Flail Chest Injuries Research Articles

Analysis of bone healing in flail chest injury: do we need to fix both fractures per rib?

Surgical rib fixation (SRF) for severe rib fracture injuries is generating increasing interest in the medical literature. It is well documented that poorly healed fractured ribs can lead to chronic pain, disability, and deformity. An unanswered question in SRF for flail chest injury is whether it is sufficient to fix one fracture per rib, on successive ribs, thus converting a flail chest injury into simple fractured ribs, or whether both ends of the floating segment of the chest wall should be fixed. This study aimed to analyze SRF in flail chest injury, assessing 3-month outcomes for nonfixed fractured rib ends in the flail segment. This is a retrospective review (2005-2013) of 60 consecutive patients who underwent SRF for flail chest injury admitted to the Alfred Hospital, Melbourne, Australia. Imaging by three-dimensional computed tomography (3D CT) of the chest at admission was compared with follow-up 3D CT at 3 months after injury. The 3-month CT scans were assessed for degree of healing and presence of residual deformity at the fracture fixation site. Follow-up CT was performed in 52 of the 60 patients. At 3 months after surgery, 86.5% of the patients had at least partial healing with good alignment and adequate fracture stabilization. Hardware failure was noted in five patients (9.6%) and occurred with the absorbable prostheses only. Six patients who had preoperative overlapping or displacement showed no improvement in deformity despite fixing the lateral fractures. Callus formation and bony bridging between adjacent ribs was often noted in the rib fractures not fixed (28 of 52 patients, 54%) This retrospective review of 3D CT chest at 3 months after rib fixation indicates that a philosophy of fixing only one fracture per rib in a flail segment does not avoid deformity and displacement, particularly in posterior rib fractures. Therapeutic study, level V; epidemiologic study, level V.

Successful Management of Severe Flail Chest via Early Operative Intervention

A review on the role of open reduction and internal fixation of flail chest injuries is presented. A 37-year-old woman involved in a motorcycle crash sustained comminuted rib fractures on her right 3rd through 12th ribs. On postinjury day 2, the patient's fifth through ninth ribs were surgically reduced and plated. Later that same day, the patient was successfully weaned from mechanical ventilation and experienced a rapid improvement in incentive spirometry volumes. Further studies are needed to definitively determine the benefits of rib plating versus conventional treatment. Through our case, we are able to demonstrate successful management of pain and chest wall instability associated with flail chest through the use of rib plating.

Flail chest injuries

Flail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation, and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, and outcomes of flail chest injuries in polytrauma patients. The National Trauma Data Bank was used for a retrospective analysis of the injury patterns, management, and clinical outcomes associated with flail chest injuries. Patients with a flail chest injury admitted from 2007 to 2009 were included in the analysis. Outcomes included the number of days on mechanical ventilation, days in the intensive care unit (ICU), days in the hospital, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death. Flail chest injury was identified in 3,467 patients; the mean age was 52.5 years, and 77% of the patients were male. Significant head injury was present in 15%, while 54% had lung contusions. Treatment practices included epidural catheters in 8% and surgical fixation of the chest wall in 0.7% of the patients. Mechanical ventilation was required in 59%, for a mean of 12.1 days. ICU admission was required in 82%, for a mean of 11.7 days. Chest tubes were used in 44%, and 21% required a tracheostomy. Complications included pneumonia in 21%, adult respiratory distress syndrome in 14%, sepsis in 7%, and death in 16%. Patients with concurrent severe head injury had higher rates of ventilatory support and ICU stay and had worse outcomes in every category compared with those without a head injury. Patients who have sustained a flail chest have significant morbidity and mortality. More than 99% of these patients were treated nonoperatively, and only a small proportion (8%) received aggressive pain management with epidural catheters. Given the high rates of morbidity and mortality in patients with a flail chest injury, alternate methods of treatment including more consistent use of epidural catheters for pain or surgical fixation need to be investigated with large randomized controlled trials. Epidemiologic/prognostic study, level IV.

The introduction of rib fracture fixation for traumatic flail chest injury: A single centre experience

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.

Severe trauma of the chest wall: surgical rib stabilisation versus non-operative treatment.

Serial rib fractures and flail chest injury can be treated by positive-pressure ventilation. Operative techniques reduce intensive care unit (ICU) stay, overall costs, mortality and morbidity, as well as pain. The aim of this study was to evaluate the benefit of surgical rib stabilisation in comparison to non-operative treatment in patients with severe trauma of the chest wall. From 2006 to 2011, the data of 44 patients with flail chest and serial rib fractures were collected retrospectively. A surgical group and an intensive care group with only intensive care therapy were formed. Rib and sternal fractures, flail chest, injury severity, thoracic injuries, mechanical ventilation, time in the ICU, overall hospital stay and mortality were evaluated. No postoperative surgical complications had been observed. The time under mechanical ventilation in the surgical group was 10.6±10.2days, whereas in the non-surgical group, it was 13.7±13.7days. Mechanical ventilation time after surgery was 6.9±6.5days. Time in the ICU for the surgical group was 16.4±13.6days, compared to the non-surgical group with 20.1±16.2days. Postoperative time in the ICU was 11.7±10.3days. The mortality in the surgical group was 10% and in the non-surgical group it was 17%. Operative rib stabilisation with plates is a safe therapy option for severe trauma of the chest wall. Provided that the duration of preoperative mechanical ventilation and time spent in the ICU is minimised due to early operation, our data suggest that the stabilisation of serial rib fractures and flail chest may lead to a reduced time of mechanical ventilation, time in the ICU and mortality.

Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest

Traumatic flail chest injury is a potentially life threatening condition traditionally treated with invasive mechanical ventilation to splint the chest wall. Longer-term sequelae of pain, deformity, and physical restriction are well described. This study investigated the impact of operative fixation in these patients. A prospective randomized study compared operative fixation of fractured ribs in the flail segment with current best practice mechanical ventilator management. In-hospital data, 3-month follow-up review, spirometry and CT, and 6-month quality of life (Short Form-36) questionnaire were collected. Patients in the operative fixation group had significantly shorter ICU stay (hours) postrandomization (285 hours [range 191 to 319 hours] for the surgical group vs 359 hours [range 270 to 581 hours] for the conservative group; p = 0.03) and lesser requirement for noninvasive ventilation after extubation (3 hours [range 0 to 25 hours] in the surgical group vs 50 hours [range 17 to 102 hours] in the conservative group; p = 0.01). No differences in spirometry at 3 months or quality of life at 6 months were noted. Operative fixation of fractured ribs reduces ventilation requirement and intensive care stay in a cohort of multitrauma patients with severe flail chest injury.

Surgical Fixation vs Nonoperative Management of Flail Chest: A Meta-Analysis

Flail chest is a life-threatening injury typically treated with supportive ventilation and analgesia. Several small studies have suggested large improvements in critical care outcomes after surgical fixation of multiple rib fractures. The purpose of this study was to compare the results of surgical fixation and nonoperative management for flail chest injuries. A systematic review of previously published comparative studies using operative and nonoperative management of flail chest was performed. Medline, Embase, and the Cochrane databases were searched for relevant studies with no language or date restrictions. Quantitative pooling was performed using a random effects model for relevant critical care outcomes. Sensitivity analysis was performed for all outcomes. Eleven manuscripts with 753 patients met inclusion criteria. Only 2 studies were randomized controlled designs. Surgical fixation resulted in better outcomes for all pooled analyses including substantial decreases in ventilator days (mean 8 days, 95% CI 5 to 10 days) and the odds of developing pneumonia (odds ratio [OR] 0.2, 95% CI 0.11 to 0.32). Additional benefits included decreased ICU days (mean 5 days, 95% CI 2 to 8 days), mortality (OR 0.31, 95% CI 0.20 to 0.48), septicemia (OR 0.36, 95% CI 0.19 to 0.71), tracheostomy (OR 0.06, 95% CI 0.02 to 0.20), and chest deformity (OR 0.11, 95% CI 0.02 to 0.60). All results were stable to basic sensitivity analysis. The results of this meta-analysis suggest surgical fixation of flail chest injuries may have substantial critical care benefits; however, the analyses are based on the pooling of primarily small retrospective studies. Additional prospective randomized trials are still necessary.

Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures

In this case report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.

Management of pulmonary contusion and flail chest

Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC. A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus. Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations. Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

Structural integrity of intramedullary rib fixation using a single bioresorbable screw

Operative management of flail chest injury is receiving increasing interest. However, we have noticed in our own practice the difficulty in achieving reliable results with posterior rib fracture fixation. In this article, we analyze and model the physiologic forces acting on posterior rib fractures and assess the suitability of an intramedullary screw fixation technique in this site. Computerized finite element analysis (FEA) was used to model a typical sixth rib and analyze the physiologic forces that act on the rib in vivo. A fracture in the posterior aspect of the rib was incorporated into the model, and an intramedullary screw fixation concept was assessed, using both a bioabsorbable polymer screw and a stainless steel screw.The records of 120 consecutive patients with flail chest were reviewed, and 26 patients were identified as having multiple posterior rib fractures with displacement. These patients formed a clinical correlation group by which to assess the FEA model. FEA modeling of the posterior rib fracture showed likely posterior displacement in response to physiologic forces. Review of the 26 patients with flail chest and displaced posterior fractures confirmed the direction of displacement. Modeling of an intramedullary screw fixation showed significant stresses in the bone/screw contact areas (stainless steel solution) and the prosthesis itself (bioabsorbable polymer solution) This FEA model demonstrates that physiologic forces cause posterior displacement at posterior rib fracture sites. Fixation solutions to counteract these forces need to overcome significant stresses at both the bone/prosthesis contact regions and within the prosthetic material itself. Epidemiologic/therapeutic study, level V.

Surgical stabilization of flail chest injuries with MatrixRIB implants: A prospective observational study

BackgroundSurgical 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. MethodsTwenty 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. ResultsPatients 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. ConclusionsAnatomic 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.

Acute respiratory distress syndrome after trauma

To determine early clinical predictors of acute respiratory distress syndrome after major traumatic injury and characterize the performance of this acute respiratory distress syndrome prediction model, and two previously published acute respiratory distress syndrome prediction models, in an independent cohort of severely injured patients. Prospective cohort study. University-affiliated level I trauma center in Seattle, WA, and nine hospitals participating in the Inflammation and Host Response to Injury Consortium. Model derivation utilized data from 224 patients participating in a randomized controlled trial. All models were validated in an independent cohort of 1,762 trauma patients. Variables strongly associated with acute respiratory distress syndrome in bivariate analysis (p<.01) were entered into a multiple logistic regression equation to generate an acute respiratory distress syndrome predictive model. We evaluated the performance of all models using the area under the receiver operator characteristic curve. Acute respiratory distress syndrome occurred in 79 subjects (35%) belonging to the development cohort and in 423 subjects (24%) from the validation cohort. Multivariable predictors of acute respiratory distress syndrome after trauma included subject age, Acute Physiology and Chronic Health Evaluation II Score, injury severity score, and the presence of blunt traumatic injury, pulmonary contusion, massive transfusion, and flail chest injury (area under the receiver operator characteristic curve 0.79 [95% confidence interval 0.73, 0.85]). Validation of the prediction model resulted in an area under the receiver operator characteristic curve of 0.71 (95% confidence interval 0.68, 0.74). Our model's performance in the validation cohort was superior to that of two other published acute respiratory distress syndrome prediction models (0.65 [95% confidence interval 0.63, 0.68] and 0.66 [95% confidence interval 0.64, 0.69], p<.01 for all comparisons). Using routinely available clinical data, our prediction model identifies patients at high risk for acute respiratory distress syndrome early after severe traumatic injury. This predictive model could facilitate enrollment of subjects into future clinical trials designed to prevent this serious complication.

Flail Chest Injury: Are We Making Any Progress?

Flail chest represents a severe injury with mortality historically reported at up to 30 per cent. Although management has changed dramatically over the past several decades, there is a paucity of large recent series. With Institutional Review Board approval, a retrospective review of all patients with flail chest admitted from January 2001 through May 2010 was undertaken. Patient demographics, outcomes, and cause of death were specifically analyzed with univariate and multivariate analysis. There were 164 patients at a median age of 51.4 years. Head injury and pulmonary contusion were present in 67 (40.8%) and 125 (77%), respectively. Pneumonia developed in 72 (43.9%). There were 41 deaths (25%), for which flail chest contributed to 15 (9.1%). Of the patients with flail chest-related death, the majority (n = 10 [66.7%]) died within 48 hours of presentation. There were only five deaths (3.0%) related to flail chest after 48 hours. Multivariate analysis of ventilator dependency revealed requirement for laparotomy (P = 0.019) or tracheostomy (P < 0.0001) and pneumonia (P = 0.0002) as significant. Pneumonia was the most significant independent predictor of overall (P < 0.0001) and intensive care unit length of stay (P < 0.0001). The mortality associated with flail chest has greatly improved; however, the rate of pneumonia remains high. Further efforts at pneumonia prevention are thus warranted.

Early Surgical Stabilization of Flail Chest With Locked Plate Fixation

To compare the results of surgical stabilization with locked plating to nonoperative care of flail chest injuries. Retrospective case-control study. Level II trauma center. From January 2005 to January 2010, 22 patients with flail chest treated with locked plate fixation were compared with a matched cohort of 28 nonoperatively managed patients at our institution. Open reduction internal fixation of rib fractures with 2.7-mm locking reconstruction plates. Demographic data, such as age, sex, injury severity score, number of fractures, and lung contusion severity, were recorded. Intensive care unit data concerning length of stay (LOS), tracheostomy, and ventilator days were noted. Operative data, such as time to OR, operative time, and estimated blood loss, were recorded. Hospital data, including total hospital LOS, need for reintubation, and home oxygen requirements, were documented. Average follow-up period of operatively managed patients was 17.84 ± 4.51 months, with a range of 13-22 months. No case of hardware failure, hardware prominence, wound infection, or nonunion was reported. Operatively treated patients had shorter intensive care unit stays (7.59 vs. 9.68 days, P = 0.018), decreased ventilator requirements (4.14 vs. 9.68 days, P = 0.007), shorter hospital LOS (11.9 vs. 19.0 days, P = 0.006), fewer tracheostomies (4.55% vs. 39.29%, P = 0.042), less pneumonia (4.55% vs. 25%, P = 0.047), less need for reintubation (4.55% vs. 17.86%, P = 0.34), and decreased home oxygen requirements (4.55% vs. 17.86%, P = 0.034). This study demonstrates the potential benefits of surgical stabilization of flail chest with locked plate fixation. When compared with case-matched controls, operatively managed patients demonstrated improved clinical outcomes. Locked plate fixation seems to be safe as no complications associated with hardware failure, plate prominence, wound infection, or nonunion were noted.

Biomechanical rationale and evaluation of an implant system for rib fracture fixation

BackgroundBiomechanical research directed at developing customized implant solutions for rib fracture fixation is essential to reduce the complexity and to increase the reliability of rib osteosynthesis. Without a simple and reliable implant solution, surgical stabilization of rib fractures will remain underutilized despite proven benefits for select indications. This article summarizes the research, development, and testing of a specialized and comprehensive implant solution for rib fracture fixation.MethodsAn implant system for rib fracture fixation was developed in three phases: first, research on rib biomechanics was conducted to better define the form and function of ribs. Second, research results were implemented to derive an implant system comprising anatomical plates and intramedullary rib splints. Third, the functionality of anatomic plates and rib splints was evaluated in a series of biomechanical tests.ResultsGeometric analysis of the rib surface yielded a set of anatomical rib plates that traced the rib surface over a distance of 13–15 cm without the need for plate contouring. Structurally, the flexible design of anatomic plates did not increase the native stiffness of ribs while restoring 77% of the native rib strength. Intramedullary rib splints with a rectangular cross-section provided 48% stronger fracture fixation than traditional intramedullary fixation with Kirschner wires.ConclusionThe anatomic plate set can simplify rib fracture fixation by minimizing the need for plate contouring. Intramedullary fixation with rib splints provides a less-invasive fixation alternative for posterior rib fracture, where access for plating is limited. The combination of anatomic plates and intramedullary splints provides a comprehensive system to manage the wide range of fractures encountered in flail chest injuries.

Operative stabilization of flail chest injuries: review of literature and fixation options

BackgroundFlail chest injuries cause significant morbidity, especially in multiply injured patients. Standard treatment is typically focused on the underlying lung injury and involves pain control and positive pressure ventilation. Several studies suggest improved short- and long-term outcomes following operative stabilization of the flail segments. Despite these studies, flail chest fixation remains a largely underutilized procedure.MethodsThis article reviews the relevant literature concerning flail chest fixation and describes the different implants and techniques available for fixation. Additionally, an illustrative case example is provided for description of the surgical approach.ResultsTwo prospective randomized studies, five comparative studies, and a number of case series documented benefits of operative treatment of flail chest injuries, including a decreased in ventilation duration, ICU stay, rates of pneumonia, mortality, residual chest wall deformity, and total cost of care. Historically, rib fractures have been stabilized with external plates or intramedullary implants. The use of contemporary, anatomically contoured rib plates reduced the need for intraoperative plate bending. Intramedullary rib splints allowed less-invasive fixation of posterior fractures where access for plating was limited.ConclusionOperative treatment can provide substantial benefits to patients with flail chest injuries and respiratory compromise requiring mechanical ventilation. The use of anatomically contoured rib plates and intramedullary splints greatly simplifies the procedure of flail chest fixation.

Prognostic factors in flail-chest patients☆

The records of 250 patients presenting with flail-chest injury in a level I trauma centre were reviewed and analysed in order to determine prognostic factors. There were 250 consecutive trauma patients with flail chest, 183 men (73.2%) and 67 women (26.8%) ranging in age from 18 to 91 years, admitted to our hospital. The leading cause of injury was road traffic accident. One hundred and six patients (42.4%) were conservatively treated, while 117 (46.8%) needed thoracic drainage. Ventilatory assistance was used in 28 cases (11.2%). Only 19 (7.6%) required thoracotomy and/or laparotomy. The mortality rate reached 8.8%. Patients were divided into three groups: group I consisted of 105 patients (70/35) with an isolated flail chest (Injury Severity Score (ISS): 16); group II included 58 cases (48/10) with extrathoracic fractures (ISS: 25-30); and group III comprised 87 patients (65/22) with injuries to the brain or to thoracic or abdominal organs requiring thoracotomy and/or laparotomy (ISS: >40). Parameters such as age, sex, ISS, presence of extrathoracic fractures, haemopneumothorax and head injury as well as the need for mechanical support in an intensive care unit (ICU) and mortality were evaluated. The mortality rate in group III was higher compared to those of groups I and II (16% vs 3.8% and 6.9%, respectively) and the difference was found to be statistically significant. Laparotomy and thoracotomy affected mortality, while age, pneumothorax and head injury did not. Finally, mechanical support was used only in a few cases. (1) ISS is the strongest predictor of outcome associated with increased mortality; and (2) mechanical support was not considered a necessity for the treatment of flail chest.

Anatomically Contoured Plates for Fixation of Rib Fractures

: Intraoperative contouring of long bridging plates for stabilization of flail chest injuries is difficult and time consuming. This study implemented for the first time biometric parameters to derive anatomically contoured rib plates. These plates were tested on a range of cadaveric ribs to quantify plate fit and to extract a best-fit plating configuration. : Three left and three right rib plates were designed, which accounted for anatomic parameters required when conforming a plate to the rib surface. The length lP over which each plate could trace the rib surface was evaluated on 109 cadaveric ribs. For each rib level 3-9, the plate design with the highest lP value was extracted to determine a best-fit plating configuration. Furthermore, the characteristic twist of rib surfaces was measured on 49 ribs to determine the surface congruency of anatomic plates with a constant twist. : The tracing length lP of the best-fit plating configuration ranged from 12.5 cm to 14.7 cm for ribs 3-9. The corresponding range for standard plates was 7.1-13.7 cm. The average twist of ribs over 8-cm, 12-cm, and 16-cm segments was 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constant twist of anatomic rib plates was not significantly different from the average rib twist. : A small set of anatomic rib plates can minimize the need for intraoperative plate contouring for fixation of ribs 3-9. Anatomic rib plates can therefore reduce the time and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates.

Pilot study of operative fixation of fractured ribs in patients with flail chest

Flail chest is a serious injury in trauma with a significant mortality rate, and long-term pain and disability. Traditionally, management has consisted of internal pneumatic splinting, leading to prolonged periods of mechanical ventilation, and its attendant complications. The aim of this study was to assess the safety of operative fixation of broken ribs in flail chest using absorbable prostheses. Thirteen consecutive patients with severe flail chest injury were enrolled in this pilot study. Surgery was planned after viewing three-dimensional reconstructions of the computed tomography scans of the chest. The plates were applied to the external cortical surface of the rib after reducing the fracture. Segmentally fractured ribs were usually plated only once to convert the flail segment to simple fractured ribs and correct the paradoxical wall motion abnormality. All patients had a good surgical result. On average, four ribs were fixed per patient. All patients were able to be weaned from mechanical ventilation and all patients were discharged from the hospital. There were no deaths. No plates had to be removed. In all patients, the flail chest was successfully stabilized and paradoxical chest wall movement was eliminated. This pilot study of operative fixation of broken ribs in patients with flail chest, using absorbable plates and screws, has shown the technique to be safe and effective. On the basis of these results, a prospective randomized trial has commenced at The Alfred Hospital, comparing this management strategy with conservative management.

ANATOMICALLY CONTOURED PLATES FOR FIXATION OF RIB FRACTURES

Background : Intraoperative contouring of long bridging plates for stabilization of flail chest injuries is difficult and time consuming. This study implemented for the first time biometric parameters to derive anatomically contoured rib plates. These plates were tested on a range of cadaveric ribs to quantify plate fit and to extract a best-fit plating configuration. Methods : Three left and three right rib plates were designed, which accounted for anatomic parameters required when conforming a plate to the rib surface. The length lP over which each plate could trace the rib surface was evaluated on 109 cadaveric ribs. For each rib level 3-9, the plate design with the highest lP value was extracted to determine a best-fit plating configuration. Furthermore, the characteristic twist of rib surfaces was measured on 49 ribs to determine the surface congruency of anatomic plates with a constant twist. Results : The tracing length lP of the best-fit plating configuration ranged from 12.5 cm to 14.7 cm for ribs 3-9. The corresponding range for standard plates was 7.1-13.7 cm. The average twist of ribs over 8-cm, 12-cm, and 16-cm segments was 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constant twist of anatomic rib plates was not significantly different from the average rib twist. Conclusions : A small set of anatomic rib plates can minimize the need for intraoperative plate contouring for fixation of ribs 3-9. Anatomic rib plates can therefore reduce the time and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates.