BACKGROUND: Plastic Surgeons have helped develop rigid fixation of sterotomies with our Cardiothoracic colleagues. Clinical studies have shown improved bony union and chest wall stability compared to traditional wire fixation.
Flail chest injuries with multiple rib fractures are treated with endotracheal intubation and ventilation. Internal fixation of flail segments is rarely performed because of difficulties with exposure and questionable efficacy. Open reduction and internal fixation of the traumatic flail chest should theoretically shorten ventilator time, decrease ICU stay, reduce the need for tacheostomies and the risk of barotrauma, and even lower mortality.
Applying the pectoralis major dissection we use for sternal reconstruction to expose the rib fractures and the percutaneous trochar system we use to fix mandible fractures gives us an approach to reducing and fixing large unstable flail chests through a midline sternotomy incision.(Figure 1 intra-operative view. Figure 2 Post- operative radiograph))
METHODS: The index patient had a complete costo-chondral dissociation from exuberent use of a rib spreader. He had a large unstable flail segment and faced prolonged ventilation. Exposure of the rib fractures by elevating pectoralis major flaps, was simple. The fractures were fixed using the existing sternal plating system together with the percutaneous trochar from a mandible fracture set.
The concept was then extended to patients with severe flail segments where prolonged intubation and ventilation were expected. The procedure has evolved to using submuscular disection of the lat. dorsi and seratus muscles to gain access to posterior fractures. Case reports include polytrauma patients admitted to the Trauma Surgery service between 1/15/2007 and 12/22/2008 that sustained significant flail segments. Mechanisms of injury included seven motor vehicle collisions, and one fall from 35 feet. All patients had multiple significant other injuries varying from head, spine, intra-abdominal and intra-thoracic injury to long bone and facial fractures. The average injury severity score was 35±10.
RESULTS: Flail segments underwent repair between two and nine days post-injury. Patients required a mean of 12.2 ±7.6 days on the ventilator with a mean of 7.9 ±4.9 days after surgery. Mean time in the ICU was 14.7 ±7.8 days.
Compared to historical controls and other studies in the literature these patients required shorter ventilator times and shorter ICU stays
CONCLUSIONS: This study aims to outline a protocol for percutaneous rib fixation using limited incisions and principles learned from standard reconstructive operations.
The protocol appears to have reduced the ICU and ventilator times in this small patient cohort. The technique holds promise for improved outcomes in polytrauma patients with flail chest injuries.