Abstracts journal "Polytrauma" 3/2015

Secondary care organization

THE HEALTH OF THE WORKING POPULATION

IN NOVOKUZNETSK FOR 2008-2014
Zhilina N. M.

Zhilina N. M.

Novokuznetsk State Institute of Postgraduate Medicine,

Novokuznetsk, Russia

The issue of preservation of health in the workers in a large industrial center of Siberia with developed mining and metals industry is relevant and it requires detailed study.

Objective – to identify the main trends and patterns of health status in the working population of a large industrial city in Siberia (on the example of Novokuznetsk).
Results. The health of the workers of Novokuznetsk is evaluated using the integral index – health index, which includes overall morbidity (outpatient and inpatient), temporary disability, health assessment, disability and mortality in working individuals, as well as the indicators of demographic burden in the working population.
According to the research results we make the conclusion about the existence of the natural associations between health of the workers, working conditions and some indicators of health.
Conclusion. It is necessary to implement the complex measures for improving the existing situation at the level of state, regional and municipal government.
Key words: workers’ health; trends; integrated indicators; patterns of associations.

Materials and methods. The study was conducted on the basis of the information of Kustovoy medical information-analytical center for the years 2008-2014. The information about the population structure of Novokuznetsk was obtained from the Territorial Department of State Statistics.

For 2008-2014 one could observe the decreasing indicators of temporary incapacity, disability, and mortality in Novokuznetsk. At the same time, among the persons working in Novokuznetsk we revealed an increase in morbidity according to addressing to the medical institutions. Since 2010 we registered the increasing morbidity and injury rate in the workers; as for health status according to chronic diseases, we observed the growth in the amount of recurrent (most severe) disability groups, the increase in the number of readmissions, a very low percentage of admitted patients by referrals from outpatient services, and the high percentage of suicides.

Information about author:

Zhilina N.M., Doctor of Engineering Science, professor of chair of medical cybernetics and informatics, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Address for correspondence:

Zhilina N.M., Prospect Stroiteley, 5, Novokuznetsk, Kemerovo region, Russia, 654005

Novokuznetsk State Institute of Postgraduate Medicine

Tel: +7 (3843) 45-83-11; +7 (913) 323-31-49

E-mail: zhilina.ngiuv@yandex.ru

REFERENCES

1. News of occupational safety. http: www.znakcomplect.ru/news/example - Home (accessed 1.09.2010). Russian

2. Chechenin GI, Zhilina NM, Saprykina TV, Netage TG, Ruzaev YuV, Kozlova NA Conceptual and organizational-methodological approaches to the creation of social-hygienic monitoring the health of the population and habitat as a tool for making evidence-based decisions. Doctor and Information Technologies. 2004; (6): 20-31. Russian

3. Chechenin GI, Zhilina NM, Yunusova VA, Rychehova NM. Automated information system "Health Monitoring in Workers" . In: Launch Complex. Novokuznetsk, 2008. 27 p. Russian

4. Pishchalnikova TS, Yunusova VA, Saprykina TV, Mirsaburova LA. The Concept of creating and maintaining a database of calculation indices. Novokuznetsk, 1996. 121 p. Russian

5. Zhilina NM. An algorithm for integration of indicators for application to an automatic information system for social hygienic monitoring. Informatics and Control Systems. 2009; 4(22): 150-152. Russian

New medical technologies

Tactics of staged surgical treatment of spine and spinal cord injury in polytrauma

Yakushin O.A., Pronskikh Al.A., Novokshonov A.V., Fedorov M.Yu.

Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia

Objective – to optimize tactics of staged surgical treatment of spine and spinal cord injuries in polytrauma.

Materials and methods. The materials are based on treatment for 63 patients with dominating or concurrent injuries to the spine and the spinal cord in polytrauma. After complex examination the following combinations of injuries were found: a spine and spinal cord injury (SSCI) and traumatic brain injury (TBI) – 13 (20.6 %); SSCI and thoracic injury – 13 (20.6 %), SSCI, TBI and skeletal injury – 7 (11.2 %), SSCI and abdominal injury – 1 (1.6 %), SSCI, TBI, skeletal, thoracic and abdominal injuries – 29 (46 %). According to our common concept of medical assistance we carried out surgical treatment for 61 patients with polytrauma who received 150 prescribed surgeries for different anatomic locations in terms of identified combinations of injuries.

Results. Tactics of surgical treatment for patients with polytrauma consists in strict adherence to a diagnostic algorithm and substantiated sequence of surgical interventions with intensive care. The first stage (within 6 hours) includes emergent surgical interventions for elimination of life-threatening states (severe traumatic brain injury, thoracic and abdominal injuries with ongoing bleeding). During the following 3 days delayed interventions are realized (primary reconstructive operations for the spine and the spinal cord, osteosynthesis for skeletal injuries).

Conclusion. Realization of emergent surgical interventions for elimination of life-threatening states within the first 6 hours and delayed operations within 3 days for patients with spine and spinal cord injuries in polytrauma allowed reducing duration of artificial lung ventilation and hospital stay, with 65.3 % of satisfactory and good functional outcomes.

Key words: polytrauma; spinal injury; spinal cord injury; chest injury; surgical tactics.

Information about authors:

Yakushin O.A., candidate of medical science, traumatologist-orthopedist, neurosurgery department #2, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Pronskikh Al.A., traumatologist-orthopedist, department of traumatology and orthopedics #1, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Novokshonov A.V., MD, PhD, head of neurosurgery department #2, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Fedorov M.Yu., candidate of medical science, head of neurosurgery department #1, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Yakushin O.A., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, 652509

Tel: +7 (384-56) 2-40-16

E-mail: avn1952@rambler.ru

REFERENCES:

1. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Novokshonov AV, Agalaryan AKh. Polytrauma. Septic complications. Novosibirsk : Nauka Publ., 2005. 391 p. Russian

2. Gumanenko EK, Kozlov VK. Polytrauma: traumatic disease, immune dysfunction, a modern strategy of treatment. Moscow : GEOTAR Media Publ., 2008. 608 p. Russian

3. Stepanov GA. New methods of reconstructive microsurgery for severe injuries to the spinal cord. Moscow : SCIENCE-PRESS Publ., 2011. 120 p. Russian

4. Samokhvalov IM, Badalov VI, Petrov AN, Rud AA, Grebnev DG, Petrov YuN. The causes of complications and unsatisfactory outcomes in severe concomitant spinal injuries in level I trauma center. Infection in Surgery. 2012; 10 (3): 12-16. Russian

5. Shchedrenok VV, Yakovenko IV, Moguchaya OV. The clinical organizational aspects of concomitant traumatic brain injury. Saint Petersburg : The publishing office by Polenov Neurosurgery Institute, 2010. 435 p. Russian

6. Gumanenko EK, Samokhvalov IM. Military field surgery of local wars and armed conflicts. Moscow : GEOTAR Media Publ., 2011. 672 p. Russian

7. Concomitant mechanical injury : the manual for doctors. Tulupov AN, editor. Saint Petersburg : Stiks Publ., 2012. 393 p. Russian

8. Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R, Stombaugh HA. Perils of rib fractures. Am. Surg. 2008; 74 (4): 310-314.

9. Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J. Trauma Acute Care Surg. 2014; 76: 462-468.

10. Sharipova IA. Polytrauma. V. 1: The general and intrathoracic complications. Moscow : RAMS Publ., 2008. 296 p. Russian

11. Shchedrenok VV, Dorovskikh GN, Moguchaya OV, Anikeev NV, Sebelev KI, Yakovenko IV. Clinical radial diagnostics of isolated and concomitant traumatic brain injury. Saint Petersburg : Publishing office by Polenov Neurosurgery Institute, 2012. 448 p. Russian

Anesthesiology and critical care medicine

INTERCOMMUNICATION OF INDEXES OF CARDIOVASCULAR SYSTEM AND ENDOTHELIAL DYSFUNCTION IN PATIENTS WITH TRAUMATIC SHOCK

Stukanov M.M., Yudakova T.N., Maksimishin S.V., Girsh A.O.

Omsk Emergency Aid Station,

Kabanov City Clinical Hospital #1,

City Clinical Hospital of Emergency Medical Aid #1,

Omsk State Medical Academy,

Omsk, Russia

Objective – to reveal an associativity of parameters of central hemodynamics and vascular endothelial function at the background of its morphological assessment in patients with traumatic shock.

Materials and methods. The research included 50 patients with traumatic shock of 3rd degree who were distributed into two groups. The indexes of central hemodynamics and vascular endothelial function were estimated at the background of morphological assessment with subsequent conduction of statistical analysis of the received results.

Results. It was revealed that in the patients with traumatic shock of 3rd degree the fundamental pathogenetic factor defining hemodynamic violations was hypovolemia of absolute (owing to acute hemorrhage) and relative (due to development of endothelial failure) origin which played a key role in development of organ and systemic violations.

Conclusion. Traumatic shock of degree III is hypovolemic owing to its origin, but also redistributive.

Key words: traumatic shock; indexes of central hemodynamics and of vascular endothelial function.

Information about authors:

Stukanov M.M., candidate of medical science, head physician, Omsk Emergency Aid Station, Omsk, Russia.

Yudakova T.N., candidate of medical science, head of department of resuscitation and intensive care, Omsk Emergency Aid Station, Omsk, Russia.

Maksimishin S.V., candidate of medical science, deputy head physician of anesthesiology and resuscitation, Kabanov City Clinical Hospital of Emergency Medical Aid #1, Omsk, Russia.

Girsh A.O., MD, PhD, professor of chair of anesthesiology and critical care medicine, Omsk State Medical Academy, Omsk, Russia.

Address for correspondence:

Yudakova T.N., Pereleta St., 7, building 3, 48, Omsk, Russia, 644112

Tel: +7 (950) 339-10-02

E-mail: tatyudakova@mail.ru

REFERENCES

1. Intensive therapy: national guidelines. B. R. Gelfand editors. Moscow : Medicine Publ., 2009. 954 ð. Russian

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3. Rebrova OYu. Statisticheski analysis of medical data: application of a package of the applied STATISTICA programs. Moscow : Medicine Publ., 2006. 305 ð. Russian.

4. Mehta D, Malik AB. Signaling mechanisms regulating endothelial permeability. Physiological Reviews. 2006; 86: 279-367.

5. Ait-Oufella H, Maury E, Lehoux S, Guidet B, et al. The endothelium: physiological functions and role in microcirculatory failure during severe sepsis. Intensive Care Med. 2010; 36 (8): 1286-1298.

6. Reitsma S, Slaaf DW, Vink H, van Zandvoort MA, et al. The endothelial glycocalyx: composition, functions, and visualization. Pflugers Arch. 2007; 454: 345–359.

7. Malcova OG, Medvedeva SYu, Leiderman IN. Interrelation of violations of a lipidic exchange and endotelial dysfunction in patients with heavy sepsis. Messenger of the Ural Medical Academic Science. 2012; (3): 17-22. Russian

8. Yudakova TN, Girsh AO, Maksimishin SV. The relationship of indexes of cardiovascular system and endothelial dysfunction in patients with hemorrhagic shock. Anesthesiology and Reanimatology. 2013; (6): 11-14. Russian

COMPARATIVE ANALYSIS AND CORRECTION

OF microcirculatory disorders in ISOLATED SEVERE brain injury And POLYTRAUMA

Kan S.L., Churlyaev Yu.A., Kosovskikh A.A., Fomkin O.G., Dantsiger D. G.

Novokuznetsk State Institute of Postgraduate Medicine,

Novokuznetsk, Russia

Objective – to compare the changes in microcirculation in critical conditions caused by isolated severe brain injuries and polytrauma to develop a differentiated approach to intensive care.

Materials and methods. The examination included 138 patients with severe trauma. The patients were divided into 2 groups: basic – 82 victims, and the intervention group – 56 injured patients. Inside the main and intervention groups the patients were divided into 2 subgroups according to the localization of traumatic injury: the subgroup 1 – 34 patients with severe TBI of the main group, the average age – 44.8 ± 1.8; the subgroup 1a – 20 patients with severe TBI in the intervention group, the average age – 43.6 ± 2.2; the subgroup 2 – 48 victims of the main group with polytrauma, the average age – 42 ± 2.8; the subgroup 2a – 36 victims in the intervention group with polytrauma, the average age – 42.5 ± 3. Microcirculation was evaluated with cutaneous laser doppler flowmetry, which was carried out with the laser analyzer for capillary blood flow "LAKK-02" (LASMA, Russia). At the same time we took blood samples for examination of structural and functional state of the endothelium. The control group consisted of 35 healthy volunteers, the mean age – 42.1 ± 1.2. The duration of follow-up was 7 days.

Results. Microcirculatory disorders in polytrauma differed from the same disorders in isolated traumatic brain injury in terms of basic early posttraumatic decrease in peripheral tissue perfusion in case of identical response to an injury from the part of modulators of microcirculatory bed and vasoconstrictive activity of the endothelium. Early goal-oriented correction of microcirculatory disorders allows improving tissue perfusion in severe traumatic injuries.

Conclusion. The results of microcirculatory disorders in severe traumatic injuries indicate that the complex of intensive therapy must be differentiated, with consideration of functional changes in microcirculation.

Key words: polytrauma; isolated severe head injury; microcirculation; endothelium.

Information about authors:

Kan S.L., candidate of medical science, docent of chair of anesthesiology and critical care medicine, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Churlyaev Yu.A., MD, PhD, head of chair of anesthesiology and critical care medicine, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Kosovskikh A.A., candidate of medical science, assistant of chair of anesthesiology and critical care medicine, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Fomkin O.G., candidate of medical science, assistant of chair of anesthesiology and critical care medicine, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Dantsiger D.G., MD, PhD, head of chair of healthcare organization and public health, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Address for correspondence:

Kan S.L., Prospect Stroiteley, 5, Novokuznetsk, Russia, 654057

Tel: +7 (923) 628-60-73

Å-mail: kansergey1980@mail.ru

REFERENCES

1. Sallisalmi M. Microcirculation and hemorheology in critically-ill patients. Academic dissertation. Unigrafia. Helsinki. 2013. 104 p.

2. Polenov SA. Fundamentals of microcirculation. Regional Circulation and Microcirculation. 2008; 7: (1(25)) : 5-19. Russian

3. Moroz VV, Bobrinskaja IG, Vasilyev VYu, et al. SHOCK. A teaching aid for students, residents, postgraduate students and doctors. Moscow, 2011. 31 p. Russian

4. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

5. Guidelines for Anesthesiology and Intensive Care. Edited by Polushin YuS. Saint Petersburg, 2004. 919 p. Russian

6. Bagnenko SF, Shakh BN, Lapshin VN, et al. Using Doppler flowmetry to assess microcirculation in patients with severe mechanical trauma. Anesthesiology and Intensive Care. 2003; (6): 15-18. Russian

7. Moroz VV, Churlyaev YuA. The secondary brain damage in severe traumatic brain injury. Moscow, 2006. 258 p. Russian

8. Churlyaev YuA, Verein MYu, Dantsiger DG, et al. Microcirculatory disorders, intracranial and cerebral perfusion pressure in severe traumatic brain injury. General Reanimatology. 2008; IV (5): 5-9. Russian

9. Verein MYu. General patterns of microcirculation and their correction in severe traumatic brain injury. Cand. med. sci. abstracts diss. Moscow, 2010. 24 p. Russian

10. Chuyan EN, Ananchenko MN. Individually-typological approach to the study of the processes of blood microcirculation. Scientific Notes of Taurida National University named after V.I. Vernadsky, a series of "Biology, Chemistry". 2009; 22 (3): 159-173. Russian

11. Krupatkin AI, Sidorov VV. Laser Doppler flowmetry of microcirculation. Moscow: Medicine, 2005. 415 p. Russian

12. Rebrova OYu. Statistical analysis of medical data. Application of software package STATISTICA. Moscow: Mediasphere, 2002. 312 p. Russian

13. Yakovlev AYu. Reamberin in the practice of infusion therapy for critical states: the practical advices. St. Petersburg, 2008. 54 p. Russian

14. Moroz VV, Gerasimov LV, Isakovà AA, et al. Effect of different infusion solutions for microbiology. General Reanimatology. 2010; (6): 5-11. Russian

Clinical aspects of traumatology and orthopedics

SURGICAL TREATMENT OF IMPROPERLY CONSOLIDATED FRACTURES OF DISTAL metaepiphysis OF THE RADIAL BONE

Istomin M.V., Ardashev I.P., Ivanov A.V., Zenin V.I., Shpakovsky M.S.

Podgorbunsky City Clinical Hospital #3,

Kemerovo State Medical Academy,

Department of public health of Kemerovo region,

Gorbunova City Clinical Hospital #1, Kemerovo, Russia

Objective – to estimate the results of surgical treatment in patients with improperly consolidated fractures of distal metaepiphysis of the radial bone.

Materials and methods. 72 patients (mean age of 50, 40 women and 32 men) received treatment of the improperly consolidated fractures of distal metaepiphysis of the radial bone. The time intervals from an injury to surgery were from 6 weeks till 4 months. The indications to surgery were pain syndrome, decrease in grip strength, deformation and decreasing range of motions in the radiocarpal joint. Surgical treatment included corrective osteotomy, open reposition, fixation with T-shaped AO angle stability locked plates, and replacement of radial bone defects to bone substitute Chronos or an autograft from the iliac wing. The results of treatment were estimated with NTF questionnaire and SF-36. The results were studied in 65 patients with follow-up period up to 6 months.

Results. After the period of 1 or 2 months after treatment with corrective osteotomy and Chronos bone substitute the main values of functional capacity of the hand and health-related quality of life were restoring better in comparison with the values after corrective osteotomy with an autograft for bone defects. The signs of deforming arthrosis of the hand joint were noted in 3 cases. 47 patients (72.5 %) demonstrated excellent results, 11 patients (17.5 %) – good results, 7 (10 %) – satisfactory ones.

Conclusion. Corrective osteotomy for improperly consolidated fractures of distal metaepiphysis of the radial bone by means of Chronos bone filler and fixation with T-shaped angle stability locked plate provides stable fixation, decreases injury rate and duration of surgery, and promotes quality of patients’ life in early postsurgical period.

Key words: distal metaepiphysis of the radial bone; corrective osteotomy; bone plastics.

Information about authors:

Istomin M.V., traumatologist-orthopedist, Podgorbunsky City Clinical Hospital #3, Kemerovo, Russia.

Ardashev I.P., MD, PhD, professor, head of chair of traumatology, orthopedics, field surgery, rehabilitation, anesthesiology and resuscitation, Kemerovo State Medical Academy, Kemerovo, Russia.

Ivanov A.V., first deputy chief, department of public health of Kemerovo region, Kemerovo, Russia.

Zenin V.I., Gorbunova City Clinical Hospital #1, Kemerovo, Russia.

Shpakovsky M.S., postgraduate, chair of traumatology, orthopedics, field surgery, rehabilitation, anesthesiology and resuscitation, Kemerovo State Medical Academy, Kemerovo, Russia.

Address for correspondence:

Shpakovsky M.S., Prospect Shakhterov, 68-85, Kemerovo, Russia, 650002

Tel: +7 (904) 994-06-60

E-mail: 89049940660@rambler.ru

REFERENCES:

1. Arora R. A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patient older than 70 years: non-operative treatment versus volar locking plating. J. Orthop. Trauma. 2009; 23 (4): 237-242.

2. Semenkin OM, Izmalkov SN, Ivanov MA Corrective osteotomy of the distal radius metaepiphysis for improperly fused fractures. Bulletin of Traumatology and Orthopedics named after NN Priorov. 2006; (2): 85-88. Russian

3. Semenkin OM, Izmalkov SN. A way of correcting posttraumatic deformities of the distal radial metaepiphysis. Traumatology and Orthopedics of Russia. 2010; (4): 78-83. Russian

4. Prommersberger KJ, Ring D. Corrective osteotomy for Intra-Articular Malunion of the Distal Part of the Radius. J. Bone and Joint. Surg. 2006; (88-A): 202-211.

5. Golubev IO, Krupatkin AI, Maksimov AA, Merkulov MV, Bushuyev OM, Shiryaeva GN, et al. Surgical treatment of improperly fused fractures of the distal metaepiphysis of the radius. Bulletin of Traumatology and Orthopedics. 2013; (3): 51-59. Russian

6. Wada T, Tatebe M, Ozasa Y, Sato O, Sonoda T, Hirata H, et al. Clinical outcomes of corrective osteotomy for distal radial malunion: a review of opening and closing-wedge techniques. J. Bone Joint Surg. (Am). 2011; 93 (17): 1619-26.

7. Zollinger ÐÅ, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin Ñ prevent complex regional pain syndrome in ðàtients with wrist fractures? À randomized, controlled, multicenter dose-response study. J. Âînå Joint Surg. (Am). 2007; (89): 1424-1431.

8. Cazeneuve JF, Leborgne JM, Kermad K, Hassan Y. Vitamin C and prevention of reflex sympathetic dystrophy following surgical management of distal radius fractures (French). Acta Orthop. Belg. 2002; (68): 481-484.

9. Hudak P, Amadio PC, Bombardier C, the Upper Extremity Collaborative Group. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand). American Journal of Industrial Medicine. 1996; (29): 602-608.

10. Ware JE. Measuring patients views: the optimum outcome measure.SF-36: a valid, reliable assessment of health from the patients point of view. BMJ. 1993; 306: 1429-1430.

11. Ring D, Roberge C, Morgan T, Jupiter JB. Osteotomy for malunited fractures of distal radius: a comparison of structural and structural autogenous bone graft. J. Hand Surg. Am. 2002; 27 (2): 216-222.

12. Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal radial end of the radius. J. Bone and Joint Surg. (Am). 1996; 78: 739-748.

13. Ardashev IP, Grigoruk AA, Plotnikov GA. Possible complications after taking graft from the iliac wing. In: Modern Technologies in Traumatology and Orthopedics. Moscow, 1999. p. 191-192. Russian

Functional, instrumental and laboratory diagnostics

DIAGNOSTICS OF CRANIOCEREBRAL AND EXTRACRANIAL DAMAGES IN POLYTRAUMA FROM THE STANDPOINT OF EVIDENCE-BASED MEDICINE

Shchedrenok V.V., Moguchaya O.V., Potemkina E.G., Kotov M.A., Sebelev K.I.

North Western Medical Research Center, Saint Petersburg, Russia

The frequency of polytrauma all over the world has a tendency to increase and the modern concept in its treatment at all stages is to provide medical care in an adequate volume and pace, outrunning the development of pathological processes in organs and systems affected.

Objective – to investigate the features of diagnostics of craniocerebral and extracranial damages in polytrauma from the standpoint of evidence-based medicine.

Materials and methods. The retrospective analysis included 1,903 victims with polytrauma. The proportion of various radiologic examinations differed. MSCT research included examination of the brain, facial skeleton, the cervical and thoracic spine, chest organs and pelvic bones in 23% of the victims. In 18% of the cases X-ray examination was used that conditioned by the considerable proportion of the fractures of the bones of the extremities.

Results. Owing to the features of the clinical course of polytrauma within 3 hours after admission, some damages were not diagnosed in 19 % of the patients: fractures of bones of the arch and basis of the skull, the pelvis and the backbone, multiple fractures of ribs, fractures of the scapula, lung contusion and hemothorax.

The average time spent for research of one patient during CT of the head and the cervical spine was 14.5 ± 3.5 min.; moreover, MSCT demonstrates high informational capacity. The process of MSCT research of the head, cervical, chest and lumbar departments, and the pelvis took 30.5 ± 3.5 min at average.

Conclusion. The clinical feature of polytrauma is development of syndromes of mutual burdening and overlapping, and various cerebral and somatic pseudosyndromes that significantly complicate diagnostics. The feature of a choice of radial methods for polytrauma is expediency of use of MSCT owing to a combination of short duration of an examination (on the average no more than 30.5 ± 3.5 min) and its high informational content (sensitivity 95.2 %, specificity 95.8%, accuracy 95.6 %), and at suspicion on an injury to extremities – X-ray.

Key words: craniocerebral trauma; extracranial damages; polytrauma; algorithm of diagnostics; reliability of the study.

Information about authors:

Shchedrenok V.V., MD, PhD, professor, senior researcher, North Western Medical Research Center, Saint Petersburg, Russia.

Moguchaya O.V., MD, PhD, professor, senior researcher, North Western Medical Research Center, Saint Petersburg, Russia.

Potemkina E.G., candidate of medical science, PhD candidate, North Western Medical Research Center, Saint Petersburg, Russia.

Kotov M.A., postgraduate, North Western Medical Research Center, Saint Petersburg, Russia.

Sebelev K.I., MD, PhD, head of diagnostic department, North Western Medical Research Center, Saint Petersburg, Russia.

Address for correspondence:

Shchedrenok V.V., Pestelya St., 10-34, Saint Petersburg, Russia, 191028

Tel: +7 (921) 656-14-48

E-mail: ovm55@yandex.ru

REFERENCES

1. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Kravtsov SA, Novokshonov AV, Agalaryan AKh, et al. Polytrauma. Emergency Aid and Transportation. Novosibirsk : Nauka Publ., 2008. 320 p. Russian

2. Gumanenko EK, Samokhvalov IM. Field surgery of local wars and armed conflicts. Moscow : GJeOTAR-Media, 2011. 672 p. Russian

3. Kalinichev AG, Mamontov VV, Shchedrenok VV. Severe cranio-thoracic trauma. Clinical and organizational aspects of prehospital and early hospital stages. Omsk: IP Zagursky S.B., 2011. 188 p. Russian

4. Shchedrenok VV, Dorovskikh GN, Moguchaya OV, Anikeev NV, Sebelev KI, Iakovenko IV. Clinic and beam diagnostics of isolated and combined traumatic brain injury. St. Petersburg, 2012. 456 p. Russian

5. Global status report in road safety. Geneva : World Health Organization, 2013. 318 p.

6. Pape HC, Peitzman AB, Schwab CW, Giannoudis PV. Damage control management in the polytrauma patient. NY; Dordrecht; Heidelberg; London: Springer Verlag, 2010. 463 p.

7. Dorovskikh GN. Radiologic diagnosis of polytrauma. Dr. med. sci. abstracts diss. Moscow, 2014. 45 p. Russian

8. Lumenta ChB, Rocco CD, Haase J, Mooiy JJ. Neurosurgery. European Manual of Medicine: in 2 volumes: transl. from engl. – Moscow: Panfilov, BINOM. Knowledge lab, 2013. Vol. 1. 392 p. Russian

9. Potapov AA, Likhterman LB, Zelman VL, Kornienko VN, Kravchuk AD. Evidence-based neurotraumatology. A guide for physicians. Moscow: Andreeva T.M., 2003. 517 p. Russian

10. Hosten N, Liebig T. Computed tomography of the head and spine : transl. from germ. Moscow: Medpress-inform, 2013. 576 p. Russian

11. Ternovoy SK. Fundamentals of radiation diagnostics and therapy. National leadership. Moscow: GEOTAR-Media, 2012. 992 p. Russian

12. Zakharova NE, Kornienko VN, Potapov AA, Pronin IN. Neuroimaging of Traumatic Brain Injury. Heidelberg; NY; Dordrecht; London: Springer-Verlag, 2014. – 159 p.

13. Vasilyev AYu, Maly AYu, Serova NS. Analysis of data of radiation methods based on the principles of evidence-based medicine. Moscow: GEOTAR-Media, 2008. 32 p. Russian

14. Greenhalgh T. The evidence-based medicine. Moscow: GEOTAR-Media, 2009. 288 p. Russian

USE OF SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY IN COMPLEX DIAGNOSTICS OF OSTEOPOROSIS CHANGES

Kolpinsky G.I., Zakharov I.S., Kokov A.N., Korotkevich A.A.

Kemerovo State Medical Academy,

Scientific Research Institute of Complex Problems of Cardiovascular Diseases,

Kemerovo, Russia

Objective – to determine the relationship between the level of bone metabolism and bone mineral density of lumbar vertebral bodies and the femoral neck in postmenopausal women.

Materials and methods. The study included 29 postmenopausal women who underwent SPECT radiopharmaceuticals ^99mTc-tehnefor and dual energy X-ray absorptiometry of the lumbar vertebrae and the femoral neck.

Results. There was a positive statistically significant correlation between the accumulation of standardized indicators and the level of the radiopharmaceutical in bone mineral density: for the lumbar spine r = 0.54 (p = 0.002); for femoral neck r = 0.44 (p = 0.02). With the increase of age in postmenopausal women standardized indicators decreased accumulation of the radiopharmaceutical: for the lumbar spine r = –0.44 (p = 0.02), femoral neck r = –0.37 (p=0.04).

Conclusion. Determining the level of metabolic processes in bone SPECT method may be important in the complex diagnosis and prognosis of postmenopausal osteoporotic changes, and it will facilitate timely preventive measures.

Key words: postmenopausal osteoporosis; bone mineral density; single-photon emission computed tomography.

Information about authors:

Kolpinsky G.I., MD, PhD, professor, chair of radial diagnostics, radiotherapy and oncology, Kemerovo State Medical Academy, Kemerovo, Russia.

Zakharov I.S., candidate of medical science, docent, chair of obstetrics and gynecology #1, Kemerovo State Medical Academy, Kemerovo, Russia.

Kokov A.N., candidate of medical science, head of department of radial diagnostics, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia.

Korotkevich A.A., radiologist, department of radial diagnostics, Scientific Research Institute of Complex Problems of Cardiovascular Diseases, Kemerovo, Russia.

Address for correspondence:

Zakharov I.S., Voroshilova St., 22a, Kemerovo, Russian Federation, 650029

Tel: +7 (3842) 46-51-62.

E-mail: isza@mail.ru

REFERENCES:

Zakharov IS, Kolpinsky GI, Ushakova GA, Ushakov AV, Van Wai Chan, Migal OV, et al. Prevalence of osteopenic syndrome in postmenopausal women. Medicine in Kuzbass. 2014; XIII (3): 32–36. Russian
Zakharov IS, Kolpinsky GI, Ushakov GA, Vavin GV. Biochemical markers in the diagnosis of bone remodeling in osteoporosis. Bulletin of Avicenna. 2013; (4): 119–123. Russian
Kanishi D. 99mTc-MDP accumulation mechanisms in bone. Oral Surg. Oral Med. Oral Pathol. 1993; 75 (2): 239–246.
Zakharov IS. Imaging diagnosis of osteoporosis – current state of problems. Polytrauma. 2015; (1): 69–73. Russian
Prohorova EG, Zhilyaev EV, Gordeytseva EA. Radionuclide method for assessment of the bonå mineralization. Radiology-Practice. 2011; (4): 34–40. Russian
Kapishnikov AV, Alekhin EN. Diagnostic possibilities of bone scintigraphy in osteoporotic vertebral changes and assessment of bone remodeling in patients with osteoporosis. The Bulletin of Russian Scientific Center of X-ray Radiology. 2014; (14). URL: http://vestnik.rncrr.ru/vestnik/v14/papers/aliokhin_v14.htm. (25.12.2014). Russian
Win AZ, Aparici CM. Normal SUV Values Measured from NaF18- PET/CT bone scan studies. PLoS One. 2014; 9 (9): e108429.
Cachovan M, Vija AH, Hornegger J, Kuwert T. Quantification of ^99mTc-DPD concentration in the lumbar spine with SPECT/CT. EJNMMI Research. 2013; 3 (1): 45.
Sveshnikov AA, Astapenkov DS. Threshold values of skeletal mineral density and fracture incidence. Genius of orthopedics. 2010; (2): 85–90. Russian

Researches of young scientists

Systemic inflammatory response syndrome and hypoxia values in critically ill patients

Ustyantseva I.M., Khokhlova O.I., Kozlov N.N.

Regional Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia.

Objective – to estimate the levels of acid-base balance in critically ill patients with systemic inflammatory response syndrome.

Materials and methods. 17 critically ill patients were examined who were admitted to the intensive care unit of Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky. The main group (n = 11) consisted of the patients with two or more signs of systemic inflammatory response syndrome (SIRS) (the criterions by R.C. Bone et al., 1992). The comparison group (n = 6) included patients without SIRS. Hematologic parameters (hemoglobin, red blood cells, hematocrit) and indexes of acid-base balance were estimated on days 1-3 after admission. The statistical preparation of results was made with IBM SPSS Statistics 20.0. The intergroup differences according to quantitative signs were identified with Mann-Whitney non-parametric test, qualitative differences – with Fisher’s exact test.

Results. There were no significant intergroup differences according to hematologic values. Mild and moderate anemia was observed in 36.4 % of the patients in the main group and in 50 % in the comparison group (p = 0.48). The patients with SIRS demonstrated lower oxygen partial pressure, low levels of oxyhemoglobin and low degree of oxygen saturation (decrease by 29.3 %, 26 % and 26.5 % correspondingly, p < 0.05). At the same time, the patients of this group demonstrated significant base deficiency, and the level of lactate was 3 times higher than in the comparison group (p = 0.020). The results indicate intensity of tissue hypoxia and severe disorders of energy production in critically ill patients with SIRS.

Conclusion. Critically ill patients with systemic inflammatory response demonstrate the signs of hypoxia that testify the associativity between these pathologic processes. The level of blood lactate may be used as an additional criterion for systemic inflammatory response syndrome.

Key words: systemic inflammatory response syndrome; hypoxia; critical state; acid-base balance; lactate.

Information about authors:

Ustyantseva I.M., Doctor of Biological Science, professor, deputy chief physician of clinical laboratory diagnostics, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Khokhlova O.I., MD, PhD, physician of clinical laboratory diagnostics, clinical diagnostic laboratory, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Kozlov N.N., biologist, clinical diagnostic laboratory, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Ustyantseva I.M., 7th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Tel: +7 (384-56) 2-38-88

E-mail: irmaust@gnkc.kuzbass.net

REFERENCES:

Savelyeva VS, Gelfanda BR. Sepsis in beginning of XXI century. Moscow : Litterra Publ., 2006. 172 p. Russian
Sokolov VA, Fedorova TA. Prevention and treatment of multiple organ dysfunction syndrome in birthing mothers with massive blood loss. Issues of gynecology, obstetrics and perinatology. 2006; (5): 41–48. Russian
Ou HC, Chou FP, Lin TM, Yang CH, Sheu WH. Protective effects of honokiol against oxidized LDL– induced cytotoxicity and adhesion molecule expression in endothelial cells. Chem. Biol. Interact. 2006; 161 (1): 1–13.
Gutierrez G, Wulf ME. Lactic acidosis in sepsis: another commentary. Crit Care Med. 2005; 33: 2420–2422.
Levy B, Gibot S, Franck P, Cravoisy A, Bollaert PE. Relation between muscle Na+K+ATPase activity and raised lactate concentrations in septic shock: a prospective study. Lancet 2005; 365:871–875.
Bundgaard H, Kjeldsen K, Suarez Krabbe K, van Hall G, Simonsen L, Qvist J, et al. Endotoxemia stimulates skeletal muscle Na+K+ATPase and raises blood lactate under aerobic conditions in humans. Am. J. Physiol. Heart Circ. Physiol. 2003; 284: H1028–H1034.
McCarter FD, Nierman SR, James JH, Wang L, King JK, Friend LA, et al. Role of skeletal muscle Na+K+ATPaså activity in increased lactate production in sub-acute sepsis. Life Sci. 2002; 70 (16): 1875–1888.
Leverve ÕÌ. Energy metabolism in critically ill patients: lactate is a major oxidizable substrate. Curr. Opin. Clin. Nutr. Metab. Care. 1999; 2: 165–169.
American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit. Care Med. 1992; 20: 864–874.
Ustyantseva IM, Khokhlova OI. The features of laboratory diagnostics of critical states in patients with polytrauma. Ïîëèòðàâìà. 2013; (3): 81–90. Russian
Dementyeva II. Laboratory diagnostics and clinical estimation of disorders of homeostasis in critically ill patients. Moscow : POLIGRAF–center Publ., 2007. 161 p. Russian
Levraut J, Ichai Ñ, Petit I, Ciebiera JP, Perus O, Grimaud D. Low exogenous lactate clearance as an early predictor of mortality in normolactatemic critically ill septic patients. Crit. Care Med. 2003; 31: 705–710.
Haas RH, Parikh S, Falk MJ, Saneto RP, Wolf NI, Darin N, et al. Mitochondrial Disease: a Practical Approach for Primary Care Physicians. Pediatrics. 2007; 120 (6): 1326–1333.
Parshin EV, Aleksandrovich YuS, Kushnerik LA, Blinov SA, Pshenisnov KV, Nurmagambetova BK. Indexes of oxygen status as markers of renal dysfunction in critically ill newborns. General Critical Care Medicine. 2010; 6 (2): 62–67. Russian

15. Khoroshilov SE, Nikulin AV. Efferent treatment of critical states. General Critical Care Medicine. 2012; 8 (4): 30–41. Russian

Case history

MANAGEMENT TACTICS FOR A PATIENT WITH MULTIPLE GUNSHOT WOUNDS

Shatalin A.V., Kravtsov S.A., Agalaryan A.Kh.

Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia

At the turn of XXth-XXIst centuries the development of new types of weapon resulted in changes in patterns of injuries to tissues and organs, and changing course of the wound process. Therefore, wound management is still one of the topical problems. At the present time gunshot wounds are characterized with more intense morphofunctional changes and with specific severity, combinations and multiplicity. Implementation of new medical technologies allows achieving good outcomes of treatment.

Objective – to demonstrate the clinical case of treatment of a patient with multiple gunshot wounds in conditions of timely transfer to the special multi-profile trauma center (level I trauma center).

Materials and methods. The patient S., male, age of 45, weight of 160 kg, was on duty and suffered from three gunshot wounds (a hand gun) to his head, chest and abdomen. In critical state he was admitted to Mezhdurechensk Central Hospital for realization of emergent surgical interventions: surgical preparation of a gunshot non-penetrating fracture of the frontal bone to the right, surgical preparation of the gunshot wound in the right superciliary region, enucleation of the left eye bulb, laparotomy, nephrectomy to the right, cholecystectomy, liver wound suturing, draining, surgical preparation of the chest gunshot wound to the left, left pleural cavity draining. Considering the severity of injuries (ISS = 50), increasing acute respiratory distress syndrome (ARDS) and need for high tech specialized assistance (long term ALV, endovideothoracoscopy, hemodialysis etc.), on the second day after the injury the patient was transferred by a reanimobile by the special team of the clinical center (overall distance is 300 km) to Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky. At admission the patient received the range of medical diagnostic measures, the results of which were used for recurrent surgeries. On 7th day after the injury the patient demonstrated the increasing signs of multiple organ dysfunction (respiratory, liver and renal) resulting in initiation of renal replacement therapy (RRT). The indication for initiation of dialysis therapy (in preserve diuresis) was increased plasma levels of natrium (> 150 mmol/L), osmolarity above 300 mOsm/kg and average molecules > 1 c.u.

Results. The patient received 10 surgical interventions: 3 procedures in Mezhdurechensk Central City Hospital, 7 ones in Clinical Center of Miners’ Health Protection in Leninsk-Kuznetsky. There were 30 sessions of RRT including 28 sessions of hemodialysis (extracorporeal therapy with AK-200 ULTRA) and 2 sessions of extended low-flow replacement renal therapy in the mode of hemodiafiltration with Prisma-flex. At the background of the realized intensive care measures with early introduction of extracorporeal techniques the patient demonstrated full restoration of functioning in the single kidney, as well as regressing in respiratory distress syndrome and liver insufficiency. The duration of treatment in the ICU was 71 days, ALV – 2 days. The period of hospital treatment was 132 days. The patient was discharged in satisfactory condition.

Conclusion. Treatment of patients with multiple gunshots is a complex process, which requires efforts from specialists of different profiles and significant costs. Such treatment is performed only in multi-profile facilities with trained employees and modern medical diagnostic measures.

Key words: multiple gunshot wounds; polytrauma; multiple organ dysfunction; renal replacement therapy.

Information about authors:

Shatalin A.V., MD, PhD, deputy chief physician of medical issues, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Kravtsov S.A., MD, PhD, head of center of resuscitation, intensive care and anesthesiology, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Agalaryan A.Kh., candidate of medical science, head of surgery department, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Rotkin E.A., surgeon, surgery department (the unit #1), Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Shatalin A.V., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Regional Clinical Center of Miners’ Health Protection

Tel: +7 (384-56) 2-31-25

E-mail: info@gnkc.kuzbass.net

REFERENCES:

1. Lerner AA, Fomenko MV, Rotem D, Pikkel I, Yulish M, Salamon T. Orthopaedic damage control for treatment of severe combat injuries to the extremities. Polytrauma. 2015; (1): 42-47. Russian

2. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

3. Agalaryan AKh, Shatalin AV. Diagnostics and treatment of injuries to urinary organs in patients with polytrauma. Polytrauma. 2012; (4): 35-39. Russian

4. Altemeyer KN, Oakley PA, Colema NA. Intensive care of the trauma patient. Resuscitation. 2001; 48: 37-46.

5. Timokhov VS, Yakovleva II. The pathogenetic principles of renal replacement therapy in critically ill patients. Anesthesiology and Critical Care Medicine. 2001; (6): 73–76. Russian

6. Gumanenko EK, Nemchenko NS, Goncharov AV, Pashkovsky EV. The pathogenetic features of acute period of traumatic disease. The Bulletin of Surgery by the name of I.I. Grekov. 2004; 163 (6): 52-56. Russian

7. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Kravtsov SA, Novokshonov AV, Agalaryan AKh, et al. Polytrauma. Emergency Aid and Transportation. Novosibirsk : Nauka Publ., 2008. 320 p. Russian

8. Agadzhanyan VV, Kravtsov SA, Skopintsev DA, Shatalin AV. The main directions in intensive care during interhospital transfer of patients with polytrauma. In: Emergency Aid in a Big City : the materials from the Second International Forum. Moscow, 2006. p. 18-19. Russian

9. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective –ventilation strategy on mortality in the acute respiratory distress syndrome. N. Engl. J. Med. 1998; 338: 347-354.

10. Kravtsov SA, Shatalin AV, Bogdanov SV. Treatment of multiple organ dysfunction in polytrauma with use of techniques for renal replacement therapy. In: Xth Anniversary All-Russian Conference of Traumatologist-Orthopedists. Moscow, 16-19 september 2014. Moscow, 2014. p. 129. Russian

The modern technologies of rib and sternum osteosynthesis FOR A patient with rare kind of work-related injury

Pushkin S.Yu., Benyan A.S., Ayrapetova M.P.

Samara Regional Clinical Hospital named after V.D. Seredavin,

Samara, Russia

Treatment of multiple injuries of ribs and sternum is an issue of modern medicine. The peculiarity and severity of such injuries are associated with frequent development of acute respiratory failure and subsequent diverse complications. The existence of different approaches to the treatment of patients necessitates a staged applying of treatment techniques and extensive involvement of innovative technologies.

Objective – to demonstrate an unusual type of work-related trauma resulting in unstable chest, and the successful treatment of the victim by means of staged application of various methods of stabilization, which was completed with rib and sternum osteosynthesis.

Materials and methods. The article presents an unusual type of injury of the chest. The shepherd received a heavy damage of the sternocostal complex (a transverse fracture of corpus sternum and floating fractures of 5th and 6th ribs to the left) as a result of a blow from the bull. The injury was complicated by the bilateral hemopneumothorax, flail chest and acute respiratory failure. Initially, the patient had received artificial pulmonary ventilation to ensure internal pneumatic stabilization, compensation of hemodynamic parameters and transportation to the level 1trauma center. Then the patient underwent surgery in the amount of plating internal fixation of ribs and sternum, bilateral thoracoscopy for elimination of intrapleural damages.

Results. No complications were noted. The period of ventilation in the postoperative period was 1 day, stay in the ICU - 2.5 days, the stationary period was 15 days. The patient returned to his working activity 2 months after discharge from the hospital.

Conclusion. The described conditions of the chest injury allow taking it to a rare type of work-related injury. The key to successful treatment was phasing and continuity in the application of various methods of stabilization of the thorax, and the use of modern technologies as osteosynthesis of the ribs and sternum.

Key words: rib fractures; osteosynthesis; stabilization.

Information about authors:

Pushkin S.Yu., MD, PhD, deputy chief physician of surgery, Samara Regional Clinical Hospital named after V.D. Seredavin, Samara, Russia.

Benyan A.S., candidate of medical science, head of thoracic surgery department, Samara Regional Clinical Hospital named after V.D. Seredavin, Samara, Russia.

Ayrapetova M.P., thoracic surgeon, Samara Regional Clinical Hospital named after V.D. Seredavin, Samara, Russia.

Address for correspondence:

Pushkin S.Yu., Tashkentskaya St., 159, Samara, Russia, 443095

Samara Regional Clinical Hospital named after V.D. Seredavin, Samara, Russia,

Thoracic surgery department

Tel: +7 (846) 372-51-80; +7 (927) 692-21-89

E-mail: armenbenyan@yandex.ru.

REFERENCES

1. Bemelman M, Poeze M, Blokhuis TJ, Leenen LPH. Historic overview of treatment techniques for rib fractures and flail chest. Eur J Trauma Emerg Surg. 2010; 36(5): 407–415.

2. Fitzpatrick DC, Denard PJ, Phelan D, Long WB, Madey SM, Bottlang M. Operative stabilization of flail chest injuries: review of literature and fixation options. Eur J Trauma Emerg Surg. 2010; 36: 427–433.

3. Yang Y, Dong L, Wang J. Memory alloy embracing fixator in treatment of multiple fractured ribs and flail chest. World J Emerg Med. 2010; 1(3): 212-215.

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5. Pronskikh AlA, Kravtsov SA, Pronskikh AA. Surgical restoration of chest structure in a patient with polytrauma. A case report. Polytrauma. 2014; 2: 65-70. Russian

6. Athanassiadi K, Theakos N, Kalantzi N, Gerazounis M. Prognostic factors in flail-chest patients. Eur J Cardiothorac Surg. 2010; 38: 466-471.

7. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg. 2012; 215(2): 201–205.

Bansal V, Conroy C, Chang D, Tominaga GT, Coimbra R. Rib and sternum fractures in the elderly and extreme elderly following motor vehicle crushes. Accid Anal Prev. 2011; 43(3): 661-665.

Geriatr Orthop Surg Rehabil. 2012; 3(4): 164-166.

9. Althausen PL, Shannon S, Watts C, Thomas K, Bain MA, Coll D, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011; 25(11): 641–647.

10. Byun JH, Kim HY. Factors affecting pneumonia occurring to patients with multiple rib fractures. Korean J Thorac Cardiovasc Surg. 2013; 46(2): 130-134.

11. Said SM, Goussous N, Zielinski MD, Schiller HJ, Kim BD. Surgical stabilization of flail chest: the impact on postoperative pulmonary function. Eur J Trauma Emerg Surg. 2014; 40(4): 501-505.

12. Bottlang M, Long WB, Phelan D, Fielder D, Madey SM. Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study. Injury. 2013; 44(2): 232-238.

13. Zegg M, Kammerlander C, Schmid S, Roth T, Kammerlander-Knauer U, Gosch M, et al. Multidisciplinary approach to lifesaving measures in the elderly individuals with flail chest injury with ORIF of rib fractures: a report of 2 cases.

14. Muhm M, Härter J, Weiss C, Winkler H. Severe trauma of the chest wall: surgical rib stabilization versus non-operative treatment. Eur J Trauma Emerg Surg. 2013; 39(3): 257-265.

15. Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg. 2013; 216(2): 302-311.