Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment

Background

Serial rib fractures and flail chest injury can be treated by positive-pressure ventilation. Operative techniques reduce intensive care unit (ICU) stay, overall costs, mortality and morbidity, as well as pain. The aim of this study was to evaluate the benefit of surgical rib stabilisation in comparison to non-operative treatment in patients with severe trauma of the chest wall.

Materials and methods

From 2006 to 2011, the data of 44 patients with flail chest and serial rib fractures were collected retrospectively. A surgical group and an intensive care group with only intensive care therapy were formed. Rib and sternal fractures, flail chest, injury severity, thoracic injuries, mechanical ventilation, time in the ICU, overall hospital stay and mortality were evaluated.

Results

No postoperative surgical complications had been observed. The time under mechanical ventilation in the surgical group was 10.6 ± 10.2 days, whereas in the non-surgical group, it was 13.7 ± 13.7 days. Mechanical ventilation time after surgery was 6.9 ± 6.5 days. Time in the ICU for the surgical group was 16.4 ± 13.6 days, compared to the non-surgical group with 20.1 ± 16.2 days. Postoperative time in the ICU was 11.7 ± 10.3 days. The mortality in the surgical group was 10 % and in the non-surgical group it was 17 %.

Conclusions

Operative rib stabilisation with plates is a safe therapy option for severe trauma of the chest wall. Provided that the duration of preoperative mechanical ventilation and time spent in the ICU is minimised due to early operation, our data suggest that the stabilisation of serial rib fractures and flail chest may lead to a reduced time of mechanical ventilation, time in the ICU and mortality.     

Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer

INTRODUCTION

Rib plating is becoming increasingly common as a method for stabilizing a flail chest resulting from multiple rib fractures. Recent guidelines recommend surgical stabilization of a flail chest based on consistent evidence of its efficacy and lack of major safety concerns. But complications of this procedure can occur and are wide ranging.

PRESENTATION OF CASE

We report an interesting case of a 58-year-old male patient that worked as a long-distance truck driver and had a flail chest from multiple bilateral rib fractures that occurred when his vehicle was blown over in a wind storm. He underwent open reduction with internal fixation (ORIF) of the bilateral rib fractures and they successfully healed. However, he had permanent long thoracic nerve injury on the side with the most severe trauma. This resulted in symptomatic scapular winging that impeded him from long-distance truck driving. The scapular winging was surgically corrected nearly two years later with a pectoralis major transfer augmented with fascia lata graft. The patient had an excellent final result.

DISCUSSION

We report this case to alert surgeons who perform rib fracture ORIF that long thoracic nerve injury is a potential iatrogenic complication of that procedure or might be a result of the chest wall trauma.

CONCLUSION

Although the specific cause of the long thoracic nerve injury could not be determined in our patient, it was associated with chest wall trauma in the setting of rib fracture ORIF. The scapular winging was surgically corrected with a pectoralis major transfer.     

Evaluation of efficacy and indications of surgical fixation for multiple rib fractures: a propensity-score matched analysis

Purpose

The purpose of this study was to assess the effects of recent surgical rib fixation and establish its indications not only for flail chest but also for multiple rib fractures.

Methods

Between 2007 and 2015, 187 patients were diagnosed as having multiple rib fractures in our institution. After the propensity score matching was performed, ten patients who had performed surgical rib fixation and ten patients who had treated with non-operative management were included. Categorical variables were analyzed with Fischer’s exact test and non-parametric numerical data were compared using the Mann–Whitney U test. Wilcoxon signed-rank test was performed for comparison of pre- and postoperative variables. All statistical data are presented as median (25–75 % interquartile range [IQR]) or number.

Results

The surgically treated patients extubated significantly earlier than non-operative management patients (5.5 [1–8] vs 9 [7–12] days: p = 0.019). The duration of continuous intravenous narcotic agents infusion days (4.5 [3–6] vs 12 [9–14] days: p = 0.002) and the duration of intensive care unit stay (6.5 [3–9] vs 12 [8–14] days: p = 0.008) were also significantly shorter in surgically treated patients. Under the same ventilating conditions, the postoperative values of tidal volume and respiratory rate improved significantly compared to those values measured just before the surgery. The incidence of pneumonia as a complication was significantly higher in non-operative management group (p = 0.05).

Conclusions

From the viewpoints of early respiratory stabilization and intensive care unit disposition without any complications, surgical rib fixation is a sufficiently acceptable procedure not only for flail chest but also for repair of severe multiple rib fractures.

     

Surgical stabilization of flail chest: the impact on postoperative pulmonary function

Objectives

Flail chest results in significant morbidity. Controversies continue regarding the optimal management of flail chest. No clear guidelines exist for surgical stabilization. Our aim was to examine the association of bedside spirometry values with operative stabilization of flail chest.

Methods

IRB approval was obtained to identify patients with flail chest who underwent surgical stabilization between August 2009 and May 2011. At our institution, all rib fracture patients underwent routine measurement of their forced vital capacity (FVC) using bedside spirometry. Formal pulmonary function tests were also obtained postoperatively and at three months in patients undergoing stabilization. Both the Synthes and Acute Innovations plating systems were utilized. Data is presented as median (range) or (percentage).

Results

Twenty patients (13 male: 65 %) with median age of 60 years (30–83) had a median of four ribs (2–9) in the flail segment. The median Injury Severity Score was 17 (9–41) and the median Trauma and Injury Severity Score was 0.96 (0.04–0.99). Preoperative pneumonia was identified in four patients (20 %) and intubation was required in seven (35 %). Median time from injury to stabilization was four days (1–33). The median number of plates inserted was five (3–11). Postoperative median FVC (1.8 L, range 1.3–4 L) improved significantly as compared to preoperative median value (1 L, range 0.5–2.1 L) (p = 0.003). This improvement continued during the follow-up period at three months (0.9 L, range 0.1–3.0) (p = 0.006). There were three deaths (15 %), none of which were related to the procedure. Subsequent tracheostomy was required in three patients (15 %). The mean hospital stay and ventilator days after stabilization were nine days and three days, respectively. Mean follow-up was 5.6 ± 4.6 months.

Conclusion

Operative stabilization of flail chest improved pulmonary function compared with preoperative results. This improvement was sustained at three months follow-up.     

Clinical value of total white blood cells and neutrophil counts in patients with suspected appendicitis: retrospective study

Background

Severe chest wall injuries are potentially life-threatening injuries which require a standardized multidisciplinary management strategy for prevention of posttraumatic complications and adverse outcome.

Case presentation

We report the successful management of a 55-year old man who sustained a complete ??bony disruption?? of the thoracic cage secondary to an ??all-terrain vehicle?? roll-over accident. The injury pattern consisted of a bilateral ??flail chest?? with serial segmental rib fractures, bilateral hemo-pneumothoraces and pulmonary contusions, bilateral midshaft clavicle fractures, a displaced transverse sternum fracture with significant diastasis, and an unstable T9 hyperextension injury. After initial life-saving procedures, the chest wall injuries were sequentially stabilized by surgical fixation of bilateral clavicle fractures, locked plating of the displaced sternal fracture, and a two-level anterior spine fixation of the T9 hyperextension injury. The patient had an excellent radiological and physiological outcome at 6?months post injury.

Conclusion

Severe chest wall trauma with a complete ??bony disruption?? of the thoracic cage represents a rare, but detrimental injury pattern. Multidisciplinary management with a staged timing for addressing each of the critical injuries, represents the ideal approach for an excellent long-term outcome.     

Thoraxwandstabilisierung durch Plattenosteosynthese

The improvement of mechanical respiration by surgical stabilization of the chest wall is an important measure to reduce disadvantages and complications of long time respiratory treatment. Indications are:

1. Chest wall instability with indication for emergency thoracotomy.
2. Respiratory insufficiency caused by chest wall instability, but without severe laceration of intrathoracical organs.
3. Respiratory insufficiency due to severe laceration of intrathoracical organs with additional chest wall instability as an obstacle for sufficient respirator treatment.

Prevailing injuries leading to chest wall instability are fractures of the sternum and serial or double fractures of the ventral ribs I–VII, which have their own sternal junctions. For restoration of mechanical respiration, stabilization of the sternum and ventral ribs III–VI is essential. Surgical technic and special advantage of rib plating using small ASIF-plates are described and demonstrated in clinical cases. Finally, the development of a new screwless elastic selfclasping rib plate is presented.     

Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome

Background

Conservative treatment of even severe thoracic trauma including flail chest was traditionally the standard of care. Recently, we reported possible benefits of surgical chest wall stabilization in accordance with other groups. The aim of this study was to critically review our indications and results of internal fixation of rib fractures in the long-term course.

Methods

We retrospectively analyzed the data of a consecutive series of patients with internal rib fracture fixation at our institution from 8/2009 until 12/2014, and we retrospectively studied the late outcome through clinical examination or personal interview.

Results

From 1398 patients, 235 sustained a severe thoracic trauma (AIS ≥3). In 23 of these patients, 88 internal rib fixations were performed using the MatrixRIB^® system. The median age of these operated patients was 56 years [interquartile range (IQR) 49–63] with a median ISS of 21 [IQR 16–29]. From 18 local resident patients, follow-up was obtained after an average time period of 27.6 (12–68) months. Most of these patients were free of pain and had no limitations in their daily routine. Out of all implants, 5 splint tips perforated the ribs in the postoperative course, but all patients remained clinically asymptomatic. Plate osteosynthesis showed no loss of reduction in the postoperative course. No cases of hardware prominence, wound infection or non-union occurred.

Conclusions

In our carefully selected thoracic trauma patients, locked plate rib fixation seemed to be safe and beneficial not only in the early posttraumatic course, but also after months and years, patients remain asymptomatic and complete recovery as a rule.Trial registration number KEK BASEC Nr. 2016-01679.

     

Chronic pain and its impact on quality of life following a traumatic rib fracture

Purpose

Traumatic rib fractures account for 7–40?% of trauma admissions and most of them heal spontaneously and do not contribute to disability. The prevalence of chronic pain and its impact on quality of life following a traumatic rib fracture has not been studied adequately.

Methods

A retrospective review of electronic medical records of all the traumatic rib fracture admissions from January 2007 to December 2008 was conducted. This was followed up with a brief telephonic survey of the following questions: (1) Do you have pain following the trauma? (2) If YES, how severe is your pain from a score of zero to ten? (3) Does the pain affect your life style? (4) Does the pain affect your work? (5) Do you need to take regular pain medications?

Results

One hundred and two patients responded to the survey and 23 patients (22.5?%) complained of chronic persistent pain. In patients with pain, six patients (26?%) had chronic pain that required regular use of analgesics, eight patients (35?%) complained of impairment of work life, and three patients (13?%) complained of impairment of personal quality of life. Chronic pain was not related to age, number of ribs fractured, flail chest, hemothorax and/or pneumothorax, chest tube insertion, or Injury Severity Score (ISS).

Conclusion

This study confirms the high incidence of chronic pain after a traumatic rib fracture. While the majority of the patients can manage this pain without interference of their quality of life, a few do suffer from life style/work interference and may have to resort to regular analgesic usage.     

Potential Benefits of Rib Fracture Fixation in Patients with Flail Chest and Multiple Non-flail Rib Fractures

The purpose of this study is to evaluate the potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures versus conventional treatment modalities. A retrospective reviewed study compared 86 cases which received surgical treatment between June 2009 and May 2013 to 76 cases which received conservative treatment between January 2006 and May 2009. The patients were divided into the flail chest (n?=?38) and multiple non-flail rib fracture groups (n?=?124). In the flail chest group, the mechanical ventilation time, ICU monitoring time, tracheostomies, thoracic deformity, and impaired pulmonary function and return to full-time employment were compared. In the multiple non-flail rib fracture group, fracture healing, visual analog scale (VAS) pain score, inpatient length of stay, atelectatic, pulmonary complications, and normal activity-returning time were compared. Patients in the flail chest operative fixation group had significantly shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic deformity and impaired pulmonary function, and more returned to full-time employment. Patients in the multiple non-flail rib fracture operative fixation had shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections. This study demonstrates the potential benefits of surgical stabilization of flail chest and multiple non-flail rib fractures with plate fixation. When compared with conventional conservative management, operatively managed patients demonstrated improved clinical outcomes.     

Stabilization of multiple rib fractures in a canine model

Background

Operative stabilization is frequently used in the clinical treatment of multiple rib fractures (MRF); however, no ideal material exists for use in this fixation. This study investigates a newly developed biodegradable plate system for the stabilization of MRF.

Methods

Silk fiber-reinforced polycaprolactone (SF/PCL) plates were developed for rib fracture stabilization and studied using a canine flail chest model. Adult mongrel dogs were divided into three groups: one group received the SF/PCL plates, one group received standard clinical steel plates, and the final group did not undergo operative fracture stabilization (n = 6 for each group). Radiographic, mechanical, and histologic examination was performed to evaluate the effectiveness of the biodegradable material for the stabilization of the rib fractures.

Results

No nonunion and no infections were found when using SF-PCL plates. The fracture sites collapsed in the untreated control group, leading to obvious chest wall deformity not encountered in the two groups that underwent operative stabilization.

Conclusions

Our experimental study shows that the SF/PCL plate has the biocompatibility and mechanical strength suitable for fixation of MRF and is potentially ideal for the treatment of these injuries.     

Recovery after stabilising surgery for ‘flail chest’

Background/Purpose

There is a lack of knowledge on respiratory and physical function, mobility and pain following stabilising surgery for ‘flail chest’. The purpose of this study was, therefore, to evaluate pain, respiratory function, range of motion and physical function/activity 3 and 6 months after stabilising surgery in patients with ‘flail chest’ due to trauma.

Method

Twenty-four patients diagnosed with ‘flail chest’ were, 3 and 6 months after the trauma, measured with regard to remaining pain, lung volume, breathing movements, and range of motion in the rib cage and thoracic spine. Physical function and level of physical activity were also estimated.

Results

Approximately 50 % of the patients had remaining pain after 3 months and 35 % had remaining pain after 6 months. Vital capacity was significantly decreased after 3 and 6 months compared to predicted values: >83 % after 3 months and >86 % after 6 months. There were no significant differences between the injured versus non-injured side in breathing movements, nor between the values of the range of motion between the two test occasions. The results of physical function showed mild to moderate disability 3 months after surgery and some or mild disability at 6 months. The patients were active, performing moderate exercise 1–2 h/week or light physical activities more than 4 h/week at 3 and 6 months.

Conclusions

Patients who had undergone stabilising surgery due to ‘flail chest’ showed decreased range of motion 3 and 6 months after surgery. Despite decreased range of motion and remaining pain, the breathing movements are synchronic.     

Breast reconstruction by tissue expander after radiotherapy: When the skin does not expand,the rib cage is at risk

Background

Expander-based breast reconstructions in irradiated chest walls have been documented to result in an increased risk of complications including skin necrosis, extrusion, displacement, and capsule contracture. In this article, thoracic cage deformity and rib fractures were investigated following breast reconstruction by tissue expansion.

Methods

A prospective series of 89 immediate postmastectomy tissue expander breast mound reconstructions in 81 patients, the patients were divided into two groups, reconstruction with radiotherapy (n?=?37) and without radiotherapy (n?=?52). The patients were observed for any sudden severe pain and development of capsule contracture; intraoperative assessment was done first during expander insertion then after exchange of expander with implant to detect any deformity of the chest wall. CT scans were done as an objective way to support the clinical findings in patients who developed flat or concave chest wall deformities.

Results

Patients who had reconstructions with radiotherapy developed severe capsular contractures causing severe pain and limitation in breast expansion in 35 % of reconstructions compared with 5.7 % in the control group. Twenty-six reconstructions (70.2 %) in the study group developed chest wall deformities; in four of them, the deformity was concave, and two patients (5.4 %) developed multiple rib fractures at the expander site. The overall rate of ribcage deformities in the control group was 32.6 %; all of them were simple flattening with no concave deformities. No fractures were noted in the control group.

Conclusions

Expander-based breast reconstruction in combination with radiotherapy and tight unyielding overlying skin and capsule can redirect the expansion force toward the thoracic ribcage rather than the skin causing rib deformities and possible fractures. Level of Evidence: Level IV, risk/prognostic study     

Crossover external fixator for acetabular fractures: a cadaver study

Background

Dislocated acetabular fractures in polytraumatized patients are very challenging cases to deal with. Temporary stabilization by skeletal traction is difficult in these patients. A more effective solution can be an external fixation.

Objective

The authors designed a new crossover external fixation frame for acetabular fracture. The aim of this study is the biomechanical testing of this frame on human cadavers.

Methods

This study is an experiment on ten human cadavers. The acetabular fracture C2.2 was created. The stabilization effect of external fixation was compared with stabilization by large distractor. Femoral heads’ shifts caused by standardized manipulation with the cadaver were obtained from X-ray pictures.

Results

The mean total shift in stabilization technique by external fixation was 2.56 (1–4) mm. In stabilization by large distractor, the mean of the total shift after cadaver manipulation was 5.11 (0–10) mm. No significant differences were found between stabilization by external fixation and by large distractor (p = 0.066).

Conclusions

The stabilization of acetabular fracture C2.2 by a crossover external fixator is as effective as large distractor. The crossover external fixation could be a suitable solution for the temporary stabilization of acetabular fractures in polytraumatized patients. Subsequent studies including clinical trials are necessary to confirm the authors’ suggestion.     

Evaluation of long-term results and quality of life in patients who underwent rib fixation with titanium devices after trauma

Objective

To describe the long-term results, quality of life and chronic pain after chest wall fixation for traumatic rib fracture using a quality of life (QOL) score and a numeric pain score.

Methods

Retrospective analysis of 10 consecutive patients who underwent surgery for rib fractures after trauma and reconstruction between October 2010 and March 2012. Chest rib fractures were fixed with titanium clips and bars or titanium plates and screws through a posterolateral thoracotomy. Pain was assessed with a numeric pain scale 0–10 and quality of life (QOL) with the EORTC questionnaire QLQ-C30.

Results

There were 5 males and 5 females. The median age was 58 years (range 21–80). There were no postoperative deaths. The only postoperative complication observed was a contralateral pleural effusion requiring drainage. Median length of stay of the drain and median length of hospital stay were 2 days (range 0–8) and 4 days (range 1–42 days), respectively. The average follow-up period of operatively managed patients was 14 months (range 8–23.5 months). Seven patients scored the pain as 0, one as 1 (mild), one as 4 (moderate) and one as 8 (severe). Only two patients are taking occasionally pain killers. Only one patient presents severe limitation in his life scoring his QOL as poor.

Conclusions

Titanium devices (clips and bars; screws and plates) are effective and safe for repair of rib fractures and showed good long-term results in terms of pain and quality of life after the operation.     

Impact of rib fixation on quality of life after major trauma with multiple rib fractures

Introduction

Multiple rib fractures have been shown to reduce quality of life both in the short and long term. Treatment of rib fractures with operative fixation reduces ventilator requirements, intensive care unit stay, and pulmonary complications in flail chest patients but has not been shown to improve quality of life in comparative studies to date. We therefore wanted to analyse a large cohort of multiple fractured rib trauma patients to see if rib fixation improved their quality of life.

Scoliosis after chest wall resection

Background data

There has been an increased focus on the role of rib abnormalities in the development of scoliosis. Rib resection may influence the development of scoliosis. Although scoliosis has been identified in patients after thoracotomy, most of the currently available information is from case reports.

Methods

We examined records of 37 patients who underwent a chest wall or rib resection for rib lesions at our institution during the period of 1992 to 2005. Adequate data was available in 21 patients. We gathered data on demographic information, location of resection, and changes in curvature after resection based on radiograph or scout CT films at the latest follow-up appointment.

Results

Fourteen of 21 patients developed scoliosis with a mean Cobb angle of 25.8° (10°–70°). Eleven of these 14 patients had a progressive spinal deformity after chest wall resection with an average change in curvature of 29° (10°–70°). Eight of those 11 developed a convex toward the resection, while 3/11 developed a convex away from the resection. Seven of the eight patients with resections that included a rib superior to the sixth rib developed scoliosis, while four of 13 with resections below the sixth rib developed scoliosis.

Conclusion

Patients who have had a rib or chest wall resection are at risk for developing scoliosis, particularly if the resection is performed above the sixth rib.     

Clinical outcomes of multiple rib fractures: does age matter?

Purpose

To evaluate the clinical outcomes of multiple rib fracture due to blunt trauma in young patients, a 3-year retrospective study was conducted. Patients with ≥3 rib fractures were divided into two groups (group I: <45 years old and group II: ≥45 years old). Mortality, hospital stay, ventilatory support, chest tubes insertion and associated injuries were studied.

Results

Of the 902 patients admitted with blunt chest trauma, 240 (27 %) met the inclusion criteria and 72.5 % patients were <45 years old. The most common causes of injury were motor vehicle crash (59 %) and fall (29 %). The Injury Severity Score (ISS) was higher in group I (16 ± 9 vs. 13 ± 6; p = 0.04). Hospital mortality was higher in group II (6 vs. 2 %; p = 0.18). Pneumothorax, haemothorax and ventilatory support were comparable. Patients in group II were more likely to undergo chest tubes insertion (26 vs. 14 %; p = 0.04), while group I had a significantly higher incidence of associated abdominal injuries (25 vs. 12 %; p = 0.03).

Conclusion

Old age presenting with rib fractures is associated with higher mortality in comparison to young age; however, this difference becomes statistically insignificant in the presence of multiple rib fracture.     

Is a small-bore catheter efficient for most pleural pathologies?

Purpose

Chest tubes are used for drainage of the pleural cavity. Traditionally, large-bore catheters are inserted for all indications, but there has been a recent tendency to use small-bore catheters. We share the results of our experience of using small-bore catheters for almost all indications routinely in our clinic.

Methods

A collective total of 309 small-bore chest catheters (10 F) were inserted via the Seldinger technique in 287 patients during a 5-year-period. Malignant pleural effusion and pneumothorax were the most common indications for chest tube insertion.

Results

The mean catheter duration was 5.6 days, being 5 days for pneumothorax and 6 days for malignant pleural effusion. Pleurodesis was performed effectively for malignant pleural effusions. In this series, the failure rate of small-bore catheters was 7.2 %.

Conclusion

Based on our clinical experience of using small-bore catheters, we believe that they are potentially effective for almost all pleural pathologies. Our results concur with those in the literature, but this series also includes different pleural diseases requiring chest tube insertion.