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Costal Cartilage Injury in Acute Trauma

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Costal Cartilage Injury in Acute Trauma Costal Cartilage Injury in Acute Trauma Matthew O’Brien MD, David Spizarny, MD, Daniel T Myers, MD Department of Radiology, Henry Ford Health System, Detroit, Michigan Abstract Characterization and Trauma Score The costal cartilages, (CC’s,) which can be indicative of sex, bone age, and underlying We advocate for a simple classification scheme based on type of CC disruption, (fracture, a. b. c. systemic disease processes, 1-5 often experience the large, sudden forces of acute body separation,) location, (costochondral, midchondral, costosternal or costomanubrial,) percent trauma including that of motor vehicle collisions. Despite descriptions of the imaging displacement in terms of shaft width, and separation distance. appearances on Radiographs, Ultrasound, and Magnetic Resonance Imaging, 6,7 there is a Rib fractures play a major role in assessment of the Chest Wall Trauma Score. A summary of paucity of literature describing CC injuries on Computed Tomography. Our primary intent is this impact is in the table below: to review and characterize the spectrum of CC injuries based on a ten-year retrospective review of blunt trauma related body CT studies performed at our institution between 2003 Rib Fracture Impact on Chest Wall Trauma Score Grade I II III IV V and 2013 in which such injuries were prospectively identified. Secondly we propose a Rib Fractures < 3 closed ≥ 3 closed < 3 segment ≥ 3 segment Bilateral flail chest simple schema for characterization and classification of costal cartilage injuries based on our unilateral flail chest unilateral flail chest review. We then relate that classification system to the American Association for the Surgery *Increase one grade for bilaterality of Trauma (AAST) Chest Wall Trauma Score. Finally we demonstrate some characteristic We propose that costal cartilage injuries be considered similar to rib fractures in the chest wall imaging appearances of costal cartilage injuries, and related injuries and complications. trauma score as in our experience they appear to impart similar risks and the two often coexist. d. e. Anatomy of Ribs and Costal Cartilages Pictorial Review of injuries • Costal Cartilages are the anterior-most portions of the 7 true and 3 false costal rings. a. b. • True ribs are individually attached to the sternum via CC’s. • False ribs share a cartilaginous attachment to the sternum. • Floating ribs do not contact the sternum. • Ribs 1 and 2 are uniformly thick and quite dense, with short CC’s. • Ribs increase in length from 1-7, then decrease from 7-12. • CC’s originate from the same mesenchymal sclerotomes as their Figure 5. corresponding ribs. 8 A right costochondral separation, (a) associated with trauma. After a coughing episode, a follow up study for chest wall swelling • Each rib and CC form a ring, with most plasticity imparted by reveals a large right anterior lung herniation, (b, c, d) into the chest wall soft tissues through the cartilaginous defect. A 9 postoperative study after emergent intervention (e) demonstrates reduction of the herniated lung, with internal and external the CC’s. c. d. fixation of the chest wall. • CC’s vascularize and calcify or ossify with age in various patterns which vary somewhat predictably by sex, age and Figure 1. race. 1-5, 10, 11 Diagrammatic representation of the costal cartilages, Learning Points • Calcification is present in most 20-80 year old patients, begins (blue,) in the thoracic cage. 1, 12, 13, 14 in the third decade, and may decrease plasticity. Adapted from Gray’s Anatomy, 20th edition, 1918. • CC injuries are uncommon injuries and, in our experience, may easily be overlooked. • CC trauma commonly occurs in three locations: 1. The CC attachment to the ossified rib end, or “costochondral junction,” Methods 2. In the mid-cartilage, or “midchondral” location, or After approval by our Institutional Review Board (IRB), a retrospective review of e. f. 3. At the costosternal/costomanubrial attachment. radiology reports and CT images from the radiology archive for the prospective diagnosis of • Potential complications mimic those of rib fractures, and include: costochondral injury in patients undergoing CT scan of the thorax for trauma was performed. • Associated rib fractures and other costal cartilage injuries We used a medical search engine (Softek Illuminate, Prairie Village, KS, USA) to search a • Mediastinal hematomas 10 year time frame, (January 2003–December 2013,) in patients 18 years of age or greater. • Sternal, manubrial, clavicular, and pelvic fractures Data search utilized key phrases including “costal”, “chondral”, “cartilage” and • Pneumothorax and hemothorax “costochondral,” resulting in 44 cases. Each case was reviewed by a Radiologist with 15 • Chest wall lacerations and subcutaneous emphysema years post fellowship experience in trauma imaging to confirm the presence of costal • Greater awareness of spectrum of injuries and their appearances is intended to lead to cartilage injury. Review of the electronic medical record was conducted to determine greater recognition of this traumatic injury. Figure 4. associated injuries and complications. A Costochondral fracture of the 6th rib, (a) with associated clavicular fracture, (b) indicating high energy trauma. Displaced midchondral separations are seen in noncalcified, (c) and calcified, (d) cartilages. A mildly displaced calcified costomanubrial fracture is seen in a patient status post MVC, (e). Note the well-defined hypoattenuation through the noncalcified portion of the cartilage. In another patient, multiple contiguous midchondral cartilage Common Sites and Types of CC Injury fractures (f) are significantly displaced on this coronal view. References 1. Ontell FK, Moore EH, Shepard JA, Shelton DK. The costal cartilages in health and disease. Radiographics. 1997;17(3):571-7. 2. Moskovitch G, Dedouit F, Braga J, Rougé D, Rousseau H, Telmon N. Multislice computed tomography of the first rib: a useful technique Figure 1: Distribution by Location 18 Figure 2: Distribution of Injuries for bone age assessment. J Forensic Sci. 2010;55(4):865-70. 16 3. Navani S, Shah JR, Levy PS. Determination of sex by costal cartilage calcification. Am J Roentgenol Radium Ther Nucl Med. 60 Associated Injuries / Complications 1970;108(4):771-4. 14 50 4. Rao NG, Pai LM. Costal cartilage calcification pattern--a clue for establishing sex identity. Forensic Sci Int. 1988;38(3-4):193-202. 12 Rib Fractures Most associated injuries observed in our case series were also associated with rib fractures. 5. Rejtarová O, Slízová D, Smoranc P, Rejtar P, Bukac J. Costal cartilages--a clue for determination of sex. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2004;148(2):241-3. 40 10 CI's The frequency of such injuries included rib fractures, (seen in 50% of cases,) additional CC 6. Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib 30 8 fracture. AJR Am J Roentgenol. 1999;173(6):1603-9. injuries, (48%,) mediastinal hematomas, (32%,) sternal/manubrial fractures, (22%,) chest wall 7. Subhas N, Kline MJ, Moskal MJ, White LM, Recht MP. MRI evaluation of costal cartilage injuries. AJR Am J Roentgenol. 20 Number Injuries of 6 Percent Injuries of 2008;191(1):129-32. 4 hematoms, (18%,) pneumothoraces, (20%,) hemothoraces, (9%,) chest wall lacerations, (9%,) and 10 8. Huang R, Zhi Q, Schmidt C, Wilting J, Brand-saberi B, Christ B. Sclerotomal origin of the ribs. Development. 2000;127(3):527-32. 2 clavicular fractures, (7%.) 9. Lau A, Oyen ML, Kent RW, Murakami D, Torigaki T. Indentation stiffness of aging human costal cartilage. Acta Biomater. 2008;4(1):97- 0 103. 0 CCh MC CS/CM In a few unique cases, there were late complications as well, as in one particular case in which 10. Kampen WU, Claassen H, Kirsch T. Mineralization and osteogenesis in the human first rib cartilage. Ann Anat. 1995;177(2):171-7. 1 2 3 4 5 6 7 8 9 10 11 12 Type of Injury 11. Sunwoo WS, Choi HG, Kim DW, Jin HR. Characteristics of rib cartilage calcification in Asian patients. JAMA Facial Plast Surg. Rib Number multiple small chondral separations, (figure 5,) when combined with contralateral rib fractures, 2014;16(2):102-6. Figure 2. Figure 3. functioned as a flail segment and resulted in a dramatic lung herniation which required surgical 12. Lau AG, Kindig MW, Kent RW. Morphology, distribution, mineral density and volume fraction of human calcified costal cartilage. Acta The distribution of injuries roughly follows the distribution of rib Biomater. 2011;7(3):1202-9. Most injuries are costochondral, (CCh,) closure. 13. Forman JL, Kent RW. The effect of calcification on the structural mechanics of the costal cartilage. Comput Methods Biomech Biomed followed by midchondral, (MC,) then fractures in the same group of patients. Notably, the frequency of both Engin. 2014;17(2):94-107. costosternal and costomanubrial, (CS/CM.) cartilaginous injuries (CI’s,) and rib fractures by location is directly 14. Lucet L, Le loët X, Ménard JF, et al. Computed tomography of the normal sternoclavicular joint. Skeletal Radiol. 1996;25(3):237-41. correlated with rib length; increasing in frequency from ribs 1-7, and 15. Graeber GM, Nazim M. The anatomy of the ribs and the sternum and their relationship to chest wall structure and function. Thorac Surg decreasing from 7-12. Clin. 2007;17(4):473-89, vi..
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