Surgical reconstruction of traumatic flail chest with titanium plaques

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InternationalJournalofSurgeryCaseReports50(2018)72–74

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Surgical

reconstruction

of

traumatic

flail

chest

with

titanium

plaques

Tuba

Apaydın

_,

_Berk

_Arapi

_,

_Cem

_Bas¸

_aran

a_{ThoracicSurgeryUnit,BitlisStateHospital,Bes¸MinareDistrict,SelahattinEyyübiStreetNu:160,13000,Bitlis,Turkey}

b_{DepartmentofCardiovascularSurgery,IstanbulUniversityCerrahpas¸aMedicalFaculty,KocaMustafaPas¸aDistrict,Cerrahpas¸aStreetNu:53,34096,}

Fatih, ˙Istanbul,Turkey

c_{AnesthesiologyUnit,AntalyaGazipas¸aStateHospital,CumhuriyetDistrict,HastaneStreet,07900,Gazipas¸a,Antalya,Turkey}

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Articlehistory: Received17May2018

Receivedinrevisedform25July2018 Accepted27July2018

Availableonline1August2018 Keywords: Flailchest Stabilization Titanium Plaque Trauma Casereport

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INTRODUCTION:Multipleribfracturesexposesseriousrespiratorydisordersandtheyaregenerallytreated

withnonsurgicalmethods.Nevertheless,incasesoflongtermpaindespitemedicaltreatment,

parenchy-malinjury,hematoma,posturedisorderandflailchest,surgeryisneeded.Flailchest,asthemostcritical

formofbluntchesttrauma,candisturbthehemodynamicofpatientsignificantlyandthreatenlife.This

workhasbeenreportedinlinewiththeSCAREcriteria.

PRESENTATIONOFCASE:A32yearoldmalepatientreferredtoourhospitalwithflailchestinintubated

statusduetoindustrialaccident.Inphysicalexamination,therewasdisplaceddissociationinlower1/3

ofsternumandpericardiumwaspalpatedinthesubcutaneustissue.InthoraxCT,therewasfracture

bothintheright7-8.costochondralandintheleft8.costochondraljoints.Additionally,crepitationwas

palpatedinthesejoints.Therewasflailchestintherightanteriorhemithoraxandinthelowersternum.

Patientwastreatedwithchestwallreconstructionwithtitaniumplaques.

DISCUSSION:Incasesofflailchest,afterafewdaysmechanicalventilation,implementingstabilization

providesarapidhealing.

CONCLUSIONS:Webelievethereissignificantplaceofsurgeryforstabilizationinpropercases.

©2018TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen

accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Thoraxinjuriescomposesawidespectrumfromsimplerib

frac-turestocomplex chestwallinjuries [1]. Flailchestis themost

criticalformofbluntthoraxtraumas[2–4].Thepathologyisstated

as three or more sequential ribsfractured in two places,with

orwithoutasternalcomponent,withaccompanyingparadoxical

movementofthechestwall[5].Inflailchest,withmediastinal

flut-terrelatedtotheparadoxicalmovementofthechestwall,related

tothepressureonSVCandIVC,hemodynamicscanbedisturbed

andthepatientcanundergocardiacarrest[6].Althoughinmost

ofthecasesofchestwalltraumassurgicalreconstructionisnot

needed[4–8],surgicalstabilizationwasshowntobeusefulin

cer-tainsubgroupofpatients[5].Specificguidelinesaredeficientfor

themanagementof certaincombinationsofchest wallinjuries,

becauseoftheirlowincidence.Oneinstanceisthesternochondral

dislocationaccompanyingsternalbodyfracture[5].

∗ Correspondingauthor.

E-mailaddress:tubaapaydn72@gmail.com(T.Apaydın).

2. Presentationofcase

A32yearoldmalepatientreferredtoourhospitalwithflailchest

inintubatedstatusduetoindustrialaccident.Arrivalbloodgasto

theintensivecareunitwasPh:7.46PCO2:44PO2:62Sat:92.There

wasairleakfrombothofthechesttubeswhichwereinserteddueto

hemopneumothoraxinoutercenter.Inphysicalexaminationthere

wasdisplaceddissociationinlower1/3ofsternumandpericardium

waspalpatedinthesubcutaneoustissue.Therewasfractureand

crepitationbothintheright7–8.costochondralandintheleft8.

costochondraljoints.Flailchestwaspresentintherightanterior

hemithoraxandinthelowersternum.Rightchesttubewas

con-ductedtocomco.Airleakintheleftchesttubewasinterrupted

in2.dayofhospitalization.Inthe3.dayofhospitalization,after

asternotomyincision,fracturerangewasaccessed(Fig.1a).

Dis-placedfractureswasnoticedintheright7.-8.costochondraljoints

andleft8.costochondraljointsandsternumlower1/3portion.

2flatplaquesand8screwsforthesternumand4flatplaques

and30screwsfortheright7–8.costochondralandleft8.

costochon-draljointswereusedforstabilization(Fig.1b).2hemowakdrains

wereplacedunderpectoralismuscles.Postoperatively,patientwas

transferredtotheintensivecareunitinintubatedstatus.Airleakin

therightchesttubeinterruptedpostoperatively.Inpostoperative1.

day,patientwasextubatedandmobilized.Inpostoperative2.day,

leftchesttubewasextracted.InPO3.day,thepatientwas

trans-https://doi.org/10.1016/j.ijscr.2018.07.033

2210-2612/©2018TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

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T.Apaydınetal./InternationalJournalofSurgeryCaseReports50(2018)72–74 73

Fig.1. a)Preoperativeviewofthechestwall.b)Postoperativeviewofthechest wall.

ferredtoservice.InPO5.day,rightchesttubeandhemowakdrains wereextracted.PatientwasdischargedfromhospitalinPO13.day withaprominenthealinginrespiratoryfunctionsandrecoveryof pain.Inpostoperative2.monthpolicliniccontrol,patienthadno chestwalldeformity,breathingvoicewasequalinbothhemithorax andPAgraphy(Fig.2a)andlateralgraphy(Fig.2b)wasevaluated

asnormal.

3. Discussion

Althoughmostofthepatientswithribfracturesarefollowed

ina conservativemanner;unavoidable respiratoryinsufficiency

despiteaggressivemedicaltreatment,severechestwalldeformity,

persistentpain,inabilitytoendmechanicalventilation,

thoraco-tomyneededforanotherreasonaretheindicationsforsurgical

stabilization[2–7].Inourcase,becauseofflailchestcomposinga

wideareaoftheanteriorchestwall,stabilizationprovidedarapid

andeffectivebenefitintheearlyperiod.

Exceptbilateralribs,fracturesontheanteriorcartilageareacan

causeflailonsternum[5].Inourcase,basicfactordisturbingthe

Fig.2.a)Posteroanteriorviewofpostoperativegraphy.b)Lateralviewof postop-erativegraphy.

hemodynamicsofpatientwasdisplacedfracturesontheanterior

cartilageareaandsternum.

Morbidityfactorsassociatedwithflailchestcomprises

mechani-calventilation,pneumonia,chestwalldeformitiesandchronicpain.

Pulmonarycontusionscanworsenthepatient’sprognosis.Anterior

flailsegmentshavebeenreportedtohavehighermorbidityrate

comparedtolateral[6].Ourpatient’sflailsegmentswerealsoon

anteriorlocation,buttherewasn’tanassociatedprominent

pul-monarycontusion.

Themostfrequenttreatmentmodalityforflailchestismechanic

ventilationtoday[4–8].However,intheliterature,it’sreportedthat

surgicalribstabilizationdemonstratedcoherentresultscompared

toconservativemanagement, regarding duration of mechanical

ventilation,durationofhospitalizationinintensivecareunitand

totaldurationofhospitalization,incidenceofpneumonia,andneed

fortracheostomyinflailchestpatients[1].Ourpatientwasalso

extubatedandtakenout oftheintensivecareunit withoutany

postoperativecomplicationsoonafterthesurgicalstabilization.

Dataonthesurgicalstabilizationoflateralflailchestevolves

today,however,reportsonthesurgicalapproachtosternochondral

regard-CASE

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74 T.Apaydınetal./InternationalJournalofSurgeryCaseReports50(2018)72–74

inguseoftheNussprocedureandmodifiedRavitchprocedurefor sternalstabilization[5].Weused2flatplaquesforsternumand

4flatplaquesforribswithfracturesonsternochondraljunctions

afterasternotomyincision.

Inadditiontolockedplates,otherosteosynthesismaterialslike

ribclampsystemscanbeusedoraninternalbracingofthechest

wallcanalsobeperformedbythewayofbars[8].However,clemp

systemshavesignificantriskofimplantfailureandbarshavethe

riskofsternumfracture[8].Inourcaseweusedtitaniumplaques.

Lockedplateosteosynthesishasevolvedtothemostwidespread

andsafestmethodforthesurgicaltherapyofsternumandrib

frac-tures[8].

4. Conclusion

Stabilizationofribfractureswithtitaniumplaquesisasafeand

easymethodgivingrapidresults[9].Forthisreason,inpropercases,

webelievethereissignificantplaceofsurgeryforstabilization.

Conflictsofinterest

Nonedeclared.

Funding

Thisresearchreceivednospecificgrantfromanyfundingagency

inthepublic,commercial,ornot-for-profitsectors.

Ethicalapproval

Theethicalapprovalhasbeenexemptedasitwasnotnecessary

inthiscasereportbyourinstitution.

Consent

Writteninformedconsentwasobtainedfromthepatientfor

publicationofthiscasereportandaccompanyingimages.Acopy

ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief

ofthisjournalonrequest.

Authorcontribution

TAgatheredthepatient’sdataandwrotethemanuscript.TA,

BA,CBparticipatedinthesurgery.TA,BA,CBreviewedmanuscript.

Allauthorsapprovedthefinalmanuscript.

Registrationofresearchstudies

Registrationofourstudyathttp://www.researchregistry.com

iswaivedbecauseitregisterscaseseriesorothergroupstudiesor

firstinmancases,ourcaseisasinglepatientwhichisnotafirstin

man. Guarantor TubaApaydın,MD. Acknowledgement None. References

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