a new method of treating the flail chest wall

7
A New Method of Treating the Flail Chest Wall -" " .... , ..... '~ , Rumania (.)CTAV CON.~TANFINESCU, ~uchar~,,sl, ~.D., T Rt';A'I'MENT of injury to the rib l)antl is a stringent problem in emergency surgery. Present mtthods are not founded oll a unitary and methodical practice which can supply statistical data from which conclusions and therapeutic principles may be drawn [1-3 ]. For inst:ulce, osteosynthesis is inaptfiicabte in most eases since whatever procedure is used (such as, cerclage, suture, or wiring) the operation is cmnplieated by anesthetic hazards, numtrous incisions, and long traumatizing surgical ma- neuvers that are dil'ficult to perform and not easily sut)porttd by patients with acute severe respiratory and circulatory insufficiency. The nufitiplicity of fracture foei. their occa- sional bilateral aspect, the broad laceration of tissue, tilt impossibility of obtaining effieitnt osteosynthesis in tile ehondriocostal or ehon- driosternal fracture foei. as well as tile poor restfits of immobilization render tile method inat)plicable in cases in wlfich the rib panel must be immc)biliztd immediately [4]. METIIOI)S OF TREATMENT Traction of the t)anel (Suspension or Exten- sion). This method is frequently recom- mended in the literature lint does not mttt the requirtments of treatment [5]. Practice has shown that all the proetdures used for traction of tht tmnel, including sew:ral devised at our clinic, arc not reliable. They are wrongly conceived, deficient, and technically very difficult to support. Mortover, the results as a rule are not good. The severe respirat~ry disturbances to which very mobile rib panels g~ve rise are dut to the paradoxical movements of the pantl and to a diminuti~m in the amplitude of the respiratory mf)vements of the involved htmitlmrax. The best method of treatment is that which sup- presses the paradoxical movenmnts of tile panel and favors good ventilation bv insuring both amI)litude and ahnost normal respiratory movements of tile involved henfithorax. Traction dots not meet with these end._. ~ s It suppresses the "active" paradoxical move- ments of the panel. The panel is no longer drawn inward in inspiration, but in exchange it is fixed in a converse paradoxical position and is suspended throughout expiration. In this posi- tion the portion of tile thoracic wall represented by, the panel takes absolutely no part in the respiratory movtments. What is more impor- tant is that the suspended panel in its turn pulls at the surrounding damagtd wall of the hemithorax, rtstrieting the amplitude of the respiratory movements (expiration) according to the mnount of traction exerted, hence pre- venting t:mlmonary ventilation. Traction cannot suppress the abnormal movements in the rib fracture loci and there- fore not the pain. Breathing bec~mms laborious because of the pain, and the patient avoids coughing st) that secretions accumulate in tht bronchi, one of tht most severe problems in these p,ttmnt." "~ s and a foremost complication to be avoided [6-9]. A further drawback with traction is the posture in which the patient is immobilized in bed; it is harmful from the viewpoint of puhnonary ventilation, unpleas- ant, irritating, and almost unbearable. Trac- tion is difficult to maintain because the patient moves especially during sleep when he loses control and mav Imll down the entire inst'dla- tion. After applying several known traction pro- cedures without any results, I devised and applied a system by which the rib panel was anchored bv fixing hooks resting directly upon the ribs. 604 American Jm~rnal of Surgery

Upload: octav-constantinescu

Post on 01-Dec-2016

221 views

Category:

Documents


2 download

TRANSCRIPT

Page 1: A new method of treating the flail chest wall

A New Method of Treating the Flail Chest Wall

-" " . . . . , . . . . . '~ , Rumania (.)CTAV CON.~TANFINESCU, ~uchar~,,sl, ~.D.,

T Rt';A'I'MENT of in jury to the rib l)antl is a s tr ingent problem in emergency surgery.

Present mt thods are not founded oll a uni tary and methodical practice which can supply statistical da ta from which conclusions and therapeutic principles may be drawn [1-3 ]. For inst:ulce, osteosynthesis is inaptfiicabte in most eases since whatever procedure is used (such as, cerclage, suture, or wiring) the operat ion is cmnplieated by anesthetic hazards, numt rous incisions, and long t raumat iz ing surgical ma- neuvers tha t are dil'ficult to perform and not easily sut)porttd by patients with acute severe respiratory and circulatory insufficiency.

The nufitiplicity of fracture foei. their occa- sional bilateral aspect, the broad laceration of tissue, tilt impossibility of obtaining effieitnt osteosynthesis in tile ehondriocostal or ehon- driosternal fracture foei. as well as tile poor restfits of immobilization render tile m e t h o d inat)plicable in cases in wlfich the rib panel must be immc)biliztd immediate ly [4].

METIIOI)S OF TREATMENT

Traction of the t)anel (Suspension or Exten- sion). This method is frequently recom- mended in the l i terature lint does not m t t t the requi r tments of t rea tment [5].

Practice has shown tha t all the proetdures used for traction of th t tmnel, including sew:ral devised at our clinic, arc not reliable. They are wrongly conceived, deficient, and technically very difficult to support. Mortover , the results as a rule are not good.

The severe respirat~ry disturbances to which very mobile rib panels g~ve rise are d u t to the paradoxical movements of the pant l and to a diminuti~m in the ampli tude of the respiratory mf)vements of the involved htmit lmrax. The best method of t rea tment is that which sup-

presses the paradoxical movenmnts of tile panel and favors good venti lat ion bv insuring both amI)litude and ahnost normal respiratory movements of tile involved henfithorax.

Trac t ion dots not meet with these end._. ~ s It suppresses the "ac t ive" paradoxical move- ments of the panel. The panel is no longer drawn inward in inspiration, but in exchange it is fixed in a converse paradoxical position and is suspended throughout expiration. In this posi- tion the portion of tile thoracic wall represented by, the panel takes absolutely no part in the respiratory movtments . Wha t is more impor- t an t is tha t the suspended panel in its turn pulls at the surrounding damag td wall of the hemithorax, r ts t r ie t ing the ampl i tude of the respiratory movements (expiration) according to the mnoun t of traction exerted, hence pre- vent ing t:mlmonary ventilation.

Tract ion cannot suppress the abnormal movements in the rib fracture loci and there- fore not the pain. Breathing bec~mms laborious because of the pain, and the pat ient avoids coughing st) tha t secretions accumula te in th t bronchi, one of t h t most severe problems in these p,ttmnt." "~ s and a foremost complication to be avoided [6-9]. A further drawback with traction is the posture in which the patient is immobilized in bed; it is harmful from the viewpoint of puhnonary venti lat ion, unpleas- ant, irritating, and almost unbearable. Trac- tion is difficult to maintain because the pat ient moves especially during sleep when he loses control and mav Imll down the entire inst'dla- tion.

After applying several known traction pro- cedures wi thout any results, I devised and applied a system by which the rib panel was anchored bv fixing hooks resting directly upon the ribs.

6 0 4 American Jm~rnal of Surgery

Page 2: A new method of treating the flail chest wall

T r e a t m e n t of F la i l C h e s t \Vail

The hook (Fig. 1) is actual ly a troear bent at a right angle at one end; within the trocar is a mandrel similarly bent. The horizontal limbs of the trocar and mandrel can he turned, with the aid of a but terf ly nu t tixed on the tube of the trocar, to an angle of IS0 degrees, thus closely resemMing an anchor or inverted T in shape. (Fig. 2.)

The horizontal limbs, joined together, are introduced through the intercostal space in the middle of the lmnel (like a lmneture needle) into the pleural cavity. With the aid t)f the but ter f ly nut. the horizontal limbs are ¢,pened I Nll degrees anti fixed ut)on the supra- and sut)- jaceut ribs. aneh~ring the panel and pulling it by a weight tied to a c~rd tha t runs over a trolley.

This system of traction of the panel was applied in a tKty-ei,ght year old pat ient (1. P.) with mult iple t r auma to the right anterolateral rib panel involving the sixth to the eighth ribs, paradoxical respiration, and acute respiratory insufficiency.

The t)atient was obliged to remain motionless in bed for seven days, wi thout cimnging his position. This was extremely difficult to bear, and the installation had to be readjus ted sev- eral t imes because he h a d moved during the night.

Respiration was laborious and l)ains accom- panied each movement or a t t e m p t at deep breathing. Coughing was racking because of pain and evacuat ion of the bronchi became ahnos t impossible.

We concluded tha t this method was difficult to supi)ort and its efficiency doubt fu l , there- fore. it was abandoned.

Assisted Respiration. This method presents certain drawbacks and hazards because of tile necessity of mainta in ing intut)at ion for several da vs .

This method is not current ly in use because it cannot be applied in every hospital. Specially trained personnel, a special al)paratus, and un in te r rup ted survey are necessary.

We have not had experience with this method, b u t from a s tudy of the l i terature [1,10] and from our practice of long lerm intu- bat ion in pat ients with o ther indications, such as coma, it m a y be s ta ted tha t : (1) this method demands an intact bronchial tree, free of any secretion; (2) in tubat ion main ta ined for a longer time often causes puhnonary supptmt- lion; (3) synchronizat ion of the pat ient ' s

i~ .i I

[

1 2

FIG. 1. T h e cl,~scd d e v i c e ( l m ~ k ) for a , t c l m r i u g f r a c t u r e d r i b s a n d Danel .

[?IG. 2. "['ht" S~IIIIC d e v i c e . , q ) en t ' d , a f t e r i l l t r t ) d l t c t i o t l i n t o t h e i n t e r c o > t a l VlmCe

respiration with the movenlents of the machine is diltieult and sometimes impossible, as tile pa t ien t struggles against the r h y t h m of tile respirator and is subject to severe t]ts of suffoca- t ion; (4) the in f l ammato ry lesions due to prolonged in tuba t ion m a y produce i r r i ta t ing sequelae, such as paresis of the vocal cords and stenosis. For these reasons we consider the method eomi)lieated, difficult, alld full Of hazards in cases in which t r e a t m e n t shouhl be readi ly available, efficient, and easily applica- ble. Another method of t r ea tmen t is t h a t of fixin~ the rib panel by an external t?~,ing device [11,1:,1.

Our clinical experience led us to conclude tha t correct t r e a t m e n t of tile rib panel should meet with the following condit ions: (1) to suppress the paradoxical movements of the panel; (2) to give the pa t ient mobi l i ty in bed; (3) to insure freedom of the pat ient ' s move- ments of body and limbs; (4) to reintegrate the panel in the r h y t h m and, as far as possible, in the degree of mnpl i tude of the respiratory movements of the rest of the thorax by uni t ing it to the thoraeie wall; (5) to make coughing and evacuat ion of the bronchial secretions possible; (6) to suppress pain; (7) to avoid infection o f the brcmehioalveolar tree.

The high proport ion of pa t ients with thoracic t r a u m a hospitalized direct ly or referred b y

VoL i09, 3lay 1965 6 0 ~

Page 3: A new method of treating the flail chest wall

C o n s t a n t i n e s c u

!!:i i 1

3 4

Fro. ;3. The rib panel fixing device. [-k'hematie leprc- sentalion showing how tile rib panel is fixed to the cxtrathtmtcic plaque which rusts ut)on fixed p~dllts around the panel,

FIG. 4. A [r~mt vit'w of tile same device. The plaque is larger than the panel in all direct:tins.

o t h e r u n i t s to o u r c l in ic as well as t he s e v e r e a s p e c t of m a n v of t he se cases r e p r e s e n t a n i m p o r t a n t im~t)lem in o u r p r ac t i c e . T h e s t a t i s - t ics of o u r s e rv i ce s h o w t h a t f r om J u n e 1, 1960 to J u n e 1, 196-t, 1 ,370 p a t i e n t s w i t h s i m p l e o r c o n l p l i c a t e d t h o r a c i c t r a m n a , f r a c t u r e of t h e r ibs , w i th or w i t h o u t viscertf l lesions, we re hos- p i t a l i zed . Of t h e s e p a t i e n t s t w e n t y - e i g h t o r 2 pe r c e n t r e q u i r e d t r e a t m e n t o f t h e r ib pane l .

T h e r e we re t w o s t ages i l l t h e t h e r a p e u t i c m a n a g e m e n t of i n j u r e d r ib pane l s in o u r cl inic . In t he f i rs t s t age (1960 to 1962), t h e r e was no l e ad in g t h e r a p e u t i c d o c t r i n e . T h e s e c o n d s t a g e b e g a n t o w a r d t h e e n d of 1962. T r e a t m e n t was a p p l i e d a c c o r d i n g to m o r e p rec i se i n d i c a t i o n s and t he p a n e l was fixed in cases i n d i c a t e d b y a m e t h o d a n d a p p a r a t u s wh ich I d e v i s e d in t h e c l in ic ( t he r ib p a n e l f i xa to r ) .

R i b l S z m ' l F i x a t i o n . In an a t t c l n p t to f ind a t h e r a p e u t i c s o l u t i o n w h i c h w o u l d m e e t w i t h t he a f o r e m e n t i o n e d r e q u i r e m e n t s , we f o c u s e d o u r a t t e n t i o n on a m e t h o d t h a t c o n s i s t e d of f ix ing t h e r ib p a n e l b y a d e v i c e wh ich a n c h o r s t he f r a c t u r e d r ibs d i r e c t l y tit two o r n lo r e p o i n t s a n d fixes t h e m a g a i n s t an c x t r a t h o r a c i e p l a q u e r e s t i ng u p o n t he h e a l t h y reg ion a r o u n d t h e pane l . (F ig . 3 a n d 4.)

T h e p r inc ip l e of t h e n l c t h o d c o n s i s t s in c o n j o i n i n g t he r ib pane l , e x t e r i o r p l a q u e , a n d

r c u l a i m l e r ~if t he d a n m g e d hcu l i t h~mtx in it sin~;le wh~)le, s u b j e c t to r e s p i r a t o r y i n o v e m e n t s a im a b l e to m a i l l t a i n a h u o s t n o r m a l a m p l i t u d e

T h e fixing dev icv is c~mq)osed of tile pane l t i xa tn r (l?i~ . 5) w i t h t w o l l ~ k t : ( l l imbs b e n t :it right all21cs. T h e cr~ss section1: (d the two lilnl3s ~if tilt ' tixat~w is se ln icv l i l td r ica l , :uld w h e n jo ined t~.u.ctller t he l imbs f o r m t h e t h r e a d e d tilt)t," ¢~f tile try)ear llpOI1 w h i c h t w o Ill.ItS a re f i t t ed

T h e s e c o n d p a r t of t h e a l ) i m r a t u s is a l ) laque ,ff p l a s t i c m a t e r i a l throu.~h w h i c h x - r a y s can p e n e t r a t e a n d which , w h e n h e a t e d , can 1)e m o l d e d ~m t h e reg ion to whicl , it is a t )pl ied. t h a t is. tilt.: d a m a g e d h e m : t h o r a x . (F'ig. 6.)

T h e t i s sues a n d i n t e r c o s t a l n e r v e s a re anes - t h e t i z e d w i t h 20 ml. of 1 per c e n t N o v o c a i n (~: a t t he p o i n t s a t w h i c h t h e l i x a t o r s a re i n t r o d u c e d ; a s l ight , p o i n t - l i k e incis ion is n t a d e on the skin w i t h t h e t ip of t h e b i s t o u r v to e n a b l e the t ips of the h o r i z o n t a l l imbs to p e n e t r a t e n lo re eas i ly .

T h e inc is ion is m a d e ill t i le c e n t e r of t h e i n t e r c o s t a l space , a n d t h e h (wizon ta l l imbs a re i n t r ( )duced t h r o u g h it a n d a h m g t h e p l e u r a l a s p e c t o f t h e s u p r a - a n d s u b j a c e n t r ibs . T h e f i xa to r is d r a w n b a c k s l i g h t l y to d e t e r m i n e w h e t h e r t h e l i mb s of t h e h o o k s g r a s p the r ibs well. T w o or m o r e f ixa to r s a r e t h u s m o u n t e d a t s eve ra l t ;o in t s o n t h e tmnel fo r b e t t e r a n c h o r a g e . A s te r i l e c o m p r e s s p r o t e c t s t h e w o u n d a r o u n d the fixat~)r.

T h e p l a s t i c e x t r a t h o r a c i c p l a q u e w h i c h was p r e v i o u s l y r o o M e d on t h e t h o r a x is a p p l i ed . I t s e d g e s n m s t be p l aced b e y o n d t h e s ides of the p a n e l to r e s t u p o n t h e h e a l t h y r eg ion s u r r o u n d - ing i t . c a r e f u l l y pas s ing t h e t u b e s o f t h e f ixa to r s t h r o u g h t h e s ide o p e n i n g s .

T h e p h t q u e is f ixed u p o n t h e t h o r a x w i t h t he a id o f t h e n u t s w h i c h a re a t t a c h e d t o t he f ixa tors . T h e h o o k e d l i mb s of t h e f i x a t o r Imll t h e t h o r a c i c wal l a g a i n s t t h e p l a q u e , fix i t t o the l a t t e r , t h u s f o r m i n g a s ingle wht :e w i t h the h e m : t h o r a x .

W i t h o u t i n c u r r i n g a n y h a z a r d o r c o m p l i c a - t ion as m a y b e seen f r o m o u r e x p e r i e n c e , t h i s m e t h o d h a s g i v e n v e r y good r e s u l t s in m a i n - t a i n i n g m o b i l i t y in t h e t r e a t m e n t of i n j u r e d r ib p a n e l s a c c o m p a n i e d b v p a r a d o x i c a l m o v e m e n t s a n d a c u t e r e s p i r a t o r y i n su f f i c i ency . \Ve d id no t c o n s i d e r it n e c e s s a r y to fix e v e r y c a s e of r ib pane l .

I n d i c a t i o n s d e p e n d u p o n : (1) T h e l o c a t i o n of t h e i n j u r e d pane l . A n t e r o l a t e r a l a n d l a t e ra l pane l s a r e v e r y n tob i le ; p o s t e r i o r p a n e l s a r e less mobi le . (2) T h e n u m b e r of r ib f r a g m e n t s a n d

6 0 6 A met:can Journal of Surgery

Page 4: A new method of treating the flail chest wall

T r e a t m e n t o f l ' l a i l C h e s t \ V a i l

A I~

I:IG. (:0, A, Lilt" trmcl fixing device has two. ho,kcd artn~ (a and b) t~t:ttt :it right (lllglt'S. "['he shafts art. seulicylindrieal -':nd joined t~,g.ether fornling a scrcw llll{)il which a lltit {c) i,~ itlotlilted. [{. tim instruinent a~st:mblt, d.

t he r e l a t i o n s h i p of the r ib e n d s to . h e a n o t h e r in t he f r a c t u r e ioci. A t t r i t i o n paue l s a re t h e m o s t m o b i l e ; i m p a c t i o n of the r ib e n d s in t he f r a c t u r e foetls fixes t he pane l , a n d the c o n v e r s e is t rue . (3) T h e s t a t e of t he p l e u r a a n d l u n g s p r io r to the a c c i d e n t . P a c h y p l e u r i t i s o r pu l - m o n a r y sclerosis r e s t r i c t s the m o b i l i t y of t he pane l a n d local izes i ts e f fec t s ; t im m o r e tiffs oemt rs the b e t t e r t he n t e d i a s t i n u m is fixed. All of these f a c t o r s d e t e r m i n e t he s t a t e of m o b i l i t y of t h e p a n e l u p o n w h i c h t he c l in ica l m a n i f e s t a - t ions a n d l ) u h n o n a r y c<mH~lications d e p c u d .

31ATI,;R IA I,

T h e e x p e r i e n c e of o u r c l inic in t r e a t i n g i n j u r y to d i f f e r e n t p a r t s of the r ib pane l m a y be s u m m e d up as fo l lows:

B i l a t e r a l A n t e r i o r S t e r n o c o s t a l Pane l s

CASE I. The pat ient (B. I.), th i r tv-mne years of age, was admi t ted to the clinic on Novemtmr [0. 1963, with the following diagnosis: multiple t rauma. thoracic t r auma with fracture of the fourth to sixth ribs on both sides (bilateral anterior sternoeostal panel), acute respiratory insuttieiency, and fracture of the right r a d i us .

The panel was fixed bv the panel fixing device, and the pat ient recovered.

CASl¢ at, The pat ient (B. I.), th i r ty-e ight years of age, was admi t ted to the clinic in October 1963, with the following diagnosis: thoracic t rauma, frac- ture of the third to sixth r ight and second to fifth left ribs. transversal fracture of the s ternum (hi-

Vol. 109. alay 19t~5 (~07

FIG. {~. Tile cxtrathoracic plaque of plastic matc-rial with two metallic edges.

lateral sternoeostal panel), left lmm~ttmrax, right basal h<mmgen-us opaci ty (possible in t rapuhnonary henmtoma) , and acute resp i ra t - ry instlfticiellev.

The panel was fixed by. the panel fixing device. left p leurotomy with aspiration was performed, and the pat ient recovered.

CASE IH. The pat ient (M. G.). th i r ty-four years of age, was admi t ted to the clinic on J anua ry 2, 190-t, with the following diagnosis: thoracic t rauma. comminu ted fraeture rff the right collar bone, left s ternoclavicular avulsion, fracture of the first t~ sixth right and third to lifth left ribs (bilateral sternoeostal panel); right hemothorax, extensive suheutaneous emphysema; aettte respiratory and circulatory insufficiency: cardiac arrest for which resuscitation by external cardiac massage was carried ol l t .

Page 5: A new method of treating the flail chest wall

C o n s t a n t i n c s c u

l)esl)ite real l i l l l ; t l i ( ) i i , hlo¢)d p r e s s u r e did i1~)1 rise z tb( )ve 7i) l)l l l l , fig, l l t ) t eVel l lift.el" [ i \ ' t ' h ( ) u r s .

N()twithstandi11)g the h)w blood pressure the rib panel was fixed 1)v the l~t, nel tixin< device, f()lh)wed 1)v right pleur~t, uny with aspirat ion. One h(nAr a f te r illteI'vt'llti()tl, t)h)od t)ressul'e illere;tsetl t() 1111 llllll l IV. l 'he pat ient was discharged af ter a full rec()verv.

CASE IX'. The t)atient (B. 1.), slxty-cighl years ()f age, was admi t t ed ()n l )ecemhcr l, 19112, with the ft)lh)wing diagnosis: tlu)raeic t r a u m a with 1)ilateral f ractures ()f tile ribs (anteri()r sterm)c()stal panel); t)ulm()nury sclert~sis, chronic l)r(mehitis, l)aehy- pleurit is: acute rest)iratt)rv and circulatory insufli.. cienev, llh),)d t)ressure was .t.5 ram. I IK.

Tracheos to lnv was l)erforme(t. M,)l)ilitv of the panel was alm,)st impercet)til)le due t() an old t:)achy- t)leuritis process and imhnonar3" sclerosis, s() tha t it was necessary t() i tmnobilize the l)anel.

a l )a r t frt)ln t rache()st()inv, analgesics alld Sl)nttlnl lluidiliers were given, together with aet ivat i , m of respirat ion and cout~hing.

The lUttient was discharged from the hospital a f te r recover\ ' .

A n t e r o l a t e r a l Henr i p a n e l

T h i s is a c c o m p a n i e d in g e n e r a l b y m o b i l i t y d u e to e l a s t i c i t y of t h e c o s t a l c a r t i l a g e s u p o n w h i c h i t m o v e s as on a h inge . M o b i l i t y is s o m e - t i m e s v e r y a c c e n t u a t e d b e c a u s e of d i s p l a c e - m e n t of t h e f r a c t u r e d r i b e n d s a n d c r u s h i n g of t h e t h o r a x , c r e a t i n g s e v e r e r e s p i r a t o r y d is - t u r b a n c e s . In t h e s e cases , f i xa t ion of t he p a n e l is t h e f i rs t t h e r a p e u t i c m e a s u r e .

I n o u r c l in ica l e x p e r i e n c e we h a d t h r e e c a s e s of i n j u r y to t h e a n t e r o l a t e r a l h e m i p a n e l , o n l y t w o of w h i c h r e q u i r e d f ixa t ion .

CASE I. The pa t i en t (C. A.), twenty-one years of age, was admi t t ed on J a n u a r y 30, 19(i2, wi th the following diagnosis: mul t ip le t r auma , t r a u m a t i c shock, f rac ture of the lef t col larbone and scapula, f rac ture of the first t o four th left ribs ( l e f t an tero- lateral hemipanel) , with minimal paradoxical respira- tion. f rac ture of the r ight shank bones.

T r e a t m e n t was medical, wi thou t fixation of the panel, followed by favorab le evolut ion and recovery.

CAsE H. The pa t i en t (B. G.) , th i r ty-f ive years of age, w a s admi t t ed on Angus t 9, 1964, with the following diagnosis: mul t ip le t r auma , t r a m n a of the thorax with f rac ture of the third to ninth left ribs (anterola tera l hemipanel ) , and accen tua ted disloca- tion of the ribs, wi th crashing of the left hemi thorax ; rup tu re of the left d i a p h r a g m and hernia t ion of the abdominal viscera into the left pleural cav i ty ; to ta l c rashing of the left a rm, lacerated wound, and ex- tensive lacerat ion of the left thigh and shank, open f rac ture of the left t ibiotarsal ar t icula t ion; acu te

eirculat()rv :rod resl~irat¢,rv insulticiencv, and col- lqpse, l~h)od pressure c~)uht ll()t [)e obtained.

The fedlowinR pr~,cedurcs were perf( ,rmed: ex- ph}rativc thorac{}totny, lal)arotc)my for reducing tile herniated organs, su ture of the d iaphragnl ; amput : t - tion ()f the left :tlnl. dressing of the w()unds, and immohillzati~m (ff the left leg; fixati,,n (,f the panel.

There was g~)~)d evolut ion u I, to tile lifth day when tile t)atient died suddenly, t~lt~)d pressure had risen t() 12 :urn. llg.

C.\sI.: ur. T h e pa t ien t (P. C.), th i r ty -seven years of age, was admi t t ed on June S 19G4. with a diag- nosis ()f nmlt i lde t r auma , th~,racie l.raullla with fracture of the see,rod to sixth right ribs (left an tera- lateral lmnel), right hcnmtmeumothorax , and cranial collt n.siolls.

T r e a t m e n t co1:sisted of fixation ~ffthe rib panel by the panel fixing device, and right p l eu ro tomy with aspirati~m. Recovery followed. (Fig. 7.)

A n t e r o l a t e r a l a n d L a t e r a l P a n e l s

T h e s e a r e n()t.ed for t h e i r f r e q u e n c y a n d m o b i l i t y , a n d a r e a c c o m p a n i e d : b y s e v e r e dis- t u r b a n c e s in r e s p i r a t o r y d y n a m i c s . T h e f i rs t a n d m a i n t h e r a t ) e u t i e i n d i c a t i o n in t h e s e cases is f ixa t ion of t h e p a n e l .

W h e n the p a n e l is i m p a c t e d o r i t s m o b i l i t y is r e d u c e d f r o m o t h e r causes , s u r g i c a l f i xa t ion is n o t n e c e s s a r y as long as c o u g h i n g o r o t h e r m e c h a n i s m s do n o t d i s p l a c e i t ; t h e u s u a l m e d i - ca l t r e a t m e n t is a p p l i e d .

I n o u r c l in ic t e n p a t i e n t s w i t h i n j u r y to t h e a n t e r o l a t e r a l a n d l a t e r a l r ib p a n e l w e r e t r e a t e d . T w o h a d i m p a c t e d f r a c t u r e s T w o p a t i e n t s w i t h s eve re , m u l t i p l e t r a u m a a n d l a r g e v i s c e r a l r u p t u r e s died.

F i v e of t h e t en p a t i e n t s h a d b e e n h o s p i t a l - ized in t h e c l in ic b e f o r e 19G2. O n l y in t h r e e of f ive p a t i e n t s h o s p i t a l i z e d a f t e r 1962 w a s f ixa- t i on of t h e p a n e l i n d i c a t e d .

CASE L The pa t i en t (A. C.), f if ty yea rs of age, was admi t t ed on Ju ly 13, 1963, with a diagnosis of mult iple t r auma , thoracic t r a u m a with f rac ture of the four th to t en th r ight ribs (r ight an tero la te ra l panel), and right tmeumothorax .

T r e a t m e n t consisted of fixation of the panel with the panel fixing device and right p l e u r o t o m y with aspirat ion. T h e pa t i en t recovered.

CASE H. The pa t i en t (G. C.), f i f ty- two years of age, was admi t t ed in Sep t ember 1963, with a diag- nosis of thoracic t r a u m a with f rac ture of the fourth to sixth left ribs (left an te ro la te ra l panel) , and acute respiratory insufficiency.

Treatment consisted of fixation of the panel, and the patient recovered.

(308 A merican Journa l of Surgery

Page 6: A new method of treating the flail chest wall

T r e a t m e n t o f F l a i l C h e s t \ V a i l

7 S 9

I:l(;. 7. The left anterolateral panel fixed by the panel fixing device (lmtient P. C.).

FIG. S. Side view of the right anterolateral rib panel fixed hy the l)anel fixing device.

t;'m. 9. Front view of the same panel.

CASE III. The pat ient (I. C.). l if ty-eight years of age, was admi t ted on April 23, t96-4. Diagnosis was thoracic t r auma with right anterola tera t panel over the second to tilth ribs. paradoxical movements with acute resl)iratorv insufficiency.

T r e a t m e n t consisted of fixation of the panel, and the pa t ien t recovered

P o s t e r i o r a n d P o s t e r o l a t e r a l P a n e l s

T h e s e a r e c h a r a c t e r i z e d b y redt , ced m o b i l i t y , d u e to t h e s h o u l d e r b l a d e a n d m a s s of m u s c l e s t h a t c o v e r a n d p a r t l y fix t h e m .

T h e i n f l u e n c e on r e s p i r a t o r y d y n a m i c s is i n s i g n i f i c a n t a n d is m o s t l y d u e to pa in in the f r a c t u r e loci w h i c h r e s t r i c t s t h e a m p l i t u d e of t he r e s p i r a t o r y m o v e m e n t s a n d h i n d e r s c o u g h - ing.

I n j u r y to t h e s e p a n e l s does no t , as a ru le , n e c e s s i t a t e f ixa t ion . I n o u r cl inic , t r e a t m e n t in s e v e n ca se s c o n s i s t e d of t h e a d m i n i s t r a t i o n of ana lges ics , a l e o h o l - N o v o e a i n i n f i l t r a t i o n s a long t he i n t e r c o s t a l n e r v e t r a c t s , m o b i l i z a t i o n , ac- t i v e c o u g h i n g a n d r e s p i r a t i o n , s p u t u m f luid- ifiers, ae roso l s , a n d t h e l ike. I n t h e fo l l owing t w o cases t h e p a n e l f i x ing d e v i c e was a p p l i e d in v i ew of s e v e r e r e s p i r a t o r y d i s t u r b a n c e s .

C a s e ~, Th e pat ient (R. E.), fifty-six years of age, was admi t t ed on Sel) tember 15, 1963, with a diagnosis of thoracic t r amna with f rac ture of the fourth to ninth left ribs (posterotateral panel), paradoxical respiration, r ight pneumothorax , left pul- mona ry opaci ty, and acute resp i ra tory insufficiency

T r e a t m e n t consisted of fixation of the rib panel with the panel tixing device and right p leuro tomy with aspiration. Th e pa t ien t recovered.

Ca se It. The pa t ien t (N. C.), thirty-six years of age, was admi t ted on April 29, 1 !)64, with a diagnosis of thoracic t r auma with f racture of the third to ninth left ribs (1)osterolateral panel), left hemopneu- mothorax, and acute resp i ra tory insufficiency.

Fixation of the p a n d and left p leuro tomy with aspirat ion were performed. T h e pat ient recovered.

C r u s h e d P a n e l s ( w i t h A t t r i t i o n a n d a S o f t T h o r a x )

T h e s e a re t h e m o s t s e v e r e cases as s p l i n t e r i n g of t h e r ibs is a s s o c i a t e d w i t h c o m p l e x les ions of t h e so f t p a r t s a n d v i s c e r a w i t h s e v e r e r e s p i r a - t o r y a n d c i r c u l a t o r y d i s t u r b a n c e s .

G e n e r a l l y t h e p a t i e n t , w h e n f i rs t e x a m i n e d , is in a c o m a a n d in m o s t cases d ies b e f o r e a n y a t t e m p t c a n be m a d e t o fix t h e p a n e l . D e a t h g e n e r a l l y o c c u r s w i t h i n t w o to t h r e e h o u r s a f t e r t h e a c c i d e n t d u e to s e v e r e r e s p i r a t o r y a n d a c u t e c i r c u l a t o r y i n su f f i c i ency .

T h r e e s u c h p a t i e n t s w e r e h o s p i t a l i z e d in o u r c l in ic a n d all d i e d s h o r t y a f t e r w a r d .

CONCLUSIONS

L I n j u r y to t h e r ib p a n e l c a n be t r e a t e d e f f i c i e n t l y in m o s t cases , b e a r i n g in m i n d cer - t a in p r inc ip le s .

2. T h e r e s u l t d e p e n d s on f i xa t ion of t h e r ib

Vot. too, M a y 1o6S 6 0 9

Page 7: A new method of treating the flail chest wall

C o n s t a n t i n e s c u

ixmel and its r e iu tegra t ion into the r h y t h m and a m p l i t u d e of the r e sp i r a to ry ra te of t h e ent i re thorax.

3. Fixat ion of the panel suppresses the move- merits in the f rac ture foci and t he r e fo re the pain. enabl ing the pa t i en t to cough, e v a c u a t e bronchia l secretions, and m o v e abou t .

4. The ap l )a ra tus is read i ly apl)l icable and does not incur t r auma , hazards , or compl ica- tions.

REFERENCES

1. LE BRIGAND, 1{. alia FAURf':, J. Les volets trau- mat iques de la paroi thoracique. J. Chit.. S-t : 560, 1962.

2. DOR, J. and Lt~ BRIGAND, 11. Le t r a i t emen t im- mddiat des t raumat i smes graves et fermds du thorax. J. Chit., S0: 226, 1900.

21. KF.,xu'F, I., NAF.TT, R., and AU~:R, R. M6thodes et illdieations des t r a i t emen t s des el~f()tieements thoraeiques avee volet mobile, J. Chir., 81: 351, 1961.

4. DAUMET, P. atld NIICIIEL, J. T r a u m a t i s m e thoraei- que avee volet ant6r ieur trai t6 par ost~osynthfse immddi'~te..Le Poumon, 1,1 : 219, 1958.

~. RANTZ. 13. A Dropos du t r a i t emen t des fr.tctures

bilat&'ales mult iples des c6tes par extension cont imm du s ternum. J. Chir., 586, 1959.

6. DOR, J., CUT'rOLI, J. I ). DE, l tu,~n)mcr, l'., NmoL1, M., CIIASSOS J., and I'ESC]IARI), J . . I . Insuf- fisance respiratoire chez les t raumat is6s thora- ciques. Ann . Chir., 17: 978, No. 3.-4, 1963.

7. CONSTAN'rINESCU, O. and GOICD:ANU, N. T ra t a - mentu t fracturilor de coaste. Ch.irnrgia, S01, 1959.

8. SZANTO, G., SZEKF.LV, O., alia llu, n), J. Probl~mes actuels de l)hysiopathologie gdu6rale et th6rapie des t r aumat i smes graves du thorax. ~llinerva ~l.[ed., 52: 3923, 1961.

9. TURAI, I. and CONSTANTINESCU, O. Consideral i i privimt asistenl/a mari lor pol i t rau ,na t iza l i . Chir- urght, ,183, 1964,

10. SANTO, D. and SEKEI, E, O. Leziunile. grave ale peretelui toraeie eu tu lburarea func[iei sale ~i t r a t a me n t u l lor priu respira~ie artifieialK i)re- lungit~ executat~'f cu "tjutorul aparate lor de res- pira~ie. Khirureiia, 35: 79, 1959.

11. ZAGDOUN, J. and SORDINAS, A. ~'k t)ropos du traite- merit des volets thoraciques. Uti l isat ion d ' tm fixateur externc costal. ~lH;m.. Acad. chit., 89: 26, 1963.

12. CONSTANTINIF.SCU, O. and CONSTANTINI~SCU, ~,1. S. Aparate ~i metode noi i n t r a t a m e n t u l vole tului costal (Prezentarea metodei romlne~ti de sta- bilizare a voletului) , Chirurgia, 1965 (in press).

610 A merican Journal of Surgery