[Single-port VATS-assisted internal fixation of serial rib fractures]

Current status and research progress of minimally invasive surgery for flail chest

Chest trauma accounts for ~13.5% of all traumas, and direct death from chest trauma accounts for 20–25% of all traumatic deaths. Chest trauma is the second cause of death from trauma. Frequent rib fractures, especially in patients with flail chest, often cause severe pain, chest wall softening, abnormal breathing and severe lung contusion and laceration, usually requiring thoracic surgery. In recent years, the open reduction and internal fixation treatment of rib fractures with flail chest has achieved satisfactory results, and some surgical indications have reached consensus. A number of scholars and medical centers have demonstrated the practicality and cost-effectiveness of rib fixation in flail chest, including the small incidence of pulmonary complications, the short ICU mechanical ventilation time, and the reduction of digestive tract inhibition. Open reduction and internal fixation of rib fractures involves multiple ribs. Conventional rib fractures require a large incision to achieve satisfactory exposure. Chest wall muscles, blood vessels and nerves (long thoracic and thoracodorsal nerves) are injured, resulting in a high infection rate of the incision and postoperative dysfunctions, such as limited upper limb, shoulder and back function, and long time numbness on the affected side of the chest. Therefore, the damage of muscles and nerves caused by conventional surgical methods limits the development of such surgical technique. Although the video-assisted thoracoscopic technique has become a necessary technical means for the treatment of thoracic trauma and has been applied to thoracic exploration and hemostasis, there is no report on the application of open reduction and internal fixation for rib fracture. The difficulty lies in the tightly combined bony thorax and the soft tissue of the chest wall. Therefore, experts have explored a variety of minimally invasive surgical methods for the flail chest. The current status and research progress of minimally invasive surgery for thoracic surgery are reviewed.

[Injuries of the posterior and lateral chest wall-importance of an additional clavicular fracture]

BACKGROUND

Flail chest wall injuries (FCI) are common in younger patients due to high-speed trauma and in older patients due to low-energy trauma or falls from a low height. They show a high incidence of concomitant injuries and are therefore associated with high morbidity and mortality. If there is also an ipsilateral clavicular fracture (CF), the outcome is significantly poorer. The skeleton of the shoulder and chest loses stability and can lead to a loss of function of the shoulder and a pronounced deformation of the chest wall.

OBJECTIVE

This article shows the origin and clinical importance of FCI. What importance does a concomitant ipsilateral CF have and how can these costoclavicular injuries (CCI) be managed conservatively and operatively?

MATERIAL AND METHODS

After primary emergency care of the patients with appropriate diagnostics, in the presence of CCI operative stabilization was carried out by means of locked plate osteosynthesis of the clavicle and the affected ribs via minimally invasive approaches with the patient under general anesthesia. Patients were followed up postoperatively. Various minimally invasive posterolateral approaches to the chest wall were previously performed in a corpse study and then put into practice.

RESULTS AND CONCLUSION

This study presents therapeutic options for the reconstruction of the chest wall based on the established literature and clinical examples. An ipsilateral CF combined with fractures of the 2nd-4th ribs can be treated through an innovative clavipectoral approach. For the other fractures, standard approaches to the anterolateral and posterolateral chest wall are performed, which are associated with a good outcome in clinical practice. An operative stabilization should be performed at the latest when FCI or CCI together with a dislocating fracture and a marked deformation of the thoracic wall are present. Remaining misalignments are associated with a simultaneous loss of function of the chest wall and shoulder.

[Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]

BACKGROUND

Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed.

OBJECTIVE

A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options.

MATERIAL AND METHODS

Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed.

RESULTS AND DISCUSSION

Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.