[Surgical reconstruction of chest wall instability : Indications, contraindications and timing of surgery]

The impact of energy on the thorax can lead to serial rib fractures, sternal fractures, the combination of both and to injury of intrathoracic organs depending on the type, localization and intensity. Sometimes this results in chest wall instability with severe impairment of the respiratory mechanics. In the last decade the importance of surgical chest wall reconstruction in cases of chest wall instability has greatly increased. The evidence for a surgical approach has in the meantime been supported by prospective randomized multicenter studies, multiple retrospective data analyses and meta-analyses based on these studies, including a Cochrane review. The assessment of form and severity of the trauma and the degree of impairment of the respiratory mechanism are the basis for a structured decision on an extended conservative or surgical reconstructive strategy as well as the timing, type and extent of the operation. The morbidity (rate of pneumonia, duration of intensive care unit stay and mechanical ventilation) and fatality can be reduced by a timely surgery within 72 h after trauma. In this article the already established and evidence-based algorithms for surgical chest wall reconstruction are discussed in the context of the current evidence.

[Biomechanics of thoracic wall instability]

Traumatic injuries of the thorax can entail thoracic wall instability (flail chest), which can affect both the shape of the thorax and the mechanics of respiration; however, so far little is known about the biomechanics of the unstable thoracic wall and the optimal surgical fixation. This review article summarizes the current state of research regarding experimental models and previous findings. The thoracic wall is primarily burdened by complex muscle and compression forces during respiration and the mechanical coupling to spinal movement. Previous experimental models focused on the burden caused by respiration, but are mostly not validated, barely established, and severely limited with respect to the simulation of physiologically occurring forces. Nevertheless, previous results suggested that osteosynthesis of an unstable thoracic wall is essential from a biomechanical point of view to restore the native respiratory mechanics, thoracic shape and spinal stability. Moreover, in vitro studies also showed better stabilizing properties of plate osteosynthesis compared to intramedullary splints, wires or screws. The optimum number and selection of ribs to be fixated for the different types of thoracic wall instability is still unknown from a biomechanical perspective. Future biomechanical investigations should simulate respiratory and spinal movement by means of validated models.

[Osteosynthesis of the unstable thoracic wall]

Operationsziel

Wiederherstellung einer normalen Atemmechanik und Vermeidung beatmungsassoziierter Komplikationen durch operative Stabilisierung eines instabilen Thorax bei dislozierten Rippenserien- und Sternumfrakturen, posttraumatischer Thoraxwanddeformierung, Weaning-Versagen und symptomatischen Rippenpseudarthrosen.

Indikationen

Kombination mehrerer klinischer und radiologischer Parameter wie das Ausmaß der Rippenserien- und Sternumfrakturen, der Grad der Dislokation, pathophysiologische Veränderungen der Atemmechanik, Versagen eines konservativen Therapieansatzes.

Kontraindikationen

Akute hämodynamische Instabilität und Zeichen einer systemischen Infektion.

Operationstechnik

Detaillierte präoperative Planung. Offene, möglichst minimalinvasive Reposition und winkelstabile Osteosynthese mit anatomisch vorgeformten Low-profile-Platten und/oder intramedullären Splints. Vorsichtige Repositionsmanöver und Einbringen der Implantate aufgrund enger Lagebeziehung zu Pleuraspalt, Lunge und Perikard.

Weiterbehandlung

Möglichst frühzeitiges postoperatives Entwöhnen vom Respirator sowie frühzeitige Therapie eines perioperativen Pneumothorax. Eine Implantatentfernung ist in der Regel nicht notwendig.

Ergebnisse

In einer retrospektiven Untersuchung profitierten 15 Polytraumapatienten mit instabilem Thorax von der frühen operativen Stabilisierung des Thorax innerhalb von 24–48 h und einer differenzierten, interdisziplinären Behandlungsstrategie. Beatmungsdauer und Pneumonierate waren in der Subgruppe der frühzeitig operierten signifikant niedriger als in der Gruppe der später operativ an der Thoraxwand stabilisierten Patienten. In den Subgruppen der lebensgefährlich Verletzten mit Thoraxtrauma (LVK-Thx und LOTX [LVK-Thx mit Osteosynthese am Thorax]) konnten eine längere Beatmungszeit, Intensivtherapie, Krankenhausverweildauer sowie eine erhöhte beatmungsassoziierte Komplikationsrate als in der Subgruppe der Schwerverletzten ohne Thoraxtrauma (AIS [Abbreviated Injury Scale] ≥ 3) gezeigt werden.

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

This article describes the operative stabilization of a flail chest due to traumatic serial rib fractures with extensive chest wall deformation and respiratory insufficiency. Initial conservative treatment including systemic and regional pain management and non-invasive positive pressure ventilation did not improve the pain or ventilation. Therefore, a single-port video-assisted thoracoscopic surgery (VATS) assisted internal fixation of the ribs was performed. The thoracoscopy enabled easy repositioning of the ribs and additionally an estimation of intrathoracic injuries.

[Bony injuries of the thoracic cage in multiple trauma : Incidence, concomitant injuries, course and outcome]

BACKGROUND

Thoracic trauma is considered to be responsible for 25 % of fatalities in multiple trauma and is a frequent injury with an incidence of 50 %. In addition to organ injuries, severe injuries to the bony parts of the thorax also occur and these injuries are described very differently mostly based on single center data.

OBJECTIVES

The focus of this study was on a holistic presentation of the prevalence and the incidence of thoracic trauma in patients with multiple trauma from the data of the large collective of the TraumaRegister DGU® (TR-DGU) with the objective of an analysis of concomitant injuries, therapy options and outcome parameters.

MATERIAL AND METHODS

A retrospective analysis was carried out based on the data set of the TR-DGU from the years 2009-2013. Inclusion criteria were an injury severity scale (ISS) score ≥ 16 and primary admission to a trauma center but isolated craniocerebral injury was an exclusion criterium. Patients were separated into two groups: those with rib fractures (RF) and those with flail chest (FC).

RESULTS

A total of 21,741 patients met the inclusion criteria including 10,474 (48.2 %) suffering from either RF or FC. The mean age was 49.8 ± 19.9 years in the RF group and 54.1 ± 18.2 years in the FC group. Approximately 25 % were female in both groups, 98.1 % were blunt force injuries and the median ISS was 28.0 ± 11.2 in RF and 35.1 ± 14.2 in FC. Shock, insertion of a chest tube, (multi) organ failure and fatality rates were significantly higher in the FC group as were concomitant thoracic injuries, such as pneumothorax and hemothorax. Sternal fractures without rib fractures were less common (3.8 %) than concomitant in the RF (10.1 %) and FC (14 %) groups, as were concomitant fractures of the clavicle and the scapula. Out of all patients 32.6 % showed fractures of the thoracolumbar spine, 26.5 % without rib fractures, 36.6-38.6 % with rib fractures or monolateral FC and 48.6 % concomitant to bilateral FC. Thoracotomy was carried out only in isolated cases in RF and in 10.2 % of the FC group. Operative stabilization of the thoracic cage was carried out in 3.9-9.1 % of patients in the RF group and in 17.9-23.9 % in the FC group.