A feasibility study of 60 consecutive patients operated for unstable thoracic cage

Hans P Granhed, David Pazooki, Hans P Granhed, David Pazooki

Abstract

Background: About 10% of adult patients in high-energy trauma sustain multiple rib fractures. Some of these patients suffer from flail chest leading to respiratory insufficiency. During last years interest and results for operative treatment has improved. The literature today all show positive results for surgical versus conservative treatment, specifically with regard to time spent in mechanical ventilator, complication rates and length of hospital stay.

Methods: Between September 2010 and July 2012, 60 patients with flail chest or multiple rib-fractures resulting in unstable thoracic cage were operated. 16 women and 44 men with an age between 19-86 years (mean 57). We used modern fracture techniques with plates and intramedullary splint. Thoracotomy was performed and lung lacerations were debrided (11/60). Time spent in ventilator, complications and other adverse effects was studied. The operated cohort was compared to results from six previous years, when none was operated for that diagnose (153 patients).

Results: There is a significant correlation between Injury Severity Score (ISS) and time spent in ventilator both for patients operated and not operated (p< 0,01). The mean time in ventilator was 9,01 days for not operated patients compared to 2,7 for the operated (p<0,0001). No clear pneumonias were found. We had two deaths during the acute period. The infection rate was low.

Conclusions: Open reduction and internal fixation is a safe method to treat the unstable thoracic cage with multiple rib fractures and flail chest. Complication are few. The treatment time in mechanical ventilator is significant decreased. The operative treatment is probably cost effective and can be recommended. Knowledge in thoracic surgery and modern fracture surgery is needed. This is a therapeutic consecutive, level III, cohort study with historical controls.

Keywords: Flail chest; Operation; Rib fractures; Treatment.

Figures

Figure 1
Figure 1
Age and gender (n = 60).
Figure 2
Figure 2
Multiple flail segments after a car crash.
Figure 3
Figure 3
Frequency of patients from the two series and gender compared to ISS.
Figure 4
Figure 4
Day of extubation for patients on ventilator before surgery and those who did not yet need mechanical ventilation before surgery.
Figure 5
Figure 5
Patients still on a ventilator during the first week: 153 patients with rib fractures who were not operated compared to 60 operated patients.

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