Internal Pneumatic Stabilization Research Articles

Метод фиксации костных отломков флотирующих переломов ребер

Aim. Comparative analysis of the results of surgical and nonsurgical fixation of floating rib fractures (FRF).Material and methods. The results of the treatment of 141 patients with FRF hospitalized in the RRCEM from 2017 to 2022 were studied. There were 109 men (77.3%), 32 women (22.7%). The averageage of patients was 37.8±13.5 years. All 141 patients with FRF underwent video thoracoscopy (VTS),upon completion of which two approaches were used to fix floating rib fractures: the traditional method is internal pneumatic stabilization of floating rib fractures (long-term artificial lung ventilation(ALV)) – in 85 (60.3%) patients and external rib fixation under the control of the VTS – in 56 (31.3%)patients.Results. The use of external fixation of FRF under the control of VTS helps to reduce the duration ofventilation (from 8.2±2.5 days to 2.1±1.0 days, p<0.001) and, accordingly, the length of stay of patientsin the ICU (from 9.2±2.9 days to 3.8±2.1 days, p<0.001), reduces the frequency of severe post-traumaticpneumonia (from 64.7 to 17.9%, p<0.001), which has a beneficial effect on the mortality rate, reducing itfrom 15.3% to 7.1% (p>0.05).Conclusion. The use of VTS, along with safe and reliable fixation of rib fractures, also provides full-fledgedsanitation of the pleural cavity from hemothorax, allows minimally invasive hemostasis and eliminate other intrapleural consequences of trauma, which together contributes to a significant reduction in the timeof removal of pleural drains (from 4.3±1.0 days to 5.6±1.7 days, p<0.05).

MODERN ALGORITHMS OF THORACIC CAGE STABILIZATION IN PATIENTS WITH MULTIPLE RIB FRACTURES AND FLAIL CHEST

Objectives - to improve the treatment results in patients with multiple rib fractures and flail chest via the development and implementation of modern therapeutic and tactical algorithms. Material and methods. A non-randomized prospective study has been carried out to evaluate the results of treatment in 198 patients with multiple rib fractures and flail chest in the period of 2011-2017. Three clinical types were identified: 1) patients with multiple rib fractures with disordered thoracic cage structure - 77 (38.9%); 2) patients with flail chest - 71 (35.9%); 3) patients with multiple rib fractures without disordered thoracic cage structure - 50 (25.2%). There were developed and applied the diagnostic and treatment algorithms depending on the severity of injures of sternocostal frame and intrapleural organs, the presence and severity of associated injuries and background diseases, the conditions of medical aid. Results. The treatment tactics of all patients was based on the differentiated, staged and combined use of various methods of stabilizing the thoracic cage including the advanced types of medical care. Surgical stabilization methods were used in 162 patients, in 26 of them a combination of surgical techniques was applied, in 20 - the internal pneumatic stabilization, in 42 - the conservative treatment was performed. The retrospective analysis and the obtained results compared to the results of the equivalent historical group allowed us to state the decrease of mechanical ventilation time from 11.0 ± 3.9 to 5.1 ± 3.2 days (t = 1.17; p> 0.05), the length of stay in the ICU from 11.5 ± 5.4 to 6.8 ± 3.7 days (t = 0.72; p> 0.05), the complications frequency from 36.5% to 15.9% and mortality rate from 22.3% to 8.7%. Conclusion. Modern diagnostic and treatment algorithms in patients with multiple rib fractures and flail chest are based on stage-by-stage application, succession and combination of various methods of the thoracic cage stabilization throughout the medical assistance process. The algorithms, allowing to stabilize the thorax and to improve the condition of the patients in general, make it possible to realize the full potential of modern thoracic surgery.

Epidural Analgesia With Surgical Stabilization of Flail Chest Following Blunt Thoracic Trauma in Patients With Multiple Trauma

Flail chest, often defined as the fracture of three or more ribs in two or more places, represents the most severe form of rib fractures. Conservative treatment, consisting of respiratory assistance with endotracheal intubation and mechanical ventilation (internal pneumatic stabilization) and pain control, are the current treatments of choice in the majority of patients with multiple rib fractures. However, the use of mechanical ventilation may create complications. In selected patients, operative fixation of fractured ribs within 72 h post injury may lead to better outcomes. We conducted a retrospective analysis of a series of nine cases of patients who developed flail chest after blunt trauma, and were treated with surgical osteofixation of the chest wall and postoperative epidural analgesia at the University Clinical Center of the Republic of Srpska during the period from January 2015. to December 2016. Two patients had trauma to the chest only, and the other patients had associated injuries to the head, abdomen, spine, and fractures of the pelvis and long bones. In the majority of patients (77.7%), surgical stabilization of the chest was performed on the second day following the injury, (mean, 2.33 days) and no later than 5 days after the injury. All patients received epidural analgesia with 0, 25% bupivacaine and 0, 01% morphine and intravenous multimodal analgesia, beginning 6 h after thoracotomy. The average length of ICU stay was 14.7 days (range 2–36), while the average number of days of mechanical ventilation was 8.1. The average duration of hospitalization was 25.4 days. Tracheotomy was performed in 33.3% of study patients. Mortality in the observed group was 44.4%. This study shows that surgical stabilization and epidural analgesia reduced ventilator support, shortened trauma intensive care unit stay, and reduced medical costs vs internal pneumatic stabilization.

Blunt chest trauma: possibilities to stabilize multiple and floating ribs fractures

To improve surgical treatment of patients with multiple and flotating ribs fractures. A comparative analysis of two groups of victims with rib fractures was carried out. 148 patients of the control group underwent conservative treatment, mechanical ventilation, skeletal traction. In 167 patients of the main group we used advanced surgical tactics based on differentiated, stepwise and combined chest stabilization including osteosynthesis of ribs and thoracoscopy. Immediate results for each type of stabilization were evaluated. The most durable respiratory support was observed in case of ventilation alone - internal pneumatic stabilization without surgical stabilization. Osteosynthesis of the ribs had the best outcomes compared with other methods. An efficacy of developed tactics was confirmed by significantly reduced morbidity, mortality, mechanical ventilation time and ICU-stay in main group. Surgical tactics in patients with multiple and flotating fractures of the ribs is determined by type of ribs and internal organs damage, combined trauma severity and conditions of medical care. Differentiated, stepwise and combined chest stabilization by using of high-tech methods of medical care (osteosynthesis, thoracoscopy) improves the outcomes in these patients.

СЛУЧАЙ УСПЕШНОГО ПРИМЕНЕНИЯ ОСТЕОСИНТЕЗА ПРИ ФРАГМЕНТАРНЫХ ПЕРЕЛОМАХ РЕБЕР У БОЛЬНОГО ТЯЖЕЛОЙ C ТРАВМОЙ ГРУДИ

Despite certain achievements in care provision to those with severe chest injury the problem of managing flail chest is far from being resolved. Traditional management includes forced continuous artificial pulmonary ventilation in order to provide internal pneumatic stabilization of the chest. However the results of this approach can not be recognized as satisfactory due to high frequency of complications, need for tracheostomy, long-term stay of such patients in the intensive care department, development of nosocomial infections. Early restoration of the chest carcass with the help of costal valve fixation by the plate with angular stability allows reducing the duration of the artificial pulmonary ventilation and decreasing the frequency of potential respiratory and pleural complications.

Surgical versus nonsurgical interventions for flail chest.

Thoracic trauma (TT) is common among people with multiple traumatic injuries. One of the injuries caused by TT is the loss of thoracic stability resulting from multiple fractures of the rib cage, otherwise known as flail chest (FC). A person with FC can be treated conservatively with orotracheal intubation and mechanical ventilation (internal pneumatic stabilization) but may also undergo surgery to fix the costal fractures. To evaluate the effectiveness and safety of surgical stabilization compared with clinical management for people with FC. We ran the search on the 12 May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), EMBASE Classic and EMBASE (OvidSP), CINAHL Plus (EBSCO), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), and clinical trials registers. We also screened reference lists and contacted experts. Randomized controlled trials of surgical versus nonsurgical treatment for people diagnosed with FC. Two review authors selected relevant trials, assessed their risk of bias, and extracted data. We included three studies that involved 123 people. The methods used for blinding the participants and researchers to the treatment group were not reported, but as the comparison is surgical treatment with medical treatment this bias is hard to avoid. There was no description of concealment of the randomization sequence in two studies.All three studies reported on mortality, and deaths occurred in two studies. There was no clear evidence of a difference in mortality between treatment groups (risk ratio (RR) 0.56, 95% confidence interval (CI) 0.13 to 2.42); however, the analysis was underpowered to detect a difference between groups. Out of the 123 people randomized and treated, six people died; the causes of death were pneumonia, pulmonary embolism, mediastinitis, and septic shock.Among people randomized to surgery, there were reductions in pneumonia (RR 0.36, 95% 0.15 to 0.85; three studies, 123 participants), chest deformity (RR 0.13, 95% CI 0.03 to 0.67; two studies, 86 participants), and tracheostomy (RR 0.38, 95% CI 0.14 to 1.02; two studies, 83 participants). Duration of mechanical ventilation, length of intensive care unit stay (ICU), and length of hospital stay were measured in the three studies. Due to differences in reporting, we could not combine the results and have listed them separately. Chest pain, chest tightness, bodily pain, and adverse effects were each measured in one study. There was some evidence from three small studies that showed surgical treatment was preferable to nonsurgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical ventilation, and length of ICU stay. Further well-designed studies with a sufficient sample size are required to confirm these results and to detect possible surgical effects on mortality.

Mechanical Testing of Modeled Rib Fractures with Plated Fixation on the Internal Surface

Traditionally, rib fractures have been treated non-operatively with pain control, pulmonary toilet, and internal pneumatic stabilization as necessary. Over the past decade, operative fixation of ribs has become a popular treatment option; however, this surgery carries with it significant morbidity and discomfort. A novel surgical drill with an articulating drive shaft has been developed to facilitate fixation of fractured rib(s) on the internal face of the rib via minimally invasive surgery. Prior to continued development of this novel tool, treatment efficacy of fractured ribs plated on the internal face must be compared to fixation on the external face.

Traumatic Ribs Fracture: How to Treat Them?

Flail chest complicates about 10% of patients with chest trauma and is associated with a mortality rate of 10–20% in older series, while a recent one reports no mortality. The majority of the cases are treated conservatively with internal pneumatic stabilization and pain control. In recent years, nevertheless, we assisted in the resurgence of chest wall fixation due to the availability of new devices. We report our experience in the use of mouldable titanium clips (STRACOS, Strasbourg Thoracic Osteosyntheses System; MedXpert, Heitersheim, Germany) to fix traumatic rib fracture. This device presents an advantage over previous strategies, as it is easy to apply and doesn’t require drilling and screwing of the ribs.

Tórax inestable, evolución sin osteosíntesis: presentación de un caso.

Blunt thoracic trauma is usually the result to direct impact to high velocity or falls being responsible of rib fractures. Flail chest is defined as fractures to three or four ribs in more than two segments of his length, causing a paradoxical phenomenon at thoracic box during respiration, collapsing during inhalation and expanding at exhalation. The anterior or lateral location is the most serious given their physiopathological impact; the diagnosis is established by physical examination, radiographs, chest CT and studies of respiratory physiology. Treatment is based on the internal pneumatic stabilization through mechanical ventilation and osteosynthesis. We present the case a female patient 18 years old who is admitted at General of South Hospital, because of complicated closed thoraco-abdominal trauma with right pneumothorax, left hemopneumothorax who needed chest tube placement and intubation, liver injury grade IV at the segments II and III and splenic flexure injury, entering UCI where she remained for twelve days under mechanical ventilation. It stresses the strengthening rib at absence of osteosynthesis or fixation with developments observable at imaging studies of periodic control.

Pain Management Guidelines for Blunt Thoracic Trauma

Pain Management Guidelines for Blunt Thoracic Trauma Bruce Simon;James Cushman;Robert Barraco;Vivian Lane;Fred Luchette;Maurizio Miglietta;David Roccaforte;Ruth Spector; The Journal of Trauma: Injury, Infection, and Critical Care

Operative Chest Wall Fixation with Osteosynthesis Plates

Blunt chest wall trauma is a major cause of morbidity and mortality, especially in the presence of a flail chest where paradoxical inward movement of the flail segment in inspiration is found. Patients with a flail chest require aggressive pain control, pulmonary toilet, and often intubation and mechanical ventilation to establish an internal pneumatic stabilization of the flail segment. This may result in a prolonged ICU stay and pulmonary complications including pneumonia, septicemia and barotrauma. The high mortality rate of up to 10 –36% –12 is partly due to the high prevalence of associated life-threatening extra-thoracic injuries. However, one principle cause of death consists of pneumonia and sepsis with prolonged intubation. Several potential advantages of operative chest wall stabilizations have been reported. These include reduced duration of mechanical ventilation, shortened ICU stay and hospitalization, and decreased likelihood of clinically significant long-term respiratory dysfunction and skeletal deformity. Despite the advantages of operative chest wall fixation, little consensus on the fixation technique exists. This report describes three cases of flail chest injury managed by operative stabilization with plates and screws. The criteria for surgical intervention in this trauma center are traumatic loss of 30% of pleural cavity volume, inability to wean an awake patient from the ventilator, inability to control chest wall pain despite epidural catheter, major air leak or major bleeding, or unstable sternal fracture with overlap. In all three cases a standard posterolateral thoracotomy was performed. The serratus anterior was retracted anteriorly and the latissimus dorsi was divided. To reach more cranially a small portion of the trapezius and the rhomboids were transected in cases 2 and 3. The chest was always entered and hematoma was removed. Pelvic, mandibular and customized reconstruction plates were used, with bending stiffness ranging from 1,936 over 414 to 56 kN mm, respectively. In addition to documentation of the technique, this report describes the results obtained with three distinct osteosynthesis plates and provides a historic overview of alternative fixation means.

Pneumatic stabilization for flail chest injury: an 11-year study.

The use of prolonged mechanical ventilation in the treatment of flail chest injury may increase the incidence of pulmonary morbidity. The aim of this study was to examine the results of performing internal pneumatic stabilization in our hospital. A retrospective review of the medical records of 59 patients with flail chest injury who presented within an 11-year period was conducted. During the second half of the period examined, we routinely adopted three characteristic procedures in the treatment of flail chest injury, namely, pressure support on spontaneous breathing, continuous positive airway pressure via a mask, and respiratory physical therapy by physical therapists. We compared the background, prognosis, and methods of treatment for flail chest injury before and after the introduction of these three procedures. A marked decline in the duration of endotracheal intubation and controlled mechanical ventilation, and in the frequency of pulmonary morbidity, was evident following the introduction of the above procedures.

A CASE OF SPLENIC INJURY WITH TRAUMATIC DIAPHRAGMATIC HERNIA SHOWING ONLY HEMOTHORAX

A 63-year-old woman was admitted to the hospital because of dyspnea due to a blunt trauma at a traffic accident. As she was showing the flail chest due to bilateral multiple rib fractures and left hemothorax, tracheal intubation for internal pneumatic stabilization and left thoracic drainage were conducted. Although a persistent blood loss from a thoracic drain was not remarkable and we observed conservatively, a chest com-puted tomography revealed a traumatic rupture of the left diaphragma with a hernia and a splenic injury. Suture of the ruptured diaphragma and a splenectomy were carried out through the abdominal approach. The omentum and spleen protruted through the diaphragmatic rent into the pleural cavity and the ruptured spleen was strangulated with little bleeding. No bleeding in the abdominal cavity was seen. The mechanism that the bleeding from the splenic injury showed only hemothorax was considered rare.

Surgical stabilization of multiple rib fractures successfully achieved with the use of long metalic plates

Surgical stabilization of multiple rib fractures in 5 male patients was successfully achieved with the use of orthopedic A-O metalic plates, which are called reconstruction plates. In each patient, we prevented deformity of the rib cage and flail chest which frequently occurs after multiple rib fractures. Three of these patients received emergency operations because of severe hemopneumothorax and flail chest due to crushing injuries to the chest. They were treated by the standard thoracotomy, hemostasis of intrapleural bleeding, and stabilization of fractured ribs with reconstruction plates, in addition two of the patients underwent a single lobectomy to control the pulmonary hemorrhage. Another two patients were treated with mechanical ventilation and closed-tube thoracotomy following the chest trauma because their thoracic bleeding from drainage tubes was tolerable. But flail chest and respiratory insufficiency did not improve, in spite of positive controlled ventilation as a mode of internal pneumatic stabilization. Then surgical stabilization of the fractured ribs with these plates was carried out ten to twelve days after the accidents in each case. All patients tolerated the surgical procedures well and were successfully removed from the respirator, demonstrating complete stability of the chest wall. The long metal reconstruction plates with many perforations were very useful for the external fixation of segmentary fractured ribs as an external brace. This was because they were long enough to cover the whole length of the fractured ribs and moderately soft enough to be appropriately bent or twisted by hand at the time of operation. Moreover a number of holes in it allowed the suture to pass through the plate and rib, avoiding displacement of the prosthesis. This is the first report which describes the usefulness of orthopedic reconstruction plates for the stabilization of multiple rib fractures.

Management of Flail Chest Without Mechanical Ventilation

The pathophysiology of flail chest is usually described only on the basis of paradoxical respiration, ignoring underlying pulmonary contusion. Two groups of comparable patients were treated either with early tracheal intubation and mechanical ventilation (Group 1), or with fluid restriction, diuretics, methylprednisolone, albumin, vigorous pulmonary toilet, and intercostal nerve blocks, ignoring the paradox and treating only the underlying lung (Group 2). When tracheostomy and mechanical ventilation were not used the mortality rate went from 21% to 0 ( p = 0.01), the complication rate from 100% to 20% ( p = 0.005), and the average hospitalization from 31.3 to 9.3 days ( p = 0.005). We conclude that most patients with flail chest do not need internal pneumatic stabilization if the underlying lung is treated appropriately and that tracheostomy and prolonged mechanical ventilation with a volume respirator, as practiced in most respiratory care centers, is usually a triumph of technique over judgment.

CRITICALLY CRUSHED CHESTS: A New Method of Treatment With Continuous Mechanical Hyperventilation to Produce Alkalotic Apnea and Internal Pneumatic Stabilization

CRITICALLY CRUSHED CHESTS: A New Method of Treatment With Continuous Mechanical Hyperventilation to Produce Alkalotic Apnea and Internal Pneumatic Stabilization