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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 66-68

Colonic injury during delayed surgical stabilization of rib fractures for flail chest: A case report and literature review


1 Department of Surgery, University of Massachusetts Medical School - Baystate Medical Center, Springfield, Massachusetts, USA
2 Department of Surgery, St. Francis Hospital and Medical Center, Hartford, Connecticut, USA

Date of Web Publication30-Dec-2019

Correspondence Address:
Andrew R Doben
Department of Surgery, St. Francis Hospital and Medical Center, Hartford, Connecticut
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jctt.jctt_6_19

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  Abstract 


Surgical stabilization of rib fractures (SSRFs) is becoming increasingly common, particularly in the setting of flail chest. In adult patients with flail chest, SSRF has been shown to reduce mortality, the incidence of pneumonia, and the need for tracheostomy, in addition to shortening the duration of mechanical ventilation, hospital length of stay (LOS), and intensive care unit LOS. Despite rising popularity, SSRF is not without risks. We present the case of a 22-year-old man who sustained an iatrogenic colonic injury during delayed SSRF for severe nonunion and chest wall motion abnormalities after a motorcycle collision. In multisystem injured trauma patients, it is important to remain cognizant of possible anatomic alterations that could affect surgical management. We present a very uncommon, yet devastating complication related to anatomic alterations from the initial injury.

Keywords: Flail chest, rib fractures, surgical stabilization


How to cite this article:
Grant HM, Doben AR. Colonic injury during delayed surgical stabilization of rib fractures for flail chest: A case report and literature review. J Cardiothorac Trauma 2019;4:66-8

How to cite this URL:
Grant HM, Doben AR. Colonic injury during delayed surgical stabilization of rib fractures for flail chest: A case report and literature review. J Cardiothorac Trauma [serial online] 2019 [cited 2020 Jul 5];4:66-8. Available from: http://www.jctt.org/text.asp?2019/4/1/66/274213




  Introduction Top


Rib fractures are common after blunt chest trauma and range in severity from single, nondisplaced fractures to complex injuries that impede chest wall mechanics and pulmonary function. Nonoperative management with optimization of pain control using a combination of narcotics and locoregional anesthesia has historically been the mainstay of treatment. Over the past 10 years, however, surgical stabilization of rib fractures (SSRFs) has become increasingly popular.[1] In 2017, the Eastern Association for the Surgery of Trauma (EAST) published guidelines conditionally recommending SSRF in adult patients with flail chest after blunt trauma to reduce mortality, the incidence of pneumonia, and the need for tracheostomy, as well as shorten the duration of mechanical ventilation, hospital length of stay (LOS), and intensive care unit LOS.[2] Despite the emerging body of evidence regarding the utility of SSRF, it still is only utilized in <2% of cases, and while generally safe, complications can occur.[3],[4]


  Case Report Top


An otherwise healthy 22-year-old man presented to our American College of Surgeons (ACS) Level 1 trauma institution after a motorcycle collision. He sustained numerous injuries, including multiple left-sided rib fractures with an open chest wound and flail chest [Figure 1], pulmonary lacerations, a Grade 5 splenic laceration, and diaphragmatic injury. Despite crystalloid and blood product resuscitation, he was persistently hemodynamically compromised, so splenic artery embolization was performed. Postprocedurally, he remained hypotensive and tachycardic and was subsequently taken to the operating room for exploratory laparotomy and splenectomy. Multiple diaphragmatic injuries associated with his rib fractures were noted and repaired primarily at this index operation. Due to the infected nature of his open chest wounds, he was not a candidate for SSRF; instead, he underwent serial chest wall washouts and was eventually discharged to a rehabilitation facility.
Figure 1: Three-dimensional reconstruction of computed tomography chest demonstrating multiple left-sided rib fractures

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At follow-up, computed tomography (CT) scan demonstrated severe hypertrophic nonunion of several rib fractures [Figure 2] with associated chest wall motion abnormalities. He was evaluated and deemed appropriate for delayed SSRF. He underwent elective delayed SSRF of ribs 7–9 on the left. Intraoperatively, a small pleural violation was noted and repaired primarily, and his operation was thought to be successful. His initial postoperative course was unremarkable; however, on postoperative day 2, he demonstrated evidence of septic shock, developed a massive lower gastrointestinal bleed, and had bloody drainage from his chest wound. A CT scan of the chest and abdomen with rectal contrast demonstrated free extravasation of rectal contrast into the chest [Figure 3]. He was taken emergently to the operating room for laparotomy with ongoing resuscitative efforts. Intraoperatively, a perforated segment of the left colon traversing a large diaphragmatic defect was identified, as well as a significant amount of blood and feculent material in the chest. He underwent left colectomy, transverse colostomy, and primary diaphragmatic repair with an omental buttress. A drain was left in the left upper quadrant, and fluid cultures later revealed a polymicrobial aspirate, including Escherichia coli, Bacteroides, and Strep viridans. His chest wounds were left open with serial washouts and replacement of VAC™ drainage. His hardware was left in situ. He was maintained on broad-spectrum antibiotics until cultures were eventually negative. Once adequate source control had been achieved, he was discharged to a rehabilitation facility on long-term antibiotics.
Figure 2: Three-dimensional reconstruction of computed tomography chest demonstrating severe nonunion of ribs 7–9

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Figure 3: Computed tomography chest demonstrating extravasation of rectal contrast into the chest cavity

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Subsequently, the patient suffered a deep venous thrombosis and pulmonary embolism; he completed a 3-month course of anticoagulation and underwent inferior vena cava filter placement and removal. He has also completed his course of antibiotics and undergone laparoscopic colostomy reversal with superb results. His hardware remains in situ without signs of infection, and his chest wall has demonstrated complete bony union.


  Discussion Top


SSRF is emerging as an effective treatment option in the management of unstable rib fractures; however, our case is a potent reminder that intra- and post-operative complications can be significant. For this reason, a thorough preoperative evaluation of patients with a history of multiple traumatic injuries is crucial, as it may reveal unanticipated anatomic changes that can affect surgical management. In this case, either a missed injury or a failed diaphragmatic repair may have resulted in a persistent diaphragmatic defect and the resultant colonic herniation into the chest that was not seen on our preoperative CT scan. This segment of colon then likely sustained a thermal injury when the patient's pleura was violated during his SSRF. Thus, an error in our preoperative evaluation converted an otherwise routine SSRF into a significant cause of morbidity for this patient.

The body of literature on the efficacy of SSRF is growing; however, discussions of its complications and their management are limited to case series. Two important, but relatively rare complications are hardware failure and hardware infection. Hardware failure is typically secondary to screw migration or plate failure, while potential risk factors for hardware infection include diabetes, smoking, extensive associated soft-tissue injuries or open wounds, vascular compromise, and bacterial translocation from prior tube thoracostomy.[4],[5],[6] Although hardware infections are relatively uncommon, they are associated with significant morbidity, and the optimal management is poorly defined.[5] This problem has been studied much more extensively in the orthopedic literature, with a focus on joint replacements and the fixation of traumatic fractures.[6] The current management focuses on the reduction of bacterial load and optimization of bony healing through irrigation, debridement, and antibiotic therapy with the goal of implant retention or debridement, antibiotic therapy, and implant removal or exchange.[6]

The optimal treatment for SSRF hardware infections is likely similar.[7] Based on a series of 5 patients who developed a postoperative SSRF hardware infection, Thiels et al. suggested that multimodal therapy, consisting of wound debridement, negative pressure therapy, antibiotic beads, and in some cases, hardware removal, should be employed.[6] In their series, all patients achieved bony union and had no narcotic requirements at their most recent follow-up, suggesting that good outcomes can be achieved with aggressive multimodal therapy.[6] We followed the recommendations of these esteemed authors, employing serial wound debridements, negative pressure therapy, and antibiosis, to attain a successful outcome for our patient. He achieved bony union without hardware removal, suggesting that it may be possible to achieve infection control and bony union without hardware removal in some cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kane ED, Jeremitsky E, Pieracci FM, Majercik S, Doben AR. Quantifying and exploring the recent national increase in surgical stabilization of rib fractures. J Trauma Acute Care Surg 2017;83:1047-52.  Back to cited text no. 1
    
2.
Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the eastern association for the surgery of trauma. J Trauma Acute Care Surg 2017;82:618-26.  Back to cited text no. 2
    
3.
Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: A review of outcomes and treatment practices from the national trauma data bank. J Trauma Acute Care Surg 2014;76:462-8.  Back to cited text no. 3
    
4.
Pieracci FM, Lin Y, Rodil M, Synder M, Herbert B, Tran DK, et al. Aprospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016;80:187-94.  Back to cited text no. 4
    
5.
Sarani B, Allen R, Pieracci FM, Doben AR, Eriksson E, Bauman ZM, et al. Characteristics of Hardware Failure in Patients Undergoing Surgical Stabilization of Rib Fractures. J Trauma Acute Care Surg. 2019 May 14. [Epub ahead of print].  Back to cited text no. 5
    
6.
Thiels CA, Aho JM, Naik ND, Zielinski MD, Schiller HJ, Morris DS, et al. Infected hardware after surgical stabilization of rib fractures: Outcomes and management experience. J Trauma Acute Care Surg 2016;80:819-23.  Back to cited text no. 6
    
7.
Metsemakers WJ, Kuehl R, Moriarty TF, Richards RG, Verhofstad MH, Borens O, et al. Infection after fracture fixation: Current surgical and microbiological concepts. Injury 2018;49:511-22.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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