THE MODERN TECHNOLOGIES OF RIB AND STERNUM OSTEOSYNTHESIS FOR A PATIENT WITH RARE KIND OF WORK-RELATED INJURY
Samara Regional Clinical Hospital named after V.D. Seredavin,
Samara, Russia
The literature describes multiple cases of severe thoracic injuries and offers different approaches to treating multiple fractures of ribs and the sternum [1, 2]. The most severe type of an injury to the bony frame of the chest is so called crushed chest conditioned by high energetic forces. The literature in English includes the term flail chest; also the term stove-in chest exists [3, 4]. Most domestic authors preferred the term costal valve. Also at the present time multiple double rib fractures are commonly designated as floating fracture [5]. The severity of such state is associated with appearance of a free costal fragment, which is not fixed to the sternum or the spinal column, but it conditions paradoxical movements of the chest resulting in disarrangement of respiratory biomechanics and a subjacent lung injury [6, 7]. More intense disorders of external respiration appear during combination of floating fractures of ribs and sternal fracture, because the frame function of the sternocostal complex is disordered to the fullest extent, and injuries to mediastinal structures are possible [8].
The most common cause of such injuries is road traffic accidents; falling from height is considerably rare. The role of industrial injury is not so big, but its consequences can be the same [9]. One way or another, severity of state in such patients depend not only on a type of traumatic factor and characteristics of fractures of thoracic bones, but also on a degree of injuries to intrapleural organs and presence or absence of concomitant injuries [10, 11].
The modern doctrine of rendering assistance for patients with multiple and floating costal and sternal fractures means active realization of measures for chest stabilizing with active involvement of advanced surgical techniques [12, 13]. The alternative approach to surgical internal fixation of fractures is external stabilization techniques (skeletal traction, external fixation devices) and internal pneumatic stabilization by means of special modes of artificial lung ventilation [1, 2]. However multiple studies with different levels of evidence supported the high efficiency of surgical techniques: decrease in days of artificial lung ventilation, decreasing amount of complications and decreasing mortality rates [14, 15]. At the same time, it is evident that realization of surgical treatment for rib fractures within the first hours after trauma is impossible in most patients because of unstable respiratory and hemodynamic values and it is associated with significant number of organizational and technical issues. Therefore, one can observe appropriateness of staged use of different methods for stabilization of the chest in dependence on severity of patient’s state and conditions of realization of medical assistance.
Objective – to demonstrate a clinical case of uncommon patterns of an industrial injury to the chest, and the features of tactics of treatment of the patient, i.e. staged usage of different techniques of stabilization and usage of modern techniques of osteosynthesis for ribs and the chest.
Materials and methods. On 17.06.2014 the patient A., age of 54, shepherd, suffered from a closed chest injury as result of a direct blow from a quickly running bull. The retrospective acquisition of complaints and anamnesis data showed that the patient had noted appearance of sharp intense pain in the chest, felling of shortness of breath, dizziness and apparent general weakness. His colleague transported him to the nearest district hospital where the closed chest injury and traumatic shock of degrees II-III were diagnosed.
Simultaneously with anti-shock measures the patient received some confirming diagnostic procedures including general clinical analysis, electrocardiography, plain X-ray imaging for the chest, abdominal and pleural ultrasonic examination. According to the results of the additional examination the diagnosis was made: “Closed chest injury. Multiple fractures of the ribs on both sides. Bilateral hemopneumothorax. Transverse fracture of corpus sternum. Heart contusion. Acute respiratory insufficiency. Multiple contusions of soft tissues. Traumatic shock of degrees II-III”. The information about the patient was reported to the trauma center of the level I based on Samara Regional Clinical Hospital by the name of V.D. Seredavin. The medical team including the thoracic surgeon and the anesthesiologist-intensivist made the phone consult and then arrived to the place for defining management tactics and possibilities for further transportation to the regional hospital. According to the recommendations from the specialists of the level I trauma center the physicians of the central regional hospital performed thoracocentesis and draining of both pleural cavities. For compensating the disordered parameters of external breathing the patient received tracheal intubation and artificial lung ventilation. Before arrival of the sanitary aviation team the intensive care also included prescription of appropriate volume of infusion, analgetics and prevention of infectious and thromboembolic complications. Such therapy was included into the program of anti-shock measures.
When the specialists of the regional hospital arrived, the patient’s state stabilized a little. The examination also found some floating fractures of ribs to the left and contusion of both lungs. Considering absent signs of ongoing bleeding and other states, which are indications for emergent surgical interventions on-site, the decision was made about transfer to the regional hospital for further treatment.
After arrival to the regional hospital the patient was immediately transported to the intensive care unit. Here the recurrent examination was made that included hemodynamics and breathing. Also necessary analyses were made, and artificial lung ventilation was rearranged with the parameters for internal pneumatic stabilization. Multispiral computer tomography identified multiple fractures of ribs on both sides (the ribs 5 and 6 to the right; the ribs 2, 4, 5 and 6 to the left), a floating fracture of the ribs 5 and 6 to the left, a transverse fracture of corpus sternum with divergence and diastasis of the fragments (up to 3 cm), diffuse hematoma of the mediastinum, a contusion of the lower lobes of both lungs, hemopneumothorax to the right, pneumomediastinum (Fig. 1). There were no confirmed data about injuries to the brain, the spine, abdominal organs, retroperitoneal space, the small pelvis and pelvic bones. Fibertracheobronchoscopy did not find any relevant traumatic injuries to the tracheobronchial tree. Also it showed the small amount of mucous hemorrhagic discharge from the distal bronchi. As result, sanation was made. The results of total blood analysis were as indicated: red blood cells – 3.5×1012/L, hemoglobin – 107 g/L, leukocytes – 12.8×109/L. The biochemical blood analysis showed increase in levels of creatine phosphokinase up to 3,696 U/L, lactic dehydrogenase – up to 541 U/L, C-reactive protein – up to 111 mg/L. The hemostasiologram showed the trend to hypercoagulation: prothrombin – 104 %, INR – 0.99, fibrinogen – 4.8 g/L, APTT – 33.1 sec. The analysis of blood gas composition identified decrease in ÐàÎ2 – 67 mm Hg and increase in ÐàÑÎ2 – 53 mm Hg.
Figure 1
Chest computer tomography: a) axial view; b) sagittal view; c) 3D reconstruction. The fracture of corpus sternum, floating fracture of the ribs V and VI to the left, bilateral hemopneumothorax, contusion of lower lobes of both lungs, pneumomediastinum
Therefore, while collecting the data of the laboratory instrumental examination the following clinical diagnosis was made: “Closed chest injury. Multiple bilateral rib fractures. Floating fracture of the ribs 5 and 6 to the left. Transverse fracture of corpus sternum with diastasis of fragments. Heart contusion. Mediastinal hematoma. Unstable chest. Bilateral hemopneumothorax. Contusion of lower lobes of both lungs. Pneumomediastinum. Acute respiratory insufficiency. Traumatic shock of degrees II-III”. Injury Severity Score (ISS) was 32.
The management tactics was defined according to the diagnosis and the degrees of severity of the injuries. This tactics was oriented to single-step correction of the injuries to the thoracic bone frame and the intrapleural organs after presurgical preparation (36-40 hours) including further measures for state stabilization and prevention of complications. The catheter for peridural anesthesia was installed at the level of Th IV. Before surgery the mode of artificial lung ventilation was installed within parameters of forced protective ventilation with respiratory volume of 600 ml, respiratory rate 12-14 per minute, FiO2 – 60-40 %, positive end-expiratory pressure 10 cm H2O. The presurgical values of respiratory function were as indicated: SpÎ2 – 92 %, ÐàÎ2 – 74 mm Hg, ÐàÑÎ2 – 49 mm Hg, ðÍ – 7.28, Horowitz index – 118 mm Hg.
The surgical intervention was made on 19.06.2014: 37 hours after admission to the regional hospital and 44 hours after the injury. The operation under endotracheal narcosis included the following sequential stages: 1) reposition and osteosynthesis of the sternum with Titanium Sternal Locking Body Double T-Plate (DePuy&Synthes); 2) thoracoscopy to the right, extensive dissection of mediastinal pleura for decompression of pneumomediastinum and draining the hematoma in the mediastinum, removal of small hemothorax, sanation, draining of pleural cavity; 3) external osteosynthesis for the ribs 5 and 6 to the left with use of Matrix Rib (DePuy&Synthes); 4) thoracoscopy to the left, removal of small hemothorax, sanation, pleural cavity draining (Fig. 2).
Figure 2
An intrasurgical image. Osteosynthesis of the ribs V, VI to the left.
The total time of surgical intervention was 110 minutes. Among the features of the surgery it is necessary to accent thoracoscopy to the left by means of the defects of the mediastinal pleura as result of the injury, some technical difficulties in correction of the sternum defect as result of diastasis of the fragments beyond the range of 3 cm, as well as complete expanding the pulmonary tissue during hyperventilation, despite of multiple regions of contusion of pulmonary parenchyma. Considering the position of the second line of the floating costal fracture behind the left scapula, plate fixation included covering only the single line of the fracture in the plane of the anterior axillary line.
In early postsurgical period we initiated continuous mandatory ventilation (CMV) with the principle of protective ventilation. On the next day we estimated the possibilities for restoring spontaneous breathing. The following clinical relevant criteria were noted: restoration of consciousness after medical sleep, stable hemodynamic values, absence of paradoxical movements in the chest, extension in both lungs confirmed by X-ray examination, absence of exhaust air through the drains from pleural cavities, absent obstruction of the tracheobronchial tree according to fiberbronchoscopy. Besides absent anemia, the laboratory examination confirmed positive dynamics of restoring values of respiratory system: SpÎ2 – 98 %, ÐàÎ2 – 96 mm Hg, ÐàÑÎ2 – 36 mm Hg, ðÍ – 7.30, Horowitz index – 190 mm Hg. Based on the collected results the mode of artificial lung ventilation was changed to CPAP (constant positive airway pressure) without muscle relaxation and narcotic drugs with the setting parameters: PSV – 8-4 cm H2O, FiO2 – 40 %, PEEP 4 cm H2O. Further 6 hour observation and absence of negative dynamics for each of the above mentioned parameters were the indication for training the independent breathing and subsequent full cancellation of artificial lung ventilation 25 hours after the surgical intervention.
Despite of extubation, further therapy was continued in the intensive care unit. The program of intensive care included analgetic, broncho- and mucolytic therapy, regular sanation of the tracheobronchial tree, prevention of infectious and thromboembolic complications. Presence of possibilities for peridural anesthesia significantly decreased the need for narcotic analgetics. Also early administration of physiotherapeutic procedures and remedial physical exercises should be noted. On the third day after the operation the patient was transferred to the department of thoracic surgery for continuation of appropriate treatment. The patient demonstrated fast activation, progressive decreasing pain syndrome and improvement in his general state. The events of respiratory insufficiency were completely corrected by 5th day. It was supported by the control examination of gas composition of the blood (ÐàÎ2 – 97 mm Hg, ÐàÑÎ2 – 34 mm Hg, ðÍ – 7.35) and oxygen saturation (98 %). The surgical manipulations for extracting the drains on the days 2-3, suture removal – on 9th days after the surgery. The control X-ray examination showed extension of both lungs, satisfactory position of costal implants and the sternum, absence of pathologic intrapleural states (Fig. 3). The recovered patient was discharged on 04.07.2014.
Figure 3
Plain X-ray imaging of the chest. The state after osteosynthesis of sternum and the ribs V and VI to the left.
The examination 1, 3 and 6 months after the surgery did not show any abnormalities. The signs of respiratory insufficiency were not found. There was a union of the fractured regions, of the region of postsurgical wounds and of regions of the implants without pathologic changes. The patient returned to his working activity 2 month after discharge. He received the recommendations for changing his professional activity.
CONCLUSION
The features of the described clinical case included the circumstances and characteristics of the injury, as well as the complex of curative measures including staged use of temporary stabilizing methods and final osteosynthesis of the injured thoracic bones. The possibilities of using the modern innovative techniques significantly change the traditional ideas about possibilities for treatment of patients with multiple complicated fractures of the ribs and the sternum. Further investigations should be oriented to ways for optimizing the differential and staged approaches in treatment of patients with severe thoracic injuries.