Management of flail chest injury: Internal fixation versus endotracheal intubation and ventilation

Abstract

A total of 427 patients with major chest trauma were treated in two major hospitals in Abu Dhabi, United Arab Emirates, during a 10-year period. In 64 of 426 patients, flail chest injury was the dominant factor among other injuries that were insignificant. Among 64 cases of flail chest injury, 25 were managed by internal fixation of ribs, whereas the remaining 38 were managed by endotracheal intubation and intermittent positive-pressure ventilation alone. Of the patients treated by internal fixation 80% (21/26) were weaned from the ventilator within an average of 1.3 days, whereas the remaining 20% (5/26) continued to need assisted ventilation for a longer duration; the total average duration of assisted ventilation for the whole group was 3.9 days. In comparison, among 38 patients with flail chest injury treated by endotracheal intubation and ventilation alone, the average duration of assisted ventilation was 15 days. In the group treated by internal fixation 11% (3/26) of the patients ultimately required a tracheotomy, whereas in the patients treated by intubation and ventilation alone tracheostomy was required in 37% (14/38) of the cases. In the group treated by internal fixation, chest infection was documented in 15% (4/26), septicemia in 4% (1/26), and barotrauma in 0%; in the other group these complications occurred in 50% (19/38), 24% (9/38), and 8% (3/38) of the cases, respectively. The mortality rate was 8% (2/26) in the surgically treated patients, whereas it was 29% (11/38) in the other group. All the deaths in both groups were ascribed to adult respiratory distress syndrome. Average stay in the intensive care unit was 9 days for the patients treated by internal fixation, whereas it was 21 days in the group treated by intubation and ventilation alone. The treatment of flail chest injury in our series by internal fixation resulted in speedy recovery, decreased complications, and better ultimate cosmetic and functional results and proved to be cost effective.

No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study

“…What is more astounding, however, is how our outcomes compare with previously published outcomes in nonoperative patients. 6,[8][9][10][11][12][14][15][16][17][18][19][20] When compared with the RCT by Marasco and colleagues, days on a ventilator in our study were less than half of theirs, ICU LOS in our study was more than 11 days shorter, and hospital LOS was 9 days shorter, while their pneumonia rates were 3 times higher than ours. 10 Despite our retrospective matched cohort design, our study raises some interesting questions for future examination, especially considering that the only other North American study on this topic also found no significant improvements in LOS or ventilator days with flail chest fixation.…”

Risk factors for prolonged mechanical ventilation in patients with severe multiple injuries and blunt chest trauma: a single center retrospective case–control study

“…Flail chest injury may be life‐threatening resulting from deformity of the chest wall and volume loss of the lung 8, 21, 22, 23. This severe injury of the chest wall may be demonstrated by inefficient breathing and respiratory suppression caused by chest pain and/or overdose of analgesics.…”

Introduction to Chest Wall Reconstruction: Anatomy and Physiology of the Chest and Indications for Chest Wall Reconstruction

“…Variations include posterior flail segments, anterior flail segments, and sternal flail with fracture of bilateral anterior ribs. 42 The segment requires adequate fixation to restore normal respiratory physiology. Chest wall defects, depending on their size, may be amendable to either a soft tissue or bony reconstruction.…”