| Autor | Article | Publication | Year |
|---|---|---|---|
| Ahmed Z, Mohyuddin Z | Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation | J Thorac Cardiovasc Surg. 1995 Dec;110(6):1676-80 | 1995 |
| Engel C, Krieg JC, Madey SM, Long WB, Bottlang M | Operative chest wall fixation with osteosynthesis plates | J Trauma. 2005 Jan;58(1):181-6 | 2005 |
| Helzel I, Madey SM, Fitzpatrick DC, Long WB, Bottlang M | Rib fracture fixation with intramedullary splints | Injury, 2009 Jun 30 | 2009 |
| Lardinois D, Krueger T, Dusmet M, Ghisleta N, Gugger M, Ris H | Pulmonary function testing after operative stabilization of the chest wall for flail chest | Eur J Cardiothorac Surg, 20(3): 496-501, 2001 | 2001 |
| Mohr M, Abrams E, Engel C, Long WB, Bottlang M | Geometry of Human Ribs Pertinent to Orthopaedic Chest-Wall Reconstruction | J Biomech. 2007;40(6):1310-7 | 2007 |
| Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S | Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients | J Trauma. 2002;52(4):727-32; discussion 32 | 2002 |
Ahmed Z, Mohyuddin Z (1995)
A total of 427 patients with major chest trauma were treated in two major hospitals in Abu Dhabi, United Arab Emirates, during a 10-year period. In 64 of 426 patients, flail chest injury was the dominant factor among other injuries that were insignificant. Among 64 cases of flail chest injury, 25 were managed by internal fixation of ribs, whereas the remaining 38 were managed by endotracheal intubation and intermittent positive-pressure ventilation alone. Of the patients treated by internal fixation 80% (21/26) were weaned from the ventilator within an average of 1.3 days, whereas the remaining 20% (5/26) continued to need assisted ventilation for a longer duration; the total average duration of assisted ventilation for the whole group was 3.9 days. In comparison, among 38 patients with flail chest injury treated by endotracheal intubation and ventilation alone, the average duration of assisted ventilation was 15 days. In the group treated by internal fixation 11% (3/26) of the patients ultimately required a tracheotomy, whereas in the patients treated by intubation and ventilation alone tracheostomy was required in 37% (14/38) of the cases. In the group treated by internal fixation, chest infection was documented in 15% (4/26), septicemia in 4% (1/26), and barotrauma in 0%; in the other group these complications occurred in 50% (19/38), 24% (9/38), and 8% (3/38) of the cases, respectively. The mortality rate was 8% (2/26) in the surgically treated patients, whereas it was 29% (11/38) in the other group. All the deaths in both groups were ascribed to adult respiratory distress syndrome. Average stay in the intensive care unit was 9 days for the patients treated by internal fixation, whereas it was 21 days in the group treated by intubation and ventilation alone. The treatment of flail chest injury in our series by internal fixation resulted in speedy recovery, decreased complications, and better ultimate cosmetic and functional results and proved to be cost effective.
PMID: 8523879 [PubMed - indexed for MEDLINE]
Engel C, Krieg JC, Madey SM, Long WB, Bottlang M (2005)
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 mm2, 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.
In conclusion, operative fixation of flail chest segments has been successfully achieved with a variety of osteosynthesis plates. Due to the general lack of commercially available plates for rib fracture fixation, alternative plates with widely variable constitutive properties have been used. Future research is necessary to design a specific rib plate which takes into account the structural properties and fixation constraints of ribs, to simplify the fixation technique, and to reduce complications.
Helzel I, Madey SM, Fitzpatrick DC, Long WB, Bottlang M (2009)
BACKGROUND: Intramedullary fixation of rib fractures with generic Kirschner wires has been practiced for over 50 years. However, this technique has not been advanced to address reported complications of wire migration and cut-out. This biomechanical study evaluated a novel rib splint designed to replicate the less-invasive fixation approach of Kirschner wires while mitigating their associated complications. METHODS: The durability, strength, and failure mode of rib fracture fixation with intramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs were loaded to failure to determine their strength and to induce realistic rib fractures. Subsequently, fractures were stabilised with a novel rib splint made of titanium alloy with a rectangular cross-section that was secured with a locking screw. All fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load magnitude to determine their durability. Finally, constructs were loaded to failure to determine their residual strength and failure modes. RESULTS: Native ribs had a strength of 9.7+/-5.0Nm, with a range of 3.5-19.6Nm. Fracture fixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out. Dynamic loading caused no significant decrease in construct stiffness (p=0.85) and construct subsidence remained on average below 0.5mm. The residual strength of splint constructs after dynamic loading was 1.1+/-0.24Nm. Constructs failed by splint bending in 44% of specimens and by developing fracture lines along the superior and inferior cortices in 56% of specimens. Regardless of the failure mode, all rib splint constructs recoiled elastically after failure and retained functional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex. CONCLUSIONS: Rib splints can provide sufficient stability to support respiratory loading throughout the healing phase, but they cannot restore the full strength of native ribs. Most importantly, rib splints mitigated the complications reported for rib fracture fixation with generic Kirschner wires, namely implant cut-out and migration through the lateral cortex. Therefore, rib splints may provide an advanced alternative to the original Kirschner wire technique for less-invasive fixation of rib fractures.
PMID: 19573871 [PubMed - as supplied by publisher]
Lardinois D, Krueger T, Dusmet M, Ghisleta N, Gugger M, Ris H (2001)
OBJECTIVE: This is a prospective evaluation of chest wall integrity and pulmonary function in patients with operative stabilisation for flail chest injuries. METHODS: From 1990 to 1999, 66 patients (56 men, 10 women; mean age 52.6 years) with antero-lateral flail chest (> or =4 ribs fractured at > or =2 sites) underwent surgical stabilisation using reconstruction plates. Clinical assessment and pulmonary function testing were performed at 6 months following surgery. RESULTS: Fifty-five (83%) patients had various combinations of injuries of the thorax, head, abdomen and extremities. Sixty-three (95.5%) patients underwent unilateral and 3 (4.5%) patients bilateral stabilisation with a median delay of 2.8 days (range 0-21 days) from admission. The 30-day mortality was 11% (seven of 66 patients). Immediate postoperative extubation was feasible in 31 of 66 patients (47%) and extubation within 7 days following stabilisation in 56 of 66 patients (85%). No plate dislocation was observed during the follow-up. The shoulder girdle function was intact in 51 of 57 patients (90%). Chest wall complaints were noted in 6 of 57 (11%) patients, requiring removal of implants in three cases. All patients returned to work within a mean period of 8 (range 3-16) weeks following discharge. Pulmonary function testing (n=50) at 6 months after the operation revealed a significant difference of predicted vs. recorded vital capacity (VC) and forced expiratory volume in 1s (FEV1) (P=0.04 and P=0.0001, respectively; Wilcoxon signed-rank test). The median ratio of the recorded and predicted total lung capacity (TLC) was shown to be significantly higher than 0.85 (P=0.0002; Wilcoxon signed-rank test), indicating prevention of pulmonary restriction. CONCLUSION: Antero-lateral flail chest injuries accompanied by respiratory insufficiency can be effectively stabilised using reconstruction plates. Early restoration of the chest wall integrity and respiratory pump function may be cost effective through the prevention of prolonged mechanical ventilation and restriction-related working incapacity.
PMID: 11509269 [PubMed - indexed for MEDLINE]
Mohr M, Abrams E, Engel C, Long WB, Bottlang M (2007)
Orthopedic reconstruction of blunt chest trauma can aid restoration of pulmonary function to reduce the mortality associated with serial rib fractures and flail chest injuries. Contemporary chest wall reconstruction requires contouring of generic plates to the complex surface geometry of ribs. This study established a biometric foundation to generate specialized, anatomically contoured osteosynthesis hardware for rib fracture fixation. On human cadaveric ribs three through nine, the surface geometry pertinent to anatomically conforming osteosynthesis plates was characterized by quantifying the apparent rib curvature C(A), the longitudinal twist alpha(LT) along the diaphysis, and the unrolled curvature C(U). In addition, the rib cross-sectional geometry pertinent to intramedullary fixation strategies was characterized in terms of cross-section height, width, area, and cortex thickness. The rib surface exhibited a curvature C(A) ranging from 3.8 m(-1) in the anteromedial section of rib seven to 17.3 m(-1) in the posterior section of rib three. All ribs had in common a longitudinal twist alpha(LT), ranging from 41-60 degrees. The unrolled curvature C(U) decreased gradually from ribs three to five, and increased gradually with reversed orientation from rib six to nine. The cross-sectional area remained constant along the rib diaphysis. However, the medullary canal increased in size from 29.9 mm(2) posteriorly to 41.2 mm(2) in anterior rib segments. Results of this biometric rib characterization describe a novel strategy for intraoperative plate contouring and provide a foundation for the development of specialized rib osteosynthesis strategies.
PMID: 16831441 [PubMed - indexed for MEDLINE]
Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S (2002)
BACKGROUND: We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support. METHODS: Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups. RESULTS: Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and Pao2/Fio2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19). CONCLUSION: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.
PMID: 11956391 [PubMed - indexed for MEDLINE]