{
  "abstract": "Background Costosternal cartilages and the costal margin, collectively termed costal cartilage, are hyaline cartilage connecting ribs to the sternum and to adjacent ribs, respectively. Presence of intact costal cartilage is essential for elasticity of the chest wall. Anecdotally, costal cartilage injuries are underdiagnosed on trauma CT scan in patients with rib fractures. Our aim was to determine a baseline frequency of acute costal cartilage injury among patients presenting with rib fractures.Methods We performed a retrospective cohort study of injured adult patients admitted to Level I/II trauma centers with rib fractures from January 2020 to July 2024. CT images obtained at admission were manually reviewed by chest wall surgeons for presence of costal cartilage injury. Concordance with the original radiology report was obtained. Multivariable regression was used to analyze factors associated with costal cartilage injury and missed cartilage fractures.Results 1441 patients were identified; 197 (14%) had a costal cartilage fracture. A plurality of injuries included falls (n=667, 46%). Median ISS (Injury Severity Score) was 13 (IQR: 9 to 21), median Abbreviated Injury Scale thorax score was 3 (IQR: 3 to 3), and median number of fractured ribs was 3 (IQR: 3 to 7). 294 (21%) patients had radiographic flail segments, and 136 (9%) had sternal fractures. 172 (87%) patients had a costal cartilage fracture missed on initial trauma chest CT. On multivariable analysis, ISS (adjusted OR (aOR) 1.02 (95% CI 1.01 to 1.04), radiographic flail segment (aOR 1.6 (95% CI 1.10 to 2.31)) and presence of sternal fracture (aOR 1.85 (95% CI 1.19 to 2.89)) were associated with costal cartilage fractures. Only the total number of rib fractures was associated with a missed costal cartilage fracture on univariate analysis (OR 1.17 (95% CI 1.01 to 1.36)).Conclusions Costal cartilage injuries are common and frequently are not identified during interpretation of the initial trauma CT. A higher index of suspicion is warranted for costal cartilage fractures among patients with greater injury burden, radiographic flail segment, and sternal fractures.Level of evidence Level III.",
  "authors": [
    {
      "affiliations": [
        "Stanford, Stanford, California, USA"
      ],
      "name": "Joseph D Forrester"
    },
    {
      "affiliations": [
        "Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, Minnesota, USA"
      ],
      "name": "Mohamad Abou Chaar"
    },
    {
      "affiliations": [
        "Atrium Health Navicent, Macon, Georgia, USA"
      ],
      "name": "Andrew T Barnes"
    },
    {
      "affiliations": [
        "Acute Care Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA"
      ],
      "name": "Zachary M Bauman"
    },
    {
      "affiliations": [
        "Stanford, Stanford, California, USA"
      ],
      "name": "Samy Bendjemil"
    },
    {
      "affiliations": [
        "Landstuhl Regional Medical Center, Landstuhl, Germany"
      ],
      "name": "Nizama N Betts"
    },
    {
      "affiliations": [
        "Mercer University School of Medicine, Macon, Georgia, USA"
      ],
      "name": "Benjamin Christie"
    },
    {
      "affiliations": [
        "University of Nebraska Medical Center, Omaha, Nebraska, USA"
      ],
      "name": "Raaga Dasari"
    },
    {
      "affiliations": [
        "Riverside Methodist Hospital, Columbus, Ohio, USA"
      ],
      "name": "Devoe WB"
    },
    {
      "affiliations": [
        "Division of General Surgery, Stanford University, Stanford, California, USA"
      ],
      "name": "Michelle J Earley"
    },
    {
      "affiliations": [
        "HonorHealth Scottsdale Osborn Medical Center, Scottsdale, Arizona, USA"
      ],
      "name": "Bradley Faliks"
    },
    {
      "affiliations": [
        "Atrium Health Navicent, Macon, Georgia, USA"
      ],
      "name": "Tracy J Johns"
    },
    {
      "affiliations": [
        "Landstuhl Regional Medical Center, Landstuhl, Germany"
      ],
      "name": "Connie Johnson"
    },
    {
      "affiliations": [
        "Mayo Clinic, Rochester, Minnesota, USA"
      ],
      "name": "Michelle S Junker"
    },
    {
      "affiliations": [
        "Mayo Clinic, Rochester, Minnesota, USA"
      ],
      "name": "Brian D Kim"
    },
    {
      "affiliations": [
        "Stanford, Stanford, California, USA"
      ],
      "name": "Jonathan M King"
    },
    {
      "affiliations": [
        "Department of Surgery, Stanford University, Stanford, California, USA"
      ],
      "name": "Ariel Whitney Knight"
    },
    {
      "affiliations": [
        "Riverside Methodist Hospital, Columbus, Ohio, USA"
      ],
      "name": "Alexis A Schweibinz"
    },
    {
      "affiliations": [
        "Mayo Clinic, Rochester, Minnesota, USA"
      ],
      "name": "Daniel Stephens"
    },
    {
      "affiliations": [
        "Landstuhl Regional Medical Center, Landstuhl, Germany"
      ],
      "name": "Mary Stuever"
    },
    {
      "affiliations": [
        "Department of Surgery, Stanford University, Stanford, California, USA"
      ],
      "name": "Simeng Wang"
    }
  ],
  "title": "Lost fractures: prevalence and risk factors for missed costosternal and costal cartilage fractures among patients with radiologic chest wall injury",
  "uid": "6b02b138-f8a8-593d-876d-36e8a497724b"
}