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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 49-51

To fix or not to fix: Delayed repair of anterior flail in the frail and multiply injured

Department of Surgery, Riverside Methodist Hospital (OhioHealth), Columbus, OH, USA

Date of Web Publication30-Dec-2019

Correspondence Address:
William B DeVoe
Department of Surgery, Riverside Methodist Hospital (OhioHealth), Columbus, OH
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jctt.jctt_7_19

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A 72-year-old male with a history of atrial fibrillation, remote stroke, hypertension, and chronic obstructive pulmonary disease presented following a high-speed motor vehicle collision. Injuries included bilateral segmental rib fractures with radiographic anterior flail and a right acetabular fracture. Secondary to thoracic trauma, mechanical ventilation was required and the patient underwent surgical stabilization of left-sided fractures utilizing by 75, 75, 115, and 50 mm plates for ribs 3, 4, 5, and 6, respectively, early in his hospital course followed by fixation of the right hemipelvis. A trial of extubation was unsuccessful. During reintubation, he developed marked abdominal distension and large volume pneumoperitoneum with signs of compartment syndrome. Emergent decompressive laparotomy revealed a perforated posterior prepyloric gastric ulcer that was repaired. Intensive care unit course was complicated by 72 h of multisystem organ failure; however, he recovered and was again nearing the point of ventilator liberation. Right-sided rib stabilization, albeit it delayed, was performed with fixation of 3, 4, 5, and 6 accomplished with long-segment plates bridging to costal cartilage in order to achieve stability. Dense inflammation and callous formation were encountered prolonging operative time. Tracheostomy was performed 3 days postoperatively, despite minimal ventilator requirements, given ongoing secretions and development of pseudomonal pneumonia. The patient was weaned to tracheostomy collar with in-line speaking valve within 2 weeks. This case highlights surgical rib stabilization in a frail, multiply injured patient through which ventilator wean was expedited and rehabilitation potential was optimized.

Keywords: Flail chest, frail, polytrauma, surgical stabilization of rib fractures

How to cite this article:
Dusseau BT, Goslin BJ, DeVoe WB. To fix or not to fix: Delayed repair of anterior flail in the frail and multiply injured. J Cardiothorac Trauma 2019;4:49-51

How to cite this URL:
Dusseau BT, Goslin BJ, DeVoe WB. To fix or not to fix: Delayed repair of anterior flail in the frail and multiply injured. J Cardiothorac Trauma [serial online] 2019 [cited 2020 Oct 23];4:49-51. Available from: https://www.jctt.org/text.asp?2019/4/1/49/274214

  Introduction Top

Surgical stabilization of rib fractures (SSRF) has continued to evolve and indications have been refined. It has been well documented that stabilization adds benefit to those patients with flail chest and evidence continues to mount that patients with multiple displaced fractures who fail optimal medical management or require ventilatory support also improve with surgical stabilization.[1],[2],[3],[4] Furthermore, earlier intervention appears to optimize outcomes.[5] Sternal (or anterior) flail, defined as three anterior or anterolateral fractures on either side of the sternum, is often associated with an acceleration–deceleration automobile collision with impact of the chest on the steering column. SSRF may be advantageous in this situation. An ongoing interest is the role of SSRF in either multiply injured or frail patients, which has shown promise. We present the challenging but successful management of a frail, multiply injured patient undergoing surgical stabilization of bilateral rib fractures contributing to a sternal flail type scenario.

  Case Report Top

A 72-year-old male presented to our American College of Surgeons (ACS)-verified level 2 trauma center following a high-speed head-on motor vehicle collision. His medical history included hypertension, atrial fibrillation, previous remote cerebrovascular event, chronic obstructive pulmonary disease, and diabetes mellitus. Imaging revealed bilateral anterolateral rib fractures (right 1–9 and left 2–8) and a right acetabular fracture. Head and spine imaging were negative. Respiratory status declined shortly after presentation requiring intubation and ventilatory support. Surgical stabilization of the left-sided chest wall injury (fractures 3 through 6) was performed within 48 h utilizing 75, 75, 115, and 50 mm plates [Figure 1]. Open reduction and internal fixation of the right acetabular fracture was completed on the third hospital day. After meeting the criteria for extubation the following day, the patient failed a trial of ventilator liberation resulting from poor pulmonary mechanics and pain associated with the right-sided chest wall injury. During bag mask ventilation before reintubation, he developed profound abdominal distension, hemodynamic instability, free intraperitoneal air on plain film, and signs of abdominal compartment syndrome [Figure 2]. Emergent decompressive laparotomy was performed with release of tension pneumoperitoneum. Intraoperative findings were consistent with an acute perforation secondary to barotrauma of a chronic prepyloric ulcer repaired with an omental flap.
Figure 1: Left-sided surgical stabilization of rib fracture with collapse of the right upper lobe on postoperative imaging

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Figure 2: Abdominal compartment syndrome as a result of tension pneumoperitoneum before emergent decompressive laparotomy and repair of perforated prepyloric peptic ulcer

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Expectedly, multisystem organ failure ensued over the coming 72 h. He was reliably weaned from vasopressor support, following commands, and again meeting the criteria for extubation on the tenth hospital day. Surgical stabilization of his right chest wall injury was subsequently decided upon, given that previously it appeared to be the root cause of his respiratory decline. Albeit delayed, SSRF of the right anterolateral ribs 3, 4, 5, and 6 was performed with stabilization additionally of costal cartilage disruptions (levels 5 and 6) utilizing 50, 50, 150, and 115 mm plates [Figure 3]. Intraoperative findings included significantly displaced fracture elements, right chest wall instability, and a moderate amount of early inflammatory callous formation.
Figure 3: Postoperative imaging following right-sided surgical stabilization of rib fracture and stabilization of anterior flail chest

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Immediate postoperative course was complicated by increased secretions and confirmation of pseudomonal pneumonia. Despite minimal ventilator requirements, percutaneous tracheostomy was performed, given the burden of pulmonary secretions. He was weaned to tracheostomy collar and was tolerating in-line speaking valve trials within 2 weeks and was discharged to acute rehabilitation.

  Discussion Top

The benefits of surgical stabilization for rib fractures have been well defined for many fracture patterns. Included among these are a reduction in ventilator days, pneumonia, and tracheostomy rates for flail chest and similar benefits observed in those patients having multiple, consecutive, displaced rib fractures; chest wall deformity; hemithorax volume loss; and refractory pain.[1],[2],[3],[4] Sternal or anterior flail often encompasses multiple, displaced anterolateral fractures bilaterally and has the potential to predispose patients to respiratory failure. As a less studied injury pattern, this may also be an indication for stabilization in those patients requiring ventilatory support or showing signs of poor pulmonary mechanics.[6] Often, this injury is seen in polytrauma with concomitant injuries, making timing of repair suboptimal. Outcomes of SSRF in polytrauma are varied, with reports demonstrating improvement in mortality, but no significant benefit for long-term quality of life.[7],[8] Initially thought to carry too high of a risk in the geriatric trauma population, SSRF appears likely to be of added benefit, particularly when compared to nonoperative or optimal medical management with a reduction appreciated in mortality, intensive care unit stay, and pulmonary complications while speeding recovery to functional independence.[9]

Our challenging case describes SSRF in a frail, multiply injured patient who additionally survived a relative intra-abdominal catastrophe. Discussion points are three-fold. First, in patients with a similar fracture pattern, consideration should be given at the index operation to performing bilateral rib stabilization simultaneously prior to pursuing ventilator liberation as anecdotally this appears to improve successful extubation. Our practice pattern has changed as a result of reflection on this case. Second, the decision to intervene on patients such as presented here deserves special attention, given the interplay of significant comorbidities, frailty, critical illness, and associated injuries. Honest discussion with the patient and family regarding risks and realistic outcomes should be vetted with the decision to pursue SSRF being made jointly. Finally, as SSRF is applied to increasingly complex patients, we will continue to refine what outcomes are most appropriate to measure success. Ultimately mortality and survival are paramount; however, duration of mechanical ventilation, tracheostomy rates, pneumonia, disposition, return to function, and quality of life are vital to examine when choosing to intervene on this patient population.

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


Conflicts of interest

WBD is a consultant for Acute Innovations.

  References Top

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. 1
Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Fakhry SM, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care 2014;29:139-43.  Back to cited text no. 2
Nirula R, Diaz JJ Jr., Trunkey DD, Mayberry JC. Rib fracture repair: Indications, technical issues, and future directions. World J Surg 2009;33:14-22.  Back to cited text no. 3
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
Pieracci FM, Coleman J, Ali-Osman F, Mangram A, Majercik S, White TW, et al. Amulticenter evaluation of the optimal timing of surgical stabilization of rib fractures. J Trauma Acute Care Surg 2018;84:1-0.  Back to cited text no. 5
Caragounis EC, Xiao Y, Granhed H. Mechanism of injury, injury patterns and associated injuries in patients operated for chest wall trauma. Eur J Trauma Emerg Surg 2019. Epub ahead of print.  Back to cited text no. 6
Marasco SF, Martin K, Niggemeyer L, Summerhayes R, Fitzgerald M, Bailey M, et al. Impact of rib fixation on quality of life after major trauma with multiple rib fractures. Injury 2019;50:119-24.  Back to cited text no. 7
Fokin AA, Wycech J, Weisz R, Puente I. Outcome analysis of surgical stabilization of rib fractures in trauma patients. J Orthop Trauma 2019;33:3-8.  Back to cited text no. 8
Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB 3rd. Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a level I trauma center. J Trauma Acute Care Surg 2017;82:524-7.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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