Surgical stabilization of rib fractures under extracorporeal membrane oxygenation: A case report

A 47-year-old male patient was referred to a level 1 trauma center with refractory acute respiratory distress syndrome, bilateral lung contusions, and flail chest after initial management for injuries sustained 5 days prior from an 8-m fall from a tower crane. Surgical stabilization of the rib fractures was achieved under extracorporeal membrane oxygenation support, with successful decannulation 4 days after surgery. The patient was discharged after 42 days and following multidisciplinary interventions. Use of extracorporeal membrane oxygenation support in blunt chest trauma patients presents a valuable opportunity as it may enable earlier surgical intervention and reduce in-hospital complications.

Delayed flail chest from osteomyelitis and malnutrition that emerged 3 weeks after blunt chest trauma: a case report

We present the case of a victim of a motor vehicle accident in his late 60s who suffered from severe torso injuries. He initially presented with abdominal and chest pain, and underwent emergency laparotomy for hemoperitoneum. After surgery, the patient developed pneumonia and septicemia, which were responsive to antibiotics. The patient was treated with mechanical ventilation in the intensive care unit for approximately 10 days and experienced a severe weight loss of approximately 30%, but slowly recovered without dyspnea. Notably, on hospital day 24, he experienced sudden respiratory distress and flail motion of the chest wall in a general ward. This late presentation of flail chest was attributed to non-union at rib fracture sites, and was likely exacerbated by malnutrition and osteomyelitis. Surgical stabilization of rib fractures and excision of the infected rib were successfully performed. The findings from this case highlight the complexity of managing delayed onset of flail chest. The findings from this case suggest the importance of vigilance for late emerging complications in patients with trauma, even when initial symptoms are absent.

A meta-analysis and trial sequential analysis of randomised controlled trials comparing nonoperative and operative management of chest trauma with multiple rib fractures

BACKGROUND

Operative treatment of traumatic rib fractures for better outcomes remains under debate. Surgical stabilization of rib fractures has dramatically increased in the last decade. This study aimed to perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the effectiveness and safety of operative treatment compared to conservative treatment in adult patients with traumatic multiple rib fractures.

METHODS

A systematic literature review was performed according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We searched MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials and used the Cochrane Risk-of-Bias 2 tool to evaluate methodological quality. Relative risks with 95% confidence interval (CI) were calculated for outcomes: all-cause mortality, pneumonia incidence, and number of mechanical ventilation days. Overall certainty of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, with trial sequential analysis performed to establish implications for further research.

RESULTS

From 719 records, we included nine RCTs, which recruited 862 patients. Patients were assigned to the operative group (received surgical stabilization of chest wall injury, n = 423) or control group (n = 439). All-cause mortality was not significantly different (RR = 0.53; 95% CI 0.21 to 1.38, P = 0.35, I2 = 11%) between the two groups. However, in the operative group, duration of mechanical ventilation (mean difference -4.62; 95% CI -7.64 to -1.60, P < 0.00001, I2 = 94%) and length of intensive care unit stay (mean difference -3.05; 95% CI -5.87 to -0.22; P < 0.00001, I2 = 96%) were significantly shorter, and pneumonia incidence (RR = 0.57; 95% CI 0.35 to 0.92; P = 0.02, I2 = 57%) was significantly lower. Trial sequential analysis for mortality indicated insufficient sample size for a definitive judgment. GRADE showed this meta-analysis to have very low to low confidence.

CONCLUSION

Meta-analysis of large-scale trials showed that surgical stabilization of multiple rib fractures shortened the duration of mechanical ventilation and reduced the incidence of pneumonia but lacked clear evidence for improvement of mortality compared to conservative treatment. Trial sequential analysis suggested the need for more cases, and GRADE highlighted low certainty, emphasizing the necessity for further targeted RCTs, especially in mechanically ventilated patients.

SYSTEMATIC REVIEW REGISTRATION

UMIN Clinical Trials Registry UMIN000049365.

[Surgical reconstruction of chest wall instability : Indications, contraindications and timing of surgery]

The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for a surgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including a Cochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for a structured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by a timely surgery within 72 h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.

[Biomechanics of thoracic wall instability]

Traumatic injuries of the thorax can entail thoracic wall instability (flail chest), which can affect both the shape of the thorax and the mechanics of respiration; however, so far little is known about the biomechanics of the unstable thoracic wall and the optimal surgical fixation. This review article summarizes the current state of research regarding experimental models and previous findings. The thoracic wall is primarily burdened by complex muscle and compression forces during respiration and the mechanical coupling to spinal movement. Previous experimental models focused on the burden caused by respiration, but are mostly not validated, barely established, and severely limited with respect to the simulation of physiologically occurring forces. Nevertheless, previous results suggested that osteosynthesis of an unstable thoracic wall is essential from a biomechanical point of view to restore the native respiratory mechanics, thoracic shape and spinal stability. Moreover, in vitro studies also showed better stabilizing properties of plate osteosynthesis compared to intramedullary splints, wires or screws. The optimum number and selection of ribs to be fixated for the different types of thoracic wall instability is still unknown from a biomechanical perspective. Future biomechanical investigations should simulate respiratory and spinal movement by means of validated models.

Timing to Rib Fixation in Patients With Flail Chest

INTRODUCTION

Flail chest (FC) after blunt trauma is associated with significant morbidity and prolonged hospitalizations. The goal of this study was to examine the relationship between timing of rib fixation (ORIF) and pulmonary morbidity and mortality in patients with FC.

METHODS

FC patients were identified from the Trauma Quality Improvement Program database over 3-year, ending 2019. Demographics, severity of injury and shock, time to ORIF, pulmonary morbidity, and mortality were recorded. Youden's index identified optimal time to ORIF. Patients were compared based on undergoing ORIF versus nonoperative management, then for patients undergoing ORIF based on time from admission to operation, utilizing Youden's index to determine the preferred time for fixation. Multivariable logistic regression determined predictors of pulmonary morbidity and mortality.

RESULTS

20,457 patients were identified: 3347 (16.4%) underwent ORIF. The majority were male (73%) with median age and injury severity score of 58 and 22, respectively. Patients undergoing ORIF were clinically similar to those managed nonoperatively but had increased pulmonary morbidity (27.6 versus 15.2%, P < 0.0001) and reduced mortality (2.9 versus 11.7%, P < 0.0001). Multivariable logistic regression identified ORIF as the only modifiable risk factor significantly associated with reduced mortality (odds ratio: 0.26; 95% CI:0.21-0.32, P < 0.0001). Youden's index identified the inflection point for time to ORIF as 4 d postinjury: EARLY (≤4 d) and LATE (>4 d). EARLY fixation was associated with a significant decrease in ventilator days, intensive care unit and hospital length of stay, and pulmonary morbidity.

CONCLUSIONS

Patients undergoing ORIF for FC experienced increased pulmonary morbidity; however, had an associated reduced mortality benefit compared to the nonoperative cohort. EARLY ORIF was associated with a reduction in pulmonary morbidity, without impacting the mortality benefit found with ORIF. Thus, for patients with FC, ORIF performed within 4 d postinjury may help reduce pulmonary morbidity, length of stay, and mortality.

Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials

PURPOSE

Conflicting evidence exists on the choice of surgical or non-surgical treatment of flail chest injuries. We aimed to perform a meta-analysis comparing outcomes in patients presenting flail chest undergoing surgical or non-surgical treatment.

METHODS

Embase, PubMed, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing surgery to no surgery in patients with acute unstable chest wall injuries. We computed weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs). Random effects meta-analyses were performed. Heterogeneity was assessed using I2 statistics.

RESULTS

Six RCTs (544 patients) were included, and surgical treatment was used in 269 (49.4%). Compared to no surgery, surgery reduced mechanical ventilation days (WMD - 4.34, 95% CI - 6.98, - 1.69; p < 0.01; I2 = 87%; GRADE: very low; PI - 13.51, 4.84); length of intensive care unit stay (WMD - 4.62, 95% CI - 7.19, - 2.05; p < 0.01; I2 = 78%; GRADE: low; PI - 12.86, 3.61) and the incidence of pneumonia (RR 0.50, 95% CI 0.31, 0.81; p = 0.005; I2 = 54%; GRADE: moderate; PI 0.13, 1.91). No difference in mortality (RR 0.56, 95% CI 0.19, 1.65; p = 0.27; I2 = 23%; GRADE: moderate; PI 0.04, 7.25), length of hospital stay (WMD - 5.39, 95% CI - 11.38, - 0.60; p = 0.08; I2 = 89%; GRADE: very low; PI - 11.38, 0.60), or need for tracheostomy (RR 0.59, 95% CI 0.34, 1.03; p = 0.06; I2 = 54%; GRADE: moderate; PI 0.11, 3.24) was found.

CONCLUSIONS

Our results suggest that surgical treatment is advantageous compared to non-surgical treatment for patients with flail chest secondary to rib fractures.

Operative Resection of a Chronic Flail Chest Nonunion Revealing Septic Pseudarthrosis: A Case Report

We report a case of chest wall resection for painful chest wall nonunion, 5 years after traumatic flail chest and a first attempt at surgical treatment. The decision was made to perform surgery again after 2 years of unsuccessful well-conducted analgesic treatment. During surgery, we found the same sites of pseudarthrosis and decided to perform parietectomy of the fifth, sixth, and seventh ribs. A Gore-Tex patch was used to bridge the gap created by the resection. In immediate postoperative care, the patient's pain was quickly and sufficiently eased by stage 1 and 2 pain killers. The results of bone samples taken from the pseudarthrosis sites all found Propionibacterium acnes. Five months after surgery, the patient had considerable improvement in pain sensations. Computed tomography showed healing of ribs, the plate in place, and no sign of complications.

Impact of flail chest injury on morbidity and outcome: ten years' experience at a tertiary care hospital in a developing country

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.

Stabilization of after-traumatic flail chest by minimally invasive modified NUSS procedure in patient with starting respiratory insufficiency

A flail chest is one of the possible medical conditions suffered by individuals who were injured in traffic accidents, caused by multiple fractures of the ribs and sternum. Which often results in paradoxical chest movements. The consequence may be respiratory failure and need for long-term mechanical ventilation. Such treatment require Intensive Care Unit and may be associated with the possibility of numerous complications.Modified Nuss procedure was performed in 79-year-old man, a victim of a car crash to obtain stabilization of the flail chest. After compensation of paradoxical movements on the third day it was possible to end mechanical ventilation. A quick procedure dedicated to the congenital deformation of the chest made it possible to avoid long, expensive intensive therapy with possible respiratory complications.The NUSS procedure enables the effective and safe treatment of a flail chest in a selected group of patients.

Minimally invasive surgery for anterior flail chest injury in the acute phase: series of 10 cases

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.

Retrospective comparison of operative technique for chest wall injuries

BACKGROUND

Surgical management of chest wall injuries is a common procedure. However, operative techniques are diverse, and no universal guidelines exist. There is a lack of studies comparing the outcome with different operative techniques for chest wall surgery. The aim of this study was to compare hospital outcomes between patients operated for chest wall injuries with a conventional method with large incisions and often a thoracotomy or a minimally invasive, muscle sparing method.

PATIENTS AND METHODS

A retrospective study was carried out including patients ≥18 years operated for chest wall injuries 2010-2020. Patients were divided into two groups based on the surgery performed: conventional surgery (C-group) and minimally invasive surgery (M-group). Data on demographics, trauma, surgery, and outcomes were extracted from patient records. Primary outcome was length of stay on mechanical ventilator (MV-LOS). Secondary outcomes were length of stay in intensive care (ICU-LOS) and in hospital (H-LOS), and complications such as re-operation, incidence of empyema, tracheostomy, pneumonia, and mortality.

RESULTS

Of 311 included patients, 220 were in the C-group and 91 in the M-group. The groups were similar in demographics and injury pattern. MV-LOS was 0 (0-65) in the C-group vs 0 (0-34) in the M-group (p < 0.001). ICU-LOS and H-LOS were significantly shorter in the M-group as compared to the C-group (p < 0.001), however with a large overlap. Tracheostomy was performed in 22.3% of patients in the C-group vs 5.4% in the M-group (p < 0.001). Pneumonia was diagnosed in 32.3% of patients in the C-group vs 16.1% in the M-group (p = 0.004). In-hospital mortality was lower in the M-group compared to the C-group but there was no difference in mortality within 30 days or a year.

CONCLUSIONS

Our study indicates that a minimally invasive technique was favorable regarding clinical outcomes for patients operated for chest wall injuries.

Clinical Outcomes of Minimally Invasive Surgical Stabilization of Rib Fractures Using Video-Assisted Thoracoscopic Surgery

Background

Multiple rib fractures are common in blunt chest trauma. Until recently, most surgical rib fixations for multiple rib fractures were performed via open thoracotomy. However, due to the invasive nature of tissue dissection and the resulting large wound, an alternative endoscopic approach has emerged that minimizes the postoperative complications caused by the manipulation of injured tissue and lung during an open thoracotomy.

Methods

Our study concentrated on patients with multiple rib fractures who underwent surgical stabilization of rib fractures (SSRF) between June 2018 and May 2020. We found 27 patients who underwent SSRF using video-assisted thoracoscopic surgery. The study design was a retrospective review of the patients' charts and surgical records.

Results

No intraoperative events or procedure-related deaths occurred. Implant-related irritation occurred in 4 patients, and 1 death resulted from concomitant trauma. The average hospital stay was 30.2±20.1 days, and ventilators were used for 12 of the 22 patients admitted to the intensive care unit. None of the patients experienced major pulmonary complications such as pneumonia or acute respiratory distress syndrome.

Conclusion

Minimally invasive rib stabilization surgery with the assistance of a thoracoscope is expected to become more widely used in patients with multiple rib fractures. This method will also assist patients in a quick recovery.

Surgical and perioperative management of flail chest with titanium plates: a French cohort series from a thoracic referral center

BACKGROUND

The development of titanium claw plates has made rib osteosynthesis easy to achieve and led to a renewed interest for this surgery. We report the management of patients referred to the intensive care unit (ICU) of a referral center for surgical rib fracture fixation (SRFF) after chest trauma.

METHODS

We performed a retrospective observational cohort study describing the patients' characteristics and analyzing the determinants of postoperative complications.

RESULTS

From November 2013 to December 2016, 42 patients were referred to our center for SRFF: 12 patients (29%) had acute respiratory failure, 6 of whom received invasive mechanical ventilation. The Thoracic Trauma Severity Score (TTSS) was 11.0 [9-12], with 7 [5-9] broken ribs and a flail chest in 92% of cases. A postoperative complication occurred in 18 patients (43%). Five patients developed ARDS (12%). Postoperative pneumonia occurred in 11 patients (26%). Two patients died in the ICU. In multivariable analysis, the Thoracic Trauma Severity Score (TTSS) (OR = 1.89; CI 95% 1.12-3.17; p = 0.016) and the Simplified Acute Physiology Score II without age (OR = 1.17; CI 95% 1.02-1.34; p = 0.024) were independently associated with the occurrence of a postoperative complication.

CONCLUSION

The TTSS score appears to be accurate for determining thoracic trauma severity. Short and long-term benefit of Surgical Rib Fracture Fixation should be assessed, particularly in non-mechanically ventilated patients.

Undetected traumatic cardiac herniation like playing hide-and-seek-delayed incidental findings during surgical stabilization of flail chest: A case report

BACKGROUND

Post-traumatic blunt pericardial injury is a rare condition with only a few reported cases which were generally diagnosed during initial examinations upon admission. However, pericardial injuries not bad enough to dislocate the heart may only cause intermittent electrocardiogram (ECG) changes or be asymptomatic.

CASE SUMMARY

In this case, we report a blunt pericardial injury undetected on preoperative transthoracic echocardiography and chest computed tomography. We misjudged intermittent ECG changes and blood pressure fluctuations as minor symptoms resulting from cardiac contusion and did not provide intensive treatment. The pericardial injury was found incidentally during surgical stabilization of rib fractures and was successfully repaired.

CONCLUSION

Post-traumatic blunt pericardial ruptures should be considered in patients with blunt chest trauma showing abnormal vital signs and ECG changes.

Unexpected pulmonary mechanics during positive pressure mechanical ventilation in fibrotic lung disease with concomitant flail chest

Understanding of pulmonary mechanics is essential to understanding mechanical ventilation. Typically, clinicians are mindful of peak and plateau pressures displayed on the ventilator and lung compliance, which is decreased in lung disease such as idiopathic pulmonary fibrosis (IPF). Decreased lung compliance leads to elevated peak and plateau pressures. We present a patient with IPF undergoing mechanical ventilation after cardiac arrest. Despite low lung compliance, he had normal peak and plateau pressures due to the presence of flail chest and increased chest wall compliance. This case highlights the role chest wall compliance plays in total respiratory system compliance and pulmonary mechanics.

Treatment and outcome in combined scapula and rib fractures: a retrospective study

PURPOSE

The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies.

METHODS

All adult (≥ 18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed.

RESULTS

A total of 223 patients were admitted with concurrent ipsilateral rib and scapula fractures. A total of 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only, and seven patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax and revision surgery) between groups.

CONCLUSION

Injury severity resulted in different treatment modalities. As a result, different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible; however, the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.

Flail chest injury-changing management and outcomes

PURPOSE

The purpose of this study was to assess trends in management of flail chest injuries over time and to determine impact on patient outcomes.

METHODS

A retrospective review of data from a prospectively collated database of all trauma patients admitted to a level 1 trauma service in Victoria was conducted. All trauma patients admitted to the hospital between July 2008 and June 2020 with an Abbreviated Injury Scale (AIS) code for flail chest injury were included.

RESULTS

Our study included 720 patients, mean age was 59.5 ± 17.3 years old, and 76.5% of patients were male. Length of ICU stay decreased on average by 9 h each year. Regional anaesthesia use increased by 15% per year (0% in 2009 to 36% in 2020) (p < 0.001). Surgical stabilisation of rib fractures increased by 16% per year (2.9% in 2009 to 22.3% in 2020) (p = 0.006). The use of invasive ventilation decreased by 14% per year (70% in 2008 to 27% in 2020) (p < 0.001), and invasive ventilation time decreased by 8 h per year (p = 0.007).

CONCLUSION

Over the past decade, we have seen increasing rates of regional anaesthesia and surgical rib fixation in the management of flail chest. This has resulted in lower requirements for and duration of invasive mechanical ventilation and intensive care unit stay but has not impacted mortality in this patient cohort.

Is There a Role for Rib Plating in Thoracic Trauma?

Rib fractures are a morbid consequence of blunt trauma and are associated with a highly variable clinical presentation ranging from nondisplaced rib fractures causing limited, manageable pain to severely displaced rib fractures with concomitant thoracic injuries leading to respiratory failure. Due to an evolution of techniques, hardware technology, and general acceptance, rib plating has increased substantially at trauma centers all throughout the United States over the past decade. This article aims to review the most recent and current reports for rib plating with respect to indications, preoperative evaluation and imaging, approaches, timing for intervention, outcomes in patients with flail chest and nonflail injuries, and the management of complications. From these data, it becomes clear that the surgical stabilization of rib fractures (SSRF) has a firm place in the management of thoracic trauma.

VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases

OBJECTIVES

Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest.

METHODS

From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported.

RESULTS

VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65 years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200 ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2 days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1 year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury.

CONCLUSIONS

Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.

Surgical fixation of rib fractures improves 30-day survival after significant chest injury : an analysis of ten years of prospective registry data from England and Wales

AIMS

The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries.

METHODS

A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy.

RESULTS

A total of 86,838 cases were analyzed. The rate of SRF was 1.2%. SRF significantly reduced risk of mortality (odds ratio (OR) 0.27 (95 confidence interval (CI) 0.128 to 0.273); p < 0.001) and need for tracheostomy (OR 0.22 (95% CI 0.191 to 0.319); p < 0.001) after adjustment for other covariables across the whole cohort. SRF remained protective in patients with a serious chest injury (hazard ratio (HR) 0.24 (95% CI 0.13 to 0.45); p < 0.001). The benefit in more minor chest injury was less clear. Mean LoS for patients who survived was longer in the SRF group (24.29 days (SD 26.54) vs 16.60 days (SD 26.35); p < 0.001).

CONCLUSION

SRF reduces mortality after significant chest trauma associated with both major and minor polytrauma. The rate of fixation in the UK is low and potentially underused as a treatment for severe chest wall injury. Cite this article: Bone Joint J 2022;104-B(6):729-735.

Nuss Procedure for Surgical Stabilization of Anterior Flail Chest with Mechanical Ventilation Weaning Failure: A Case Report

Flail chest is a critical medical condition in which multiple segmentally fractured adjacent ribs cause paradoxical movement of the thoracic cage in patients with severe blunt trauma injury. Surgical stabilization is considered essential in patients who require mechanical ventilation. However, there is no consensus on which surgical procedure to choose among the various available techniques or when to perform surgery. We report the case of a patient with traumatic anterior flail chest due to bilateral multiple fractures of the ribs requiring surgical stabilization in whom weaning from mechanical ventilation had failed. The Nuss procedure using double bars with the bridge technique was performed for chest wall stabilization. The patient was weaned from mechanical ventilation on postoperative day 44 and she underwent bar removal on postoperative day 71. After extensive rehabilitation for multiple trauma, she was discharged successfully. The patient currently shows no recurrence of chest wall depression in outpatient follow-up.

Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-Analysis

BACKGROUND

Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse.

METHODS

A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality.

RESULTS

Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation.

CONCLUSIONS

Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.

The incidence, clinical characteristics, and outcome of polytrauma patients with the combination of pulmonary contusion, flail chest and upper thoracic spinal injury

BACKGROUND

Chest trauma was the third most common cause of death in polytrauma patients, accounting for 25% of all deaths from traumatic injury. Chest trauma involves in injury to the bony thorax, intrathoracic organs and thoracic medulla. This study aimed to investigate the incidence, clinical characteristics, and outcome of polytrauma patients with pulmonary contusion, flail chest and upper thoracic spinal injury.

METHODS

Patients who met inclusion criteria were divided into groups: Pulmonary contusion group (PC); Pulmonary contusion and flail chest group (PC + FC); Pulmonary contusion and upper thoracic spinal cord injury group (PC + UTSCI); Thoracic trauma triad group (TTT): included patients with flail chest, pulmonary contusion and the upper thoracic spinal cord injury coexisted. Outcomes were determined, including 30-day mortality and 6-month mortality.

RESULTS

A total 84 patients (2.0%) with TTT out of 4176 polytrauma patients presented to Tongji trauma center. There was no difference in mean ISS among PC + FC group, PC + UTSCI group and TTT group. Patients with TTT had a longer ICU stay (21.4 days vs. 7.5 and 6.2; p<0.01), relatively higher 30-day mortality (40.5% vs. 6.0% and 4.3%; p<0.01), and especially higher 6-month mortality (71.4% vs. 6.5%, 13.0%; p<0.01), compared to patients with PC + FC or with PC + UTSCI. The leading causes of death for patients with TTT were ARDS (44.1%) and pulmonary infection (26.5%) during first 30 days after admission. For those patients who died later than 30 days during the 6 months, the predominant underlying cause of death was MOF (53.8%).

CONCLUSIONS

Lethal triad of thoracic trauma (LTTT) were described in this study, which consisting of pulmonary contusion,flail chest and the upper thoracic spine cord injury. Like the classic "lethal triad", there was a synergy between the factors when they coexist, resulting in especially high mortality rates. Polytrauma patients with LTTT were presented relatively high 30-day mortality and 6 months mortality. We should pay much more attention to the patients with LTTT for further minimizing complications and mortality.

An innovative technique of chest wall stabilization and reconstruction in traumatic flail chest: The figure-of-eight suture with polypropylene mesh and musculofascial flap

Surgical stabilization of the flail chest is challenging and has no established guidelines. Chest wall integrity and stability are the main factors that ensure the protection of intrathoracic organs and an adequate respiratory function. Here, we report a novel chest wall reconstruction technique in a 45-year-old man with a traumatic left flail chest and open pneumothorax diagnosed both clinically and radiographically. Rib approximation and chest wall reconstruction was done using intercostal figure-of-eight suture and polypropylene mesh with vascularized musculofascial flap. The patient improved gradually and was discharged after three weeks of total hospital stay. He returned to regular working after a month with no evidence of respiratory distress or paradoxical chest movement. Follow-up visit at one year revealed no lung hernia or paradoxical chest movement. This is a novel, feasible and cost-effective modification of chest wall reconstruction that can be adopted for thoracic wall repair in case of open flail chest, which needs emergency surgical interventions even in resource constraint settings.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury

Purpose

Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients.

Methods

A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern.

Results

In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11–0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, − 2.96 days; 95% CI − 5.70 to − 0.23; p = 0.034).

Conclusion

In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU®

Purpose

Isolated clavicle fractures (CF) rarely show complications, but their influence in the thorax trauma of the seriously injured still remains unclear. Some authors associate CF with a higher degree of chest injuries; therefore, the clavicle is meant to be a gatekeeper of the thorax.

Methods

A retrospective analysis of the TraumaRegister DGU^® (project 2017-10) was carried out involving the years 2009–2016 (ISS ≥ 16, primary admission to a trauma center). Cohort formation: unilateral and bilateral flail chest injuries (FC), respectively, with and without a concomitant CF.

Results

73,141 patients (26.5% female) met the inclusion criteria and 12,348 had flail chest injuries (FC; 20.0% CF; 67.7% monolateral FC), 25,425 other rib fractures (17.7% CF), and 35,368 had no rib fractures (6.5% CF). On average, monolateral FC patients were 56.0 ± 17.9 years old and bilateral FC patients were 57.7 ± 19 years old. The ISS in unilateral and bilateral FC were 29.1 ± 11.7 and 42.2 ± 12.9 points, respectively. FC with a CF occurred more frequently with bicycle and motorbike injuries in monolateral FC and pedestrians in bilateral FC injuries and less frequently due to falls. Patients with a CF in addition to a FC had longer hospital and ICU stays, underwent artificially respiration for longer periods, and died less often than patients without a CF. The effects were highly significant in bilateral FC. CF indicates more relevant concomitant injuries of the lung, scapula, and spinal column. Moreover, CF was associated with more injuries of the extremities in monolateral CF.

Conclusion

Due to the relevance of a concomitant CF fracture in FC, diagnostics should focus on finding CFs or rule them out. Combined costoclavicular injuries are associated with a significantly higher degree of thoracic injuries and longer hospital stays.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021)

Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.

Surgical treatment for tracheal stent prolapse in a patient with blunt tracheal trauma

Blunt tracheal injury is a rare but life-threatening condition. Several indications for treatment have been reported. Conservative treatment (i.e., stenting) can be performed when the patient is clinically stable or has medical contraindications to surgical treatment. Although some studies have reported the use of tracheal stents as treatment for iatrogenic injury and blunt trauma, the efficacy of these stents is unknown. Herein, we report a case of emergency tracheoplasty for the management of tracheal stent prolapse in a patient with blunt tracheobronchial trauma. This report highlights the necessity of being cautious about the migration and prolapse of tracheal stents, which can more frequently occur in blunt trauma than in malignant stenosis or iatrogenic injury. Due to the limitations of non-surgical treatments, early surgical intervention may be lifesaving.

A new combination technique of the modified Robicsek wire fixation and plate fixation achieves effective repair of transverse sternal fracture: a report of two cases

Background

To maximize the therapeutic effect for complicated sternal fracture, we should know advantages and disadvantages of each surgical repositioning technique, and the choice of an appropriate procedure is essential. We report two successful cases for which a combination of two existing techniques, modified Robicsek wire fixation and locked titanium plate fixation, was applied to transverse sternal fracture with flail chest.

Case presentation

One patient experienced a transverse sternal and rib fracture due to a traffic injury. Flail chest due to a highly displaced transverse sternal fracture made withdrawal of the ventilator impossible. Another patient, who developed fulminant myocarditis, experienced a transverse sternal fracture resulting from chest compression during cardiopulmonary resuscitation. Severe paradoxical respiratory movement was a limiting factor for cardiac and respiratory rehabilitation. In both cases, a transverse sternal fracture was difficult to correct non-invasively and indicated surgical repair. The surgical repositioning and fixation greatly contributed to the improvement of the respiratory movement, and the patients were successfully withdrawn ventilator support.

Conclusion

The combination of modified Robicsek wire fixation and locked titanium plate fixation for a complicated sternal fracture employs the complementary and comparative advantages of each procedure and effective fixation may be achieved.

Mechanism of injury, injury patterns and associated injuries in patients operated for chest wall trauma

PURPOSE

Chest wall injuries are common in blunt trauma and associated with significant morbidity and mortality. The aim of this study was to determine the most common mechanisms of injury (MOI), injury patterns, and associated injuries in patients who undergo surgery for chest wall trauma.

METHODS

This was a retrospective study of trauma patients with multiple rib fractures and unstable thoracic cage injuries who were managed surgically at Sahlgrenska University Hospital during the period September 2010-September 2017. The MOI, injury severity score (ISS), new injury severity score (NISS), thoracic and associated injuries were recorded. Patients were categorized according to age (years): groups I (15‒44), II (45‒64) and III ( > 64). Unstable thoracic cage injuries were classified as sternal, anterior, lateral and posterior flail chest.

RESULTS

Two hundred and eleven trauma patients with a mean age (years) of 58.2 ± 15.6, mean ISS 23.6 ± 11.0, and mean NISS 34.1 ± 10.6 were included in the study. Traffic accidents were the most common MOI in Group I (62%) and falls in Group III (59%). The most common flail segments were lateral and posterior. Sternal and anterior flail segments were more common with bilateral injuries and traffic accidents, particularly frontal collisions. Injuries in at least three body regions were also more associated with traffic accidents. Diaphragmatic injury was seen in 18% of patients who underwent thoracotomy.

CONCLUSIONS

The MOI associated with multiple rib fractures differs according to the age of the patient and is associated with different chest wall injury patterns and extra-thoracic injuries.

Far posterior rib plating: Preliminary results of a retrospective case series

INTRODUCTION

Far posterior, or paraspinal rib fractures, defined as fractures that are medial to the medial border of the scapula (and may involve the costovertebral articulation), are often treated nonoperatively. However, in certain cases, including severe displacement, persistent pain, nonunion, or persistent respiratory distress, stabilization with open reduction and internal fixation (ORIF) may be warranted. There is a paucity of literature regarding the surgical approach and clinical outcomes following ORIF for far posterior rib fractures and fracture-dislocations. The purpose of this paper is to describe the surgical approach and to report the first collection of clinical outcomes for patients undergoing paraspinal rib ORIF.

PATIENTS AND METHODS

A retrospective case series was performed at a single urban level 1 trauma center. Patients 18 years of age or older who underwent ORIF of far posterior rib fractures were included in this study. Far posterior rib fractures were defined as fractures that occurred medial to the medial border of the scapula underneath the paraspinal musculature. Data collection including patient demographics, injury characteristics, operative variables, and postoperative outcomes were collected and analyzed.

RESULTS

Twenty-six patients, with a mean age of 50.7 years, who underwent paraspinal rib ORIF were included in this study. The mean follow-up was 12.1 months. 80.8% of patients had a flail chest injury. On average, 3.4 ribs were instrumented posteriorly with 22.8% of patients requiring fixation spanning the costotransverse articulation. No intraoperative complications occurred. Only one patient required a repeat procedure. Total hospital length of stay averaged 17.3 days with an intensive care unit stay averaging 6.2 days. Total ventilator time averaged 4 days. 7 patients were diagnosed with postoperative pneumonia and 6 patients required tracheostomy.

CONCLUSION

Open reduction and internal fixation for far posterior, or paraspinal rib fractures and fracture-dislocations is a safe procedure with low complications rates and favorable postoperative outcomes including hospital length of stay, ICU length of stay, need for tracheostomy, postoperative pneumonia, and mechanical ventilation time.

Outcomes of chest wall fixation in cardiopulmonary resuscitation-induced flail chest

Chest wall injury is a common complication of cardiopulmonary resuscitation. Chest wall fixation of flail chest has been shown to improve outcomes in patients in whom trauma is the primary pathology. Its efficacy in the post-cardiopulmonary resuscitation setting where the primary event is cardiac arrest is yet to be determined. We report outcomes in a series of 4 patients who underwent rib fixation in the setting of cardiopulmonary resuscitation-induced flail chest.

A case report

INTRODUCTION

Flail chest is now usually treated by conservative methods and surgical fixation remains indicated in selected cases. Different techniques can be used for fixation. The aim of this paper is to present a case in which Judet and Sanchez-Loret plates were employed and to discuss the usefulness of this traditional technique.

PRESENTATION OF CASE

A 79-year-old woman was admitted for left thoracic trauma with severe antero-lateral flail chest. She was affected by COPD with chronic respiratory failure, ischemic heart disease, autoimmune thrombocytopenia treated on chronic steroid therapy and severe osteoporosis. CT-scan detected multiple rib fractures, left hemothorax and lung contusions. An initial conservative treatment of flail chest involved compressive bandage and then internal pneumatic stabilization in ICU, but it failed. The patient underwent successful surgical treatment of the flail chest by fixation of the anterior fractures from the second to the eight rib. Judet and Sanchez-Lloret plates were used. A bilateral pneumonia developed during the rehabilitation period and the patient died two months after operation.

DISCUSSION

Judet and Sanchez-Lloret plates represent a traditional technique for fixation of flail chest. This technique is less and less used and progressively replaced by newer materials, especially titanium plates with screws or intramedullary struts. Our patient had multiple comorbidities and a very fragile bones that advised against use of screws or intramedullary struts.

CONCLUSION

Judet and Sanchez-Lloret plates can be still considered a useful tool for the fixation of flail chest in cases of thin and fragile bones.

Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis

PURPOSE

The objective of this systematic review is to compare the safety and efficacy of surgical fixation of rib fractures against non-surgical interventions for the treatment of flail chest in the adult population.

METHODS

A search was performed on the 22nd of July 2020 to identify articles comparing surgical fixation versus clinical management for flail chest in adults, with a description of the outcome parameters (resource utility, mortality, adverse effects of the intervention and adverse progression in pulmonary status). Relevant randomised controlled trials were selected, their risk of bias assessed, and the data then extracted and analysed.

RESULTS

157 patients were included from four studies in the analyses, with 79 and 78 patients in the surgical and non-surgical groups, respectively. The pooled effects of all outcomes tended towards favouring surgical intervention. Surgical intervention was associated with lower rates of pneumonia (I² = 46%, Tau² = 0.16, p = 0.16), significantly lower rates of tracheostomy (I² = 76%, Tau² = 0.67, p = 0.02), and a significantly lower duration of mechanical ventilation (I² = 88%, Tau² = 33.7, p < 0.01) in comparison to the non-surgical management methods.

CONCLUSION

Our results suggest that surgical intervention reduces the need for tracheostomy, reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event. There is a need for further well-designed studies with sufficient sample sizes to confirm the results of this study and also detect other possible effects of surgical intervention in the treatment of traumatic flail chest in adults.

Plates versus struts versus an extracortical rib fixation in flail chest patients: Two-center experience

PURPOSES

Notwithstanding advances in medical and surgical management of flail chest, its morbidity and mortality rates are still high. Aim of this study is to compare three approaches for parietal thoracic stabilization by analyzing both early and long-term patient outcomes.

METHODS

A retrospective study from January 2006 to January 2018 involving sixty-five surgical flail chest (25 plates,11 struts and 29 wires fixations) was conducted. A mean Abbreviated Injury Scale (AIS) was 2.38±0.82 and a mean Injury Severity Score (ISS) was 32.02±8.21.

RESULTS

Struts and plates stabilizations compared with wires fixation showed an immediate restoring of the partial pressure of oxygen (90.56 mmHg vs 91.90 mmHg vs 89.23 mmHg, p = 0.021), the carbon-dioxide levels (36.00 mmHg vs 35.03 mmHg vs 38.98 mmHg, p = 0.000) and the oxygen-blood saturation (97.71% vs 98.21% vs 92.12%, p = 0.000) in the early postoperative period. Furthermore, struts and plates ensured a better recovery of daily activities up to the 3rdmonth (QoL=1.0: p<0.001 in lateral flail chest and p<0.02 in anterior and antero-lateral flail chest). At the 12thmonth no difference in QoL was found between the different approaches.

CONCLUSIONS

Plate and strut fixation revealed a lower rate of postoperative morbidity and mortality. Wires stabilization was characterized for a reduction of operative time.

[Osteosynthesis of the unstable thoracic wall]

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.

A model for evaluating the biomechanics of rib fracture fixation

INTRODUCTION

High rates of morbidity and mortality following flail chest rib fractures are well publicized. Standard of care has been supportive mechanical ventilation, but serious complications have been reported. Internal rib fixation has shown improvements in pulmonary function, clinical outcomes, and decreased mortality. The goal of this study was to provide a model defining the biomechanical benefits of internal rib fixation.

METHODS

One human cadaver was prepared with an actuator providing anteroposterior forces to the thorax and rib motion sensors to define interfragmentary motion. Cadaveric model was validated using a prior study which defined costovertebral motion to create a protocol using similar technology and procedure. Ribs 4-6 were fixed with motion sensors anteriorly, laterally and posteriorly. Motion was recorded with ribs intact before osteotomizing each rib anteriorly and laterally. Flail chest motion was record with fractures subsequently plated and analyzed. Motion was recorded in the sagittal, coronal and transverse axes.

FINDINGS

Compared to the intact rib model, the flail chest model demonstrated an 11.3 times increase in sagittal plane motion, which was reduced to 2.1 times the intact model with rib plating. Coronal and sagittal plane models also saw increases of 9.7 and 5.1 times, respectively, with regards to flail chest motion. Both were reduced to 1.2 times the intact model after rib plating.

INTERPRETATION

This study allows quantification of altered ribcage biomechanics after flail chest injuries and suggests rib plating is useful in restoring biomechanics as well as contributing to improving pulmonary function and clinical outcomes.

An increasing trend in geriatric trauma patients undergoing surgical stabilization of rib fractures

Purpose

The proportion of geriatric trauma patients (GTPs) (age ≥ 65 years old) with chest wall injury undergoing surgical stabilization of rib fractures (SSRF) nationally is unknown. We hypothesize a growing trend of GTPs undergoing SSRF, and sought to evaluate risk of respiratory complications and mortality for GTPs compared to younger adults (18–64 years old) undergoing SSRF.

Methods

The Trauma Quality Improvement Program (2010–2016) was queried for patients with rib fracture(s) who underwent SSRF. GTPs were compared to younger adults. A multivariable logistic regression analysis was performed.

Results

From 21,517 patients undergoing SSRF, 3,001 (16.2%) were GTPs. Of all patients undergoing SSRF in 2010, 10.6% occurred on GTPs increasing to 17.9% in 2016 (p < 0.001) with a geometric-mean-annual increase of 11.5%. GTPs had a lower median injury severity score (18 vs. 22, p < 0.001), but had a higher rate of mortality (4.7% vs. 1.2%, p < 0.001). After controlling for covariates, GTPs had an increased associated risk of mortality (OR 4.80, CI 3.62–6.36, p < 0.001). On a separate multivariate analysis for all trauma patients with isolated chest Abbreviated Injury Scale 3, GTPs were associated with a similar four-fold risk of mortality (OR 4.21, CI 1.98–6.32, p < 0.001).

Conclusion

Spanning 7 years of data, the proportion of GTPs undergoing SSRF increased by over 7%. Although GTPs undergoing SSRF had lesser injuries, their risk of mortality was four times higher than other adult trauma patients undergoing SSRF, which was similar to their increased background risk of mortality. Ultimately, SSRF in GTPs should be considered on an individualized basis with careful attention to risk–benefit ratio.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01526-7) contains supplementary material, which is available to authorized users.

Clinical efficacy of surgical versus conservative treatment for multiple rib fractures: A meta-analysis of randomized controlled trials

BACKGROUND

There are still controversies between surgical treatment and conservative treatment for multiple rib fractures (MRFs). No consensus has been reached concerning the indications and timing of surgery. In this meta-analysis, we aimed to determine the optimal treatment for MRFs.

METHODS

Six databases (PubMed, Medline, Embase, Cochrane, Cnki, Wanfang Database) were retrieved for all eligible randomized controlled trials (RCTs) published before January 2020. MRFs were treated either with operative reduction and internal fixation or conservative treatment. The pertinent data were retrieved. The quality of RCTs was evaluated by the modified Jadad rating scale and meta-analysis was performed using RevMan 5.3 software.

RESULTS

Seven RCTs involving 538 MRFs patients (260 were treated surgically vs. 278 conservatively) were included in this meta-analysis. Compared with conservative treatment, surgical treatment resulted in shorter length of hospital stay (WMD -8.48; 95% CI -11.34 to -5.63; P < 0.001), length of ICU stay (WMD -5.72; 95% CI -7.31 to -4.13; P < 0.001) and duration of mechanical ventilation (WMD -4.93; 95% CI -8.79 to -1.07; P = 0.01), with a lower risk of complications including pneumonia (RR 0.40; 95% CI 0.30 to 0.53; P < 0.001) and chest wall deformity (RR 0.07; 95% CI 0.03 to 0.14; P < 0.001). The sensitivity analysis carried out by excluding one study with significant heterogeneity showed that the rate of tracheostomy was lower in the surgical group than in the conservative group (RR 0.44; 95% CI 0.28 to 0.71; P = 0.0008).

CONCLUSIONS

For patients with MRFs, surgical treatment resulted in faster recovery, a lower risk of complications and better prognosis than conservative treatment.

Successful surgical treatment of Cronkhite-Canada Syndrome with bilateral flail chest: a case report

Background

Development of multiple rib fractures leading to bilateral flail chest in Cronkhite–Canada Syndrome (CCS) has not been reported.

Case presentation

A 59-year-old man presented with complaints of fatigue, chest pain, respiratory distress and orthopnea requiring ventilatory support to maintain oxygenation. CCS with bilateral anterior and posterior flail chest due to multiple rib fractures (2nd-10th on the right side and 2nd-11th on the left side). He underwent open reduction and anterior and posterior internal fixation using a titanium alloy fixator and a nickel-titanium memory alloy embracing fixator for chest wall reconstruction. He recovered gradually from the ventilator and showed improvement in his symptoms. He gained about 20 kg of weight in the follow up period (6 months after discharge from the hospital).

Conclusion

CCS is a rare, complex disease that increases the risk of developing multiple rib fractures, which can be successfully treated with open reduction and internal fixation.

Stability of Surgical Rib Fixation Hardware after Repeat Chest Trauma

Surgical management of rib fractures has long been a controversial topic, but improvements in rib plating technology have led to a recent increase in interest among surgeons. Unfortunately, follow-up data are limited in patients following rib fracture plating. We present a unique case of an adult male who had multiple ribs plated for symptomatic rib fracture nonunions and developed periprosthetic fractures following repeat trauma several months later. A 57-year-old male with a history of trauma was treated for symptomatic nonunion of several left lateral ribs with surgical rib fixation. He tolerated the procedure well and had significant improvement in his symptoms on follow-up. Several months later, he was hit by a motor vehicle while riding his bicycle. He was found to have flail chest with lateral segmental rib fractures of the first through second ribs, posterior periprosthetic fractures of the seventh through tenth ribs, and lateral fractures of the eleventh and twelfth ribs. The rib plating hardware was completely intact, except for a single displaced seventh rib screw. To our knowledge, this is the first case report of repeat chest trauma following rib plating. Interestingly, the patient developed posterior periprosthetic fractures, and hardware was completely intact except for a single screw that was displaced. The goal of this report is to describe the unique fracture pattern of a flail chest with prior rib plating and to describe potential revision plating techniques and complications that surgeons may encounter in the management of trauma patients with prior rib plating.

The benefits of early rib fixation for clinical outcomes of flail chest patients in intensive care unit

Background

In the present study, we aimed to compare clinical results of conservative and surgical stabilization approaches and to investigate the effect of early reduction in patients with a flail chest.

Methods

Between March 2013 and December 2017, 34 patients (23 males, 11 females; mean age 43.7±12.1 years; range, 20 to 74 years) with a flail chest who underwent early rib fixation were included in the surgical group and 29 patients with a flail chest (19 males, 10 females; mean age: 45.7±15.8 years; range, 24 to 74 years) who were followed with the conservative approach were included in the conservative treatment group between February 2012 and December 2017. We applied early rib reduction on the first or the next day (within 24 to 36 h) of trauma. The length of hospitalization, the presence of pneumonia and septic complications in the postoperative period, mortality, mechanical ventilation duration, tracheostomy rate, respiratory function test results, and pain scores were recorded and compared between the groups.

Results

The length of stay in the hospital and intensive care unit, and duration of mechanical ventilation were statistically significantly higher in the conservative treatment group than the surgery group (p<0.001, p<0.001, and p<0.001, respectively). None of the patients required tracheostomy in the surgical group, while five patients required tracheostomy in the conservative treatment group (p=0.004). Mortality rates were 2.94% and 20.69% in the surgery and conservative treatment groups, respectively (p=0.027). Pain scores were statistically significantly different in favor of the surgical group compared to the conservative treatment group (p=0.0038 and p=0.044, respectively).

Conclusion

The results of our study show that early fixation and weaning reduce the need for mechanical ventilation, length of hospitalization, the need for tracheostomy, and mortality rates. This approach also provides a significant improvement in the long-term pain complaints and pulmonary function tests of patients with a flail chest.

Testing the clinical validity of the Bemelman Rib Fracture Management Guideline

Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89-0.9995) and 0.83 (0.70-0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76-0.92) and 0.98 (0.85-0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.

Epidemiology of adult rib fracture and factors associated with surgical fixation: Analysis of a chest wall injury dataset from England and Wales

INTRODUCTION

Chest wall trauma is commonly seen in patients admitted with both high and low-energy transfer injury. Whilst often associated with other injuries, it is also seen in isolation following simple falls in the older patient. Fixation of the chest wall grows in popularity as part of optimising patient care, particularly in terms of critical care stay. There is currently no description of the epidemiology of these injuries at a national level; nor has there been identification of factors that predict which of these patients undergoes surgery.

METHODS

The United Kingdom Trauma Audit & Research Network (TARN) database was analysed for the period April 2016 to 30th May 2017 for all adult patients presenting with a rib or sternal fracture. Characteristics of the population were described and a binary logistic regression model constructed to explore the influences of several explanatory variables on whether fixation was performed.

RESULTS

Of 16,638 patients with chest wall trauma, 402 underwent fixation. Most chest wall injury patients were admitted under three specialties (orthopaedics (19.1%), emergency medicine (16.6%) and general surgery (17.7%)). The odds of fixation in unilateral flail chest was 107.51 (p <0.0001), in bilateral flail or combined complexsternal fracture 47.63 (p = 0.007) and in 3 or more non-flail ribs 15.62 (p<0.0001) when compared to less than three non-flail rib fractures. The odds of fixation was higher in an MTC (p<0.0001) compared to a non-specialist hospital. The odds of fixation was higher in older patients (1.02, p<0.0001) and the more severely injured (1.02, p<0.0001).

CONCLUSION

There is considerable variation nationally in the management of chest wall trauma. Injury type, patient age and care setting contribute to decision making in fracture fixation. This unique national dataset characterises for the first time the nature of contemporary chest wall trauma management and should help inform the design of future research on this topic.

An unexpected fracture of a titanium rib plate in a patient with traumatic brain injury

Surgical stabilization of rib fractures has been accepted and successfully performed for the management of patients with multiple rib fractures. Several types of devices, such as titanium bar, plate, and screws, are used for rib stabilization. Titanium devices provide a strong support for rib fixation and chest wall reconstruction and are rarely associated with complications. Herein, we report an unusual case of mechanical failure associated with a broken titanium plate. A 47-year-old man was treated with surgical stabilization of rib fractures using titanium plates after blunt trauma leading to epidural hematoma and massive hemothorax. After decompressive craniectomy, bleeding control, and rib fixation for chest trauma, he developed hyperactive delirium, which was not well controlled. On the 17 day of operation, a chest radiograph showed a broken rib plate. Surgeons who perform surgical rib stabilization should be aware that titanium plates are vulnerable to breakage under some conditions, such as hyperactive delirium.