Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

 

Chest injury is one of the leading medical social problems of the modern age. In general injury rate thoracic injury takes 3d place and reaches 12-15 %. The mortality after chest injury is 55-60 % [7, 13]. The actuality of the problem of closed chest injury (CHI) is associated with its high frequency, large amount of complications (45.6-75 %), high level of mortality (32-76.2 %), long duration of treatment and long term rehabilitation of patients [1, 12]. According to E.A. Vagner closed chest injuries are distinguished as with injury to internal organs, without injury to internal organs, isolated CI and concomitant CI. In patients with isolated chest injury the mortality reaches 17 %, in severe concomitant injury – 76 % [5]. CHI has the greatest clinical significance in patients with polytrauma. In the general structure of polytrauma chest injury takes 23-56.9 %, but among died patients CHI is the immediate cause of death in 25-50 % of cases [1, 2, 4]. According to the summarized data, the frequency of fractured ribs in closed chest injury varies from 35 to 92 %; in patients who died after chest injury floating rib fractures are observed in 52.1-63.6 % of cases [2, 3, 8, 10]. In case of bilateral fractures with floating sternocostal segment the mortality reaches 85.7 % [2, 3]. In 80-90 % of cases chest injury with disintegration of costal frame is accompanied by lung injuries, intrapleural complications, such as hemothorax and pneumothorax; it is related to most severe injuries [2, 3, 6, 9].

The large percentage of severe complications, such as traumatic shock, adult respiratory distress syndrome (ARDS), congestive pneumonia, severe respiratory insufficiency etc., develop at days 1-2 in posttraumatic period and relate to the period of acute response of the body to trauma [1, 7, 11]. Chest excursion decrease is one of the leading causes which provoke worsening state and development of these complications. Therefore, the problem of structure restoration of injured chest acquires actuality.

Our clinic offered the original fixator for restoration of chest framework (Fig. 1) – a metal plate with angle stability, 4 hooks at the lateral surface for securing to the upper border of a rib. The plate has 4 holes with thread for locking screws (The patent of RF for useful model #126260 from 02.08.2012 “Plate for osteosynthesis in multiple floating rib fractures”).

Figure 1

Appearance of the fixator

 

The characteristics of the fixator are available rib hooks, the possibility of its intrasurgical modeling for better reposition of rib fractures, presence of angle stability. In technical sense the surgery is performed under endovideothoracoscopic control from low invasive approach with minimal blood loss. All above mentioned factors allow making decisions about rib osteosynthesis, achieving good reposition, decreasing injuries and time of surgical intervention.

Objective – with a clinical case to show the possibilities of surgical restoration of chest framework using the original fixator for a patient with polytrauma, with closed chest injury as the leading injury.

MATERIALS AND METHODS

Patient P., female, 1968 year of birth, was admitted to the clinic on day 2 after trauma. Industrial injury – the massive door leaf of railway hangar fell onto her. First aid was realized in the level I trauma center: bilateral draining of pleural cavities, initial surgical debridement, and initiation of artificial lung ventilation (ALV). The patient was admitted to Clinical Center of Miners’ Health Protection with a reanimobile during conditions of constant antishock therapy: controlled artificial lung ventilation with positive end expiratory pressure, infusion therapy, anaesthesia etc. According to the scale by Pape the state was agonal on admission [11], ISS = 24.

The diagnosis was made on the basis of results of clinical examination, laboratory, instrumental and radiographic diagnostic methods: “Polytrauma. Closed complicated fractures of 2^nd, 3d, 4^th, 5^th, 6^th, 7^th, 8^th, 9^th, 10^th, 11^th ribs to the left, with flotation of 3d, 4^th, 5^th, 6^th, 7^th, 8^th ribs. Closed complicated fractures of 2^nd, 3d, 4^th, 5^th, 6^th, 7^th, 8^th, 9^th ribs to the right, with flotation of 6^th, 7^th, 8^th, 9^th ribs. Bilateral hemopneumothorax. Contusion of both lungs. ARDS of degrees 2-3. Heart contusion. Chest subcutaneous emphysema. Spinal cord injury. Complicated contusion of cervical spine, spinal cord contusion at cervical level, right hemiparesis. Brain concussion. Contused wound of occipital region to the right. Multiple bruises and scratches of the head, chest and upper extremities. Anterior abdominal wall contusion”.

Severe closed chest injury and gross disorders of chest framework were the dominating injuries, which defined severity of state and injury of the patient (Fig. 2, 3). 36 fractures of 22 ribs were diagnosed.

Figure 2

Chest X-ray on admission

Figure 3

Chest multispiral computer tomography (CMSCT) on admission

 

After admission to Clinical Center of Miners’ Health Protection the treatment was performed in the intensive care unit. After realization of the complex of diagnostic measures and preliminary presurgical preparation emergently and after 3 hours the following surgical interventions were performed.

Thoracoscopic revision was performed. Based on the methods of radial diagnostics, clinical examination and endovideothoracoscopic revision the locations of the greatest chest deformations resulting in its framework corruption were defined. The surgical intervention was performed for restoration of chest structure: open reposition, osteosynthesis of 5^th and 6^th ribs with angle stability plate and screws to the left, fixation of fractures of 4^th, 5^th, 6^th, and 7^th ribs with paracostal suturing, parietal pleura suturing (surgery  time – 1 hour 40 minutes). The surgery was completed with draining of pleural cavities to the left and to the right. Drains were connected to the system of passive aspiration according to Bulau-Petrov.

Considering the necessity of realization of long term ALV, instrumental debridement and visualization of tracheobronchial tree, the lower tracheostomy according to Bjork was performed.

As for visual and clinical aspects, the surgical intervention allowed removing flotation in the injured segment, excluding paradoxical breathing and stabilizing frame of the right half of the chest.

After surgery the patient was transferred to the intensive care unit. The treatment was carried out according to Damage control orthopedics. On the day 3 after trauma after stabilization of state to subcompensation level according to Pape, the staged surgical intervention was performed – endovideothoracoscopic revision of the right thoracic cavity, the locations with the greatest deformations of the right half of the chest resulting in framework disarrangement were defined; opened reposition, osteosynthesis of 6^th and 8^th ribs with angle stability plate and screws to the right, parietal pleura defect suturing (Fig. 4).

Figure 4

Postsurgical radiographs of the patient

 

The patient received treatment in the intensive care unit where she had the intensive therapy complex including respiratory support with planned decrease in its intensity. In early postsurgical period the events of posttraumatic bilateral polysegmentary pneumonia developed as a natural result. Restoration of chest structure allowed reducing degree of intensity of forced ventilation, and, first of all, withdrawing from high parameters of positive end expiratory pressure. PEEP stayed at the level of 5-7 mm H₂O during 7 days; further it was abandoned. The restored chest framework allowed activating the patient (passive change of position in the bed, including pronation position), performing ALV in the auxiliary modes that permitted to remove pneumonia events at days 15-16. Despite the fact that the patient’s state stabilized, the independent breathing was ineffective. The auxiliary modes of respiratory support (ASB) were continued. The control R-grams of chest organs identified the remaining atelectasis of the lower lobe of the right lung. On day 19 after trauma the surgical intervention was performed – video-assisted right minithoracotomy, revision, removal of clotted right hemothorax, pleural cavity debridement to the right. The lung spread. The patient was transferred to independent breathing on day 20. From the first day of postsurgical period the intensive postsurgical gymnastics was carried out for restoration of movement in gross joints, as well as breathing exercises. On day 25 after trauma the staged activation of the patient started. The patient was allowed to sit with her lowered legs on the bed. Therapeutic physical training was initiated for strengthening the muscles of the extremities. Also it included passive and active development of movements in the right elbow, knee and shoulder joints. On day 37 after trauma the patient was transferred to the specialized department.

On day 58 after trauma the patient was discharged in satisfactory state for outpatient treatment. The postsurgical wounds healed with primary intention. There were no purulent septic complications and migration of metal constructions. Neurologic symptoms retrograded completely. The motion range in the large joints of the right upper and the right lower extremities restored completely.

 

CONCLUSION

Therefore, early restoration of chest structure with the original fixator under endovideothoracoscopy control allowed maximal rapid mobilization of the patients, preventing severe respiratory complications and reducing duration of ALV.