The crushed chest. Management of the flail anterior segment

Surgical treatment of flail chest and rib fractures

Despite significant advances in critical care management, flail chest remains a clinically significant finding, with a mortality rate of up to 33%. Nonsurgical management is associated with prolonged ventilator support, pneumonia, respiratory difficulties, and lengthy stays in the intensive care unit, as well as chronic pain from nonunion and malunion of the bony thorax. Treatment with aggressive pulmonary toilet, ventilator support, and different modalities of pain control remains the benchmark of care. However, several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work. The success of these surgical constructs compared with those of historical attempts at open fixation is largely the result of modern plating technology and improvement in surgical approaches. Clinical evidence continues to grow regarding proper indications and techniques for surgical stabilization of flail chest.

Historic overview of treatment techniques for rib fractures and flail chest

Introduction

From the beginning of the twentieth century till the current time, an overview is presented of the surgical treatment for rib fractures and flail chest.

Methods

Many techniques have been used to stabilize the thorax wall. There has been no follow-up for the most described techniques and the evidence provided is at its best at L3–4. This, together with the noninvasiveness of mechanical ventilation, has made the latter the golden standard.

Conclusion

However, the recent introduction of better and fully dedicated materials provides the possibility of exploring the surgical treatment of chest injuries. The authors make a case for operative treatment of rib fractures and flail chest.

Intramedullary fixation of fracture of the sternum

A case of fracture of the sternum in a patient suffering from osteogenesis imperfecta is presented. Internal fixation was carried out using a plate which was placed within the medulla. The described technique is simple and useful for the rarely indicated operative treatment of fractures of the sternum.