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Ann Thorac Surg 1999;67:1826-1827
© 1999 The Society of Thoracic Surgeons
a Italian Institution of Cardiac Surgery, Via Genova, 4, 10126 Torino, Italy
b Department of Thoracic Surgery, University of Turin, Turin, Italy
To the Editor
Flail chest is a common chest injury during wartime and in high-speed motor vehicle accidents. Anterior flail chest is not as common as the lateral segmental flail chest, nevertheless, it happens frequently enough that it represents a significant cause of ventilation insufficiency that may cause paradoxical respiration and hence respiratory distress.
The management in cases of both anterior or lateral flail chest remains controversial. The traditional treatment has been the use of mechanical ventilation to "internally splint" the chest until fibrous union has occurred. Nevertheless, a significant morbidity related to complication of tracheotomy and a high incidence of in-hospital pulmonary infection accompanies the internal pneumatic stabilization [1].
Surgical stabilization is generally preferred, especially in the case of anterior flail chest because of the need of surgical exploration to manage concomitant vascular or lung pathologies.
It was very interesting to read the original work by Oyarzun and colleagues in which a rib stabilization was obtained in two patients suffering from flail chest by an acetabular plate fixed by mean of additional titanium screws [2]. We also believe that a prompt surgical stabilization can be helpful in order to obtain a faster weaning from mechanical ventilation, thereby reducing morbidity and mortality.
In our experience, a surgical stabilization in the case of flail chest was done by using an easier and less invasive method inspired from the original technique that we routinely use to correct chest wall deformities (ie, pectus excavatum) [3]. In fact, from the mechanical point of view when we perform a surgical correction of pectus excavatum with our technique, we have a condition similar to an anterior flail chest. After sternum and rib osteothomy, necessary to obtain a good mobilization of the depressed chest wall, the stabilization of fragmented bones is obtained by a self-retaining sea gull wing prosthesis inserted under the sternum, with the wings allocated over the adjacent ribs. Keeping in mind the same philosophy, we used this technique in two cases of flail chest (anterior and lateral).
A 24-year-old man was admitted at the emergency room in shock after a thoracic blunt trauma because of a fall onto his back from a 5-meter height. Physical examination showed paradoxical movement of the chest wall with spontaneous ventilation. A chest roentgenogram showed multiple bilateral fractures of the fourth and fifth ribs and an oblique fracture of the sternum. Because of the worsening of clinical conditions, the patient received an orotracheal intubation and a mechanical ventilation. Surgical stabilization was performed a few hours later by a bilateral thoracotomy. A 25-cm-long steel strut molded in the fashion of a sea gull wing prosthesis was used to stabilize the sternum and the fractured ribs. The prosthesis was positioned under the sternum and ribs fractured, leaning against the intact ribs (Fig 1). An outside steel wire was used to stabilize the sternum. Finally, the chest was closed and drained with two 32F chest tubes. Weaning from mechanical ventilation was successful over the next 12 h without further pulmonary complications. The patient was discharged after 2 weeks from the hospital, and the prosthesis was removed 4 months after its insertions through a small skin incision by gentle traction.
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Because of the critical care needed by the patient, a prompt mechanical ventilation was started by orotracheal insertion of a tube. By local anesthesia with 2% Xilocaine, a small incision was done over the sixth rib to insert a sea gull wing prosthesis under the flail chest. A no. 3 silk stitch was used to secure a traction of the fractured ribs and to correctly allocate the prosthesis (Fig 2). A tibia fracture was also stabilized at the same time. After 2 h, a complete weaning from ventilation was possible and the patient was extubated. Discharge from the hospital was possible after 10 days, and 4 months later, the prosthesis was removed using local anesthesia as in the previous case.
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A variety of surgical techniques have been reported in the past to stabilize the flail chest, such as external towel clip traction (high risks of osseous and soft tissue infections), application of overlapping rib struts, and intramedullar wiring [4–6]. We agree with the philosophy of surgical stabilization as proposed also by Oyarzun and colleagues [2], in which the mechanical relief of fractured ribs was done by a plate and screws, but we believe that this surgical approach may be difficult to perform in a case of osteoporosis or bone fragmentation that can be present after a trauma. Moreover, the proposed technique can be uncomfortable for the patient because of the not so easily removable materials used to stabilize the ribs. On the other hand, a strut stabilization by a sea gull wing prosthesis in our experience: 1) can allow a fast recovery of the bone and an easier weaning from the mechanical ventilation; 2) does not require screws or other hardware to fix; and 3) can be easily removed after the completion of bone fixation (4 to 6 months later).
In conclusion, we congratulate Oyarzun and colleagues for their strong contribution in this very critical field of trauma, especially for stressing the idea to surgically treat patients with flail chest in order to reduce ventilation time and the subsequent risks of respiratory infections.
References
This article has been cited by other articles:
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  A. Granetzny, M. Abd El-Aal, E. Emam, A. Shalaby, and A. Boseila Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status Interactive CardioVascular and Thoracic Surgery, December 1, 2005; 4(6): 583 - 587. [Abstract] [Full Text] [PDF]
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 P. Carbognani, L. Cattelani, M. Rusca, and G. Bellini A technical proposal for the complex flail chest Ann. Thorac. Surg., July 1, 2000; 70(1): 342 - 343. [Full Text] [PDF]
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G. M. A. Dato, E. Aidala, and E. Ruffini Reply Ann. Thorac. Surg., July 1, 2000; 70(1): 343 - 343. [Full Text] [PDF]
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