A technical proposal for the complex flail chest

Abstract

We read with interest the article by Oyarzum and colleagues [1Oyarzun J.R. Bush A.P. McCormick J.R. Bolanowski P.J.P. Use of 3.5-mm acetabular reconstruction plates for internal fixation of flail chest injuries.Ann Thorac Surg. 1998; 65: 1471-1474Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar] and the referred letter of Actis Dato and colleagues [2Actis Dato G. Aidala E. Ruffini E. Surgical management of flail chest.Ann Thorac Surg. 1999; 67 ([Letter]): 1826-1827Abstract Full Text PDF PubMed Scopus (9) Google Scholar] that refocused a pathology—the flail chest injuries—in which surgery is indicated only in a minority of cases and the technical solutions are frequently tailored to the single case. We wish to report our experience in the treatment of a complex bilateral flail chest with sternal disruption (Fig 1) in a 75-year-old male who underwent a crushing trauma. The surgical solution was proposed and carried out 5 days after the admission to the intensive care unit as the patient had no associated cerebral injuries, a limited pulmonary contusion and no possibility of weaning from the ventilator because of a severe instability of a large part of the anterior and lateral chest wall. This was caused by a transverse fracture of the sternum and multiple bilateral rib fractures from the third to the ninth on the right side and from the fourth to the seventh on the left side. Through a clamshell skin incision we reached the sternum and the costal plane and a 50 cm long steel bar molded on the chest wall profile was inserted between the intercostal muscles and under the sternum after having divided the mammary vessels and its ends were tied to solid rib segments. The disconnected sternum and the segments of fractured ribs adjacent to the bar were fixed to it with nonabsorbable stiches and those distant were stabilized with the Judet’ devices (Fig 2). Each pleural cavity was drained with two 32 F tubes. The weaning from mechanical ventilation was carried out in 72 hours and the patient was discharged after 15 days from the operation. The surgical stabilization of the complex post-traumatic flail chest, when indicated, can be sometimes a difficult challenge necessitating original technical solutions [1Oyarzun J.R. Bush A.P. McCormick J.R. Bolanowski P.J.P. Use of 3.5-mm acetabular reconstruction plates for internal fixation of flail chest injuries.Ann Thorac Surg. 1998; 65: 1471-1474Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 2Actis Dato G. Aidala E. Ruffini E. Surgical management of flail chest.Ann Thorac Surg. 1999; 67 ([Letter]): 1826-1827Abstract Full Text PDF PubMed Scopus (9) Google Scholar, 3Vichard P. Zeil A. Dreyfus-Schmidt G. Les formes anatomo-cliniques des fractures du sternum. Place et modalites de l’osteosyntese des fractures instables.Chirurgie. 1989; 115: 89-94PubMed Google Scholar, 4Haasler G.B. Open fixation of flail chest after blunt trauma.Ann Thorac Surg. 1990; 49: 993-996Abstract Full Text PDF PubMed Scopus (41) Google Scholar]. In the case of a very large defect of stability involving the lateral and the anterior part of the chest wall we suggest that the use of the extra pleural long bar that we have proposed associated, when necessary, with other standard devices can be very useful. It can work as a load-bearing axis to which fractured segments of rib and sternum can be fixed to quickly restore a normal respiratory dynamic. ReplyThe Annals of Thoracic SurgeryVol. 70Issue 1Preview Full-Text PDF