Ann Thorac Surg 2001;72:600-601
© 2001 The Society of Thoracic Surgeons
Case report
Operative stabilization of a flail chest six years after injury
Matthew S. Slater, MDa,
John C. Mayberry, MDb,
Donald D. Trunkey, MDb
a Department of Surgery, Division of Cardiothoracic Surgery, Oregon Health Sciences University, Portland, Oregon, USA
b Department of Surgery, Division of Trauma, Oregon Health Sciences University, Portland, Oregon, USA
Accepted for publication August 2, 2000.
Address reprint requests to Dr Slater, Division of Cardiothoracic Surgery/L353, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd, Portland, OR 97201
e-mail: slaterm{at}ohsu.edu
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Abstract
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We report a case of operative stabilization of an incompetent upper chest wall 6 years following flail chest. The indications for stabilization were chronic pain and dyspnea associated with rib malunion and loss of hemithorax volume. At operation, multiple pseudoarthroses were encountered and partial resection of ribs three and four was required. Malleable plates were used to bridge the gaps created by the resection and were secured in place with sternal wire. The patient reported a dramatic relief of symptoms and, at 18 months postoperatively, continues to work full-time on his cattle ranch essentially pain-free.
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Introduction
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A flail chest is diagnosed when multiple, consecutive ribs are fractured in two or more places creating an incompetent region of chest wall. Although a large body of literature exists regarding the acute operative and nonoperative management of flail chest, limited information is available regarding management of its chronic disability [1–3]. We report the case of a 59-year-old man with pain and chest wall instability persisting 6 years after injury. Rib resection and stabilization of the incompetent chest wall with malleable fixation plates resulted in symptomatic relief and anatomic improvement in chest wall contour.
The patient was a 59-year-old man who sustained a left flail chest and a left scapula fracture in an all-terrain-vehicle crash 6 years previously. He was treated nonoperatively but had persistent left chest wall and shoulder pain. At 1 year postinjury, he was noted to have a nonunion of his scapular fracture and the inferior third of his scapula was resected.
The patient was seen in consultation 6 years postinjury. He described the painful sensation of a rib jabbing into his lung with a deep breath and upper left chest wall motion when lifting or rotating his shoulder. He also complained of dyspnea on exertion. His symptoms significantly limited his ranch work. Chest radiograph revealed multiple left sided rib fractures with significant deformity of the upper left hemithorax. (Fig 1) A computed tomography scan of the chest was obtained, demonstrating mal-union of multiple rib fragments with intrusion of rib ends into lung parenchyma. There was significant rib overlap resulting in hemithorax volume loss.
We performed a left posterior-lateral thoracotomy and found several pseudoarthroses of rib fractures with overlap of fracture segments. Portions of the most deformed ribs (third and fourth) were resected including the pseudoarthroses (approximately 10 cm each). It was necessary to enter the pleural space to adequately assess the nature of the deformity, release the underlying lung, and to facilitate resection of the densely scarred and adherent rib fragments. The resulting defects were bridged and stabilized with 3.5-mm and 4.5-mm Arbeitgemeindschaft fur Osteosynthesefragen reconstruction plates. The plates were secured to the posterior and anterior rib remnants with 24-auge steel wire. (Fig 2) A 36F chest tube and a epidural pain control catheter were placed. The patient was discharged home on postoperative day 5 with a dramatic improvement in pain. Three weeks postoperatively, his activity had surpassed his preoperative level. Eighteen months postoperatively, he is working full-time on his ranch with a significant improvement in dyspnea and is essentially pain-free.
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Fig 2. Postoperative posterior-anterior chest radiograph demonstrating reconstruction plates and improved chest wall architecture.
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Comment
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Long-term (months to years postinjury) sequellae of severe chest wall trauma are common. Landercasper and colleagues interviewed 32 patients with a mean of 5 years after flail chest and found that 63% reported dyspnea, 49% experienced chest pain, and 25% experienced chest tightness [1]. Spirometry was abnormal in 57%. The authors concluded that "objective long-term disability, therefore, often follows flail chest injury." Beal and Oreskovitch evaluated 22 patients who had sustained flail chest as their only significant injury and concluded that 64% had significant long-term disability [2]. Chest wall pain (worsened by activity in all cases), deformity, and dyspnea on exertion were the most frequently reported symptoms.
In current practice, however, most patients with flail chest are not surgically stabilized. Instead, prolonged mechanical ventilation and regional pain control techniques are utilized until the incompetent segment stabilizes by fibrous union [3]. Operative stabilization of flail chest, however, is being increasingly recognized as a valid approach to improve pulmonary mechanics in selected trauma patients [4–6]. Operative stabilization has been associated with a reduction in ventilator days, length of intensive care unit stay, pulmonary infection, and mortality [4, 5]. Several operative techniques have been developed, including Kirshner wires, polypropylene mesh, and malleable metal plates [3–6]. Debate centers on patient selection and the timing of surgical intervention.
There have been minimal reports of the utility of flail chest stabilization for chronic pain and disability. Cacchione and coworkers recently reported a similar case of rib malunion 2 years following multiple rib fractures successfully treated by titanium ribbon plates and screws [7]. We conclude that wider application of rib stabilization by plating may be indicated in selected patients for the relief of chronic chest wall pain.
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References
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Landercasper J., Cogbill T., Lindesmith L. Long-term disability after flail chest injury. J Trauma 1984;24:410-414.[Medline]
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Beal S., Oreskovitch M. Long-term disability associated with flail chest injury. Am J Surg 1985;150:324-326.[Medline]
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Mayberry J.C., Trunkey D.D. The fractured rib in chest wall trauma. Chest Surg Clin North Am 1997;7:239-261.[Medline]
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Ahmed Z., Mohyuddin Z. Management of flail chest injury: Internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995;110:1676-1680.[Abstract/Free Full Text]
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Voggenreiter G., Neudeck F., Aufmkolk M., Obertacke U., Schmit-Neuerburg K. Operative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion. J Am Coll Surg 1998;187:130-138.[Medline]
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Oyarzun J.R., Bush A.P., McCormick J.R., Bolanowski P.J.P. Use of 3.5 mm acetabular reconstruction plates for internal fixation of flail chest injuries. Ann Thorac Surg 1998;65:1471-1474.[Abstract/Free Full Text]
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Cacchione R.N., Richardson J.D., Seligson D. Painful nonunion of multiple rib fractures managed by operative stabilization. J Trauma 2000;48:319-321.[Medline]
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Abstract
Introduction
