Open Fixation in Flail Chest:
ORIGINAL CONTRIBUTION
Review of 64 Patients
Akın Eraslan Balcı, MD, Șevval Eren, MD, Ömer Çakır, MD, M Nesimi
Eren, MD
Division of Thoracic and Cardiovascular Surgery Dicle and Fırat University School of Medicine Diyarbakır, Turkey
ABSTRACT The strategy for treatment of flail chest remains controversial. Various alternatives
were assessed by reviewing the records of 64 patients treated from 1991 through 2000.
Patients were classified according to therapeutic approach: group 1 was 27 patients who
underwent open fixation of the fractured ribs, group 2 was 19 patients managed by intermittent
positive-pressure ventilation, and group 3 was 18 patients managed mainly by synchronized
intermittent mandatory ventilation. Two patients initially treated by ventilation underwent
successful open fixation. In group 1, ventilatory support was required in 21 (77.8%) patients
postoperatively, the mean duration of ventilation was 3.1 days, mean hospital stay was 18.3
days, morbidity was 11.1% (3/27), and mortality was 11.1%. In groups 2 and 3, the mean time
for stabilization of paradoxical chest wall movement was 6.6 days, and mean duration of
ventilation was 7.2 days. Mortality was 27.0% (10/37) in patients treated nonsurgically; 21.0%
(4/19) in group 2, and 33.3% (6/18) in group 3. In groups 2 and 3, pain control required epidural
analgesia in 13 (35.1%) cases, intercostal nerve blockade in 16 (43.2%), and narcotic or
nonnarcotic parenteral analgesia in 8 (21.6%). Open fixation is a successful treatment modality
for traumatic flail chest.
(Asian Cardiovasc Thorac Ann 2004;12:11–5)
INTRODUCTION
cartilage fractures, and 64 were diagnosed as having Limited studies on flail chest have been reported
and
flail chest injuries (9.3% of all rib fractures and 6% of the treatment remains highly controversial.1–3
Traditional
all blunt traumas were flail injuries). The records of all management focuses on treatment of the flail
segment
64 patients with flail chest were reviewed. Flail chest to ameliorate the flail respiration, or on treating the
was defined as a chest wall segment consisting of 3 or underlying pulmonary contusion to improve gas
more ribs broken sequentially in at least two locations exchange.4,5 Early surgical stabilization of flail chest
has
on chest radiography. Paradoxical motion of the chest been advocated previously but has not gained
widespread
wall was present in all patients including those intubated acceptance.5,6 Our clinical and surgical
experience of
on admission. To gauge progression of the lesion, the flail chest was reviewed to assess the
effectiveness of
extent of contusion was assessed from successive various management alternatives.
chest radiographs during the first 48 hours of hospital admission. A pulmonary contusion score was
assigned PATIENTS AND METHODS
to each chest radiograph by dividing the lung fields into Over the 10 years from 1991 through 2000, 1069
adult
upper, middle, and lower thirds and assigning a score patients with blunt trauma, who were not in cardiac
of 1 to 3 in each region on the basis of the extent of arrest, were admitted to our trauma center. Of these,
opacification.7 Scores of 1–3 were accepted as minimal, 688 were diagnosed as having simple rib or
costal
4–6 as moderate, and 7–9 as severe contusion.
For reprint information contact: Akın Eraslan Balcı, MD Tel: 90 424 238 8080 Fax: 90 424 233 5038 Email:
abalci@firat.edu.tr Division of Thoracic Surgery, Fırat University School of Medicine, 23100 Elazığ, Turkey.
RDIOVASCULAR & THORACIC AN
2004, VOL. 12, NO. 1 11 ASIAN CA NALS
Open Fixation in Flail Chest Balcı
Table 1. Characteristics of patients managed by surgical and nonsurgical
treatment
Surgical Nonsurgical Variables Fixation IPPV Non-IPPV No. of patients 27
19 18 Mean age (years) 34.6 ± 8.4 30.7 ± 8.4 31.7 ± 11.1 Male/female (ratio) 20/7 (2.9) 15/4 (3.8) 13/5
(2.6) Associated injury 21 (77.8%) 14 (73.7%) 13 (72.2%) Mean ISS 21.0 ± 7.4 18.2 ± 7.8 18.6 ± 8.3 > 8
rib fractures 6 (22.2%) 4 (21.0%) 4 (22.2%) Bilateral flail 4 (14.8%) 2 (11.1%) 2 (11.1%) Pulmonary
contusion 13 (48.1%) 8 (42.1%) 8 (44.4%) Chest tube drain 16 (59.3%) 11 (57.9%) 11 (61.1%)
Tracheostomy 0 3 (15.8%) 4 (22.2%)
IPPV = intermittent positive-pressure ventilation; ISS = injury severity score.
approximated with 1/0 or 2/0 silk sutures. Both ends of
the fractured rib were stabilized to the costal cartilage
According to the treatment modality used, the patients without a bone perforator, using only simple needle
were classified into 3 groups: group 1 was 27 patients suturing. The silk thread was transferred out through
managed surgically by open fixation of the fractured the skin by needle after rapping around the rib, and
ribs, group 2 was 19 patients managed by traction was applied to the fractured segment by tying
endotracheal intubation for intermittent weights (0.5–1.0 kg) to the ends of the silk thread. The
positive-pressure ventilation (IPPV), and group 3 was same surgical team performed all operations of the
18 patients managed by non-IPPV (generally, same type. In the nonsurgically treated patients,
synchronized intermittent mandatory ventilation). The stabilization time was measured from initialization of
reason for differentiating between IPPV and non-IPPV ventilatory support to the disappearance of paradoxical
was the reported effect of IPPV treatment for flail motion. The predicted forced vital capacity was
chest.8–10 In all patients intubated and supported by a measured in all patients.
respirator, inspired oxygen fraction and positive
end-expiratory pressure were adjusted so that oxygen The choice of treatment method in this study was
saturation of 95% could be achieved along with carbon based on individual patient indications, so the mode of
dioxide tension < 45 mmHg. Indications for open selection was not randomized, therefore, the groups
fixation were impairment of respiration or general were
condition, with the clinical diagnosis of evident ot statistically comparable. For each group, variables
dyspnea, total or subtotal paradoxical movement of the ere compared between survivors and non-survivors
hemithorax, and blood gas measurements PaCOmost y univariate analysis of variance (ANOVA).
dislocated 2 > 40 mmHg. As and unstable a of rule, ultivariate ANOVA was performed to determine
PaOonly 2 < 3 60 or mmHg 4 and of the ribs were
hich of the notable variables by univariate ANOVA
considered for stabilization. With a bone perforator, edicted mortality.
holes were made at the tips of the ribs and they were
eeding intubation for longer than 5 days, and those
RESULTS All 3 groups were similar although not th failed extubation, persistent tracheal secretions, or
comparable statistically (Table 1). The mean age of severe head injury.
the 64 patients was 32.6 years (range, 21–64 years)
and the male/female ratio was 3. Associated injuries he causes of flail chest were traffic accidents in 36
were found in 48 (75.0%) patients: to the head in 16 6.2%) cases, falls from heights in 19 (29.7%), and
(25.0%), to the abdomen in 12 (18.7%), to soft tissues ushing industrial accidents in 9 (14.1%). Of the 36
or bones in 11 (17.2%), and to the thoracic cavity in 9 atients who suffered unremitting pain, 19 received
(14.1%). The mean Injury Severity Score (ISS) was oracic epidural analgesia and 17 had intercostal
19.7. Fourteen patients (21.8%) had more than 8 rib erve blockade. Epidural analgesia and nerve
fractures with a unilateral flail, and 10 patients (15.6%) ockade had a limited effect on pain and needed to be
had multiple rib fractures with a bilateral flail. Balanced peated. Epidural analgesia was patient-controlled
or negative fluid status for pulmonary contusion, and th 4 mL·h–1 of 0.10% bupivacaine and 10 mg·mL–1
vigorous pulmonary toilet were attempted in all ntanyl. Ventilatory support was required in 58
patients. Chest tube drainage was carried out in 38 0.6%) patients. The significant factors in ventilatory
(59.4%) patients with hemopneumothorax. A ssistance detected by multivariate analysis were ISS
tracheostomy was performed in 7 (10.9%) patients 21, shock
ASIAN CARDIOVASCULAR & THORACIC ANNALS 12 2004, VOL. 12, NO. 1
Balcı Open Fixation in Flail Chest
Table 2. Results of surgical and nonsurgical treatment of flail chest
Surgical Nonsurgical Variables Fixation IPPV Non-IPPV No. of patients 27 19 18 Ventilation (days) 3.1 ± 1.8 6.6 ± 5.9
7.8 ± 5.7 Hospital stay (days) 18.3 ± 7.6 17.2 ± 6.6 21.3 ± 7.1 Morbidity 3 (11.1%) 2 (10.5%) 2 (11.1%) Mortality 3
(11.1%) 4 (21.0%) 6 (33.3%)
IPPV = intermittent positive pressure ventilation.
on admission (blood pressure < 80 mmHg), associated pulmonary contusion, and associated injuries
(especially head and abdominal injuries). Heavy sedation or paralysis was required in 11 (17.2%) patients
who were agitated or needed high oxygen. All other patients were sedated with midazolam. Twenty-nine
patients (45.3%) had moderate to severe pulmonary contusions (18 patients scored 4–6, 11 scored 7–9).
Pulmonary contusions occurred in 12/14 (85.7%) patients with more than 8 rib fractures, 7/10 (70.0%)
with multiple rib fractures and bilateral flail, and 10/40 (25.0%) of the remaining patients. Analysis of the
frequency of pulmonary contusion revealed that patients with > 8 rib fractures or multiple fractures with
bilateral flail chest had more pulmonary contusion (mean contusion score 7.1 versus 4.4 in the others;
chi-squared test, p < 0.05).
Thirteen (20.3%) patients died. Primary determinants of adverse outcome were associated injuries, blood
loss > 6 units, bilateral flail, and age > 50 years in groups 2 and 3; all except bilateral flail predicted an
adverse outcome in group 1. Pulmonary function tests 30 days after discharge showed forced vital
capacity was 68%–78% of predicted. There was no difference ( p = 0.21) between group 1 versus groups
2 and 3.
Among the 27 group 1 patients, 4 (14.8%) were unconscious on admission, 3 (11.1%) had undergone
abdominal surgery, and 1 (3.7%) had severe head trauma. Fractures were anterior in 19 (70.4%) and
lateral in 8 (30%). An anterolateral thoracotomy was performed in 20 (74.1%) and a posterolateral
thoracotomy in 7 (25.9%). Indications for fixation of flail chest were concomitant thoracic operations that
allowed simultaneous repair of the flail segment (12 patients), gross instability of a large segment of the
chest wall (11 patients), or severe unremitting pain related directly to the fractures (4 patients). Indications
for thoracic operations that allowed the simultaneous repair of a flail segment were massive air leak from
the lung parenchyma in 6, bleeding in 4, and rupture of a bronchus in 2; primary suture of the ruptured
bronchus
2004, VOL. 12, NO. 1 13 ASIAN CARDIOVASCULAR & THORACIC ANNALS was performed in 2, intercostal artery
ligation in 3, and suturation of lung parenchyma in 7. No resection was performed. Thirteen (48.1%)
patients were operated upon during the first 12 hours because of associated injuries (thoracotomy for
bleeding in 4, diaphragm injury in 3, open chest wound in 3, ruptured spleen in 2, and ruptured liver in 1).
All except 2 patients were operated on within the first 48 hours of trauma. The other 2 were intubated on
the 2nd and 4th days after the trauma while they were hospitalized due to impaired respiration. On the 1st
or 2nd day of IPPV, they underwent open fixation because of blood gas deterioration. Both were weaned
from the ventilator within 24 hours and discharged from hospital 6 and 8 days after open fixation. Pain
control was achieved with nonnarcotic analgesics, even in patients who had undergone surgery due to
unremitting pain. No epidural analgesia was needed postoperatively. The rate of ventilatory support was
77.8% (21/27) postoperatively; none of the 6 who were not ventilated died. The duration of ventilation
ranged from 1.5 to 22 days, and hospital stay ranged from 9 to 32 days (Table 2). Morbidity in group 1
comprised postoperative bleeding in 1 and atelectasis in 2 cases; no reoperation was needed,
bronchoscopic aspiration was sufficient to resolve atelectasis. The mortality rate was 11% in group 1 and
14.3% (3/21) among those receiving ventilatory support. Two of the patients who died had undergone
abdominal surgery and were unconscious at the time of admission, the other died immediately
postoperatively from probable myocardial contusion suspected from electrocardiographic anomalies.
All 37 nonsurgically treated patients (groups 2 and 3) were admitted within the first day of the trauma
causing flail chest and all were conscious. None had undergone a non-thoracic operation before
admission. Fractures were anterior in 16 patients (43.2%) and lateral in 21 (56.8%). All patients received
effective pain control with epidural analgesia in 13 (35.1%), intercostal nerve blockade in 16 (43.2%), and
narcotic or nonnarcotic parenteral analgesia in 8 (21.6%). However, all suffered pain in spite of epidural
analgesia or intercostal blockade. Additional parenteral analgesia
Open Fixation in Flail Chest Balcı
PaCOfailure 2 requiring hemodialysis developed in one
was needed to reduce the pain, with opioid drugs most
patient and she died after the 3rd dialysis (17 days
frequently used. The mean duration of paradoxical
after the trauma). One chest wall deformity (pectus
chest wall movement was 6.6 days (range, 3–21
carinatum-like appearance of right upper hemithorax)
days), and ventilatory support (Table 2) ranged from 3
was observed.
to 23 days (mean, 7.2 days). The mean hospital stay
was 19.6 days (range, 8–33 days) and morbidity was
11.1% (pneumonia successfully treated with
DISCUSSION The treatment of flail chest injuries has
isepamicin in 3, and atelectasis in 1). A diagnosis of evolved over the last 4 decades from immediate
pneumonia was established by high fever (> 39°C), endotracheal intubation for at least 7–10 days with a
infiltration on chest radiographs, and culture of mandatory tracheostomy until there was no movement
tracheobronchial aspiration material. Atelectasis of the flail segment, to the present when every effort is
persisted during ventilatory support; after weaning, made to provide good analgesia and avoid intubation.
bronchoscopy was performed to resolve it. Overall Many series showed a need for intubation in only 50%
mortality in the nonsurgical patients was 10/37 of patients with flail chest, and mortality rates from
(27.0%). Five of the patients who died had been relatively isolated injuries may be as low as 5%. It is
diagnosed with pneumonia; antibiotic treatment was felt that the major injury requiring ventilatory support is
unsuccessful. Two had severe head trauma and underlying pulmonary contusion and not the motion of
mannitol was administered to resolve brain edema. the chest wall. Some have advocated operative
Acute respiratory distress syndrome with a high fixation of a flail segment so that there is no motion,
but this greatly over simplifies the pathophysiology of
despite respiratory treatment occurred in 2. Renal the problem. We evaluated patients on the basis of
underlying pulmonary injury, especially pulmonary
contusion, and applied appropriate treatment. We egree of deformity or paradoxical motion was more
advocate early surgical treatment in high ISS trauma pparent.
cases.
ne reason for the controversy concerning treatment
The results were not skewed by other factors in the that mortality for flail chest has not changed in
surgical group, but some patients in groups 2 and 3 ertain centers over the past several decades. This is
may have had a poor prognosis from other injuries and espite obvious advances in the overall care of trauma
been considered too ill to operate on (mean ISS in ctims and marked improvements in ventilatory
group 1, 18.3 versus 21.0 in groups 2 and 3). Some upport techniques.12,13 However, decreases in
patients may require ventilatory support despite ortality from 30%–40% in 1976 to 11%–60% in the
surgical treatment. Prolonged paradoxical motion of 980s have been reported.5 The major cause of
the chest wall before spontaneous stabilization occurs ortality and morbidity is respiratory failure resulting
can lead to additional mechanical impact on the om contusion or laceration by a detached rib
contused lung area by the flail segment. Furthermore, agment. With large flail segments, mediastinal shift is
the broken rib tips may disrupt the lung parenchyma. ossible, with accompanying decreased venous return
Early surgical stabilization can prevent additional injury the heart. Depressed rib segments impart a
as well as promote earlier weaning from the ventilator. ushing injury and may penetrate the diaphragm,
Less analgesia may be ng, heart or aorta.14 In this series, massive air leaks
required postoperatively, and these factors may lower om lung parenchyma and bleeding caused by flail
morbidity for isolated flail injuries. Open fixation of the egments were observed. Impaired pulmonary
chest wall may be a good alternative for patients who nction has been documented in long-term survivors;
have deteriorated under ventilatory treatment because 3% of patients reported dyspnea, 49% reported
it shortens the ventilator time and decreases mortality. ersistent pain, 57% had abnormal spirometry, and
0% had abnormal treadmill tests.5 Pulmonary tests
There have been no randomized studies of surgical vealed no significant differences in our series. It has
and nonsurgical treatment, most studies are ot been proved that IPPV is beneficial in traumatic
retrospective, and the choice of whether or not to carry ail chest, in the absence of other indications.8
out surgery is highly variable and based entirely on the creases in routinely performed tracheostomy with
surgeon’s experience.11 The obvious indication for a ng-term ventilation until the flail segment stabilized or
surgical approach is an internal injury requiring a ntil the pulmonary contusion was no longer present
thoracotomy. Some surgeons routinely perform open n the chest radiograph led to a high incidence of
fixation of flail chest when a thoracotomy is undertaken osocomial infections and tracheostomy complications
for other indications.5 In our opinion, this is the correct at resulted in severe disability or death.12,15 In this
approach; however, surgical intervention should also eries, the most prominent factors causing an adverse
be considered in patients with excessive paradoxical utcome were associated injuries and pulmonary
movement, deteriorating clinical status, or unremitting ontusion. We observed more contusion in patients
pain. The locations of the fractures differed between th > 8 rib fractures and with bilateral flail. Pneumonia
the surgical and nonsurgical groups, and surgery was as an important cause of mortality.
performed in some group 1 patients because the
ASIAN CARDIOVASCULAR & THORACIC ANNALS 14 2004, VOL. 12, NO. 1
Balcı Open Fixation in Flail Chest
Different methods have been used for the stabilization of fractured segments, all of which have been
reported
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