{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,18]],"date-time":"2026-10-18T02:33:48Z","timestamp":1792290828157,"version":"4.4.0"},"reference-count":14,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2026,1,9]],"date-time":"2026-01-09T00:00:00Z","timestamp":1767916800000},"content-version":"unspecified","delay-in-days":8,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2025,12,26]]},"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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)).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of evidence<\/jats:title>\n                    <jats:p>Level III.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/tsaco-2025-002020","type":"journal-article","created":{"date-parts":[[2026,1,9]],"date-time":"2026-01-09T14:40:24Z","timestamp":1767969624000},"page":"e002020","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":5,"title":["Lost fractures: prevalence and risk factors for missed costosternal and costal cartilage fractures among patients with radiologic chest wall injury"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8558-6180","authenticated-orcid":false,"given":"Joseph D","family":"Forrester","sequence":"first","affiliation":[{"name":"Stanford, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9584-2184","authenticated-orcid":false,"given":"Mohamad","family":"Abou Chaar","sequence":"additional","affiliation":[{"name":"Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew T","family":"Barnes","sequence":"additional","affiliation":[{"name":"Atrium Health Navicent, Macon, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zachary M","family":"Bauman","sequence":"additional","affiliation":[{"name":"Acute Care Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samy","family":"Bendjemil","sequence":"additional","affiliation":[{"name":"Stanford, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nizama N","family":"Betts","sequence":"additional","affiliation":[{"name":"Landstuhl Regional Medical Center, Landstuhl, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin","family":"Christie","sequence":"additional","affiliation":[{"name":"Mercer University School of Medicine, Macon, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raaga","family":"Dasari","sequence":"additional","affiliation":[{"name":"University of Nebraska Medical Center, Omaha, Nebraska, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Devoe","family":"WB","sequence":"additional","affiliation":[{"name":"Riverside Methodist Hospital, Columbus, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle J","family":"Earley","sequence":"additional","affiliation":[{"name":"Division of General Surgery, Stanford University, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bradley","family":"Faliks","sequence":"additional","affiliation":[{"name":"HonorHealth Scottsdale Osborn Medical Center, Scottsdale, Arizona, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tracy J","family":"Johns","sequence":"additional","affiliation":[{"name":"Atrium Health Navicent, Macon, Georgia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Connie","family":"Johnson","sequence":"additional","affiliation":[{"name":"Landstuhl Regional Medical Center, Landstuhl, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle S","family":"Junker","sequence":"additional","affiliation":[{"name":"Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian D","family":"Kim","sequence":"additional","affiliation":[{"name":"Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-7144-3214","authenticated-orcid":false,"given":"Jonathan M","family":"King","sequence":"additional","affiliation":[{"name":"Stanford, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8046-9324","authenticated-orcid":false,"given":"Ariel Whitney","family":"Knight","sequence":"additional","affiliation":[{"name":"Department of Surgery, Stanford University, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexis A","family":"Schweibinz","sequence":"additional","affiliation":[{"name":"Riverside Methodist Hospital, Columbus, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Stephens","sequence":"additional","affiliation":[{"name":"Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary","family":"Stuever","sequence":"additional","affiliation":[{"name":"Landstuhl Regional Medical Center, Landstuhl, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2897-7652","authenticated-orcid":false,"given":"Simeng","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Surgery, Stanford University, Stanford, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,1,9]]},"reference":[{"key":"2026010906401628000_11.1.e002020.1","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1097\/BOT.0000000000002919","article-title":"Anatomy of the Ribs, Sternum, and Costal Margin","volume":"38","author":"Haase","year":"2024","journal-title":"J Orthop Trauma"},{"key":"2026010906401628000_11.1.e002020.2","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-199412000-00018"},{"key":"2026010906401628000_11.1.e002020.3","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1016\/j.injury.2016.11.026","article-title":"Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines","volume":"48","author":"Pieracci","year":"2017","journal-title":"Injury"},{"key":"2026010906401628000_11.1.e002020.4","doi-asserted-by":"publisher","DOI":"10.1148\/radiol.2017162429"},{"key":"2026010906401628000_11.1.e002020.5","doi-asserted-by":"publisher","DOI":"10.1007\/s00068-020-01368-3"},{"key":"2026010906401628000_11.1.e002020.6","doi-asserted-by":"publisher","DOI":"10.1097\/JSM.0b013e31825b55ed"},{"key":"2026010906401628000_11.1.e002020.7","doi-asserted-by":"crossref","first-page":"139","DOI":"10.5603\/FM.a2016.0030","article-title":"Isolated costal cartilage fractures: the radiographically overlooked injuries","volume":"76","author":"Yuan","year":"2017","journal-title":"Folia Morphol (Warsz)"},{"key":"2026010906401628000_11.1.e002020.8","doi-asserted-by":"crossref","DOI":"10.1177\/2325967115627623","article-title":"Chondral Rib Fractures in Professional American Football: Two Cases and Current Practice Patterns Among NFL Team Physicians","volume":"4","author":"McAdams","year":"2016","journal-title":"Orthop J Sports Med"},{"key":"2026010906401628000_11.1.e002020.9","doi-asserted-by":"crossref","first-page":"e267","DOI":"10.1016\/j.athoracsur.2018.08.076","article-title":"Fracture of the Costal Cartilage: Presentation, Diagnosis, and Management","volume":"107","author":"Sollender","year":"2019","journal-title":"Ann Thorac Surg"},{"key":"2026010906401628000_11.1.e002020.10","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1097\/TA.0000000000004145","article-title":"Hardware failure for anterior chest wall and costal cartilage injuries: A single-center experience","volume":"96","author":"Varre","year":"2024","journal-title":"J Trauma Acute Care Surg"},{"key":"2026010906401628000_11.1.e002020.11","doi-asserted-by":"crossref","first-page":"861","DOI":"10.1097\/TA.0000000000004440","article-title":"Surgical management of costal margin rupture associated with intercostal hernia: Evolution of techniques","volume":"97","author":"Wijerathne","year":"2024","journal-title":"J Trauma Acute Care Surg"},{"key":"2026010906401628000_11.1.e002020.12","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1007\/s00068-023-02343-4","article-title":"Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1)","volume":"50","author":"Eriksson","year":"2024","journal-title":"Eur J Trauma Emerg Surg"},{"key":"2026010906401628000_11.1.e002020.13","doi-asserted-by":"crossref","DOI":"10.1016\/j.tcr.2025.101129","article-title":"Breaking waves and cartilage: Surgical management of costal cartilage injuries in surfing-related trauma","volume":"55","author":"Bendjemil","year":"2025","journal-title":"Trauma Case Rep"},{"key":"2026010906401628000_11.1.e002020.14","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1097\/TA.0000000000004068","article-title":"Costal margin injuries and trans-diaphragmatic intercostal hernia: Presentation, management and outcomes according to the Sheffield classification","volume":"95","author":"Byers","year":"2023","journal-title":"J Trauma Acute Care Surg"}],"container-title":["Trauma Surgery &amp; Acute Care Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/tsaco-2025-002020","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,9]],"date-time":"2026-01-09T14:40:26Z","timestamp":1767969626000},"score":1,"resource":{"primary":{"URL":"https:\/\/tsaco.bmj.com\/lookup\/doi\/10.1136\/tsaco-2025-002020"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":14,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1,9]]},"published-print":{"date-parts":[[2026,1]]}},"alternative-id":["10.1136\/tsaco-2025-002020"],"URL":"https:\/\/doi.org\/10.1136\/tsaco-2025-002020","relation":{},"ISSN":["2397-5776"],"issn-type":[{"value":"2397-5776","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1]]}}}