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Anterior Flail Chest and Sternal Fracture: To Fix or Not To Fix?

Thoracic Surgery Department, Nice University Hospital, France

We read with interest the study of Dr Potaris on management of sternal fractures published in Asian Cardiovasc Thorac Ann 2002;10:145–9.

Their large experience well defines the two main clinical situations in which sternal fracture has to be managed: the isolated sternal fracture, when the patient can be early discharged if no sign of cardiac contusion are present at chest X-ray and ECG, and the multi-injured chest, whose prognosis is never linked to sternum.

In our opinion, the management of sternal fractures with anterior flail chest deserves a comment.

Respiratory failure after chest trauma is mainly linked to lung contusion, bronchial blood and secretions, hemo and/or pneumothorax. The presence of paradoxical movement in spontaneously breathing patients can be without clinical relevance. But in some borderline situation, pain control and sternal fixation can avoid or reduce¹ the need of mechanical ventilation.

None of the 239 patients of the series required a sternal fixation but some anterior flail chests could be in the series. In the series of isolated fracture (n=112), there is an 88 years old patient with chronic obstructive lung disease who developed respiratory failure progressively and died of ARDS after two months of ventilation.

In the group of patients with multiple injuries (n=127), of the 4 patients with flail chest, 2 developed respiratory distress and required ICU admission.

Could sternal fixation eventually avoid these respiratory complications? It is impossible to say, mainly because contribution of flail chest to respiratory failure is usually moderate compared with lung contusion. Anyway, we do believe that there are some patients at high risk for mechanical ventilation, without major lung contusion, who deteriorate progressively their respiratory status principally for their pain and for their paradoxical movement. In these cases, after an optimal pain management with epidural analgesia,² if respiratory function is still deteriorating, surgical fixation can be useful.³

The problem is to choose the less aggressive procedure. A sternal flail chest means that bilateral chondrosternal fractures are present and their fixation would requires a bilateral approach. Sternal traction represents an alternative. It is easy to perform, minimally invasive for the patient and it can be done in the ICU in about 20 minutes. Classically the traction has to be maintained for 4-8 weeks but with intensive chest physiotherapy brilliant results can be obtained after 3 weeks.

At the University Hospital of Nice, in the last 12 months 474 patients were admitted to Emergency Department with the diagnosis of chest trauma. Twenty-seven of them (5.7%) had a diagnosis of sternal fracture. Two patients with severe anterior flail chest had sternal traction for 4 weeks and mechanical ventilation was avoided.

Indication to sternal traction is rare but it has to be kept in mind in the management of sternal fracture.

REFERENCES

1. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S. Surgical stabilization or internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52:727–32.[Medline]

2. Mackersie RC, Shackford SR, Hoyt DB, Karagianes TG. Continuous epidural fentanyl analgesia: ventilatory function improvement with routine use in treatment of blunt chest trauma. J Trauma 1987;27:1207–12.[Medline]

3. Henley MB, Peter RE, Benirschke SK, Ashbaugh D. External fixation of the sternum for thoracic trauma. J Orthop Trauma 1991;5:493–7.[Medline]

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				J B Borman, L Aharonson-Daniel, B Savitsky, K Peleg, and the Israeli Trauma Group Unilateral flail chest is seldom a lethal injury Emerg. Med. J., December 1, 2006; 23(12): 903 - 905. [Abstract] [Full Text] [PDF]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniel Pop Jérôme Mouroux Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Leo, F. Articles by Mouroux, J. Search for Related Content PubMed PubMed Citation Articles by Leo, F. Articles by Mouroux, J. Related Collections Chest wall