Experimental flail chest: ventilatory function with fixation of flail segment in internal and external position

Historic overview of treatment techniques for rib fractures and flail chest

Introduction

From the beginning of the twentieth century till the current time, an overview is presented of the surgical treatment for rib fractures and flail chest.

Methods

Many techniques have been used to stabilize the thorax wall. There has been no follow-up for the most described techniques and the evidence provided is at its best at L3–4. This, together with the noninvasiveness of mechanical ventilation, has made the latter the golden standard.

Conclusion

However, the recent introduction of better and fully dedicated materials provides the possibility of exploring the surgical treatment of chest injuries. The authors make a case for operative treatment of rib fractures and flail chest.

Use of a latissimus dorsi myocutaneous flap for one-stage reconstruction of the thoracic wall after en bloc resection of primary rib chondrosarcoma in five dogs

OBJECTIVE

To describe a thoracic wall reconstructive technique using a latissimus dorsi myocutaneous flap after en bloc resection of primary rib chondrosarcoma and report outcome in 5 dogs.

STUDY DESIGN

Retrospective study.

ANIMALS

Dogs (n=5) with primary rib chondrosarcoma.

METHODS

Medical records (2003-2005) were reviewed for signalment, staging investigations, surgical findings, complications, and outcomes. Owners and veterinary surgeons were contacted for outcome information.

RESULTS

A latissimus dorsi myocutaneous flap provided an air-tight thoracic wall closure after chondrosarcoma resection. Paradoxical respiratory movement of the flap occurred; however, from physical examination and blood gas analysis (2 dogs), ventilation was adequate. All flaps survived, 1 had superficial skin necrosis distally and 2 had minor wound dehiscence. One dog without tumor-free margins died of tumor-related disease 56 days after surgery. Tumor recurrence did not occur in 4 dogs with tumor-free margins. One dog was euthanatized 10 months after surgery for unrelated disease; 3 dogs were alive at writing (median follow-up: 20 months; range, 18-27 months) and all had a satisfactory functional and cosmetic outcome.

CONCLUSIONS

Reconstruction of ventral thoracic wall defects using a latissimus dorsi myocutaneous flap yields a functional, cosmetic outcome.

CLINICAL RELEVANCE

A latissimus dorsi myocutaneous flap can be used as a successful 1-stage reconstructive technique for ventral thoracic wall defects.

P, Pratibha V, Steven M, Steven R. Age-Adjusted Outcomes in Traumatic Flail Chest Injuries in the Elderly

Severe chest trauma does not independently predict poor outcome in elderly patients. We chose a specific injury, flail chest, to determine whether age factored into outcome of these patients. A retrospective chart review of all trauma admissions to our Level I trauma center between January 1994 and January 1998 sustaining flail chest was undertaken. Sixty-eight patients were identified, but ten patients were excluded because of death on arrival. Fifty-eight patients were included in the study and separated into groups. The first group comprised those under the age of 55 (n = 32) and the second comprised those over age 55 (n = 26). Parameters evaluated were age, Injury Severity Score (ISS), neurologic injury, the need for mechanical ventilation, need for tracheostomy, length of stay, and death. Statistical analysis was performed with Wilcoxon t test, χ2, and logistic regression where appropriate. A 95 per cent confidence interval was sought as determinant of significance. Of the 58 surviving patients analyzed there was no significant difference between the groups regarding ISS, length of stay, days on the ventilator, head injury, tracheostomy, or development of pneumonia or adult respiratory distress syndrome. The likelihood of death was shown to increase by 132 per cent for every 10 years starting at the second decade and continuing to the eighth decade of life. The likelihood of death also increased by 30 per cent for each unit increase in ISS. The likelihood of death decreased by 23 per cent for every day survived in the hospital. Blunt chest trauma directly impacts respiratory mechanics. Elderly patients are more likely to have comorbid conditions and less likely to tolerate traumatic respiratory compromise. Age (and its effects on the body) is the strongest predictor of outcome with flail chest and is associated with an increased mortality ( P ≤ 0.05).