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Ann Thorac Surg 2000;70:342-343
© 2000 The Society of Thoracic Surgeons

Correspondence

A technical proposal for the complex flail chest

Paolo Carbognani, MDa, Leonardo Cattelani, MDa, Michele Rusca, MDa, Giancarlo Bellini, MDb

a Department of Thoracic Surgery, University of Parma, V. Gramsci 14, 43100 Parma, Italy
b Department of Intensive Care Unit, University of Parma, Via Gramsci 14, 43100 Parma, Italy

e-mail: carbogna{at}ipruniv.cce.unipr.it

To the Editor

We read with interest the article by Oyarzum and colleagues [1] and the referred letter of Actis Dato and colleagues [2] that refocused a pathology—the flail chest injuries—in which surgery is indicated only in a minority of cases and the technical solutions are frequently tailored to the single case. We wish to report our experience in the treatment of a complex bilateral flail chest with sternal disruption (Fig 1) in a 75-year-old male who underwent a crushing trauma. The surgical solution was proposed and carried out 5 days after the admission to the intensive care unit as the patient had no associated cerebral injuries, a limited pulmonary contusion and no possibility of weaning from the ventilator because of a severe instability of a large part of the anterior and lateral chest wall. This was caused by a transverse fracture of the sternum and multiple bilateral rib fractures from the third to the ninth on the right side and from the fourth to the seventh on the left side.



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  		Fig 1. The CT scan image shows the wide anterior and lateral flail chest, areas of pulmonary contusion and drained bilateral pleural effusion.

 
Through a clamshell skin incision we reached the sternum and the costal plane and a 50 cm long steel bar molded on the chest wall profile was inserted between the intercostal muscles and under the sternum after having divided the mammary vessels and its ends were tied to solid rib segments. The disconnected sternum and the segments of fractured ribs adjacent to the bar were fixed to it with nonabsorbable stiches and those distant were stabilized with the Judet’ devices (Fig 2). Each pleural cavity was drained with two 32 F tubes. The weaning from mechanical ventilation was carried out in 72 hours and the patient was discharged after 15 days from the operation. The surgical stabilization of the complex post-traumatic flail chest, when indicated, can be sometimes a difficult challenge necessitating original technical solutions [1–4]. In the case of a very large defect of stability involving the lateral and the anterior part of the chest wall we suggest that the use of the extra pleural long bar that we have proposed associated, when necessary, with other standard devices can be very useful. It can work as a load-bearing axis to which fractured segments of rib and sternum can be fixed to quickly restore a normal respiratory dynamic.



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  		Fig 2. The postoperative xray that pointed out the chest stabilized with the 50 cm. long bar and the Judet devices.

 
References

  1. 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]
  2. Actis Dato G., Aidala E., Ruffini E. Surgical management of flail chest. Ann Thorac Surg 1999;67:1826-1827.[Free Full Text]
  3. Vichard P., Zeil A., Dreyfus-Schmidt G. Les formes anatomo-cliniques des fractures du sternum. Place et modalites de l’osteosyntese des fractures instables. Chirurgie 1989;115:89-94.[Medline]
  4. Haasler G.B. Open fixation of flail chest after blunt trauma. Ann Thorac Surg 1990;49:993-996.[Abstract/Free Full Text]

Related Article

Reply
Guglielmo M. Actis Dato, Enrico Aidala, and Enrico Ruffini
Ann. Thorac. Surg. 2000 70: 343. [Extract] [Full Text] [PDF]



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