type loadings. LEDs were mounted to multiple ribs bilaterally at varying locations on the ribcage. The internal chest potentiometer available in the Hybrid III dummy was used. The latter series, aimed at examining the system accuracy, consisted of tests with LEDs mounted to the 4 corners of the sternum, termed sternum-mounted LED tests; rib-mounted tests wherein LEDs were mounted either to a specific rib or in the intercostal space of two successive ribs; rib-mounted tests with rotated chest simulating oblique loading; and indenter-mounted isolated LED tests. An electro-hydraulic testing device was used to apply compressive loads via an indenter in all tests. Displacement profiles were extracted from the optical system records, drop-out evaluations were conducted, and the system accuracy was evaluated by comparing data from the indenter and/or internal chest potentiometer.

RESULTS

In general, results indicated that the RibEye system captures rib cage deformations effectively. Under symmetric loading, LEDs on the sternum responded similar to the internal chest potentiometer. The accuracy of the system depended on the location of position of the LEDs on the rib, magnitude of rib deformation, and potential interference from internal dummy structures such as the presence of the internal chest potentiometer. Optimum locations for LED placement were found to be at a distance of 9 cm, measured along the outer curvilinear path of the rib from the mid-sternum on either side. At this location, the system showed no signal drop-out at deflections representative of the United States current frontal impact Injury Assessment Reference Values. Signal drop-out was also depended on the type of loading: diagonal belt-type loading produced more signal loss. Mounting LEDs away from the center of the rib representing eccentric superior-inferior (z) axis placement also resulted in loss of accuracy.

CONCLUSIONS

These controlled evaluations provide a fundamental understanding of the performance of the system as installed in the 50th percentile male Hybrid III dummy and its ability to measure both antero-posterior and lateral components of deflections at multiple ribs, including the sternum for frontal impact applications. The system may be optimally used to gather rib deflection data without signal drop-out under symmetrical and asymmetrical loadings when LEDs are mounted on the superior-inferior centerline of the ribs with no eccentricity along the z-axis and at the 9-cm location from the mid-sternum on either side of the ribcage and at any corner on the sternum to obtain sternum deflections.

The effect of obesity on the restraint of automobile occupants

As obesity rates increase, the protection of obese occupants will become increasingly important in vehicle and restraint design. As a first step in this effort, this study seeks to compare the kinematics, dynamics, and injuries of obese post mortem human surrogates (PMHS) to (approximately) 50(th) percentile adult male PMHS in frontal impact sled tests with a force-limiting, pre-tensioning restraint system. Forty-eight km/h, frontal impact sled tests were performed with a sled buck representing the rear seat occupant compartment of a 2004 mid-sized sedan. The restraint system consisted of a 3-point belt with a pretensioner and a progressive force-limiter at the retractor. The test subjects were either obese PMHS or approximately 50(th) percentile adult male PMHS. Instrumentation included accelerometer packages on the spine. Deformation of the subjects' chests were measured using chestbands placed nominally at the superior-inferior locations of the 4(th) and 8(th) ribs. Tension in the restraint system was measured at the upper shoulder belt, lower shoulder belt, and the lap belt. Motion of the head, shoulder, pelvis, and knee were recorded using high-speed video. Two obese PMHS (average mass 137 kg, average stature 186 cm) and three approximately mid-sized male PMHS (average mass 68 kg, average stature 176 cm) were tested. The obese PMHS exhibited significantly greater forward motion of the head and the pelvis compared to the mid-sized PMHS. The obese PMHS also exhibited backwards torso rotation at the time of maximum forward excursion, whereas the mid-sized PMHS did not. The obese PMHS exhibited average maximum chest compressions of approximately 44% (+/- 9% standard deviation) of their initial chest depths, and exhibited 26 g (+/- 2 g) average 3 ms clip maximum chest resultant acceleration. In comparison, the mid-sized PMHS exhibited averages of 29% (+/- 9%) maximum chest compression and 35 g (+/- 4 g) maximum 3 ms clip chest acceleration. The obese PMHS exhibited 7 and 2 rib fractures, with maximum chest AIS scores of 3 and 2. The mid-sized PMHS exhibited 12, 2, and 17 rib fractures, with maximum chest AIS scores of 4, 1, and 4, respectively. This study is the first (to the authors' knowledge) to compare the kinematic, dynamic, and injury behaviors of obese and mid-sized PMHS in frontal impact sled tests with a force-limiting, pretensioning restraint system. The unfavorable kinematics observed with the obese PMHS highlights the difficulty of designing restraint systems to adequately restrain obese occupants, even with currently available advanced restraint technologies.

Rear seat occupant thorax protection in near side impacts

Thoracic side-airbags (SAB) have proven to protect front seat occupants in side impacts. This benefit has not been evaluated for rear seat occupants who are typically small statured. The objective was to analyze field data from rear seat occupants in near side impacts, and evaluate the effect of a SAB in the rear seat, through full scale vehicle tests. A field study using the NASS-CDS database was performed to review rear seat crash characteristics, occupant injuries (Abbreviated Injury Scale 3+, AIS3+) and injury sources. Full scale tests were performed with the side impact dummy SID-IIs at two different crash severities, with and without SAB in a midsize passenger car. Field data showed that of all AIS3+ injured restrained occupants 13 years and older, 59% had AIS3+ thoracic injuries and 38% had AIS3+ head injuries. The thoracic injuries were distributed to lungs (60%), skeletal fractures (38%) and injuries to arteries (1,26%) and heart (0,1%). For AIS3+ injured children, age 4-12, 51% had AIS3+ thoracic injuries and 54% had AIS3+ head injuries. Compared to adults, children sustained less fractures and more lung injuries. The rear side interior was the main injury source regardless of age group. In the full scale tests, the thoracic side-airbag reduced the average rib deflection by 50% and resulted in an AIS3+ injury risk reduction from 36% to 3%. At the higher impact speed, SAB reduced the injury risk from 93% to 24%. The full scale crash tests showed that SAB offer a significant potential for thoracic injury reduction in the crash severities causing the majority of serious injuries in real life crashes.