STABILIZATION OF THE CHEST STRUCTURE IN FRAGMENTARY RIB FRACTURES AS A KEY FACTOR OF RESTORATION OF EXTERNAL BREATHING FUNCTION IN POLYTRAUMA
Irkutsk State Medical University,
Irkutsk Regional Clinical Hospital,
Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia
Due to the increasing rates of injuries after road accidents one can note the significant increase in the amount of patients with multiple fragmentary rib fractures. The disordered function of external breathing is the main point of polytrauma in disordered chest structure, but appearance of various complications worsens the severe state of a patient and results in mortality in 30-50 % of cases [1].
There are various approaches to treatment of fragmentary rib fractures with low invasive techniques, for example, external fixing devices, videothoracoscopic fixation of rib fragments with lavsan suture [2, 3].
The open techniques include external extramedullary osteosynthesis with use of the modified device SGR-20 and K-wire [4], transperiosteal fixation of bone fragments with lavsan suture [3], combination of K-wire and cyanoacryl glue [5], suturing with SGR-20 with tantalic braces [6]. At the present time, surgeons prefer some cost materials such as MATRIXRIB, but their availability is very limited in general surgery units [7]. In our clinic we use SRKCh-22 device (a suturing device for ribs, the clavicle and the mandible) for metal osteosynthesis (Fig. 1). The device is produced in the Russian Federation. There are availableexpendable materials (staples). Its use in the surgical thoracic unit was initiated in 2005 and was offered by professor Alexander Kogan. In 2006 we presented our first experience with intrapleural fixation using this device [8].
The objective of the study – to present the experience of restoration of chest structure in the patients with polytrauma with use of the device SRKCH-22.
Figure 1.The device SKRCH-22
MATERIALS AND METHODS
The retrospective analysis included the patients with multiple rib fractures and disordered chest frame. The patients received intrapleural osteosynthesis. The study corresponded to the Ethical principles of medical research with human subjects 2000 and the Rules for clinical practice in the Russian Federation confirmed by the Health Ministry of Russia, June 19, 2003, No.266. The inclusion criterion was realization of intrapleural metal osteosynthesis for a patient with chest injury admitted to the surgical thoracic unit. The exclusion criterion was refusal from analysis of personal data from the clinical record. The results of the study were analyzed with the descriptive statistical methods with presentation of the median (25-75 % quartiles) for indication of countable values and % for indication of uncountable values.
For 2005-2016 metal osteosynthesis of the ribs with SRKCh-22 was conducted for 40 patients in the thoracic surgery unit. There were 5 cases, where the sanitary aviation thoracic surgeons performed the operations in the surgery units of the central regional hospitals of Irkutsk region. The median of thepatients’ age was 49 (44-59). There were 35 men (88 %). The characteristics of the associated injuries are presented in the table.
The structure of associated injuries in multiple fracture of the ribs with disordered chest frame
| Injury localization | Number of patients (proportion) |
| Traumatic brain injury |
14 (35 %) |
| Fracture of radial bone |
3 (8 %) |
| Fracture of clavicle |
4 (10 %) |
| Fracture of shin bones |
4 (10 %) |
| Fracture of femoral bone |
2 (5 %) |
| Fracture of pelvis |
2 (5 %) |
| Spleen injury |
2 (5 %) |
| Bilateral multiple fracture of ribs |
20 (50 %) |
The unilateral location of the injuries was identified in a half of the cases. Bilateral fragmentary fractures of the ribs were identified in 20 patients. Intrapleural complications were identified in all patients, including hemopneumothorax in 25 (63 %) (bilateral in 2 cases).
The standard exanimation of polytrauma in a special facility for 24 hour emergency care included transfer to the anti-shock unit, inspection by traumatologist, neurosurgeon, thoracic and abdominal surgeon. The medical and diagnostic procedures were conducted simultaneously with the anti-shock measures in dependence on severity of condition: tracheal intubation, artificial lung ventilation, magistral vein catheterization, pleural cavity draining, laparocentesis, bladder catheterization. The ongoing bleeding was an indication for urgent surgical hemostasis. After hemodynamics stabilization a patient was transported to the radiologic unit for realization of multispiral computer tomography (MSCT). The volume of reconstructive intervention was determined according to results of computer tomography.
The indication for surgical restoration of chest structure was floating fractures of the anteriolateral segments of the ribs, fractures of two and more ribs along one or two anatomic lines with disorder of chest structure; rib fractures in complicated chest injury requiring thoracotomy. The contraindications for metal osteosynthesis were agonal state, prevailing injuries to other anatomical regions with necessity for prolonged ALV or other surgical interventions, severity of injuries with Military Field Surgery-State at Admission = 41 [9]. Metal fixation for rib fractures between the posterior axillary and paravertebral lines were not performed because of traumatic approach, big muscular mass relating to the breathing act and providing the frame function. The surgery was performed 6-48 hours after admission, considering the absence of contraindications. Metal fixation was conducted with the stapler for the clavicle, the ribs and the lower mandible (SRKCh-22) produced by Krasnogvardeets JSC (Saint Petersburg), the registration license 29/01030301/2726-01.
Technique of surgical intervention
The surgery was conducted with combined analgesia: combination of endotracheal narcosis with subpleural and (or) epidural introduction of the anesthetic drug. H-shaped approach with muscular dissection and subsequent extrapleural mobilization of the ribs were conducted in case of fractures along the anterior and middle or middle and posterior axillary lines. Then metal fixation with SRKCh-22 was conducted for the superjacent and subjacent ribs and, after all the others, for the “projection” rib. Additional approaches were made for fractures of the ribs which were distant from the main incision. The surgery was completed with installation of the tube drain under the prepared musculocutaneous flap. Lateral thoracotomy, sanitation of the pleural cavity and correction of drains were conducted for fractures along the single line and presence of clotted hemothorax. Then the musculocutaneous flap was prosected to two super- and subjacent ribs, and metal fixation with SRKCh-22 was conducted. Displaced sternal fractures were treated with H-shaped approach, clavicle fractures – with the projection approach. The bone fragments were put together and metal fixation was performed. The important tactical moment of the use of SRKCh-22 is restoration of the frame only by means of matching the rib fragments along the anteriolateral surface of the chest. We do not fix rib fractures with location along the posterior surface of the chest and we believe that the muscular mass thickness is sufficient for supporting the frame.
RESULTS
One patient (2.5 %) died among 40 operated patients. The lethal outcome was determined by severe traumatic brain injury. For other patients spontaneous breathing was initiated in the early postsurgical period (the days 2-3 after the surgery). They did not require for any narcotic analgetics and regionary anesthesia on the 3rd day. There were no cases of nosocomial pneumonia. There were no wound complications. The median of a bed-day was 18 (14-22) days.
The clinical case
The patient M., age of 33, was admitted on September 1, 2014. The diagnosis was: “Associated injury. Closed chest injury. Closed fractures of the ribs 1-3 to the right, multiple fragmentary fractures of the ribs 1-11 to the left. Pulmonary contusion. Closed fracture of the left clavicle with displaced fragments. Closed traumatic brain injury. Brain concussion”. The complications: “Bilateral pneumothorax. Big hemothorax to the left. Atelectasis of the lower lobe to the left. Bilateral posttraumatic lower lobe pneumonia. Subcutaneous emphysema”.
From the history it is known that the injury appeared as result of the road traffic accident (the driver). Within 48 hours the patients was in the central regional hospital according to his place of residence. Because of increasing respiratory insufficiency, the sanitary aviation team transported him to the clinic. At the moment of admission his condition was severe and was determined by disordered integrity of the rib frame and respiratory insufficiency. ALV was with the intubation tube. We noted the chest asymmetry, paradoxial movement of its left half. Auscultation showed the breathing with rigid pattern and weakness in the posteroinferior departments. The stertors were dry and wet. Cardiac tones were rhythmical, AP – 120/75 mm Hg, HR – 105 per minute. The liver did not emerge outside the edge of the costal arch. The spleen was of the normal size. Diuresis was adequate. The patient received MSCT: fractures to the left 7-11 – along the posterior axillary line; 1-9 – along the paravertebral line (Fig. 2); 1, 2, 5, 6 – along the middle clavician line; 5-6 – along the scapular line. The right-side fractures: the ribs 1, 2, 3 – along the scapular line. Limited bilateral pneumothorax. Atelectasis of the lower lobe and middle hemothorax to the left. Left pleural cavity was recurrently drained in the intercostal spaces 2 and 7 to the left; the air and 550 ml of lysed blood were achieved. Ruvilua-Greguar test was negative. The draining for the right pleural cavity in the 2nd intercostal space was along the middle clavicular line. Extrapleural metal fixation for the fragmentary fractures of the ribs 4, 5, 6, 7 and 8 to the left was performed on September 3, 2014 (Fig. 3). The postsurgical period was without complications. Independent breathing was initiated. Extubation was after 24 hours. The drains were removed on the 2nd day. The skin sutures were removed on the 9th day. On the 15th day the patient was discharged in satisfactory condition. At 5 months after the surgical treatment the patient received chest MSCT. It showed the satisfactory state of bone fragments and the formed callus (Fig. 4).
Figure 2. MSCT of the patient M.: multiple fractures of ribs to the left
Figure 3. The intrasurgical picture of the patient M.: metal osteosynthesis of fragmentary fractures of ribs 4-8
Figure 4. MSCT of the patient M. 5 months after surgery: the shaped callus in the regions of rib fractures
DISCUSSION OF RESULTS
A chest injury with disordered frame is always accompanied by lung contusion and disorder of external breathing function. This circumstance allows classifying such type of injuries as polytrauma regardless of presence of associated injuries. Rib fixation is related to the final techniques of stabilizing the chest frame. The modern techniques, with orientation to both rigid and flexible constructs, have every reason to be the most physiological material. At the same time, their high price and low availability for Russian healthcare prevent the use in daily clinical practice. The use of SRKCh-22 allows solving the problem of restoration of external breathing function in patients with disordered chest frame and it does not increase the costs of surgical intervention.
CONCLUSION
Intrapleural fixation with SRKCh-22 for chest injury is an efficient and reliable variant of restoration of the sternocostal frame. The advantages of the technique include its availability, a possibility for conduction in conditions of central regional hospitals and early activation of patients with polytrauma.
REFERENCES
1. Benyan AS, Korymasov EA, Pushkin SYu, Kameev IR. Grounds for the additional indications for rib osteosynthesis in the closed chest trauma. Annals of Surgery. 2015; (4): 27-33. Russian ( Бенян А.С., Корымасов Е.А., Пушкин С.Ю., Камеев И.Р. Обоснование расширения показаний к остеосинтезу ребер при закрытой травме грудной клетки // Анналы хирургии. 2015. № 4. С. 27-33)
2. Tseymah EA, Bondarenko AV, Menshikov AA, Levin AV, Zimonin PE, Kazartsev AV. Minimally invasive techniques in complex treatment of patients with severe concomitant trauma and a dominant chest trauma. Tuberculosis and Lung Disease. 2016; 94 (7): 47-55. Russian ( Цеймах Е.А., Бондаренко А.В., Меньшиков А.А., Левин А.В., Зимонин П.Е., Казарцев А.В. Миниинвазивные технологии в комплексном лечении больных с тяжелой сочетанной травмой с доминирующей травмой груди // Туберкулез и болезни легких.2016. Т. 94, № 7. С. 47-55)
3. Derkacheva LV. Treatment policy and surgical technique in patients with floating rib fractures in the closed chest trauma. Abstracts of candidate of medical science. Saint Petersburg, 1999. P. 20. Russian (Деркачева Л.В. Лечебная тактика и техника операций у больных с флотирующими переломами ребер при закрытой травме груди: aвтореф. дис …. канд. мед. наук. СПб., 1999. 20 c.)
4. Shapot YuB. Closed chest polytrauma accompanied by shock. Abstracts of doctor of medical science. Perm, 1987. P. 44. Russian ( Шапот Ю.Б. Закрытая сочетанная травма груди, сопровождающаяся шоком: автореф. дис … д-ра. мед. наук. Пермь, 1987. 44 с.)
5. Wagner EA. Surgery of chest injuries. Moscow: Medicine Publ., 1981. P. 288. Russian ( Вагнер Е.А. Хирургия повреждений груди. М.: Медицина, 1981. 288 с.)
6. Garin ND, Gorkin NS. SGS-20 apparatus for stitching ribs and sternum. Journal of Surgery. 1959; (7): 143-145. Russian ( Гарин Н.Д., Горкин Н.С. Аппарат СГС-20 для сшивания ребер и грудины. Вестник хирургии. 1959. № 7. С. 143-145)
7. Pushkin SYu, Korymasov EA, Benyan AS, Kameev IR. The first experience of using the plates «MATRIXRIB» in traumatic chest deformation. News of Surgery. 2014; 22 (5): 611-614. Russian ( Пушкин С.Ю., Корымасов Е.А., Бенян А.С., Камеев И.Р. Первый опыт применения пластин «MATRIXRIB» при травматической деформации грудной клетки // Новости хирургии. 2014. Т. 22, № 5. С. 611-614)
8. Makhutov VN, Travnikov AI, Ilyicheva EA, Alexandrov AV, Grigoryev EG Surgical treatment of traumatic injuries of the chest with its structure damage. Chest and Cardiovascular Surgery. 2006; (5): 43-46. Russian. ( Махутов В.Н., Травников А.И., Ильичева Е.А., Александров А.В., Григорьев Е.Г. Хирургическое лечение травматических повреждений грудной клетки с нарушением ее каркасности // Грудная и сердечно-сосудистая хирургия. 2006. № 5. С. 43-46)
9. Gumanenko EK, Boyarintsev VV, Vaschenkov VV. Methodology for objective assessment of trauma severity (Part 1: Evaluation of the severity of mechanical damages). Journal of Surgery. 1997; (2): 55-59. Russian. (Гуманенко Е.К., Бояринцев В.В., Ващенков В.В. Методология объективной оценки тяжести травм (Часть 1. Оценка тяжести механических повреждений) // Вестник хирургии. 1997. № 2. С. 55-59)