Rib Osteosynthesis for Sub-Acute Management of a Flail Chest in a Tertiary Centre in a Low-Middle Income Country of Sub-Saharan Africa: Case Report at Douala Laquintinie Hospital

Background: Costal fracture surgical is still a debate, therefore we shall select between early and delay surgical management. Case Report: We are reporting two cases of post road traffic clash delay ribs fractures osteosynthesis involving a 63-year-old man with multistage fractures on the left and pulmonary pinning of one of the costal arches, complicated by a homolateral haemothorax and a 41-year-old man with a bilateral flail chest. Conclusion: The simple postoperative course and the immediate postoperative improvement in the patient’s clinical respiratory condition enabled us to discuss the time frame for management, in this case the indication for early or later surgery.

Memory alloy embracing fixator in treatment of multiple fractured ribs and flail chest

BACKGROUND： With the development of internal fixation materials, simple operation with internal fixation has become a tendency. Ni-Ti shape memory alloy embracing fixator has such advantages as slight injury, easy operation, security, reliable fixation, and better histocompatibility. The present study was to explore curative effect and postoperative results of Ti-Ni shape memory alloy embracing ？ xator in patients with multiple fractured ribs and ？ ail chest.METHODS： The curative effect and long-term follow-up results were observed after internal ？ xation with a shape memory alloy embracing ？ xator in patients with multiple fractured ribs and ？ ail chest from January 2006 to December 2009.RESULTS： All patients were cured with an average hospital stay of 10.31±3.14 days. Post-operative pain was less severe than preoperative pain （P=0.02）.The rate of postoperative complications such as atelectasis, pulmonary infection, etc was 17.65%. There were fewer long-term complications and less in？ uence on daily work and life.CONCLUSIONS： It is practical to perform an operation for fracture of multiple ribs using a Ti-Ni shape memory alloy embracing ？ xator. The ？ xator, which is less traumatic, simple, safe, and reliable, has a good-histocompatibility and fewer postoperative complications.

Undetected traumatic cardiac herniation like playing hide-and-seek-delayed incidental findings during surgical stabilization of flail chest:A case report

BACKGROUND Post-traumatic blunt pericardial injury is a rare condition with only a few reported cases which were generally diagnosed during initial examinations upon admission.However,pericardial injuries not bad enough to dislocate the heart may only cause intermittent electrocardiogram(ECG)changes or be asymptomatic.CASE SUMMARY In this case,we report a blunt pericardial injury undetected on preoperative transthoracic echocardiography and chest computed tomography.We misjudged intermittent ECG changes and blood pressure fluctuations as minor symptoms resulting from cardiac contusion and did not provide intensive treatment.The pericardial injury was found incidentally during surgical stabilization of rib fractures and was successfully repaired.CONCLUSION Post-traumatic blunt pericardial ruptures should be considered in patients with blunt chest trauma showing abnormal vital signs and ECG changes.

Thoracic Epidural Analgesia versus Dexmedetomidine Infusion in Traumatic Flail Chest

Background: Traumatic flail chest is a serious injury that can impair ventilation and affect patient outcome. Thoracic epidural analgesia is the gold standard to provide adequate analgesia in flail chest, however, it may be unavailable in some patients due to coagulopathy, failure or difficult insertion. We compared between parenteral dexmedetomidine and thoracic epidural block with plain local anesthetic in flail chest cases. Patients and methods: fifty eight trauma patients with flail chest randomly allocated into either Group E (n = 29): epidural group, patients received mid-thoracic epidural analgesia using 6 ml mixture of 0.125% bupivacaine and 2 μg/ml fentanyl, which followed by continuous infusion of 6 ml/hour;Group D (n = 29): dexmedetomidine group, patients received loading dose of dexmedetomidine 1 μg/kg over 30 min, after a continuous infusion at a rate of 0.5 μg/kg/hr. The primary outcomes were to assess the effect of analgesic type on ventilation (PaO2/FIO2 ratio, PaCO2). The secondary outcomes were to compare analgesic effect, hemodynamics, the need for ventilation and ICU stay. Result: PaO2/FIO2 ratio was significantly higher in epidural group and PaCO2 was significantly lower in epidural group (p value < 0.05). The incidence of mechanical ventilation was significantly lower in epidural group than in dexmedetomidine group (6 patients group versus 13 patients, p value < 0.04). Mean arterial blood pressure was significantly lower in dexmedetomidine group than in epidural group (94.3 ± 6.84 mmHg versus 102 ± 5.72 mmHg, p value < 0.001). Moreover, heart rate was significantly lower in dexmedetomidine group than epidural group (89.97 ± 6.22 bpm versus 96.07 ± 9.3 bpm, p value = 0.004). VAS was significantly lower in epidural group (p value < 0.001). Throughout different measuring points, RAMSAY score was significantly higher in dexmedetomidine group. Conclusion: Epidural analgesia is more effective than parenteral dexmedetomidine in flail chest, but dexmedetomidine can represent a good alternative if epidural is not possible.

An innovative technique of chest wall stabilization and reconstruction in traumatic flail chest:The figure-of-eight suture with polypropylene mesh and musculofascial flap

Surgical stabilization of the flail chest is challenging and has no established guidelines.Chest wall integrity and stability are the main factors that ensure the protection of intrathoracic organs and an adequate respiratory function.Here,we report a novel chest wall reconstruction technique in a 45-year-old man with a traumatic left flail chest and open pneumothorax diagnosed both clinically and radiographically.Rib approximation and chest wall reconstruction was done using intercostal figure-of-eight suture and polypropylene mesh with vascularized musculofascial flap.The patient improved gradually and was discharged after three weeks of total hospital stay.He returned to regular working after a month with no evidence of respiratory distress or paradoxical chest movement.Follow-up visit at one year revealed no lung hernia or paradoxical chest movement.This is a novel,feasible and cost-effective modification of chest wall reconstruction that can be adopted for thoracic wall repair in case of open flail chest,which needs emergency surgical interventions even in resource constraint settings.

The natural history of flail chest injuries

Purpose： Flail chest （FC） injuries represent a significant burden on trauma services because of its high morbidity and mortality. Current gold standard conservative management strategies for FC, are now being challenged by renewed interest in surgical rib fixation. This retrospective epidemiological study sets out to evaluate FC patients, and quantify the natural history of this injury by studying the injury patterns, epidemiology and mortality of patients sustaining FC injuries admitted to a major trauma centre （MTC）. Methods： A retrospective cohort analysis has been conducted at an MTC with full trauma service. All patients （age 〉 16 years） sustaining FC were included. Patient demographics, injury characteristics and inpatient stay information were extracted. Results： Two hundred and ninety-three patients were identified, with a mean injury severity score （ISS） of 28.9 （range 9-75）, average age of 56.1 years （range of 16-100）, and a male predominance （78%）. Road traffic accidents accounted for 45% （n = 132） of injuries, whilst 44% were fall or jump from height （n = 129）. Associated lung contusion was present in 133 patients （45%） while 76% of patients were found to have 5 or more ribs involved in the flail segment （n = 223） with 96% （n = 281 ） having a unilateral FC. Inpatient treatment was required 19.9 days （range 0-150 days） with 59% of patients （n = 173） requiring intensive care unit （ICU） level care for 8.4 days （range 1-63） with 61.8% requiring mechanical ventilation （n = 107） for 10.5 days （range 1-54）, and Z8g underwent rib fixation with rib plates （n = 23）. The mortality rate was found to be 14% （n = 42）. A non-significant trend towards improved outcomes in the conservative group was found when compared with the fixation group; ventilation days （6.94 vs 10.06, p = 0.18） intensive treatment unit （ITU） length of stay （LOS） （12.56 vs 15.53, p = 0.28） and hospital LOS （32.62 vs 35.24, p = 0.69）. Conclusion： This study has successfully described the natural history of flail chest injuries, and has found a nonsignificant trend towards better outcomes with conservative management. With the cohort and management challenges now defined, work on outcome improvement can be targeted. In addition the comnarahility of results to other studies makes collaboration with other MTCs a realistic vrovosal.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021(C-STTRF 2021)

Rib fracture is the most common injury in chest trauma.Most of patients with rib fractures were treated conservatively,but up to 50%of patients,especially those with combined injury such as flail chest,presented chronic pain or chest wall deformities,and more than 30%had long-term disabilities,unable to retain a full-time job.In the past two decades,surgery for rib fractures has achieving good outcomes.However,in clinic,there are still some problems including inconsistency in surgical indications and quality control in medical services.Before the year of 2018,there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad,focusing on the guidance of the overall treatment decisions and plans;another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures.The Chinese Society of Traumatology,Chinese Medical Association,and the Chinese College of Trauma Surgeons,Chinese Medical Doctor Association organized experts from cardiothoracic surgery,trauma surgery,acute care surgery,orthopedics and other disciplines to participate together,following the principle of evidence-based medicine and in line with the scientific nature and practicality,formulated the Chinese consensus for surgical treatment of traumatic rib fractures(STTRF 2021).This expert consensus put forward some clear,applicable,and graded recommendations from seven aspects:preoperative imaging evaluation,surgical indications,timing of surgery,surgical methods,rib fracture sites for surgical fixation,internal fixation method and material selection,treatment of combined injuries in rib fractures,in order to provide guidance and reference for surgical treatment of traumatic rib fractures.