Cardiopulmonary Resuscitation-Induced Hardware Failure After Surgical Stabilization of Flail Chest

William T Head,Christopher S Thomas,Evert A Eriksson

doi:10.7759/cureus.15549

Abstract

Flail chest occurs when three or more ribs have concurrent fractures in two or more places. Flail chest is a marker of injury severity and is associated with increased morbidity and mortality. The management of flail chest includes multiple nonoperative components in addition to surgical stabilization, which has been shown to lower mortality rates to those of multiple rib fractures with a stable chest wall (i.e., no flail chest). The resulting stability of the chest wall may be a more accurate prognostic indicator than the actual number of ribs fractured. Surgical stabilization has been associated with various complications. The overall incidence of hardware failure is relatively rare and often involves the anterolateral and lateral regions of the chest wall. We present a unique case of a 48-year-old male involved in a motor vehicle accident with multiple traumatic injuries, including flail chest. He ultimately underwent surgical stabilization across six separate ribs in nine total locations. The patient’s condition deteriorated several weeks later, and he required cardiopulmonary resuscitation. High impact forces caused hardware failure in three separate locations along the chest wall, i.e., anteriorly, anterolaterally, and posterolaterally. The most significant failure occurred anteriorly with sternal plate and screw separation. We suspect that hardware failure in the anterior and anterolateral regions indicates that the sternum and costochondral junction may be dynamic areas of the chest wall that dissipate forces differently than do the bone of ribs.

Highlights

Rib fractures occur frequently in patients with thoracic trauma and are among the most common injuries encountered after a blunt mechanism of injury [1]
Their presence largely serves as a marker of injury severity, and they have been associated with a 10% overall mortality rate
An increased number of fractures has been associated with increased mortality, which is concerning for those with flail chest and those over 65 years old

Summary

Introduction

Rib fractures occur frequently in patients with thoracic trauma and are among the most common injuries encountered after a blunt mechanism of injury [1]. An analysis of over 100,000 patients with rib fractures showed that flail chest injuries were significantly more likely to require the following: epidural catheter, chest tube, tracheostomy, mechanical ventilation, intensive care unit (ICU) admission, increased length of stay, and hospital readmission [3] They were more likely to experience the following complications: pneumonia, acute renal failure, bleeding requiring transfusion, major wound disruption, surgical site infection, and short-term and long-term mortality [3]. A repeat chest CT scan revealed greater displacement and offset of the previously identified fractures as well as improved visibility of the costocartillage fractures (Table 1) He was deemed to be an appropriate surgical candidate on HD 13 and received surgical stabilization of rib fractures (SSRF) on the left side. After his cardiac event, CT revealed hardware failure with one locking screw separating from a plate at the left costochondral junction and another along the sternum (Table 1). Computerized tomography image highlighting locking screw and plate separation from the sternum at the level of the fifth rib

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Disclosures