Thorac Surg Clin 17 (2007) 2533

Brian L. Pettiford, MD, James D. Luketich, MD,

Rodney J. Landreneau, MD

 Thoracic

trauma is quite common in the

US
Thoracic trauma accounting for + 20%
of all trauma death in the US
Most of thoracic injury sustain in motor
vehicle crash is blunt in nature
Blunt Injury
Forces
Compressi
on

Shearing

Blast

 The

common result of compressive injury

to the thoracic cage is rib fracture
Flail chest occurs in 10% of thoracic
trauma cases, with mortality rate
between 10-15%

Schematic of flail chest physiology. (From Mayberry J, Trunkey D. The

fractured rib in chest wall trauma. Chest Surg Clin N Am 1997;7:253;
with permission.)

 Requirement :
Injury mechanism : Motor vehicle crash
Physical examination

Paradoxical motion
Severe chest wall pain
Respiratory insufficiency
Decrease breath sound

Plain chest radiograph

Anteroposterior chest X-Ray
Chest & Abdominal CT Scan

 Primary

focus : Adequate ventilation

management
Mid 1950s Intermiten positive

pressure ventilation was 1st used

Late 1960s-early 1970s
tracheostomy+ mechanical ventilation
Mid 1970s combination of fluid
restriction, corticosteroid, aggressive
pulmonary toilet,& pain killer

At present:
Admission to trauma ICU
Aggressive pulmonary toilet
Pain control

Adequate Analgesia fasilitates

pulmonary toilet an dearly mobilization
1.Sistemic Opioid
2.Control anasthesia with continuos
infusion
3.Bupivacain intercostal nerve block
4.Epidural analgesia
5.Thoracic paravertebral block
6.NSID

 High

mortality rate is primarily caused

by associated injury
Injury Severity Score (ISS) has been
useful to determine the outcome
Indication of Early Mechanical Ventilator:
ISS > 23
Head or truncal organ injury
Shock on admission
Blood transfusion within the 1 st 24 hour

 Indication:
Other intrathoracic injury which require

thoracotomy
Unsuccessfully weaned from mechanical
ventilator
Severe chest instability
Persistent pain secondary to malunion
fracture
Persistent/progressive loss of pulmonary
function

(A) Chest radiograph of Luque rod fixation of posterolateral flail chest

stabilized with orthopedic external fixation devices. (B) Plain film
approximately 3 months after device removal. (From Landreneau R,
Hinson J, Hazelrigg S, et al. Strut fixation of an extensive flail chest. Ann
Thorac Surg 1991;51:474; with permission. Copyright 1991, The

(A) Chest radiograph showing volume loss and rib cage deformity after
multiple left-sided rib fractures. (B) Postoperative film at 1 month
following metallic strut placement. Note improved volume in the left
hemithorax. (From Haasler G. Open fixation of flail chest after blunt
trauma. Ann Thorac Surg 1990;49:994; with permission. Copyright

Judet Struts and application pliers. (From Tanaka H, Yukioka T,

Yamaguti Y, et al. Surgical stabilization of internal pneumatic
stabilization? A prospective randomized
study of management of severe flail chest patients. J Trauma
2002;52:729; with permission.)

Schematic of steps 1 through 6

for 3.5-mm acetabular
reconstruction plate fixation
along each side of the fracture
site. (From Oyarzun J, Bush A,
McCormick JR, et al. Use of 3.5mm acetabular reconstruction
plates
for internal fixation of flail chest
injuries. Ann Thorac Surg
1998;65:1472; with permission.

Disadvatage of the metal prothesis:

It absorbs most of the stress directed
toward the affected rib, resulting in
delayed wound healing
The rigidity exceeds that of the
affected ribs may result in screw
loosening, plate dislocation, or
chronic chest wall pain, requiring
subsequent removal

Absorbable polyactide polymer plates &

screwcombine with cerclage
Promotes fracture healing
Preclude of the need for prothesis removal

Long term benefit of surgicalmanagement

include the restoration of normal chest
wall geometry and improve pulmonary
function testing

Chest films made (A) preoperatively,

(B) immediately postoperatively, and
(C) 1 year postoperatively. (From
Oyarzun J, Bush A, McCormick JR, et al.
Use of 3.5-mm acetabular
reconstruction plates for internal
fixation of flail
chest injuries. Ann Thorac Surg
1998;65:1473; with permission.

Example of absorbable reconstruction

plate secured with absorbable suture
cerclage. (From Mayberry J, Terhes J,
Ellis T, et al. Absorbable plates for rib
fracture repair: preliminary
experience. J Trauma 2003;55:836;
with permission.)

 Flail

chest is an uncommon
consequence of blunt trauma
Isolated flail chest may be successfully
managed with aggressive pulmonary
toilet including facemask oxygen, CPAP,
and chest physiotherapy
Adequate analgesia is of paramount
importance in flail chest patient
Early intubation and mechanical
ventilation is paramount in patients
with refractory respiratory failure or
other serious traumatic injuries

 Surgical

stabilization is associated
with a faster ventilator wean, shorter
ICU time, less hospital cost, and
recovery of pulmonary function in a
select group of patients with flail
chest