Progresses in clinical treatment of multiple rib fractures and flail chest_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SHEN Xu ¹ , ZHU Yunke ² , ZHANG Hanlu ² , ZHUO Zeguo ¹ , LI Gang ³ , SONG Tieniu ¹ , XU Zhijie ¹ , ALAI Guha ¹ , YAO Peng ¹ , ZHONG Xia ¹ , WANG Yucheng ¹ ,  LIN Yidan ²

1. West China Medical College of Sichuan University, Chengdu, 610041, P.R.China;
2. West China Hospital of Sichuan University, Chengdu, 610041, P.R.China;
3. Department of Thoracic Surgery, Tibet Branch of West China Hospital, Chengdu, 610041, P.R.China;

Corresponding author：

LIN Yidan, Email: linyidan.academy@foxmail.com

Keywords：

Multiple rib fractures; flail chest; surgical indication; surgical time; surgical method

DOI：

10.7507/1007-4848.202012060

Video：

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The incidence of rib fracture in patients with chest trauma is about 70%. Simple rib fractures do not need special treatment. Multiple rib fractures and flail chest are critical cases of blunt trauma, which often cause serious clinical consequences and need to be treated cautiously. Nowadays, there is a controversy about the diagnosis and treatment of multiple rib fractures and flail chest. In the past, most of the patients were treated by non-operative treatment, and only less than 1% of the patients with flail chest underwent surgery. In recent years, studies have confirmed that surgical reduction and internal fixation can shorten the hospital stay, and reduce pain and cost for patients with flail chest, but there is still a lack of relevant clinical consensus and guidelines for diagnosis and treatment, which leads to great differences in clinical diagnosis and treatment plans. This article reviewed the treatment, surgical indications and surgical timing of multiple rib fractures and flail chest.

Citation： SHEN Xu, ZHU Yunke, ZHANG Hanlu, ZHUO Zeguo, LI Gang, SONG Tieniu, XU Zhijie, ALAI Guha, YAO Peng, ZHONG Xia, WANG Yucheng, LIN Yidan. Progresses in clinical treatment of multiple rib fractures and flail chest. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(7): 858-862. doi: 10.7507/1007-4848.202012060 Copy

1.	Zreik NH, Francis I, Ray A, et al. Blunt chest trauma: Bony injury in the thorax. Br J Hosp Med (Lond), 2016, 77(2): 72-77.
2.	Zuckerman S. Experimental study of blast injury to the lungs. Lancet, 1940, 236(6104): 219-224.
3.	Desaga H. Blast Injuries. In: German Aviation Medicine, World War Ⅱ, Vol. 2, Chap XIV-D. Washington, DC: US Government Printing Office, 1950. 1274-1293..
4.	Cameron GR, Short RHD, Wakeley CPG. Pathological changes produced in animals by depth charges. Br J Surg, 1942, 30: 49.
5.	Clark SL, Ward JW. The effects of rapid compression waves on animals submerged in water. Surg Gynecol Obstet, 1943, 77: 403.
6.	Trinkle JK, Richardson JD, Franz JL, et al. Management of flail chest without mechanical ventilation. Ann Thorac Surg, 1975, 19(4): 355-363.
7.	Chien CY, Chen YH, Han ST, et al. The number of displaced rib fractures is more predictive for complications in chest trauma patients. Scand J Trauma Resusc Emerg Med, 2017, 25(1): 19.
8.	Allen GS, Coates NE. Pulmonary contusion: A collective review. Am Surg, 1996, 62(11): 895-900.
9.	Nirula R, Diaz JJ, Trunkey DD, et al. Rib fracture repair: Indications, technical issues, and future directions. World J Surg, 2009, 33(1): 14-22.
10.	Cohen EA. Treatment of the flail chest by towel clip traction. Am J Surg, 1955, 90(3): 517-521.
11.	Avery EE, Benson DW, Morch ET. Critically crushed chests; a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization. J Thorac Surg, 1956, 32(3): 291-311.
12.	Dor J, Chasson J, Paoli JM, et al. Treatment of traumatic thoracic "shutters" by "internal pneumatic stabilization". Ann Chir Thorac Cardiovasc, 1964, 3: 314-322.
13.	Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma, 2002, 52(4): 727-732.
14.	Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg, 2005, 4(6): 583-587.
15.	Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg, 2013, 216(5): 924-932.
16.	段文飞. 多层螺旋 CT 容积再现及曲面重建诊断肋骨及肋软骨轻微骨折的临床价值. 中国综合临床, 2016, 32(1): 69-72.
17.	叶熊, 张睢扬. 肺部超声的临床应用进展. 国际呼吸杂志, 2012, 32(14): 1117-1120.
18.	Xia H, Zhu D, Li J, et al. Current status and research progress of minimally invasive surgery for flail chest. Exp Ther Med, 2020, 19(1): 421-427.
19.	Liu X, Xiong K. Surgical management versus non-surgical management of rib fractures in chest trauma: A systematic review and meta-analysis. J Cardiothorac Surg, 2019, 14(1): 45.
20.	Beks RB, de Jong MB, Sweet A, et al. Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: Study protocol. BMJ Open, 2019, 9(8): e023660.
21.	Beks RB, Peek J, de Jong MB, et al. Fixation of flail chest or multiple rib fractures: Current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg, 2019, 45(4): 631-644.
22.	Ingoe HM, Coleman E, Eardley W, et al. Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open, 2019, 9(4): e023444.
23.	Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: A systematic review. Eur J Trauma Emerg Surg, 2017, 43(2): 163-168.
24.	Kocher GJ, Sharafi S, Azenha LF, et al. Chest wall stabilization in ventilator-dependent traumatic flail chest patients: Who benefits? Eur J Cardiothorac Surg, 2017, 51(4): 696-701.
25.	Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury, 2017, 48(2): 307-321.
26.	Fokin AA, Wycech J, Weisz R, et al. Outcome analysis of surgical stabilization of rib fractures in trauma patients. J Orthop Trauma, 2019, 33(1): 3-8.
27.	He Z, Zhang D, Xiao H, et al. The ideal methods for the management of rib fractures. J Thorac Dis, 2019, 11(Suppl 8): S1078-S1089.
28.	Pieracci FM, Rodil M, Stovall RT, et al. Surgical stabilization of severe rib fractures. J Trauma Acute Care Surg, 2015, 78(4): 883-887.
29.	陈刚, 乔贵宾. 创伤性肋骨骨折的处理: 广东胸外科行业共识(2017 年版). 中国胸心血管外科临床杂志, 2018, 25(5): 362-367.
30.	苏志勇, 姜天烁, 张镱镭, 等. 肋骨骨折分区对外科手术的指导意义. 中华胸心血管外科杂志, 2014, 30(7): 415-416.
31.	Berninger MT, Kellermann F, Woltmann A, et al. Single-port VATS-assisted internal fixation of serial rib fractures. Unfallchirurg, 2018, 121(4): 335-338.
32.	夏洪刚, 王冬滨, 张永民, 等. 一种微创肋骨骨折内固定手术专用肌性胸壁撑开器械: 中国, 201721524911. X [P]. 2019-08-02.
33.	Xia H, Zhu P, Li J, et al. Thoracoscope combined with internal support system of chest wall in open reduction and internal fixation for multiple rib fractures. Exp Ther Med, 2018, 16(6): 4650-4654.
34.	苏志勇, 主编. 胸部创伤治疗学. 北京: 科学出版社, 2018. 247-249.
35.	Lee SK, Kang do K. Nuss procedure for surgical stabilization of flail chest with horizontal sternal body fracture and multiple bilateral rib fractures. J Thorac Dis, 2016, 8(6): E390-392.
36.	Mitchell JD. Blunt chest trauma: Is there a place for rib stabilization? J Thorac Dis, 2017, 9(Suppl 3): S211-S217.
37.	Fitzpatrick DC, Denard PJ, Phelan D, et al. Operative stabilization of flail chest injuries: Review of literature and fixation options. Eur J Trauma Emerg Surg, 2010, 36(5): 427-433.
38.	Fowler TT, Taylor BC, Bellino MJ, et al. Surgical treatment of flail chest and rib fractures. J Am Acad Orthop Surg, 2014, 22(12): 751-760.
39.	Morodomi Y, Okamoto T, Tagawa T, et al. A novel method of using bioabsorbable materials for the surgical repair of flail chest. J Trauma Acute Care Surg, 2016, 81(5): 984-987.

1. Zreik NH, Francis I, Ray A, et al. Blunt chest trauma: Bony injury in the thorax. Br J Hosp Med (Lond), 2016, 77(2): 72-77.
2. Zuckerman S. Experimental study of blast injury to the lungs. Lancet, 1940, 236(6104): 219-224.
3. Desaga H. Blast Injuries. In: German Aviation Medicine, World War Ⅱ, Vol. 2, Chap XIV-D. Washington, DC: US Government Printing Office, 1950. 1274-1293..
4. Cameron GR, Short RHD, Wakeley CPG. Pathological changes produced in animals by depth charges. Br J Surg, 1942, 30: 49.
5. Clark SL, Ward JW. The effects of rapid compression waves on animals submerged in water. Surg Gynecol Obstet, 1943, 77: 403.
6. Trinkle JK, Richardson JD, Franz JL, et al. Management of flail chest without mechanical ventilation. Ann Thorac Surg, 1975, 19(4): 355-363.
7. Chien CY, Chen YH, Han ST, et al. The number of displaced rib fractures is more predictive for complications in chest trauma patients. Scand J Trauma Resusc Emerg Med, 2017, 25(1): 19.
8. Allen GS, Coates NE. Pulmonary contusion: A collective review. Am Surg, 1996, 62(11): 895-900.
9. Nirula R, Diaz JJ, Trunkey DD, et al. Rib fracture repair: Indications, technical issues, and future directions. World J Surg, 2009, 33(1): 14-22.
10. Cohen EA. Treatment of the flail chest by towel clip traction. Am J Surg, 1955, 90(3): 517-521.
11. Avery EE, Benson DW, Morch ET. Critically crushed chests; a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization. J Thorac Surg, 1956, 32(3): 291-311.
12. Dor J, Chasson J, Paoli JM, et al. Treatment of traumatic thoracic "shutters" by "internal pneumatic stabilization". Ann Chir Thorac Cardiovasc, 1964, 3: 314-322.
13. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma, 2002, 52(4): 727-732.
14. Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg, 2005, 4(6): 583-587.
15. Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg, 2013, 216(5): 924-932.
16. 段文飞. 多层螺旋 CT 容积再现及曲面重建诊断肋骨及肋软骨轻微骨折的临床价值. 中国综合临床, 2016, 32(1): 69-72.
17. 叶熊, 张睢扬. 肺部超声的临床应用进展. 国际呼吸杂志, 2012, 32(14): 1117-1120.
18. Xia H, Zhu D, Li J, et al. Current status and research progress of minimally invasive surgery for flail chest. Exp Ther Med, 2020, 19(1): 421-427.
19. Liu X, Xiong K. Surgical management versus non-surgical management of rib fractures in chest trauma: A systematic review and meta-analysis. J Cardiothorac Surg, 2019, 14(1): 45.
20. Beks RB, de Jong MB, Sweet A, et al. Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: Study protocol. BMJ Open, 2019, 9(8): e023660.
21. Beks RB, Peek J, de Jong MB, et al. Fixation of flail chest or multiple rib fractures: Current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg, 2019, 45(4): 631-644.
22. Ingoe HM, Coleman E, Eardley W, et al. Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open, 2019, 9(4): e023444.
23. Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: A systematic review. Eur J Trauma Emerg Surg, 2017, 43(2): 163-168.
24. Kocher GJ, Sharafi S, Azenha LF, et al. Chest wall stabilization in ventilator-dependent traumatic flail chest patients: Who benefits? Eur J Cardiothorac Surg, 2017, 51(4): 696-701.
25. Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines. Injury, 2017, 48(2): 307-321.
26. Fokin AA, Wycech J, Weisz R, et al. Outcome analysis of surgical stabilization of rib fractures in trauma patients. J Orthop Trauma, 2019, 33(1): 3-8.
27. He Z, Zhang D, Xiao H, et al. The ideal methods for the management of rib fractures. J Thorac Dis, 2019, 11(Suppl 8): S1078-S1089.
28. Pieracci FM, Rodil M, Stovall RT, et al. Surgical stabilization of severe rib fractures. J Trauma Acute Care Surg, 2015, 78(4): 883-887.
29. 陈刚, 乔贵宾. 创伤性肋骨骨折的处理: 广东胸外科行业共识(2017 年版). 中国胸心血管外科临床杂志, 2018, 25(5): 362-367.
30. 苏志勇, 姜天烁, 张镱镭, 等. 肋骨骨折分区对外科手术的指导意义. 中华胸心血管外科杂志, 2014, 30(7): 415-416.
31. Berninger MT, Kellermann F, Woltmann A, et al. Single-port VATS-assisted internal fixation of serial rib fractures. Unfallchirurg, 2018, 121(4): 335-338.
32. 夏洪刚, 王冬滨, 张永民, 等. 一种微创肋骨骨折内固定手术专用肌性胸壁撑开器械: 中国, 201721524911. X [P]. 2019-08-02.
33. Xia H, Zhu P, Li J, et al. Thoracoscope combined with internal support system of chest wall in open reduction and internal fixation for multiple rib fractures. Exp Ther Med, 2018, 16(6): 4650-4654.
34. 苏志勇, 主编. 胸部创伤治疗学. 北京: 科学出版社, 2018. 247-249.
35. Lee SK, Kang do K. Nuss procedure for surgical stabilization of flail chest with horizontal sternal body fracture and multiple bilateral rib fractures. J Thorac Dis, 2016, 8(6): E390-392.
36. Mitchell JD. Blunt chest trauma: Is there a place for rib stabilization? J Thorac Dis, 2017, 9(Suppl 3): S211-S217.
37. Fitzpatrick DC, Denard PJ, Phelan D, et al. Operative stabilization of flail chest injuries: Review of literature and fixation options. Eur J Trauma Emerg Surg, 2010, 36(5): 427-433.
38. Fowler TT, Taylor BC, Bellino MJ, et al. Surgical treatment of flail chest and rib fractures. J Am Acad Orthop Surg, 2014, 22(12): 751-760.
39. Morodomi Y, Okamoto T, Tagawa T, et al. A novel method of using bioabsorbable materials for the surgical repair of flail chest. J Trauma Acute Care Surg, 2016, 81(5): 984-987.

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