Asian Cardiovasc Thorac Ann 2004;12:11-15
© 2004 Asia Publishing EXchange Ltd
Open Fixation in Flail Chest: Review of 64 Patients
Akin Eraslan Balci, MD,
evval Eren, MD,
Ömer Çakir, MD,
M Nesimi Eren, MD
Division of Thoracic and Cardiovascular Surgery, Dicle and Firat University School of Medicine, Diyarbakir, Turkey
For reprint information contact: Akin Eraslan Balci, MD Tel: 90 424 238 8080 Fax: 90 424 233 5038 Email: abalci{at}firat.edu.tr Division of Thoracic Surgery, Firat University School of Medicine, 23100 Elazi
, Turkey.
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ABSTRACT
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The strategy for treatment of flail chest remains controversial. Various alternatives were assessed by reviewing the records of 64 patients treated from 1991 through 2000. Patients were classified according to therapeutic approach: group 1 was 27 patients who underwent open fixation of the fractured ribs, group 2 was 19 patients managed by intermittent positive-pressure ventilation, and group 3 was 18 patients managed mainly by synchronized intermittent mandatory ventilation. Two patients initially treated by ventilation underwent successful open fixation. In group 1, ventilatory support was required in 21 (77.8%) patients postoperatively, the mean duration of ventilation was 3.1 days, mean hospital stay was 18.3 days, morbidity was 11.1% (3/27), and mortality was 11.1%. In groups 2 and 3, the mean time for stabilization of paradoxical chest wall movement was 6.6 days, and mean duration of ventilation was 7.2 days. Mortality was 27.0% (10/37) in patients treated nonsurgically; 21.0% (4/19) in group 2, and 33.3% (6/18) in group 3. In groups 2 and 3, pain control required epidural analgesia in 13 (35.1%) cases, intercostal nerve blockade in 16 (43.2%), and narcotic or nonnarcotic parenteral analgesia in 8 (21.6%). Open fixation is a successful treatment modality for traumatic flail chest.
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INTRODUCTION
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Limited studies on flail chest have been reported and the treatment remains highly controversial.1–3 Traditional management focuses on treatment of the flail segment to ameliorate the flail respiration, or on treating the underlying pulmonary contusion to improve gas exchange.4,5 Early surgical stabilization of flail chest has been advocated previously but has not gained widespread acceptance.5,6 Our clinical and surgical experience of flail chest was reviewed to assess the effectiveness of various management alternatives.
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PATIENTS AND METHODS
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Over the 10 years from 1991 through 2000, 1069 adult patients with blunt trauma, who were not in cardiac arrest, were admitted to our trauma center. Of these, 688 were diagnosed as having simple rib or costal cartilage fractures, and 64 were diagnosed as having flail chest injuries (9.3% of all rib fractures and 6% of all blunt traumas were flail injuries). The records of all 64 patients with flail chest were reviewed. Flail chest was defined as a chest wall segment consisting of 3 or more ribs broken sequentially in at least two locations on chest radiography. Paradoxical motion of the chest wall was present in all patients including those intubated on admission. To gauge progression of the lesion, the extent of contusion was assessed from successive chest radiographs during the first 48 hours of hospital admission. A pulmonary contusion score was assigned to each chest radiograph by dividing the lung fields into upper, middle, and lower thirds and assigning a score of 1 to 3 in each region on the basis of the extent of opacification.7 Scores of 1–3 were accepted as minimal, 4–6 as moderate, and 7–9 as severe contusion.
According to the treatment modality used, the patients were classified into 3 groups: group 1 was 27 patients managed surgically by open fixation of the fractured ribs, group 2 was 19 patients managed by endotracheal intubation for intermittent positive-pressure ventilation (IPPV), and group 3 was 18 patients managed by non-IPPV (generally, synchronized intermittent mandatory ventilation). The reason for differentiating between IPPV and non-IPPV was the reported effect of IPPV treatment for flail chest.8–10 In all patients intubated and supported by a respirator, inspired oxygen fraction and positive end-expiratory pressure were adjusted so that oxygen saturation of 95% could be achieved along with carbon dioxide tension < 45 mmHg. Indications for open fixation were impairment of respiration or general condition, with the clinical diagnosis of evident dyspnea, total or subtotal paradoxical movement of the hemithorax, and blood gas measurements of PaO2 < 60 mmHg and PaCO2 > 40 mmHg. As a rule, only 3 or 4 of the most dislocated and unstable ribs were considered for stabilization. With a bone perforator, holes were made at the tips of the ribs and they were approximated with 1/0 or 2/0 silk sutures. Both ends of the fractured rib were stabilized to the costal cartilage without a bone perforator, using only simple needle suturing. The silk thread was transferred out through the skin by needle after rapping around the rib, and traction was applied to the fractured segment by tying weights (0.5–1.0 kg) to the ends of the silk thread. The same surgical team performed all operations of the same type. In the nonsurgically treated patients, stabilization time was measured from initialization of ventilatory support to the disappearance of paradoxical motion. The predicted forced vital capacity was measured in all patients.
The choice of treatment method in this study was based on individual patient indications, so the mode of selection was not randomized, therefore, the groups were not statistically comparable. For each group, variables were compared between survivors and non-survivors by univariate analysis of variance (ANOVA). Multivariate ANOVA was performed to determine which of the notable variables by univariate ANOVA predicted mortality.
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RESULTS
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All 3 groups were similar although not comparable statistically (Table 1
). The mean age of the 64 patients was 32.6 years (range, 21–64 years) and the male/female ratio was 3. Associated injuries were found in 48 (75.0%) patients: to the head in 16 (25.0%), to the abdomen in 12 (18.7%), to soft tissues or bones in 11 (17.2%), and to the thoracic cavity in 9 (14.1%). The mean Injury Severity Score (ISS) was 19.7. Fourteen patients (21.8%) had more than 8 rib fractures with a unilateral flail, and 10 patients (15.6%) had multiple rib fractures with a bilateral flail. Balanced or negative fluid status for pulmonary contusion, and vigorous pulmonary toilet were attempted in all patients. Chest tube drainage was carried out in 38 (59.4%) patients with hemopneumothorax. A tracheostomy was performed in 7 (10.9%) patients needing intubation for longer than 5 days, and those with failed extubation, persistent tracheal secretions, or a severe head injury.
The causes of flail chest were traffic accidents in 36 (56.2%) cases, falls from heights in 19 (29.7%), and crushing industrial accidents in 9 (14.1%). Of the 36 patients who suffered unremitting pain, 19 received thoracic epidural analgesia and 17 had intercostal nerve blockade. Epidural analgesia and nerve blockade had a limited effect on pain and needed to be repeated. Epidural analgesia was patient-controlled with 4 mL·h-1 of 0.10% bupivacaine and 10 mg·mL-1 fentanyl. Ventilatory support was required in 58 (90.6%) patients. The significant factors in ventilatory assistance detected by multivariate analysis were ISS > 21, shock on admission (blood pressure < 80 mmHg), associated pulmonary contusion, and associated injuries (especially head and abdominal injuries). Heavy sedation or paralysis was required in 11 (17.2%) patients who were agitated or needed high oxygen. All other patients were sedated with midazolam. Twenty-nine patients (45.3%) had moderate to severe pulmonary contusions (18 patients scored 4–6, 11 scored 7–9). Pulmonary contusions occurred in 12/14 (85.7%) patients with more than 8 rib fractures, 7/10 (70.0%) with multiple rib fractures and bilateral flail, and 10/40 (25.0%) of the remaining patients. Analysis of the frequency of pulmonary contusion revealed that patients with > 8 rib fractures or multiple fractures with bilateral flail chest had more pulmonary contusion (mean contusion score 7.1 versus 4.4 in the others; chi-squared test, p < 0.05).
Thirteen (20.3%) patients died. Primary determinants of adverse outcome were associated injuries, blood loss > 6 units, bilateral flail, and age > 50 years in groups 2 and 3; all except bilateral flail predicted an adverse outcome in group 1. Pulmonary function tests 30 days after discharge showed forced vital capacity was 68%–78% of predicted. There was no difference ( p = 0.21) between group 1 versus groups 2 and 3.
Among the 27 group 1 patients, 4 (14.8%) were unconscious on admission, 3 (11.1%) had undergone abdominal surgery, and 1 (3.7%) had severe head trauma. Fractures were anterior in 19 (70.4%) and lateral in 8 (30%). An anterolateral thoracotomy was performed in 20 (74.1%) and a posterolateral thoracotomy in 7 (25.9%). Indications for fixation of flail chest were concomitant thoracic operations that allowed simultaneous repair of the flail segment (12 patients), gross instability of a large segment of the chest wall (11 patients), or severe unremitting pain related directly to the fractures (4 patients). Indications for thoracic operations that allowed the simultaneous repair of a flail segment were massive air leak from the lung parenchyma in 6, bleeding in 4, and rupture of a bronchus in 2; primary suture of the ruptured bronchus was performed in 2, intercostal artery ligation in 3, and suturation of lung parenchyma in 7. No resection was performed. Thirteen (48.1%) patients were operated upon during the first 12 hours because of associated injuries (thoracotomy for bleeding in 4, diaphragm injury in 3, open chest wound in 3, ruptured spleen in 2, and ruptured liver in 1). All except 2 patients were operated on within the first 48 hours of trauma. The other 2 were intubated on the 2nd and 4th days after the trauma while they were hospitalized due to impaired respiration. On the 1st or 2nd day of IPPV, they underwent open fixation because of blood gas deterioration. Both were weaned from the ventilator within 24 hours and discharged from hospital 6 and 8 days after open fixation. Pain control was achieved with nonnarcotic analgesics, even in patients who had undergone surgery due to unremitting pain. No epidural analgesia was needed postoperatively. The rate of ventilatory support was 77.8% (21/27) postoperatively; none of the 6 who were not ventilated died. The duration of ventilation ranged from 1.5 to 22 days, and hospital stay ranged from 9 to 32 days (Table 2). Morbidity in group 1 comprised postoperative bleeding in 1 and atelectasis in 2 cases; no reoperation was needed, bronchoscopic aspiration was sufficient to resolve atelectasis. The mortality rate was 11% in group 1 and 14.3% (3/21) among those receiving ventilatory support. Two of the patients who died had undergone abdominal surgery and were unconscious at the time of admission, the other died immediately postoperatively from probable myocardial contusion suspected from electrocardiographic anomalies.
All 37 nonsurgically treated patients (groups 2 and 3) were admitted within the first day of the trauma causing flail chest and all were conscious. None had undergone a non-thoracic operation before admission. Fractures were anterior in 16 patients (43.2%) and lateral in 21 (56.8%). All patients received effective pain control with epidural analgesia in 13 (35.1%), intercostal nerve blockade in 16 (43.2%), and narcotic or nonnarcotic parenteral analgesia in 8 (21.6%). However, all suffered pain in spite of epidural analgesia or intercostal blockade. Additional parenteral analgesia was needed to reduce the pain, with opioid drugs most frequently used. The mean duration of paradoxical chest wall movement was 6.6 days (range, 3–21 days), and ventilatory support (Table 2
) ranged from 3 to 23 days (mean, 7.2 days). The mean hospital stay was 19.6 days (range, 8–33 days) and morbidity was 11.1% (pneumonia successfully treated with isepamicin in 3, and atelectasis in 1). A diagnosis of pneumonia was established by high fever (> 39°C), infiltration on chest radiographs, and culture of tracheobronchial aspiration material. Atelectasis persisted during ventilatory support; after weaning, bronchoscopy was performed to resolve it. Overall mortality in the nonsurgical patients was 10/37 (27.0%). Five of the patients who died had been diagnosed with pneumonia; antibiotic treatment was unsuccessful. Two had severe head trauma and mannitol was administered to resolve brain edema. Acute respiratory distress syndrome with a high PaCO2 despite respiratory treatment occurred in 2. Renal failure requiring hemodialysis developed in one patient and she died after the 3rd dialysis (17 days after the trauma). One chest wall deformity (pectus carinatum-like appearance of right upper hemithorax) was observed.
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DISCUSSION
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The treatment of flail chest injuries has evolved over the last 4 decades from immediate endotracheal intubation for at least 7–10 days with a mandatory tracheostomy until there was no movement of the flail segment, to the present when every effort is made to provide good analgesia and avoid intubation. Many series showed a need for intubation in only 50% of patients with flail chest, and mortality rates from relatively isolated injuries may be as low as 5%. It is felt that the major injury requiring ventilatory support is underlying pulmonary contusion and not the motion of the chest wall. Some have advocated operative fixation of a flail segment so that there is no motion, but this greatly over simplifies the pathophysiology of the problem. We evaluated patients on the basis of underlying pulmonary injury, especially pulmonary contusion, and applied appropriate treatment. We advocate early surgical treatment in high ISS trauma cases.
The results were not skewed by other factors in the surgical group, but some patients in groups 2 and 3 may have had a poor prognosis from other injuries and been considered too ill to operate on (mean ISS in group 1, 18.3 versus 21.0 in groups 2 and 3). Some patients may require ventilatory support despite surgical treatment. Prolonged paradoxical motion of the chest wall before spontaneous stabilization occurs can lead to additional mechanical impact on the contused lung area by the flail segment. Furthermore, the broken rib tips may disrupt the lung parenchyma. Early surgical stabilization can prevent additional injury as well as promote earlier weaning from the ventilator. Less analgesia may be required postoperatively, and these factors may lower morbidity for isolated flail injuries. Open fixation of the chest wall may be a good alternative for patients who have deteriorated under ventilatory treatment because it shortens the ventilator time and decreases mortality.
There have been no randomized studies of surgical and nonsurgical treatment, most studies are retrospective, and the choice of whether or not to carry out surgery is highly variable and based entirely on the surgeon’s experience.11 The obvious indication for a surgical approach is an internal injury requiring a thoracotomy. Some surgeons routinely perform open fixation of flail chest when a thoracotomy is undertaken for other indications.5 In our opinion, this is the correct approach; however, surgical intervention should also be considered in patients with excessive paradoxical movement, deteriorating clinical status, or unremitting pain. The locations of the fractures differed between the surgical and nonsurgical groups, and surgery was performed in some group 1 patients because the degree of deformity or paradoxical motion was more apparent.
One reason for the controversy concerning treatment is that mortality for flail chest has not changed in certain centers over the past several decades. This is despite obvious advances in the overall care of trauma victims and marked improvements in ventilatory support techniques.12,13 However, decreases in mortality from 30%–40% in 1976 to 11%–60% in the 1980s have been reported.5 The major cause of mortality and morbidity is respiratory failure resulting from contusion or laceration by a detached rib fragment. With large flail segments, mediastinal shift is possible, with accompanying decreased venous return to the heart. Depressed rib segments impart a crushing injury and may penetrate the diaphragm, lung, heart or aorta.14 In this series, massive air leaks from lung parenchyma and bleeding caused by flail segments were observed. Impaired pulmonary function has been documented in long-term survivors; 63% of patients reported dyspnea, 49% reported persistent pain, 57% had abnormal spirometry, and 70% had abnormal treadmill tests.5 Pulmonary tests revealed no significant differences in our series. It has not been proved that IPPV is beneficial in traumatic flail chest, in the absence of other indications.8 Increases in routinely performed tracheostomy with long-term ventilation until the flail segment stabilized or until the pulmonary contusion was no longer present on the chest radiograph led to a high incidence of nosocomial infections and tracheostomy complications that resulted in severe disability or death.12,15 In this series, the most prominent factors causing an adverse outcome were associated injuries and pulmonary contusion. We observed more contusion in patients with > 8 rib fractures and with bilateral flail. Pneumonia was an important cause of mortality.
Different methods have been used for the stabilization of fractured segments, all of which have been reported to be successful.16–18 We did not apply any struts or metallic fixation device to fractured ribs because they are expensive and difficult to obtain. It was easy to suture the tips of the fractured ribs within a hole opened with a perforator and it was not necessary to enter the pleural cavity. Additional advantages of this method are the short operation time, no reoperation to remove a fixation device, no installation of foreign material, no special knowledge or experience, no special postoperative maintenance, and applicability anywhere. Surgery allowed excellent assessment of the intrathoracic trauma, removal of hazardous rib fragments, repair of visceral lacerations and air leaks, control of bleeding and evacuation of collections. We did not use an external chest bandage because of the limiting effect on the respiratory movement of the chest.
Placement of a thoracic epidural catheter was problematic not only because of the angle of the spinal processes and the smaller space but also because it was difficult to put patients with flail chest in the proper position to place the catheter, thus we do not advise its routine use. None of the patients who underwent surgery needed strong pain medication postoperatively.
Although the groups did not fulfill statistical comparability criteria, mortality seemed to be lower in group 1 despite these patients being more severely injured. Duration of ventilation was shorter in group 1, and the hospital stay and morbidity were similar to those in the nonsurgical groups. It was concluded that surgical fixation is a successful treatment modality in patients with traumatic flail chest.
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This article has been cited by other articles:
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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.
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ABSTRACT
INTRODUCTION
