Surgical fixation of flail chest injuries calls for multidisciplinary team
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Isolated rib fractures are common injuries that are treated nonoperatively. However, in the setting of multiple rib fractures, there may be chest wall instability or a flail chest.
These injuries are a result of high energy trauma and have high rates of morbidity and mortality. Although historically the treatment of flail chest injuries was nonoperative, there has been an increased interest in surgical fixation of these injuries in the last 2 decades.
A recently presented large, randomized control trial reported improved ventilator-free days, shorter hospital length of stay and lower mortality with surgery compared with nonoperative management, specifically in the subset of patients who were on mechanical ventilation at the time of presentation. However, surgery did not improve the rates of complications, such as pneumonia, sepsis or tracheostomy. Therefore, patient selection is important, as not all patients may benefit from surgery.
It is important to treat these patients with the help of a multidisciplinary team, including ICU, respiratory therapy and trauma surgery. The aid of a trauma or thoracic surgeon may be especially helpful if there are other intrathoracic injuries, such as a diaphragm tear or lung laceration.
Surgical planning
Given the anatomy of the rib cage, when multiple ribs are fractured, these are commonly broken in two locations (anterolateral and posterior), which can create a flail segment. Commonly, fractures are more displaced at one of two locations, while the others are minimally displaced. Not all fractures require fixation, and the goal of surgery is to stabilize the chest wall to allow it to move as a single unit, improving respiratory mechanics and decreasing pain. Surgical fixation should be focused on the displaced fractures, while minimally displaced or undisplaced fractures do not necessarily require stabilization.
The surgical approach depends upon the location of fractures. Anterior or lateral fractures require a thoracotomy-type approach, while a posterior approach can be used for posterior fractures. The incision is made centered over the fracture zone. Multiple ribs can be fixed via a single approach. It is helpful to review the CT scan, as well as the 3D reconstruction images, to understand the location of fractures relative to local structures (sternum, scapula, spinous processes, chest tube, etc.) (Figure 1).
Source: Niloofar Dehghan, MD, FRCS
The patient is placed in the lateral decubitus position. The ipsilateral arm is free draped and placed over a sterile, padded Mayo stand. Free draping the arm can help with positioning of the scapula and retracting it out of the way.
A regular endotracheal tube can be used. Double lumen ventilation with deflation of the lung is not necessary. If a chest tube is present preoperatively, we prep this into the operative field and remove it once access to the pleural cavity is established. At the conclusion of the case, a new sterile chest tube is placed through a separate incision and tunneled subcutaneously away from plate and screw fixation, to lower the risk of infection. Irrigation of the pleural cavity and evacuation of retained hemothorax can also help decrease the risk of infection.
Approaches
Thoracotomy approach
The thoracotomy approach is useful for anterior, anterolateral and posterolateral fractures. A curvilinear incision is made centered over the fractured ribs requiring fixation. Dissection is carried out through subcutaneous tissues and fascia. For anterolateral fractures, a muscle-splitting window is created through the serratus anterior muscle. In general, two to three ribs can be accessed through each window and another muscle-splitting window can be created more cranial/caudal to access additional fractures. For more posterolateral fractures, the latissimus dorsi muscle may need to be retracted. One should be mindful of the long thoracic nerve along the lateral border of the serratus anterior, as well as the thoracodorsal nerve at the lower border of the latissimus dorsi (Video).
Posterior approach
The posterior approach is used for posterior rib fractures and a longitudinal incision is made centered over the fractured ribs requiring fixation (Figure 2). Deep dissection is between the latissimus dorsi caudally, trapezius cranially, and border of scapula laterally (triangle of auscultation). The trapezius is retracted out of the way cranially, the scapula is retracted laterally and the latissimus dorsi caudally. The erector spinae muscles are encountered and reflected, exposing the underlying ribs. (Figure 3)
Fixation methods, postoperative care
Fracture reduction and fixation is relatively straightforward. In general, precontoured, rib-specific locking plates are used, but if these are not available, pelvic reconstruction plates can also be used and these do require contouring. In cases of significant displacement, one end of the rib may be significantly caved into the thoracic cavity. This can be reduced with the aid of small fragment reduction clamps to pull the rib out from the thoracic cavity (Figure 4). Once the fracture is reduced, a plate is placed over the rib and secured with a minimum of three bicortical screws on either side of the fracture (Figure 5). If the fracture is comminuted, bridge fixation can be applied. Segmental fractures may be fixed with a single plate or two separate plates, depending on the distance between the fractures.
Chest tube management is per standard protocols. The chest tube may be removed when output is less than 100 mL per day and the lung has re-expanded. Chest physical therapy, incentive spirometry and pain management are required postoperatively.
- References:
- Dehghan N, et al. Poster 487. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; Aug. 31-Sept. 3, 2021; San Diego.
- Dehghan N. Fixation of the chest wall. In: Schemitsch EH, McKee MD, eds. Operative Techniques: Orthopaedic Trauma Surgery. 2nd ed. Elsevier; September 2019.
- Dehghan N. Chapter 45, Chest wall injuries. In: Tornetta III P, Ricci WM, McQueen MM, Court-Brown CM, McKee MD, eds. Rockwood and Green’s Fractures in Adults. 9th ed. Philadelphia: Wolters Kluwer; March 2019.
- For more information:
- Niloofar Dehghan, MD, FRCSC, an orthopedic trauma surgeon, chief of orthopedic trauma at The CORE Institute and associate professor at University of Arizona College of Medicine, Phoenix, can be reached at 18444 N. 25th Ave., Suite 210, Phoenix, AZ 85023; email: niloofar.dehghan@thecoreinstitute.com.
- Aaron Nauth, MD, FRCSC, an orthopedic trauma surgeon and assistant professor at University of Toronto, can be reached at 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6 Canada; email: aaron.nauth@unityhealth.to.
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