The most common pathologies in thorax traumas are multiple rib fractures, but costal cartilage fractures could be easily overlooked. To the best of our knowledge, few series that aimed specifically to diagnose and manage COSTAL CARTILAGE fractures are available in the literature[4,5].
It is difficult to detect costal cartilage fractures by ordinary X-rays in the diagnosis of costal cartilage fractures. Besides, it is also difficult to detect costal cartilage fractures by the bone window reconstruction in chest CT. Therefore, in case of violent trauma to the anterior chest wall, great importance should be attached to cross-sectional CT images to avoid missing costal cartilage fractures. In case of suspected costal cartilage fractures or if cross-sectional images suggest costal cartilage fractures, three-dimensional (3D) imaging of cartilage may be performed to show costal cartilage fractures. It is also reported in some literatures that ultrasonic diagnosis can be used to help detect costal cartilage fractures. Since bedside ultrasound can also be helpful in locating the fracture, it was also performed for the surgical localization of costal cartilage fractures before the operation.[6]
Since the 1st-7th ribs and the sternum are connected by the costal cartilage, the 8th-10th costal cartilages form a costal arch, and the 11th and 12th ribs are floating ribs, the 8th-12th costal cartilages are believed to have little impacts on the stability of the chest wall. We mainly fixed the fractures of the 1st-7th costal cartilages.[7] We chose an arc incision from the sternum to the lower margin of the pectoralis major, which could fully expose the sternum end and the rib-costal cartilage junction after the pectoralis major was dissociated, so as to obtain a good surgical field of view. At present, no literature or manufacturer’s technical document explains whether the internal fixation with plate and screw can be performed directly on costal cartilages. The technical document of Johnson & Johnson just recommends attaching the internal fixator to the bony component. Therefore, we chose to fix both ends of internal fixation materials to the surface of ribs and the sternum, respectively. [8]Meanwhile, costal cartilages were fixed with screws after reduction. In this way, the separation of the fracture site of costal cartilages could be avoided to the greatest extent, thus lowering the probability of injuring the internal mammary artery and ensuring better blood supply to the fracture site. In fokin’s paper, the plate was fixed to the costal cartilage with strapping rather than screws. Nevertheless, he did not mention the reason for this operation[9]. During our follow-up visits, all costal cartilage fractures healed well without re-displacement or bone ununion.
It has been proved in our previous studies that the fractures of multiple continuous ribs may cause severe impairment of pulmonary function (PF). [10–11]Meanwhile, it has also been proved that the internal fixation of rib fracture can significantly improve the impaired PF in the acute phase, which has also been confirmed by a great number of studies[12–14]. In this study, we confirmed that costal cartilage fractures may also cause the impaired integrity of thoracic cage.[15] Since the costal cartilage is the starting point of the connection between the sternum and ribs, a fracture and dislocation of the costal cartilage may easily lead to impaired respiratory function. Even though only a small number of (2–3) costal cartilages are fractured, the local collapse of the thoracic cage may also be caused, which may also directly lead to a severe impairment of lung function. After fracture fixation, the FVC and FEV1 of all patients were significantly improved. There were significant differences in these indicators before and after the operation (P < 0.05). Meanwhile, since the fixation reduced the stimulation of the intercostal nerve by the movement of the fracture site of ribs, patients’ pains were significantly improved by internal fixation; and there was significant difference in the pain score before and after the operation (P < 0.05).