After initial assessment and management by ATLS® protocol in our emergency department [14], the patient was transferred to the surgical intensive care unit (SICU) for ongoing resuscitation and ventilatory management. After radiologic workup by conventional films and

“total body” computed tomography (CT) scan, the patient was diagnosed with the following injury pattern (Figure 1 2 3): Figure 1 Initial chest radiograph (A) and coronal CT scan reconstruction (B) on arrival in the emergency department. Despite placement of bilateral chest drains, there is a persistent, extensive hemothorax on the right side, and signs of bilateral lung contusions. The arrow in panel B points out the T9 hyperextension injury in the coronal plane. Figure 2 Displaced transverse sternal fracture in coronal CT scan (A) and operative site (B) after exposure for the sternal fracture see more fixation procedure. The arrows point out the impressive fracture diastasis of about 3 cm, with the retrosternal pericardium exposed in panel B. Figure 3 Sagittal CT scan (A) and STIR sequence in MRI (B) of the T9 hyperextension injury (arrows). The asterisk in panel B alludes to the extensive prevertebral

hematoma. Severe chest trauma with bilateral “flail chest” with serial segmental rib fractures (C1-8 on right side, C1-10 on left side), bilateral pulmonary contusions, and bilateral hemo-pneumothoraces, a displaced transverse sternum fracture with 3 cm diastasis, bilateral midshaft clavicle fractures, and an unstable T9 hyperextension injury. The GF120918 nmr unstable T9 fracture was associated with a chronic hyperostotic Methocarbamol ankylosing condition (“diffuse idiopathic skeletal hyperostosis”; DISH) of the thoracic spine, as revealed in the sagittal CT scan reconstruction (Figure 3A). An MRI of the T-spine was obtained to further assess for an associated disc or ligamentous injury, and to rule out the presence of an epidural hematoma, any of which may alter the surgical plan and modality of spinal fixation or

fusion. After resuscitation in the SICU, and adequate thoracic pain control by epidural anesthesia, the patient was taken to the OR on day 4 for fracture fixation. A decision was made for surgical fixation of bilateral clavicle fractures, the sternal fracture, and the T9 spine fracture, in order to achieve adjunctive stability of the thoracic cage and to allow early functional rehabilitation without restrictions. The patient was placed on a radiolucent flat-top operating table in supine position. The technique of positioning, preparation and draping, aimed at addressing both clavicle fractures and the sternum fracture in one session, are depicted in Figure 4. Figure 4 Technique of patient positioning and draping for surgical fixation of the bilateral clavicle fractures and the displaced sternal fracture.