WHAT IS FLAIL CHEST?
Flail chest is defined as 3 or more consecutive ribs fractured in 2 or more places.
Rib fractures are among the most common traumatic injury found in greater than 20% of all patients who suffer thoracic trauma. The majority of these are a result of a blunt
trauma/mechanism and are often associated with other traumatic injuries. The most common associated injury is lung contusion. Rib fractures impart an increased morbidity and mortality with the highest mortality associated with a flail chest in the elderly population. These injuries are potentially fatal, with in-hospital mortality rates of up to 12% (eighty-four of 711) for patients
with multiple rib fractures and up to 33% (thirty of ninety-two) for patients with a flail chest. Computed Tomography (CT) scans, which are now commonly performed during the routine workup for trauma patients, have been shown to be the most sensitive imaging study for detecting rib fractures
HOW HAS FLAIL CHEST BEEN TREATED HISTORICALLY?
Several reports describing internal fixation of flail chest injuries appeared in the 1950s. Common surgical techniques included simple wire suture fixation of the fracture ends and rush rod fixation of the flail segment. In the late 1950s the medical treatment of the underlying lung injury by ‘internal splinting’ of flail chest segments using positive pressure ventilation became popular Fracture of ribs; a logical treatment.
A small number of reports were published beginning in the 1960s with generally improved results relative to non-surgical historical control groups. More recently, two comparative studies noted a reduction in mortality of 38 and 78% due to surgical stabilization.
In a mid-1970s report, Trinkle et al. . . provided compelling evidence that many patients fared better with adequate pain control and pulmonary toilet [including medical management of their pulmonary injury] than those placed on mechanical ventilation. This remains the standard today. Mechanical ventilation is reserved for patients with persistent respiratory insufficiency or failure after adequate pain control or when complications related to excessive narcotic use occur. Patient-controlled analgesia (PCA) machines, oral pain medications, and indwelling epidural catheters form the mainstay of current treatment.
Operative treatment can provide substantial benefits to patients with flail chest injuries and respiratory compromise requiring mechanical ventilation. The use of anatomically contoured rib plates and intramedullary splints greatly simplifies the procedure of flail chest fixation.
The mainstay of treatment has been pain control and respiratory support with positive pressure ventilation. However, over the past 2 decades, there has been mounting evidence to suggest that open reduction and internal fixation of ribs benefits patients.
Despite these seemingly superior results, operative fixation of flail chest injuries remains an underutilized intervention. Mayberry et al. . . surveyed a series of 405 cardiothoracic, trauma and orthopedic surgeons concerning their views on chest wall fixation. They found that most surgeons felt chest wall fixation was indicated in some cases, but that very few had experience using the technique. They also found that most surgeons were unfamiliar with the literature concerning chest wall fixation and that there was an unfamiliarity of fixation techniques and instrumentation by the surgeons who typically operate on the chest.
Patients with severe chest wall injuries develop not only acute morbidities, but also long-term pain and disabilities. Fortunately, most patients with chest wall injuries are successfully treated with analgesics, anti-inflammatory drugs, epidural anesthesia, and aggressive pulmonary toilet. The use of positive pressure ventilation results in improved patient outcomes. However, this technique requires prolonged time on mechanical ventilation, resulting in secondary pulmonary infections and subsequently high mortality rates of 10–36%. Moreover, positive pressure ventilation is not always able to reduce and stabilize the bony injury and may even result in painful fracture malunion or symptomatic chest wall deformity.
It has been suggested that patients with flail chest and no contusion have better outcomes if surgical stabilization is performed early, while patients with flail chest and pulmonary contusion should be fixed only if paradoxical motion or progressive collapse is noted.
The indications for internal fixation [rib plating] remain confined to the most severely injured patients with flail chest or chronic non-unions; however, there remains debate whether or not less severely injured patients would benefit as well.
In general, there is a decrease in the number of days requiring mechanical ventilation, number of days in the ICU, and the rate of chest infection, all favoring operative fixation of the flail segment.
Many surgeons are not aware of the published reports on flail chest fixation.
The use of anatomically contoured titanium plates and splints greatly simplifies the procedure of flail chest fixation. The pre-contoured plates are used for complex fractures and are long enough to allow bridging fixation of multiple fractures, including the entire flail segment, if desired. Because they are thin and manufactured from titanium, they are able to flex with respiration, limiting the risk of hardware or fixation failure secondary to repetitive loading. Additionally, the plates are low profile and prevent hardware irritation to minimize the need for removal after the fractures heal.
[There are other plating hardware out there, yet since this method was the one used on me – I am including only this one here in this compiled post.]
INDICATIONS FOR RIB PLATING
For adult blunt trauma patients, a hemothorax, pneumothorax, or pulmonary contusion seen on chest X-ray will almost always be associated with a rib fractures, whether or not identified clinically or by X-ray. In paediatric patients the ribs are more pliable and less likely to fracture, although there will still be significant contusion of chest wall structures.
Polytrauma with the presence of pneumothorax, hemothorax, pulmonary contusion evaluated on the chest computed tomography (CT) scans, and pneumonia.
Flail chest from multiple myeloma, sternal absence, or total sternectomy more frequently responds well to surgical fixation. Underlying pulmonary injury with respiratory insufficiency resulting from changes in tidal volume and minute ventilation in these patients is rare.
Indications for rib plating in severe blunt chest trauma also includes:
When standard therapies fail: Standard therapy consists of pain control, aggressive pulmonary hygiene, positive pressure therapy with an acapella device, and frequent chest therapy (chest wall percussion, deep breathing, and coughing exercises).
BENEFITS OF SURGICAL RIB PLATING
Surgical treatment was preferable to nonsurgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical ventilation, shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic chest deformity and impaired pulmonary function, shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections.
Surgical stabilization of flail chest in thoracic trauma patients has beneficial effects with respect to reduced incidence of pneumonia and septicaemia, and an overall reduced mortality when compared with patients who received non-operative management.
RISKS OF NOT RIB PLATING
Pneumonia is often the common pathway to acute respiratory failure resulting from rib fractures, and prevention offers the best means to avoid potentially preventable deaths. The main goal of treatment is to prevent pneumonia and other complications of rib fractures (eg, nonunion). Respiratory failure can lead to death.
Risks of not plating can also result in long term narcotic use and chronic pain. Also the patient should be plated in a timely manner. The longer a patient endures pain for a rib fracture, the less likely it is to successfully treat that chronic pain with surgery.
RISKS OF RIB PLATING
Repair requires addressing chronic pain, paradoxical breathing motion, restoring cosmetic contours and lung herniation. Rigid prosthetic reconstruction can result in a restrictive physiology, while flexible prosthetic reconstruction does not adequately recreate the structure needed for breathing mechanics.
Plate fracture and screw migration are possible complications. Rib fixation is likely to fail in the setting of pneumonia which increases stress on the fixation through coughing.
Patient factors including smoking, diabetes and chronic cough with COPD are all contributors to wound healing and failed fixation.
Other factors include infection and the multitude of risks that go along with having a surgery. Potential disadvantages of both rigid and nonrigid internal fixation systems include interference with CT and MRI (magnetic resonance imaging) studies, stress shielding, palpable implants, and the potential need for another operation for implant removal due to pain or loosening of implants.
(Recently, anatomically contoured titanium intramedullary struts designed for rib fracture fixation have been introduced and have improved rotational stability. A
broad flat design and the addition of a single unicortical locking screw to hold the strut suggest that this implant design may lessen the risk of dislodgment and migration.)
LONG TERM OUTCOME AND PROGNOSIS
Overall, patients with flail chest have a 5-34% reported mortality if they reach the hospital alive. Patients who do not need mechanical ventilation do better statistically, and overall mortality seems to increase with increasing injury severity scores (ISS), age, and number of total rib fractures.
Reports in the medical literature note a high level of long-term disability in patients sustaining flail chest. Beal and Oreskovich reported a 22% disability rate with over 63% having long-term problems, including persistent chest wall pain, deformity, and dyspnea on exertion. Kishikawa et al, . .however, noted resolution of altered pulmonary function within 6 months, even with chest wall deformity still present.
Many are able to return to full time employment, some are not. For patients who survive, difficulties with chronic chest wall pain, deformity, longstanding disability and poor quality of life are common, despite the best repairs.
Ultimately though, breathing is improved dramatically and pain if often reduced, though not always fully eliminated.
BEST RESPONSE TIMES FOR SURGERY
It is most beneficial if surgery is performed in the first 48 hours after the admission. Rapid intervention is a topic of discussion with regard to the different case-control studies on flail chest fixation. The longer the surgery is delayed, the greater the length of ICU or hospital stay is, and the difference between the two groups decreases. Many experts also believe that the underlying lung injury, rather than the bone injury, is the major contributor to the morbidity and mortality following flail chest injuries.
The timing of surgical stabilization following blunt chest trauma is felt to be important, with many investigators favoring early intervention within a few days of the primary injury. Rib fixation early in the patient’s hospital course avoids factors such as inflammation, severe hematoma, and early callous formation which can complicate operative reduction of the fractures. Of course, the timing of surgery must be made in the context of the patients overall clinical condition, and occasionally must be delayed while other injuries and conditions are stabilized.
Patients with flail chest and no contusion have better outcomes if surgical stabilization is performed early after admission, while patients with flail chest and pulmonary contusion should be fixed only if paradoxical motion or progressive collapse is noted.
[Only discussing these here, as this is what was used on me for ribs 5,6,7,8 ,9 and 10 on the right side of my body.]
The plates are used for complex fractures, and we separately treat the fracture without bridging the flail chest. Since they are thin and are manufactured from titanium, they are able to maintain flexibility with respiration movements, thereby limiting the risk of hardware failure secondary to iterative loading. Additionally, the plates are low-profile, prevent hardware irritation, and minimize the need for removal after the fractures heal.
The dominant method currently used employs a plating system designed for placement on the outer cortex of the rib, secured with bicortical screws. At least two centimeters of exposed rib on either side of the fracture are required to ensure adequate fixation. The majority of studies regarding rib fixation have used this technique, citing advantages of ease of use and adaptability to a variety of clinical situations.
WHO SHOULD PERFORM THE SURGERY?
Currently, a variety of surgical subspecialties participate in rib stabilization of blunt chest trauma patients—trauma (or acute care) surgeons, orthopedic trauma surgeons, [traumatologist], and thoracic surgeons. Each subspecialty brings specific expertise to the care of these patients, and each is critical in a high functioning trauma unit. The trauma/acute care surgeons often are the attending of record, and have the best overall knowledge of the management of the polytrauma patient. The orthopedic surgeons are perhaps most familiar with the hardware and instrumentation crucial to fracture fixation. Finally, the thoracic surgeons clearly are best acquainted with the anatomy of the chest wall, and are best equipped to deal with other intrathoracic pathology. However, the reality is that thoracic surgeons often delegate the care of these patients to others. It is incumbent for thoracic surgeons to maintain an active interest in this area of our specialty, lest it slip away to other able subspecialists; it is difficult to argue against the notion that the care of the chest trauma patient is optimized when dedicated thoracic surgeons are involved.
MY SURGEON and MY RIB PLATING STORY
The motor vehicle accident was January 4, 2014 – a Saturday. A polytrauma resulted. Eventually, I would have a surgery for rib plating, but not until 9 months after presenting to ER for the first time, followed by several months between inpatient/outpatient care. The Trauma Surgeon’s first and only attempt with repairing my shattered Scapula was on October 8, 2014 – yep, 9 months after the accident (where he planned to plate the Scapula as well, but didn’t follow through with the plating (for reasons unknown to us still).
I had fractured all the ribs in multiple places on the right side of my body. I had lung contusions on the right lung, a hole in my right lung, pneumothorax, hemothorax, and ended up with flail chest, followed by a chest tube put in through my back. I also had fractured 5,6,7,8,9,and 10 transverse processes in my spine. I developed atelectasis and pneumonia twice over the course of my struggle to survive until my surgery.
The Trauma Surgeon I had, kept dismissing my complaints of inescapable and disabling pain and severe difficulty breathing, though actively aware of my flail chest and the full scope of all my injuries (polytrauma) that resulted from the accident. I had also developed pneumonia twice in a 4 month time frame after released from Neuro Rehabilitation. The Trauma Surgeon seemed more interested in following an “observational scapula study” he was running, that I had been entered into, while in the hospital right after my accident (which did not eliminate the possibility of surgery for repair of my shattered scapula as part of the study guidelines). I also was NOT in a study regarding my rib injuries. He continued to document that my bones were healed, when in fact, they were not. In reality, I was only getting worse. I had a LOT of medical things going on with my body. Despite this, he released me for full Physical Therapy (PT) and Occupational Therapy (OT) with no restrictions. In fact, he got such tunnel vision, that he said my bones should be healed all these months later and he wasn’t interested in doing any follow-up in checking the status of the bones healing process. In fact, his go to statement to me on a regular basis was to “try harder in therapy” and “lose weight” and it would resolve my pain. This was not only bad dismissive advice that resulted in neglecting my needs, unbeknownst to me and all my therapists, I was still broken, still had flail chest with no healing, and this exacerbated my injuries.
Once he finally ordered the CT Scans 8 months after the accident (after much prodding from my PCP, Medical Case Manager, and my family), he discovered I still had flail chest with absolutely NO HEALING…not even cartilage built up….and all the fractured ribs were still nonunion fractures. Even my Scapula continued to remain shattered with no healing and was also nonunion. It was then something miraculous happened. He acknowledged that we have a situation that was emergent.
Suddenly his attitude changed dramatically and he said we needed to do surgery right away. He even momentarily appeared to be compassionate. He said he had never in all his years as a provider, had ever seen anyone not heal at all..not even cartilage growth. That I was a first for him in that way. I was hoping this was a breakthrough, that his demeanor would change and he would be remorseful. That thought process was short lived, because at no time during the whole experience, did he ever apologize for allowing me to suffer for so long, for not listening, not acting on my many complaints, or for being wrong.
Then he dropped a bomb in my world – I had a “75% chance of dying on the operating room table with all the complications and risk factors at this point” he told us. However, this surgery would give me the best outcome to move forward without deformity or death. A 75% chance of dying on the table was a better outcome than not getting it done? I was PETRIFIED!!! I couldn’t hold back the tears or the fear or the emotions that come along with having to make a seemingly impossible choice.
His original plan for the surgery was to plate as many ribs as possible and go higher as he was able – though going higher (ribs 1-4) would be more risky, with a higher risk of death. He ended up plating 5,6,7,8,9,10 and left 2, 3, and 11 not plated, though still fractured. He was unable to plate rib 11 since it was a floating rib and he needed to be able to put two locking screws on either side of the fracture and the rib was not long enough to do so. He left 3 and 4 not plated, since plating that high risked morbidity and was too risky for me. His hope was that the plating of the other ribs and pulling the chest wall back in place would allow ribs 3 and 4 to heal on their own, as now aligned to each other. Rib 2 remained aligned and he hoped it would heal on it’s own. Rib 1 was not damaged and was holding everything precariously in place, until I was finally “plated”.
His original plan for my right shoulder was a Modified Judet Procedure which would include plating my Scapula with an “L shaped” stainless steel plate. Instead he removed some shattered pieces, rounded off some bone and did not reconstruct nor repair the Scapula before closing me back up. Both surgeries he estimated would take 2-2.5 hours. It ended up being almost 8 hours.
I spoke very candidly to him, in what would be our last appointment, months later. I told him that as a patient, I never cared for his seeming condescending personality as he made me and those with me, feel belittled. He was always rushing and didn’t like to be questioned about his decisions, or questions in general. His ego would often get the best of him, even when dealing with my other providers. He absolutely lacked (at that time) the ability to actively listen and follow through on my complaints as a patient and I continued to deteriorate. He was remiss in responding in a timely manner to my Primary Care Physician’s (PCP) requests for evaluating my fractures and follow up requests for CT Images. He also did not respond to my PT and OT therapists. It was very frustrating for all involved. I was SUFFERING. I was DYING.
HOWEVER, I will say this. The surgeon I had, despite all his screw-ups out of the operating room, is notably an absolutely talented and skilled artist with the scalpel in the Operating Room and I truly believe that if my ribs had NOT been plated, and if not for his surgical skills – I would be dead today! I am enormously thankful for his skills in this regard. I am not grateful for the nerve damage I sustained due to the delay in treatment though. I also told him that I truly hoped this experience with me would be something he carried throughout his career and work with future patients. “Don’t get tunnel vision and make assumptions about a patient’s healing. Don’t make assumptions when a patient is overweight that they are just lazy. LISTEN to them. Follow through in a timely manner and don’t feel threatened if a patient asks questions and wants to know more about their treatment plan or what is being put in their body. Self-Advocacy does not equal competing with a provider.” I assured him I did not dislike HIM (didn’t really know him on a personal level), but rather disliked the lack of communication and continued lack of follow through.
He was the ONLY Surgeon in the entire State of Michigan who was trained to do rib plating. Also the only Surgeon in this region for that matter. He did order an MRI of my back in Spring 2015 as I was hurting so bad and having trouble walking without enormous pain (fifteen months post accident and the first MRI done of my back by any provider since the wreck). I also kept complaining about loss of function in my right arm and hand, pain in my right side, and back pain through Spring of 2015 and since the rib / first shoulder surgery to him and my other providers (a little late to care about that now folks I thought). He eventually referred me to an Orthopedic surgeon named Dr. Peter Cole in St. Paul, Minnesota (MN) in the Spring of 2015. He said if anyone could fix my scapula he could. He said that since I was not happy with him that Dr. Cole would also be able to follow up on my ribs as he also plated ribs. I have not spoken to the Surgeon from Michigan since that Spring (I found out later he had moved out of state and had apparently also gone through a bitter divorce). I will never forget him though, how he treated me – or didn’t treat me…. and would not be opposed to sitting down with him again some day and discussing my case more thoroughly.
Multiple rib fracture with instability of chest wall. Crutcher RR, Nolen TM
Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status.
Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients.
Operative fixation of chest wall fractures: an underused procedure?
Richardson JD, Franklin GA, Heffley S, Seligson D
Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. Mayberry JC, Ham LB, Schipper PH, Ellis TJ, Mullins RJ
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