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Alanwer KM, Refat AM, Negm EM. Impact of flail chest injury on morbidity and outcome: ten years' experience at a tertiary care hospital in a developing country. BMC Anesthesiol 2023; 23:229. [PMID: 37403012 DOI: 10.1186/s12871-023-02185-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/18/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND One of the worst types of severe chest injuries seen by clinicians is flail chest. This study aims to measure the overall mortality rate among flail chest patients and then to correlate mortality with several demographic, pathologic, and management factors. METHODOLOGY A retrospective observational study tracked a total of 376 flail chest patients admitted to the emergency intensive care unit (EICU) and surgical intensive care unit (SICU) at Zagazig University over 120 months. The main outcome measurement was overall mortality. The secondary outcomes were the association of age and sex, concomitant head injury, lung and cardiac contusions, the onset of mechanical ventilation (MV) and chest tubes insertion, the length of mechanical ventilation and ICU stay in days, injury severity score (ISS), associated surgeries, pneumonia, sepsis, the implication of standard fluid therapy and steroid therapy, and the systemic and regional analgesia, with the overall mortality rates. RESULTS The mortality rate was 19.9% overall. The shorter onset of MV and chest tube insertion, and the longer ICU, and hospital length of stay were noted in the mortality group compared with the survived group (P-value less than 0.05). Concomitant head injuries, associated surgeries, pneumonia, pneumothorax, sepsis, lung and myocardial contusion, standard fluid therapy, and steroid therapy were significantly correlated with mortality (P-value less than 0.05). MV had no statistically significant effect on mortality. Regional analgesia (58.8%) had a significantly higher survival rate than intravenous fentanyl infusion (41.2%). In multivariate analysis, sepsis, concomitant head injury, and high ISS were independent predictors for mortality [OR (95% CI) = 568.98 (19.49-16613.52), 6.86 (2.86-16.49), and 1.19 (1.09-1.30), respectively]. CONCLUSION The current report recorded mortality of 19.9% between flail chest injury patients. Sepsis, concomitant head injury, and higher ISS are the independent risk factors for mortality when associated with flail chest injury. Considering restricted fluid management strategy and regional analgesia may help better outcome for flail chest injury patients.
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Affiliation(s)
- Khaled M Alanwer
- Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ali Mohammed Refat
- Cardiothoracic Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Essamedin M Negm
- Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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Shiroff AM, Wolf S, Wu A, Vanderkarr M, Anandan M, Ruppenkamp JW, Galvain T, Holy CE. Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis. J Trauma Acute Care Surg 2023; 94:538-545. [PMID: 36730674 PMCID: PMC10045967 DOI: 10.1097/ta.0000000000003828] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/04/2022] [Accepted: 10/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Treatment for multiple rib fractures includes surgical stabilization of rib fractures (SSRF) or nonoperative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates versus NOM. Our study evaluated postoperative outcomes for multiple rib fracture patients following SSRF versus NOM in a real-world, all-comer study design. METHODS Multiple rib fracture patients with inpatient admissions in the PREMIER hospital database from October 1, 2015, to September 30, 2020, were identified. Outcomes included discharge disposition, and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, Abbreviated Injury Scale and Injury Severity Scores, and provider characteristics were determined for all patients. Patients were excluded from the cohort if they had a thorax Abbreviated Injury Scale score of <2 (low severity patient) or a Glasgow Coma Scale score of ≤8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting so that all patient data were kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links. RESULTS A total of 203,450 patients were included, of which 200,580 were treated with NOM and 2,870 with SSRF. Compared to NOM, patients with SSRF had higher rates of home discharge (62% SSRF vs. 58% NOM) and lower rates of lung-related readmissions (3 months, 3.1% SSRF vs. 4.0% NOM; 12 months, 6.2% SSRF vs. 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF versus NOM was 1.166 (95% confidence interval [CI], 1.073-1.266; p = 0.0002). Similarly, ORs for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF versus NOM (OR [3 months], 0.764 [95% CI, 0.606-0.963]; p = 0.0227 and OR [12 months], 0.799 [95% CI, 0.657-0.971]; p = 0.0245). CONCLUSION Surgical stabilization of rib fractures results in greater odds of home discharge and lower rates of lung-related readmissions compared with NOM at 12 months of follow-up. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Nakagawa T, Masuda R, Yamada S, Iwazaki M. Minimally invasive surgery for anterior flail chest injury in the acute phase: series of 10 cases. Gen Thorac Cardiovasc Surg 2023:10.1007/s11748-023-01908-9. [PMID: 36905532 DOI: 10.1007/s11748-023-01908-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/16/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Anterior flail chest frequency represents a significant case of ventilator insufficiency. Surgical stabilization of acute phase of trauma is considered to effectively shorten the period of ventilation compared to conservative treatment using mechanical ventilation. We have applied minimally invasive surgery to stabilize the injured chest wall. METHODS Surgical stabilization of predominantly anterior flail chest segments was performed using one or two bars as per the Nuss procedure, during the acute phase of chest trauma. Data from all patients were examined. RESULTS Ten patients received surgical stabilization using the Nuss method between 1999 and 2021. All patients had already been mechanically ventilated prior to surgery. The mean period from trauma to surgery was 4.2 days (range, 1-8 days). The number of bars used was one for 7 patients, and two for 3 patients. The mean operation time was 60 min (range, 25-107 min). All patients were extubated from artificial respiration without surgical complications or mortality. Mean total ventilation period was 6.5 days (range, 2-15 days). All bars were removed in a subsequent surgery. No collapses or fracture recurrences were observed. CONCLUSION This method is simple and effective for fixed anterior dominant frail segment.
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Affiliation(s)
- Tomoki Nakagawa
- Division of General Thoracic Surgery, Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa, 259-1193, Japan
| | - Ryota Masuda
- Division of General Thoracic Surgery, Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa, 259-1193, Japan
| | - Shunsuke Yamada
- Department of General Thoracic Surgery, Tokai University Hachioji Hospital, Hachioji, Tokyo, 192-0032, Japan.
| | - Masayuki Iwazaki
- Division of General Thoracic Surgery, Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa, 259-1193, Japan
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Biomechanical characteristics of rib fracture fixation systems. Clin Biomech (Bristol, Avon) 2023; 102:105870. [PMID: 36623327 DOI: 10.1016/j.clinbiomech.2023.105870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Abstract
BACKGROUND The primary aim of this study was to determine and compare the biomechanical properties of a fractured or intact rib after implant fixation on an embalmed thorax. METHODS Five systems were fixated on the bilateral fractured or intact (randomly allocated) 6th to 10th rib of five post-mortem embalmed human specimens. Each rib underwent a four-point bending test to determine the bending structural stiffness (Newton per m2), load to failure (Newton), failure mode, and the relative difference in bending structural stiffness and load to failure as compared to a non-fixated intact rib. FINDINGS As compared to a non-fixated intact rib, the relative difference in stiffness of a fixated intact rib ranged from -0.14 (standard deviation [SD], 0.10) to 0.53 (SD 0.35) and for a fixated fractured rib from -0.88 (SD 0.08) to 0.17 (SD 0.50). The most common failure mode was a new fracture at the most anterior drill hole for the plate and screw systems and a new fracture within the anterior portion of the implant for the clamping systems. INTERPRETATION The current fixation systems differ in their design, mode of action, and biomechanical properties. Differences in biomechanical properties such as stiffness and load to failure especially apply to fractured ribs. Insight in the differences between the systems might guide more specific implant selection and increase the surgeon's awareness for localizing hardware complaints or failure.
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Milson N, Treger I, Vered M, Acker A, Kalichman L. Hospital-Based Rehabilitation of Patients Who Had Undergone an Open Reduction and Internal Fixation of the Ribs Due to a Flail Chest: Case Series. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16026. [PMID: 36498097 PMCID: PMC9739889 DOI: 10.3390/ijerph192316026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 06/17/2023]
Abstract
Flail chest, a severe chest injury, is caused by multiple rib fractures. The open reduction and internal fixation (ORIF) of rib fractures is an effective treatment; however, the patients' subsequent condition remains unsatisfactory in terms of the activities of daily living (ADL) and pain. No research study has, as yet, reported on hospital-based rehabilitation of patients who had undergone an ORIF. Our aim was to evaluate the efficacy of hospital-based rehabilitation of flail chest post-ORIF patients. Physical therapists assessed the pain, functional independence measure (FIM), and the Berg balance test. A total of three females and four males (mean age 59.43 ± 18.88) were hospitalized. A significant reduction in pain was observed (7.00 ± 1.83 upon admission to 4.10 ± 2.05 pre-discharge (Z = -2.07, p = 0.027). A significant improvement in FIM (69.43 ± 14.86 upon admission to 113.57 ± 6.40 pre-discharge, Z = -2.37, p = 0.018), and the Berg balance test (35.23 ± 5.87 upon admission to 49.50 ± 3.40 pre-discharge, Z = -2.37, p = 0.018), was observed. Upon admission, all the patients required moderate to complete ADL assistance. Upon discharge, all were independent for all ADL functions. Patients after flail chest post-ORIF can benefit from hospital-based rehabilitation.
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Affiliation(s)
- Nehama Milson
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Iuly Treger
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
- Department of Medicine, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84101, Israel
| | - Michal Vered
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
| | - Asaf Acker
- Rehabilitation Department, Soroka University Medical Center, Beer Sheva 84101, Israel
- Department of Medicine, Faculty for Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84101, Israel
| | - Leonid Kalichman
- Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
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The Surgical Timing and Complications of Rib Fixation for Rib Fractures in Geriatric Patients. J Pers Med 2022; 12:jpm12101567. [PMID: 36294705 PMCID: PMC9604660 DOI: 10.3390/jpm12101567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/15/2022] [Accepted: 09/18/2022] [Indexed: 11/16/2022] Open
Abstract
Rib fractures (RF) are a common injury that cause significant morbidity and mortality, especially in geriatric patients. RF fixation could shorten hospital stay and improve survival. The aim of this retrospective study was to evaluate the clinical impact and proper surgical timing of RF fixation in geriatric patients. We reviewed all the medical data of patients older than 16 years old with RF from the trauma registry database between January 2017 and December 2019 in Chang Gung Memorial Hospital. A total of 1078 patients with RF were enrolled, and 87 patients received RF fixation. The geriatric patients had a higher chest abbreviated injury scale than the non-geriatric group (p = 0.037). Univariate analysis showed that the RF fixation complication rates were significantly related to the injury severity scores (Odds ratio 1.10, 95% CI 1.03–1.20, p = 0.009) but not associated with age (OR 0.99, 95% CI 0.25–3.33, p = 0.988) or the surgical timing (OR 2.94, 95% CI 0.77–12.68, p = 0.122). Multivariate analysis proved that only bilateral RF was an independent risk factor of complications (OR 6.60, 95% CI 1.38–35.54, p = 0.02). RF fixation can be postponed for geriatric patients after they are stabilized and other lethal traumatic injuries are managed as a priority.
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Management of Advanced Aged Patients with Rib Fractures: Current Evidence and Review of the Literature. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2020008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Elderly patients (age > 60 years old) represent the majority of the victims of major trauma, and rib fractures account for 10% of all trauma admissions. Due to the growing interest in surgical rib fixation and the lack of evidence on the best treatment available, we aimed to compare the conservative and operative approaches among the elderly population with multiple rib fractures. The systematic review identified seven eligible studies from over 321 papers collected through the database screening process. The mortality rate, considered the primary outcome, was higher in the conservative-treated group than the operatively-treated patients (8.3% vs. 3%). Considering the secondary outcomes investigated, the overall intensive care unit stay and in-hospital length of stay were longer in the operatively-treated patients (6.3 and 13.3 vs. 4.7 and 7.7, respectively). Conversely, the operative treatment showed favorable results regarding the pneumonia complication rate (5.8% vs. 9.6%), while the duration of mechanical ventilation was similar for both treatments. Surgical stabilization of rib fractures in the elderly population appears to be associated with a survival advantage and avoiding pulmonary complications. However, the individual contribution of operative and conservative treatment in reducing morbidity and mortality in the elderly with multiple rib fractures remains unclear.
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Mischler D, Schopper C, Gasparri M, Schulz-Drost S, Brace M, Gueorguiev B. Is intrathoracic rib plate fixation advantageous over extrathoracic plating? A biomechanical cadaveric study. J Trauma Acute Care Surg 2022; 92:574-580. [PMID: 34686638 DOI: 10.1097/ta.0000000000003443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The high morbidity following surgical interventions on the chest wall because of large incisions often prevents surgeons from operative rib fracture treatment. Minimally invasive approaches to the intrathoracic side of the rib could allow for smaller incisions with lower morbidity while maintaining stability of fixation. The aim of this study was to explore the biomechanical competence of intrathoracic versus extrathoracic plating in a human cadaveric rib fracture model and investigate the effect of plating using two versus three screws per fracture fragment. METHODS Twenty pairs of fresh-frozen human cadaveric ribs from elderly female donors aged 82.4 ± 7.8 years were used. First, the stiffness of each native rib was calculated via nondestructive (2 N-5 N) biomechanical testing under two loading conditions: ramped two-point bending and combined ramped tensile bending with torsional loading. Second, the ribs were fractured under three-point bending with their intrathoracic side put under tensile stress. Third, specimens were assigned to four groups (n = 10) for either intrathoracic or extrathoracic plating with two or three screws per fragment. Following instrumentation, all ribs were dynamically tested over 400,000 cycles under combined sinusoidal tensile bending with torsional loading (2 N-5 N at 3 Hz). Finally, all specimens were destructively tested under ramped two-point bending. RESULTS Following instrumentation and cyclic testing, significantly higher construct stiffness was observed for intrathoracic vs. extrathoracic plating under anatomical loading conditions (p ≤ 0.03). No significant differences were detected for implant subsidence after plating with two or three screws per fragment (p ≥ 0.20). CONCLUSION This study demonstrates significantly higher construct stiffness following intrathoracic over extrathoracic plating, thus indicating superior plate support of the former. In the clinical context, using only two instead of three screws per fragment not only could maintain stability of fixation but also decrease surgery time and costs, and allow for smaller incisions with lower morbidity. LEVEL OF EVIDENCE Therapeutic/Care Management; Level V.
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Affiliation(s)
- Dominic Mischler
- From the AO Research Institute Davos (D.M., C.S., B.G.), Davos, Switzerland; Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH (C.S.), Johannes Kepler University Linz, Austria; Division of CT Surgery, Medical College of Wisconsin (M.G.), Milwaukee, Wisconsin; Department of Surgery, University Hospital Erlangen (S.S.-D.), Erlangen, Germany; and DePuy Synthes (M.B.), West Chester, Pennsylvania
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Christie DB, Nowack TE, Nonnemacher CJ, Montgomery A, Ashley DW. Surgical Stabilization of Rib Fractures Improves Outcomes in the Geriatric Patient Population. Am Surg 2022; 88:658-662. [DOI: 10.1177/00031348211060432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Rib fractures in the ≥65-year-old population have been shown to strongly influence mortality and pneumonia rates. There is a growing body of evidence demonstrating improvements in the geriatric patient’s survival statistics and respiratory performances after surgical stabilization of rib fractures (SSRF). We have observed a strong survival and complication avoidance trend in geriatric patients who undergo SSRF. The purpose of our study was to evaluate the outcomes of geriatric patients with rib fractures treated with SSRF compared to those who only receive conservative therapies. Methods We performed a retrospective review of our trauma registry analyzing outcomes of patients ≥65 years with rib fractures. Patients admitted from 2015 to 2019 receiving SSRF (RP group) were compared to a nonoperative controls (NO group) admitted during the same time. Bilateral fractures were excluded. Independent variables analyzed = ISS, mortalities, hospital days, ICU days, pleural space complications, and readmissions. Follow-up was 60 days after discharge. Group comparison was performed using Kolmogorov-Smirnov, Shapiro-Wilk, and Mann-Whitney U tests. Results 257 patients were analyzed: 172 in the NO group with mean age of 75 (65-10) and 85 in the RP group with mean age of 74 (65-96). Mean ISS = 13 (1-38) for the NO group and 20 (9-59) for the RP group ( P < .001). Mean hospital days = 8 (1-39) and 15 (3-49) in NO and RP groups, respectively. Mean ICU days = 10 (1-32) and 8 (1-11) in NO and RP groups, respectively. Deaths, pneumonia, readmissions, and pleural effusions in the NO group were statistically significant ( P < .01). Analysis of complications revealed 4 RP patients (4.7%) with respiratory complications out to 60 days and 65 NO patients (37.8%) ( P < .001). Conclusions Surgical stabilization of rib fractures appears to be associated with a survival advantage and an avoidance of respiratory-related complications in the ≥65-year-old patient population.
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Affiliation(s)
| | - Timothy E. Nowack
- Department of Trauma Surgery and Critical Care, Mercer University School of Medicine, Macon, GA, USA
| | | | - Anne Montgomery
- Department of Trauma Surgery and Critical Care, Mercer University School of Medicine, Macon, GA, USA
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Spering C, von Hammerstein-Equord A, Lehmann W, Dresing K. [Osteosynthesis of the unstable thoracic wall]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2020; 33:262-284. [PMID: 33289872 PMCID: PMC7722258 DOI: 10.1007/s00064-020-00688-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 03/08/2020] [Accepted: 03/29/2020] [Indexed: 11/27/2022]
Abstract
Operationsziel Wiederherstellung einer normalen Atemmechanik und Vermeidung beatmungsassoziierter Komplikationen durch operative Stabilisierung eines instabilen Thorax bei dislozierten Rippenserien- und Sternumfrakturen, posttraumatischer Thoraxwanddeformierung, Weaning-Versagen und symptomatischen Rippenpseudarthrosen. Indikationen Kombination mehrerer klinischer und radiologischer Parameter wie das Ausmaß der Rippenserien- und Sternumfrakturen, der Grad der Dislokation, pathophysiologische Veränderungen der Atemmechanik, Versagen eines konservativen Therapieansatzes. Kontraindikationen Akute hämodynamische Instabilität und Zeichen einer systemischen Infektion. Operationstechnik Detaillierte präoperative Planung. Offene, möglichst minimalinvasive Reposition und winkelstabile Osteosynthese mit anatomisch vorgeformten Low-profile-Platten und/oder intramedullären Splints. Vorsichtige Repositionsmanöver und Einbringen der Implantate aufgrund enger Lagebeziehung zu Pleuraspalt, Lunge und Perikard. Weiterbehandlung Möglichst frühzeitiges postoperatives Entwöhnen vom Respirator sowie frühzeitige Therapie eines perioperativen Pneumothorax. Eine Implantatentfernung ist in der Regel nicht notwendig. Ergebnisse In einer retrospektiven Untersuchung profitierten 15 Polytraumapatienten mit instabilem Thorax von der frühen operativen Stabilisierung des Thorax innerhalb von 24–48 h und einer differenzierten, interdisziplinären Behandlungsstrategie. Beatmungsdauer und Pneumonierate waren in der Subgruppe der frühzeitig operierten signifikant niedriger als in der Gruppe der später operativ an der Thoraxwand stabilisierten Patienten. In den Subgruppen der lebensgefährlich Verletzten mit Thoraxtrauma (LVK-Thx und LOTX [LVK-Thx mit Osteosynthese am Thorax]) konnten eine längere Beatmungszeit, Intensivtherapie, Krankenhausverweildauer sowie eine erhöhte beatmungsassoziierte Komplikationsrate als in der Subgruppe der Schwerverletzten ohne Thoraxtrauma (AIS [Abbreviated Injury Scale] ≥ 3) gezeigt werden.
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Affiliation(s)
- Christopher Spering
- Klink für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | | | - Wolfgang Lehmann
- Klink für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Klaus Dresing
- Klink für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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Apostolakis E, Papakonstantinou NA, Liakopoulou A, Chlapoutakis S. External flail chest stabilization; The simple, low-cost way. J Cardiovasc Thorac Res 2020; 13:174-175. [PMID: 34326973 PMCID: PMC8302900 DOI: 10.34172/jcvtr.2020.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/30/2020] [Indexed: 12/04/2022] Open
Abstract
Flail chest is a life-threatening clinical entity which can be complicated by respiratory insufficiency. Paradoxical motion of a part of chest wall is the basic cause to put the blame on. Consequently, stabilization of the chest wall is occasionally of paramount importance to achieve early extubation in a patient with post-trauma respiratory insufficiency. Hereby, a simple, low cost, harmless and effective approach of external stabilization is presented.
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Affiliation(s)
- Efstratios Apostolakis
- Cardiothoracic Surgery Department, University Hospital of Ioannina, School of Medicine, Ioannina, Greece
| | | | - Alexandra Liakopoulou
- Cardiothoracic Surgery Department, University Hospital of Ioannina, School of Medicine, Ioannina, Greece
| | - Serafeim Chlapoutakis
- Cardiothoracic Surgery Department, University Hospital of Ioannina, School of Medicine, Ioannina, Greece
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Nowack T, Nonnemacher C, Christie DB. Video-Assisted Thoracoscopic Surgery as an Adjunct to Rib Fixation. Am Surg 2020; 88:1338-1340. [PMID: 32845731 DOI: 10.1177/0003134820943642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Timothy Nowack
- 5223 Department of Trauma Surgery, Mercer University School ofMedicine, The Medical Center, Navicent Health, Macon, GA, USA
| | - Cory Nonnemacher
- 5223 Department of Trauma Surgery, Mercer University School ofMedicine, The Medical Center, Navicent Health, Macon, GA, USA
| | - D Benjamin Christie
- 5223 Department of Trauma Surgery, Mercer University School ofMedicine, The Medical Center, Navicent Health, Macon, GA, USA
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郭 辅, 朱 凤, 邓 玖, 杜 哲, 赵 秀. [Risk factors for mechanical ventilation in patients with severe multiple trauma]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2020; 52:738-742. [PMID: 32773812 PMCID: PMC7433611 DOI: 10.19723/j.issn.1671-167x.2020.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To eludicate the risk factors of mechanical ventilation and prolonged mechanical ventilation in patients with severe multiple injuries. METHODS Consecutive patients with severe multiple injures who were treated in Peking University People's Hospital Trauma Medical Center between December 2016 and December 2019 were enrolled in this restropective chart-review study. According to mechanical ventilation and ventilatory time, the patients were divided into mechanical ventilation (MV) group and non-mechanical ventilation (NMV) groups, prolonged mechanical ventilation (PMV) group and shortened mechanical ventilation (SMV) groups. Clinical data such as gender, age, base excess, mechanism of injury, Glasgow Coma Scale (GCS), abbreviated injury scale (AIS) and injury severity score (ISS) were collected. To indentify the risk factors of mechanical ventilation and prolonged mecha-nical ventilation, univariate and multivariate Logistic analyses were carried out. RESULTS In the present study, 112 patients (82 male, 30 female) with severe multiple injuries having a median age of 52 (range: 16-89 years) and a median ISS of 34 (range: 16-66) were enrolled. The primary mechanism of injury was traffic accident injury and falling injury. In the study, 62 and 50 patients were assigned to MV and NMV groups, respectively. Logistic analysis showed that GCS (OR=0.72, 95%CI: 0.53-0.92, P=0.03), base excess (OR=0.56, 95%CI: 0.37-0.88, P=0.002) and multiple rib fracture (OR=1.72, 95%CI: 1.60-2.80, P=0.012) were independent significant risk factors for mechanical ventilation after severe multiple injuries. Within the mechanical ventilation group, 38 and 24 patients were assigned to PMV and SMVgroups, respectively. Compared with the SMV group, the PMV group had a higher ISS and higher rate of severe head trauma. The length of hospital stay of PMV group was longer than that of SMV groups. Meanwhile, the incidence of tracheotomy in PMV group was high. CONCLUSIONS GCS, base excess and rib fracture might be independent risk factors for mechanical ventilation. Higher ISS and lower GCS might prolong the ventilatory time and the length of hospital stay. Meanwhile, the incidence of tracheotomy was high in PMV group because of the longer ventilatory time and poor consciousness.
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Affiliation(s)
- 辅政 郭
- />北京大学人民医院创伤救治中心,北京 100044Department of Trauma Center, Peking University People's Hospital, Beijing 100044, China
| | - 凤雪 朱
- />北京大学人民医院创伤救治中心,北京 100044Department of Trauma Center, Peking University People's Hospital, Beijing 100044, China
| | - 玖旭 邓
- />北京大学人民医院创伤救治中心,北京 100044Department of Trauma Center, Peking University People's Hospital, Beijing 100044, China
| | - 哲 杜
- />北京大学人民医院创伤救治中心,北京 100044Department of Trauma Center, Peking University People's Hospital, Beijing 100044, China
| | - 秀娟 赵
- />北京大学人民医院创伤救治中心,北京 100044Department of Trauma Center, Peking University People's Hospital, Beijing 100044, China
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14
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Marro A, Chan V, Haas B, Ditkofsky N. Blunt chest trauma: classification and management. Emerg Radiol 2019; 26:557-566. [DOI: 10.1007/s10140-019-01705-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/02/2019] [Indexed: 12/23/2022]
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15
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Shih KS, Truong TA, Hsu CC, Hou SM. Biomechanical investigation of different surgical strategies for the treatment of rib fractures using a three-dimensional human respiratory model. ACTA ACUST UNITED AC 2019; 64:93-102. [PMID: 29095691 DOI: 10.1515/bmt-2017-0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/09/2017] [Indexed: 01/17/2023]
Abstract
Rib fracture is a common injury and can result in pain during respiration. Conservative treatment of rib fracture is applied via mechanical ventilation. However, ventilator-associated complications frequently occur. Surgical fixation is another approach to treat rib fractures. Unfortunately, this surgical treatment is still not completely defined. Past studies have evaluated the biomechanics of the rib cage during respiration using a finite element method, but only intact conditions were modelled. Thus, the purpose of this study was to develop a realistic numerical model of the human rib cage and to analyse the biomechanical performance of intact, injured and treated rib cages. Three-dimensional finite element models of the human rib cage were developed. Respiratory movement of the human rib cage was simulated to evaluate the strengths and limitations of different scenarios. The results show that a realistic human respiratory movement can be simulated and the predicted results were closely related to previous study (correlation coefficient>0.92). Fixation of two fractured ribs significantly decreased the fixation index (191%) compared to the injured model. This fixation may provide adequate fixation stability as well as reveal lower bone stress and implant stress compared with the fixation of three or more fractured ribs.
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Affiliation(s)
- Kao-Shang Shih
- Department of Orthopedic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan, ROC.,College of Medicine, Fu Jen Catholic University, Taipei 242, Taiwan, ROC
| | - Thanh An Truong
- Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei 106, Taiwan, ROC
| | - Ching-Chi Hsu
- Graduate Institute of Applied Science and Technology, National Taiwan University of Science and Technology, No. 43, Sec. 4, Keelung Rd., Taipei 106, Taiwan, ROC
| | - Sheng-Mou Hou
- Department of Orthopedic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan, ROC
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16
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Pieracci FM, Leasia K, Whitbeck S. Barriers to conducting a multi-center randomized controlled trial of surgical stabilization of rib fractures (and how to overcome them). J Thorac Dis 2019; 11:S1049-S1060. [PMID: 31205762 DOI: 10.21037/jtd.2018.12.126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical stabilization of rib fractures (SSRF) has become a standardized procedure, routinely performed at trauma centers over the last 40 years, however, it remains a controversial practice. Multicenter, randomized controlled trials (RCT) would provide compelling evidence in the efficacy of SSRF but there are theoretical obstacles involved with execution and design of this type of investigation. Through the systematic review of current literature on the topics of SSRF for flail and non-fail patterns, medical device industry conflicts of interests, working with international review boards (IRB), the surveyed opinions of surgeons, and through the experience gained from conducting a multicenter RCT on SSRF, it was possible to identify the major barriers that come with successful implementation of this type of study. In identifying these obstacles, it was then possible to propose their solutions, specifically to the issues that make the effort underpowered, underfunded, understaffed, with not enough time for completion. These barriers can be overcome with understanding, up front, that a mutlicenter RCT of SSRF will involve a multi-year and multi-hundred thousand dollar commitment, with support from parent organizations, and a dedicated, full-time research staff (and the solutions of how to overcome them). These barriers stem from poor planning which result specifically in an effort that is underpowered, under funded, under staffed, with not enough time for completion.
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Affiliation(s)
- Fredric M Pieracci
- Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, Denver, CO, USA
| | - Kiara Leasia
- Trauma, Acute Care Surgery, and Surgical Critical Care, Denver Health Medical Center, Denver, CO, USA
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17
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Michelitsch C, Acklin YP, Hässig G, Sommer C, Furrer M. Operative Stabilization of Chest Wall Trauma: Single-Center Report of Initial Management and Long-Term Outcome. World J Surg 2019; 42:3918-3926. [PMID: 29959488 DOI: 10.1007/s00268-018-4721-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Christian Michelitsch
- Division of Thoracic Surgery, Department of Surgery, Cantonal Hospital, Loëstrasse 170, 7000, Graubünden, Switzerland.
| | - Yves Pascal Acklin
- Division of Trauma Surgery, Department of Surgery, Cantonal Hospital, Graubünden, Switzerland
| | - Gabriela Hässig
- Division of Thoracic Surgery, Department of Surgery, Cantonal Hospital, Loëstrasse 170, 7000, Graubünden, Switzerland
| | - Christoph Sommer
- Division of Trauma Surgery, Department of Surgery, Cantonal Hospital, Graubünden, Switzerland
| | - Markus Furrer
- Division of Thoracic Surgery, Department of Surgery, Cantonal Hospital, Loëstrasse 170, 7000, Graubünden, Switzerland
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18
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Olland A, Puyraveau M, Guinard S, Seitlinger J, Kadoche D, Perrier S, Renaud S, Falcoz PE, Massard G. Surgical stabilization for multiple rib fractures: whom the benefit? -a prospective observational study. J Thorac Dis 2019; 11:S130-S140. [PMID: 30906577 DOI: 10.21037/jtd.2018.10.122] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Surgical repair has demonstrated a beneficial effect on outcome for patients presenting with flail chest or with multiple rib fractures. We hypothesized that benefit on outcome parameters concerns predominantly patients being extubated within 24 hours post-operatively. Methods We prospectively recorded all patients presenting with chest traumatism eligible for surgical repair with anticipated early extubation according to our institutional consensus (flail chest, major deformity, poor pain control, associated lesions requiring thoracotomy). We compared outcomes of patients extubated within 24 hours post-operatively to those who required prolonged ventilator support. We tested predictive factors for prolonged intubation with univariate and multivariate analysis. Results From 2010 to 2014, 132 patients required surgical repair. Two thirds were extubated within 24 hours following surgical repair. Pneumonia was the main complication and occurred in 30.3% of all patients. Patients extubated within 24 hours following surgical repair had significantly shorter ICU stay and shorter in-hospital stay (P<0.0001 both). Pneumonia occurred significantly more often in patients with longer mechanical ventilation (over 24 hours) (P<0.0001) and the overall post-operative complications rate was higher (P=0.0001). Main independent risk factors for delayed extubation were bilateral chest rib fractures and initially associated pneumothorax. Conclusions We conclude that patients extubated within 24 hours after repair have an improved outcome with reduced complication rate and shorter hospital stay. The initial extent of the trauma is an important risk factor for delayed extubation and high complication rate despite surgical stabilization.
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Affiliation(s)
- Anne Olland
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
| | - Marc Puyraveau
- Clinical Methodology Center, University Hospital Besançon, Besançon, France
| | - Sophie Guinard
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Joseph Seitlinger
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
| | - Déborah Kadoche
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Stéphanie Perrier
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Stéphane Renaud
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France
| | - Pierre-Emmanuel Falcoz
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
| | - Gilbert Massard
- Thoracic Surgery Department, 'Nouvel Hôpital Civil', University Hospital Strasbourg, 67000 Strasbourg, France.,INSERM (French National Institute of Health and Medical Research) UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000 Strasbourg, France
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19
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Mitev K, Neziri D, Stoicovski E, Mitrev Z. Surgical plate fixation of multiple rib fractures: a case report. J Med Case Rep 2018; 12:150. [PMID: 29807546 PMCID: PMC5972397 DOI: 10.1186/s13256-018-1683-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/07/2018] [Indexed: 11/29/2022] Open
Abstract
Background The healthcare system in developing countries is limited; particularly, medical specialties such as emergency and trauma medicine are underdeveloped. Consequently, trauma injuries sustained in traffic accidents result in chronic morbidity more often than similar cases in developed countries. Multiple rib fractures induce significant patient morbidity. Current international guidelines recommend a multidisciplinary, surgery-based treatment approach to achieve optimal clinical benefit. Case presentation We admitted a 41-year-old Albanian man to our emergency department following a pedestrian-vehicle accident 5 days earlier. He presented with severe upper thoracic pain, chest deformity, dyspnea, tachycardia, subcutaneous emphysema, and hematoma. Chest radiography pointed to hypoventilated lung fields and a minor pleural effusion. Computed tomographic scans indicated displaced fractures of right lateral ribs 5 –11, hyperdensity regions from bone fragments, and pulmonary contusion. The treatment consisted of surgical fixation of ribs 7–10 using titanium reconstruction plates and cortical locking screws. The patient’s clinical condition rapidly improved postoperatively. Follow-up at 6 weeks confirmed a full return to preoperative daily activities and a high quality of life. Conclusions In this case report, we present a novel and promising development in the field of trauma medicine in the Republic of Macedonia. Trauma injuries can be treated via advanced multidisciplinary medical care according to international standards, allowing optimal health recovery.
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Affiliation(s)
- Konstantin Mitev
- Department of Orthopedic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia. .,Faculty of Medical Sciences, University Goce Delchev, Shtip, Republic of Macedonia.
| | - Dashurie Neziri
- Department of Orthopedic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia
| | - Emil Stoicovski
- Department of Orthopedic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia
| | - Zan Mitrev
- Department of Thoracic Surgery, Zan Mitrev Clinic, Skopje, Republic of Macedonia
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20
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Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB. Chest Wall Stabilization Leads to Shortened Chest Tube Stay Time in Rib Fracture Patients after Traumatic Chest Wall Injury. Am Surg 2018. [DOI: 10.1177/000313481808400519] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rib fixation has become a strategy for patients with displaced rib fractures and hemo/ pneumothoraces (HTX/PTX). Rib plating improves pain control and respiratory mechanics, thereby reducing recovery times and morbidity/mortality. Current treatment consists of chest tube placement, pain control, and pulmonary toilet. The addition of rib plating should reduce time till HTX/PTX resolution and chest tube removal. The study compares chest tube stay time in ribplated patients with those managed with current treatment. We hypothesize that patients undergoing rib plating will have a reduction in chest tube stay times. A retrospective review of a Level 1 trauma registry was performed. Rib-plated patients (n = 70) from 2013 to 2015 were compared with a randomly selected, nonoperative, injury-matched, historical (2003–2008) control group (n = 60). Demographics were obtained. Independent variables analyzed include Injury Severity Score (ISS), intensive care unit days, length of stay, and chest tube stay times. 60 control patients had an average ISS of 19 and age of 51 years, compared with ISS of 20 and age of 56 years in plated patients. Plated patients had a reduction in chest tube days, 6.5 versus 8.4 days, P value = 0.02. Plated patients had 14 intensive care unit days versus 19 days, P value = 0.09. T tests were performed to confirm significance. Reduction in chest tube days improves patient pain and allows for improved ambulation and pulmonary toilet, helping reduce respiratory complications. Our review shows that plating may prove beneficial in reducing complications associated with management of HTX/PTX in the setting of rib fractures.
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Affiliation(s)
- Michael T. Fitzgerald
- Department of Trauma Surgery and Critical Care, The Medical Center, Navicent Health, Mercer University School of Medicine, Macon, Georgia
| | - Dennis W. Ashley
- Department of Trauma Surgery and Critical Care, The Medical Center, Navicent Health, Mercer University School of Medicine, Macon, Georgia
| | - Hesham Abukhdeir
- Department of Trauma Surgery and Critical Care, The Medical Center, Navicent Health, Mercer University School of Medicine, Macon, Georgia
| | - D. Benjamin Christie
- Department of Trauma Surgery and Critical Care, The Medical Center, Navicent Health, Mercer University School of Medicine, Macon, Georgia
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21
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Han SH, Chon SH, Lee JH, Lee MK, Kwon OS, Kim KH, Kim JS, Lee HH. Rib Fixation for a Patient with Severely Displaced and Overlapped Costal Cartilage Fractures. JOURNAL OF TRAUMA AND INJURY 2018. [DOI: 10.20408/jti.2018.31.1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sung Ho Han
- Department of Traumatology, Cheju Halla General Hospital, Jeju, Korea
| | - Soon-Ho Chon
- Department of Thoracic and Cardiovascular Surgery, Cheju Halla General Hospital, Jeju, Korea
| | - Jong Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Cheju Halla General Hospital, Jeju, Korea
| | - Min Koo Lee
- Department of Traumatology, Cheju Halla General Hospital, Jeju, Korea
| | - Oh Sang Kwon
- Department of Traumatology, Cheju Halla General Hospital, Jeju, Korea
| | - Kyoung Hwan Kim
- Department of Traumatology, Cheju Halla General Hospital, Jeju, Korea
| | - Jung Suk Kim
- Department of Traumatology, Cheju Halla General Hospital, Jeju, Korea
| | - Ho hyoung Lee
- Department of Traumatology, Cheju Halla General Hospital, Jeju, Korea
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22
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Okabe Y. Risk factors for prolonged mechanical ventilation in patients with severe multiple injuries and blunt chest trauma: a single center retrospective case-control study. Acute Med Surg 2018; 5:166-172. [PMID: 29657729 PMCID: PMC5891117 DOI: 10.1002/ams2.331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/20/2017] [Indexed: 11/25/2022] Open
Abstract
Aim Blunt chest trauma is common and is associated with morbidity and mortality in patients with multiple injuries, frequently requiring invasive mechanical ventilation. The aim of this study was to elucidate risk factors for prolonged mechanical ventilation (PMV). Methods Consecutive adult patients with multiple severe injuries and blunt chest trauma who treated in Chiba Emergency Medical Center (Chiba, Japan) between January 2008 and December 2015 were enrolled in this retrospective chart‐review study. According to ventilatory time, the patients were divided into PMV (≥7 days) and shortened mechanical ventilation (SMV; <7 days) groups. Thoracic Trauma Severity Score (TTSS) was calculated. To identify risk factors for PMV, univariate and multivariate logistic analyses and receiver operating characteristic analysis were carried out. Results Eighty‐four and 49 patients were assigned to PMV and SMV groups, respectively. Compared with the SMV group, the PMV group had a significantly larger number of fractured ribs (P < 0.01), higher rate of severe Glasgow Coma Scale (GCS ≤8) (P < 0.05) and flail chest (P < 0.001), higher TTSS (P < 0.001), or longer intensive care unit and hospital stay (both P < 0.001). Logistic analysis showed that severe GCS (odds ratio [OR] = 4.6, P < 0.01), flail chest (OR = 3.0, P < 0.05), and TTSS (OR = 1.2; P < 0.01) were independent significant risk factors. Receiver operating characteristic analyses showed that the area under the curves for TTSS, flail chest, and severe GCS were 0.74, 0.70, and 0.58, respectively. When the three factors were combined, the area under the curve increased to 0.8. Conclusion Severe GCS (≤8), flail chest, or TTSS may be independent risk factors. Combining the three risk factors could provide high predictive performance for PMV.
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Affiliation(s)
- Yasuyuki Okabe
- Division of Acute Care Surgery Chiba Emergency Medical Center Chiba Chiba Prefecture Japan
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Abstract
The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.
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Affiliation(s)
- Steven E Brooks
- Geriatric Trauma Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Department of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA; Pediatric Intensive Care Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Department of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA.
| | - Allan B Peetz
- Emergency General Surgery, Division of Trauma, Surgical Critical Care, Vanderbilt University Medical Center, Medical Arts Building Suite 404, 1211 21st Avenue South, Nashville, TN 37212, USA
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24
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Abstract
Management of chest trauma is integral to patient outcomes owing to the vital structures held within the thoracic cavity. Understanding traumatic chest injuries and appropriate management plays a pivotal role in the overall well-being of both blunt and penetrating trauma patients. Whether the injury includes rib fractures, associated pulmonary injuries, or tracheobronchial tree injuries, every facet of management may impact the short- and long-term outcomes, including mortality. This article elucidates the workup and management of the thoracic cage, pulmonary and tracheobronchial injuries.
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Affiliation(s)
- Bradley M Dennis
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Seth A Bellister
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
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25
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Divisi D, Barone M, Crisci R. Surgical Management of Flail Chest: State of Art and Future Perspectives. CURRENT SURGERY REPORTS 2017. [DOI: 10.1007/s40137-017-0184-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a Level I trauma center. J Trauma Acute Care Surg 2017; 82:524-527. [PMID: 28030506 DOI: 10.1097/ta.0000000000001330] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fractures after chest wall trauma are a common injury; however, they carry a significant morbidity and mortality risk. The impact of rib fractures in the 65-year and older patient population has been well documented as have the mortality and pneumonia rates. We hypothesize that patients 65 years and older receiving rib plating (RP) have decreased mortality, complication rates, and an accelerated return to normal functional states when compared with controls. METHODS With institutional review board approval, a retrospective review analyzed patients 65 years and older with rib fractures admitted from 2009 to 2015 receiving RP (RP group) (n = 23) compared to nonoperative, injury-matched controls admitted from 2003 to 2008 (NO group) (n = 50). Patients were followed prospectively with regard to lifestyle and functional satisfaction. Independent variables analyzed included Injury Severity Score (ISS), number of rib fractures, mortalities, hospital days, intensive care unit days, pneumonia development, respiratory complications, readmission rates, need for and length of rehabilitation stay time. Comparisons were by χ tests/Fisher's exact tests, Student's t tests and Wilcoxon rank sum tests. RESULTS From 2003 to 2008, 50 NO patients were admitted with ages ranging 65 to 97 years, average ISS of 18.47 (14.28-22.66) versus ages ranging from 63 to 89 years, average ISS of 20.71 (15.7-25.73) for the RP group (n = 23). Average hospital days were 16.76 (10.35-23.18) and 18.36 (13.61-23.11) in the NO and RP groups, respectively. Average intensive care unit days were 11.65 (6.45-16.85) and 8.29 (5.31-11.26) days in the NO and RP groups, respectively. Four respiratory readmissions, two deaths, seven pneumonias, seven pleural-effusions, and 19 recurrent pneumothoraces were encountered in the NO group versus 0 in the RP group (p < 0.001). An equal percentage of patients in both groups entered rehabilitation facilities with average stay time of 18.5 and 28.53 days for the RP and NO groups, respectively. CONCLUSION RP in the 65-year and older trauma population demonstrates a measurable decrease in mortality and respiratory complications, improves respiratory mechanics, and permits an accelerated return to functioning state. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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27
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Fagevik Olsén M, Slobo M, Klarin L, Caragounis EC, Pazooki D, Granhed H. Physical function and pain after surgical or conservative management of multiple rib fractures - a follow-up study. Scand J Trauma Resusc Emerg Med 2016; 24:128. [PMID: 27793168 PMCID: PMC5084382 DOI: 10.1186/s13049-016-0322-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 10/23/2016] [Indexed: 11/21/2022] Open
Abstract
Background There is scarce knowledge of physical function and pain due to multiple rib fractures following trauma. The purpose of this follow-up was to assess respiratory and physical function, pain, range of movement and kinesiophobia in patients with multiple rib fractures who had undergone stabilizing surgery and compare with conservatively managed patients. Methods A consecutive series of 31 patients with multiple rib fractures who had undergone stabilizing surgery were assessed >1 year after the trauma concerning respiratory and physical function, pain, range of movement in the shoulders and thorax, shoulder function and kinesiophobia. For comparison, 30 patients who were treated conservatively were evaluated with the same outcome measures. Results The results concerning pain, lung function, shoulder function and level of physical activity were similar in the two groups. The patients who had undergone surgery had a significantly larger range of motion in the thorax (p < 0.01) and less deterioration in two items in Disability Rating Index (sitting and standing bent over a sink) (p < 0.05). Discussion It is questionable whether the control group is representative since the majority of patients were invited but refused to participate in the follow-up. In addition, this study is too small to make a definitive conclusion if surgery is better than conservative treatment. But we see some indications, such as a tendency for decreased pain, better thoracic range of motion and physical function which would indicate that surgery is preferable. If operation technique could improve in the future with a less invasive approach, it would presumably decrease post-operative pain and the benefit of surgery would be greater than the morbidity of surgery. Conclusions Patients undergoing surgery have a similar long-term recovery to those who are treated conservatively except for a better range of motion in the thorax and fewer limitations in physical function. Surgery seems to be beneficial for some patients, the question remains which patients. Trial registration FoU i Sverige (R&D in Sweden), No 106121
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Affiliation(s)
- Monika Fagevik Olsén
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden. .,Department of Physical Therapy, Sahlgrenska University Hospital and Sahlgrenska Academy at Gothenburg University, Gothenburg, SE 413 45, Sweden.
| | - Margareta Slobo
- Department of Physical Therapy, Sahlgrenska University Hospital and Sahlgrenska Academy at Gothenburg University, Gothenburg, SE 413 45, Sweden
| | - Lena Klarin
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva-Corina Caragounis
- Department of Surgery, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - David Pazooki
- Department of Surgery, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Hans Granhed
- Department of Surgery, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
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Forward DP, Ollivere BJ, Ng JWG, Coughlin TA, Rollins KE. Current concepts in rib fracture fixation. ACTA ACUST UNITED AC 2016. [DOI: 10.1302/2048-0105.55.360464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rib fracture fixation by orthopaedic and cardiothoracic surgeons has become increasingly popular for the treatment of chest injuries in trauma. The literature, though mainly limited to Level II and III evidence, shows favourable results for operative fixation. In this paper we review the literature and discuss the indications for rib fracture fixation, surgical approaches, choice of implants and the future direction for management. With the advent of NICE guidance and new British Orthopaedic Association Standards for Trauma (BOAST) guidelines in production, the management of rib fractures is going to become more and more commonplace.
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Nickerson TP, Thiels CA, Kim BD, Zielinski MD, Jenkins DH, Schiller HJ. Outcomes of Complete Versus Partial Surgical Stabilization of Flail Chest. World J Surg 2016; 40:236-41. [PMID: 26374224 DOI: 10.1007/s00268-015-3169-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rib fractures are common after chest wall trauma. For patients with flail chest, surgical stabilization is a promising technique for reducing morbidity. Anatomical difficulties often lead to an inability to completely repair the flail chest; thus, the result is partial flail chest stabilization (PFS). We hypothesized that patients with PFS have outcomes similar to those undergoing complete flail chest stabilization (CFS). METHODS A prospectively collected database of all patients who underwent rib fracture stabilization procedures from August 2009 until February 2013 was reviewed. Abstracted data included procedural and complication data, extent of stabilization, and pulmonary function test results. RESULTS Of 43 patients who underwent operative stabilization of flail chest, 23 (53%) had CFS and 20 (47%) underwent PFS. Anterior location of the fracture was the most common reason for PFS (45%). Age, sex, operative time, pneumonia, intensive care unit and hospital length of stay, and narcotic use were the same in both groups. Total lung capacity was significantly improved in the CFS group at 3 months. No chest wall deformity was appreciated on follow-up, and no patients underwent additional stabilization procedures following PFS. CONCLUSION Despite advances in surgical technique, not all fractures are amenable to repair. There was no difference in chest wall deformity, narcotic use, or clinically significant impairment in pulmonary function tests among patients who underwent PFS compared with CFS. Our data suggest that PFS is an acceptable strategy and that extending or creating additional incisions for CFS is unnecessary.
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Affiliation(s)
- Terry P Nickerson
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Cornelius A Thiels
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Brian D Kim
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Martin D Zielinski
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Donald H Jenkins
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Henry J Schiller
- Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Lee SK, Kang DK. Nuss procedure for surgical stabilization of flail chest with horizontal sternal body fracture and multiple bilateral rib fractures. J Thorac Dis 2016; 8:E390-2. [PMID: 27293864 DOI: 10.21037/jtd.2016.04.05] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Flail chest is a life-threatening situation that paradoxical movement of the thoracic cage was caused by multiply fractured ribs in two different planes, or a sternal fracture, or a combination of the two. The methods to achieve stability of the chest wall are controversy between surgical fixation and mechanical ventilation. We report a case of a 33-year-old man who fell from a high place with fail chest due to multiple rib fractures bilaterally and horizontal sternal fracture. The conventional surgical stabilization using metal plates by access to the front of the sternum could not provide stability of the flail segment because the fracture surface was obliquely upward and there were multiple bilateral rib fractures adjacent the sternum. The Nuss procedure was performed for supporting the flail segment from the back. Flail chest was resolved immediately after the surgery. The patient was weaned from the mechanical ventilation on third postoperative day successfully and was ultimately discharged without any complications.
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Affiliation(s)
- Sung Kwang Lee
- Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, South Korea
| | - Do Kyun Kang
- Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, South Korea
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Akkuş M, Utkusavaş A, Hanözü M, Kaya M, Bakir I. Stabilization of Flail Chest and Fractured Sternum by Minimally Invasive Repair of Pectus Excavatum. Thorac Cardiovasc Surg Rep 2015; 4:11-3. [PMID: 26693119 PMCID: PMC4670315 DOI: 10.1055/s-0035-1563399] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 06/26/2015] [Indexed: 12/02/2022] Open
Abstract
We report a 55-year-old male patient with a massive flail chest that required chest stabilization by minimally invasive repair of pectus excavatum (MIRPE) employing a Nuss bar. Surgical stabilization of severe flail chest and fractured sternum with Nuss bar by MIRPE is a safe and useful treatment modality in properly selected patients.
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Affiliation(s)
- Murat Akkuş
- Department of Thoracic Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ayfer Utkusavaş
- Department of Pulmonology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Hanözü
- Department of Thoracic Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Kaya
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ihsan Bakir
- Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Snapping scapular syndrome secondary to rib intramedullary fixation device. Int J Surg Case Rep 2015; 17:158-60. [PMID: 26629853 PMCID: PMC4701874 DOI: 10.1016/j.ijscr.2015.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/12/2015] [Accepted: 11/12/2015] [Indexed: 11/22/2022] Open
Abstract
Intramedullary rib fixation has become popular. Snapping scapula syndrome is a cause of persistent pain around the scapulothoracic joint. We present a case of snapping scapula secondary to migration of a intramedullary rib splint into the scapulothoracic joint.
Background Scapulo-thoracic joint disorders, including bursitis and crepitus, are commonly misdiagnosed problems and can be a source of persistent pain and dysfunction Presentation of the case This article describes an unusual case of a snapping scapula syndrome secondary to a migration through the lateral cortex of a rib splint intramedullary fixation device into the scapulothoracic joint. Discussion Recently, the operative fixation of multiple ribs fractures with intramedullary fixation devices has become popular. Despite the good outcomes with new rib splint designs, concern remains about the potential complications related to potential loss of fracture reduction with migration of the wire resulting in pain or additional injury to the surrounding tissues. Conclusion Surgeons should pay attention to any protrusion of intramedullary rib implants, especially in the evaluation of routine X-rays following surgical treatment. We should be aware of the possibility of this rare cause of snapping scapula syndrome to avoid delayed diagnosis and consider removing the implant will resolve the pain.
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Bonne SL, Turnbull IR, Southard RE. Technique for repair of fractures and separations involving the cartilaginous portions of the anterior chest wall. Chest 2015; 147:e199-e204. [PMID: 26033132 DOI: 10.1378/chest.14-0757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Internal fixation of the ribs has been shown in numerous studies to decrease complications following traumatic rib fractures. Anterior injuries to the chest wall causing cartilaginous fractures, although rare, can cause significant disability and can lead to a variety of complications and, therefore, pose a unique clinical problem. Here, we report the surgical technique used for four patients with internal fixation of injuries to the cartilaginous portions of the chest wall treated at our center. All patients had excellent clinical outcomes and reported improvement in symptoms, with no associated complications. Patients who have injuries to the anterior portions of the chest wall should be considered for internal fixation of the chest wall when the injuries are severe and can lead to clinical disability.
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Affiliation(s)
- Stephanie L Bonne
- Department of Surgery, Section of Acute and Critical Care Surgery, Washington University in St. Louis, St. Louis, MO.
| | - Isaiah R Turnbull
- Department of Surgery, Section of Acute and Critical Care Surgery, Washington University in St. Louis, St. Louis, MO
| | - Robert E Southard
- Department of Surgery, Section of Acute and Critical Care Surgery, Washington University in St. Louis, St. Louis, MO
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Zehr M, Klar N, Malthaner RA. Risk Score for Predicting Mortality in Flail Chest. Ann Thorac Surg 2015; 100:223-8. [PMID: 26037539 DOI: 10.1016/j.athoracsur.2015.03.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/21/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Flail chest injuries are associated with high mortality and morbidity. Despite evidence that operative repair of flail chest is beneficial, it is rarely done. We sought to create a simple risk score using available preoperative covariates to calculate individual risk of mortality in flail chest. METHODS A logistic regression model was trained on Ontario Trauma Registry data to generate a mortality risk score. The final model was validated for calibration and discrimination and corrected for optimism. RESULTS The model uses five risk factors that are readily obtained during the initial assessment of the trauma patient: age, Glasgow Coma Score, ventilation, cardiopulmonary resuscitation, and number of comorbidities. It was determined that less than 6 points is consistent with 1% observed mortality, 6 to 10 points predicts 5% mortality, 11 to 15 points predicts 22% mortality, and 16 or more points predicts 46% mortality. CONCLUSIONS We have developed a simple model that can be easily applied at bedside to predict mortality in patients with flail chest by accessing a spreadsheet program in an application or other handheld computer device. This model has the potential to be a useful tool for surgeons considering operative repair of flail chest.
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Affiliation(s)
- Meaghan Zehr
- Department of Epidemiology and Biostatistics, Division of Thoracic Surgery, Western University, London, Ontario, Canada
| | - Neil Klar
- Department of Epidemiology and Biostatistics, Division of Thoracic Surgery, Western University, London, Ontario, Canada
| | - Richard A Malthaner
- Department of Epidemiology and Biostatistics, Division of Thoracic Surgery, Western University, London, Ontario, Canada; Department of Surgery, Division of Thoracic Surgery, Western University, London, Ontario, Canada.
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Xu JQ, Qiu PL, Yu RG, Gong SR, Ye Y, Shang XL. Better short-term efficacy of treating severe flail chest with internal fixation surgery compared with conservative treatments. Eur J Med Res 2015; 20:55. [PMID: 26003405 PMCID: PMC4443506 DOI: 10.1186/s40001-015-0146-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 05/15/2015] [Indexed: 11/13/2022] Open
Abstract
Background The objective of the study is to provide evidence for selecting the best treatment approach for severe flail chest by comparing surgical and conservative treatments. Methods This is a retrospective study in which 32 patients with severe flail chest were treated in the Fujian Provincial Hospital (China) between July 2007 and July 2012 with surgical internal rib fixation (n = 17) or conservative treatments (n = 15). Mechanical ventilation time, intensive care unit (ICU) stay time, pulmonary infection, antibiotic treatment duration, acute physiology and chronic health evaluation II (APACHE II) scores 7 and 14 days after trauma, rate of tracheostomy, and rate of endotracheal re-intubation were compared. Results One patient died in the conservative treatment group. Better short-term outcomes were observed in the surgery group, such as total mechanical ventilation time (10.5 ± 3.7 vs. 13.7 ± 4.4 days, P = 0.03), ICU stay (15.9 ± 5.0 vs. 19.6 ± 5.0 days, P = 0.05), pulmonary infection rate (58.8 % vs. 93.3 %, P = 0.02), and APACHE II scores on the 14th day (6.5 ± 3.8 vs. 10.1 ± 4.7, P = 0.02). No difference was observed in the therapeutic time of antibiotics, rate of tracheostomy, and the rate of endotracheal re-intubation between the two groups. Conclusions Results suggest that internal fixation surgery resulted in better outcomes in the management of severe flail chest compared with conservative treatments.
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Affiliation(s)
- Jing-Qing Xu
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Pei-Li Qiu
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Rong-Guo Yu
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Shu-Rong Gong
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Yong Ye
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
| | - Xiu-Ling Shang
- SICU, Fujian Provincial Hospital, Fujian Medical University Affiliated Provincial Teaching Hospital, Fuzhou, 350001, China.
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Flail chest in polytraumatized patients: surgical fixation using Stracos reduces ventilator time and hospital stay. BIOMED RESEARCH INTERNATIONAL 2015; 2015:624723. [PMID: 25710011 PMCID: PMC4331314 DOI: 10.1155/2015/624723] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 11/11/2014] [Indexed: 11/18/2022]
Abstract
Objectives. Conservative management of patients with flail chest is the treatment of choice. Rib fracture repair is technically challenging; however, with the advent of specially designed molding titanium clips, surgical management has been simplified. Surgical stabilization has been used with good outcomes. We are reporting on our institutional matched-case-control study. Methods. Between April 2010 and April 2011, ten polytraumatized patients undergoing rib stabilization for flail chest were matched 1 : 1 to 10 control patients by age ±10 years, sex, neurological or vertebral trauma, abdominal injury, and arm and leg fractures. Surgery was realized in the first 48 hours. Results. There were no significant differences between groups for matched data and prognostic scores: injury severity score, revised trauma score, and trauma injury severity score. Ventilator time (142 ± 224 versus 74 ± 125 hours, P = 0.026) and overall hospital stay (142 ± 224 versus 74 ± 125 hours, P = 0.026) were significantly lower for the surgical group after adjustment on prognostic scores. There was a trend towards shorter ICU stay for operative patients (12.3 ± 8.5 versus 9.0 ± 4.3 days, P = 0.076). Conclusions. Rib fixation with Stracos is feasible and decreases the length of ventilation and hospital stay. A multicenter randomized study is warranted so as to confirm these results and to evaluate impact on pulmonary function status, pain, and quality of life.
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Kim JJ, Kim YH, Moon SW, Choi SY, Jeong SC. Nuss Procedure for Severe Flail Chest After Blunt Trauma. Ann Thorac Surg 2015; 99:e25-7. [DOI: 10.1016/j.athoracsur.2014.10.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 10/01/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
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Abstract
Despite significant advances in critical care management, flail chest remains a clinically significant finding, with a mortality rate of up to 33%. Nonsurgical management is associated with prolonged ventilator support, pneumonia, respiratory difficulties, and lengthy stays in the intensive care unit, as well as chronic pain from nonunion and malunion of the bony thorax. Treatment with aggressive pulmonary toilet, ventilator support, and different modalities of pain control remains the benchmark of care. However, several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work. The success of these surgical constructs compared with those of historical attempts at open fixation is largely the result of modern plating technology and improvement in surgical approaches. Clinical evidence continues to grow regarding proper indications and techniques for surgical stabilization of flail chest.
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Wiese MN, Kawel-Boehm N, Moreno de la Santa P, Al-Shahrabani F, Toffel M, Rosenthal R, Schäfer J, Tamm M, Bremerich J, Lardinois D. Functional results after chest wall stabilization with a new screwless fixation device. Eur J Cardiothorac Surg 2014; 47:868-75. [DOI: 10.1093/ejcts/ezu318] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 07/13/2014] [Indexed: 11/13/2022] Open
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Vana PG, Neubauer DC, Luchette FA. Article Commentary: Contemporary Management of Flail Chest. Am Surg 2014; 80:527-35. [DOI: 10.1177/000313481408000613] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.
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Affiliation(s)
| | - Daniel C. Neubauer
- Stritch School of Medicine, Loyola University of Chicago, Maywood, Illinois
| | - Fred A. Luchette
- Department of Surgery
- Stritch School of Medicine, Loyola University of Chicago, Maywood, Illinois
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Lee SA, Hwang JJ, Chee HK, Kim YH, Lee WS. Flail chest stabilization with Nuss operation in presence of multiple myeloma. J Thorac Dis 2014; 6:E43-7. [PMID: 24822124 DOI: 10.3978/j.issn.2072-1439.2014.02.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/19/2014] [Indexed: 12/31/2022]
Abstract
Nowadays the Nuss operation has been widely adopted as a minimally invasive procedure and standard surgical choice in pectus excavatum. However, much debate and concern have been raised regarding its applicability in adults with pectus excavatum flail chest and other thoratic wall deformities, as compared with younger patients, in terms of complications after surgery. To stabilize the segment of paradoxical chest wall movement we performed the Nuss operation on a patient with multiple myeloma who sustained blunt thoracic trauma. The patient presented with paradoxical movement of the thoracic wall and sternum instability due to multiple myeloma, which led to severe dyspnea, hypoxemia, hypercapnea, and bedridden state. His condition progressed to acute respiratory distress syndrome and did not respond to conservative treatment. We performed the Nuss operation on the patient, and his clinical symptoms were relieved after surgery. The patient regained the ability to walk unassisted and was discharged from the hospital without any specific events.
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Affiliation(s)
- Song Am Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Jae Joon Hwang
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Hyun Keun Chee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Yo Han Kim
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
| | - Woo Surng Lee
- 1 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do, Republic of Korea
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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 2013; 40:501-5. [PMID: 26816247 DOI: 10.1007/s00068-013-0344-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 09/30/2013] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- S M Said
- Division of Thoracic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
| | - N Goussous
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - M D Zielinski
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - H J Schiller
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - B D Kim
- Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
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Schulz-Drost S, Mauerer A, Grupp S, Hennig FF, Blanke M. Surgical fixation of sternal fractures: locked plate fixation by low-profile titanium plates--surgical safety through depth limited drilling. INTERNATIONAL ORTHOPAEDICS 2013; 38:133-9. [PMID: 24122047 DOI: 10.1007/s00264-013-2127-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 09/13/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Operative treatment of sternal fractures has become a matter of increasing interest. Anterior plating seems to be the most appropriate method for fixing sternal fractures. However, there are several concerns in relation to the operative procedure such as severe injuries to mediastinal organs, patient comfort and proper stabilisation, for example. This paper describes a safe method of anterior sternal plating using locked plate fixation with limited depth drilling. METHODS Ten patients with sternal fractures were included in this cohort study and were treated by anterior plating using one or two plates in parallel through a median approach to the sternum. Follow up was performed after six weeks, 12 weeks and six months. RESULTS Follow up revealed no serious complications. One patient suffered from postoperative wound seroma. No problems were caused by the plates. CONCLUSIONS Sternal plating using low profile locked titanium plates seems to be a safe and stable method with a high level of patient comfort.
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Sellers EL, Fearon PV, Ripley C, Vincent A, Barnard S, Williams JR. The introduction of rib fracture fixation for traumatic flail chest injury: A single centre experience. TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613497146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction High energy chest trauma resulting in flail chest injury or multiple rib fractures is associated with increased rates of patient morbidity and mortality. Operative fixation of acute rib fractures causing flail chest is thought to reduce morbidity by reducing pain and improving chest mechanics enabling earlier ventilator weaning. A variety of operative techniques have been described historically and we report on our unit’s experience of the introduction of acute rib fracture fixation using contoured locking plates. Methods Between December 2010 and 2011, 10 patients underwent acute rib fracture fixation under the joint care of orthopaedic and thoracic surgeons. Outcome measures included patient demographics, time ventilated pre-operatively, time ventilated post-operatively and time spent on intensive treatment unit/high dependency unit (ITU/HDU) post operatively. Results The median time from presentation to surgery was 5 days (range 2–12 days), the median time ventilated post-operatively was 2 days (range 1–4 days) and the median number of days spent on ITU/HDU post-operatively was 6 days (range 2–11 days). All but two patients, who did not require post-operative ventilation, were weaned off the ventilator within 4 days of surgery. Conclusions Our results appear positive in terms of time spent ventilated post-operatively but no conclusion can be drawn as we have no comparable non-operative group. We have however shown that rib fracture fixation can be carried out successfully and safely in a trauma centre with few post-operative complications reported to date. Further evidence on rib fracture fixation is required from a large, multi-centre randomised controlled trial.
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Affiliation(s)
- Emma L Sellers
- Trauma and Orthopaedic Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Paul V Fearon
- Trauma and Orthopaedic Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Colin Ripley
- Trauma and Orthopaedic Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Angus Vincent
- Trauma and Orthopaedic Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Sion Barnard
- Cardiothoracic Surgery Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - John R Williams
- Trauma and Orthopaedic Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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Abstract
Operative management of thoracic injuries is an increasingly accepted technique, with multiple reports of improved patient outcomes as compared with nonoperative treatment. Despite the evolving support of rib fracture fixation, descriptions of surgical approaches and tactics remain limited. We present this information to allow surgeons to begin or improve treatment of these injuries. In addition, we present the initial treatment results of a series of 21 patients treated with the approaches described within.
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Muhm M, Härter J, Weiss C, Winkler H. Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment. Eur J Trauma Emerg Surg 2013; 39:257-65. [DOI: 10.1007/s00068-013-0262-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 01/30/2013] [Indexed: 11/25/2022]
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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; 44:232-8. [PMID: 22910817 DOI: 10.1016/j.injury.2012.08.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 07/31/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgical stabilization of flail chest injury with generic osteosynthesis implants remains challenging. A novel implant system comprising anatomic rib plates and intramedullary splints may improve surgical stabilization of flail chest injuries. This observational study evaluated our early clinical experience with this novel implant system to document if it can simplify the surgical procedure while providing reliable stabilization. METHODS Twenty consecutive patients that underwent stabilization of flail chest injury with anatomic plates and intramedullary splints were prospectively enrolled at two Level I trauma centres. Data collection included patient demographics, injury characterization, surgical procedure details and post-operative recovery. Follow-up was performed at three and six months to assess pulmonary function, durability of implants and fixation and patient health. RESULTS Patients had an Injury Severity Score of 28±10, a chest Abbreviated Injury Score of 4.2±0.4 and 8.5±2.9 fractured ribs. Surgical stabilization was achieved on average with five plates and one splint. Intra-operative contouring was required in 14% of plates. Post-operative duration of ventilation was 6.4±8.6 days. Total hospitalization was 15±10 days. At three months, patients had regained 84% of their expected forced vital capacity (%FVC). At six months, 7 of 15 patients that completed follow-up had returned to work. There was no mortality. Among the 91 rib plates, 15 splints and 605 screws in this study there was no hardware failure and no loss of initial fixation. There was one incidence of wound infection. Implants were removed in one patient after fractures had healed. CONCLUSIONS Anatomic plates eliminated the need for extensive intraoperative plate contouring. Intramedullary rib splints provided a less-invasive fixation alternative for single, non-comminuted fractures. These early clinical results indicate that the novel implant system provides reliable fixation and accommodates the wide range of fractures encountered in flail chest injury.
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Affiliation(s)
- Michael Bottlang
- Legacy Research Institute, 1225 NE 2nd Ave, Portland, OR 97232, United States.
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49
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Liovic P, Šutalo ID, Marasco SF. Stress analysis of a centrally fractured rib fixated by an intramedullary screw. Comput Methods Biomech Biomed Engin 2012; 17:944-57. [DOI: 10.1080/10255842.2012.727402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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50
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Ramponi F, Meredith GT, Bendinelli C, Söderlund T. Operative management of flail chest with anatomical locking plates (MatrixRib). ANZ J Surg 2012; 82:658-9. [DOI: 10.1111/j.1445-2197.2012.06159.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Fabio Ramponi
- Department of Cardiothoracic Surgery; John Hunter Hospital; The University of Newcastle; Newcastle; New South Wales; Australia
| | - Graham T. Meredith
- Department of Cardiothoracic Surgery; John Hunter Hospital; The University of Newcastle; Newcastle; New South Wales; Australia
| | - Cino Bendinelli
- Trauma Unit; John Hunter Hospital; The University of Newcastle; Newcastle; New South Wales; Australia
| | - Tim Söderlund
- Trauma Unit; John Hunter Hospital; The University of Newcastle; Newcastle; New South Wales; Australia
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