Attending Surgeon Kern Medical Center, United States
Introduction: Flail chest is among the most devastating injuries with mortality rates reaching 40%. Flail chest presents following thoracic or sternal injury of the anterior or lateral chest wall. Flail segment is defined as 2 fractures in at least 3 consecutive ribs. Flail chest occurs when the flail segment is accompanied by paradoxical chest wall movement. Historically treatment has focused on analgesia, respiratory support and early mobilization. Surgical stabilization has yielded promising data, however, there remains no consensus on timing, location or patient selection. Herein, we describe our experience utilizing immediate surgical stabilization in a patient with flail chest with an optimal recovery.
Description: A 50-year-old man presented after an 20-foot fall where he was subsequently impaled by a tree. Exam revealed respiratory distress, hypoxemia, severe left chest wall deformity with paradoxical chest wall movement and a 3cm penetrating wound at the 3rd intercostal space. Thoracostomy returned 300 mL of sanguineous fluid. Imaging revealed a moderate left hemopneumothorax, emphysematous chest wall changes and fractures of ribs 1-6. Decision was made to proceed to the operating room where thoracotomy exposed a laceration transecting the left lower lung lobe, extending to the left hilum and inferior pulmonary vein. Operative interventions included removal of the devascularized lower lobe segment, ligation of the inferior pulmonary vein and its tributaries and plating of the flail segment at ribs 3-8. He was extubated on POD 1. Chest tubes were removed on POD 3, and he was optimized for discharge on POD 5 including adequate pain control, and overall functional status. He remains without major complications or disability on follow up 6 months post inciting injury.
Discussion: Despite polytrauma, our patient readily obtained adequate analgesic effect, early extubation and mobilization following rib stabilization leading to a reduction in overall hospital length of stay. In turn, this prevented acute complications such as associated pneumonia, retained hemothorax, uncontrolled pain and immobility, minimizing risk for long-term complications. We believe surgical intervention in the immediate or acute setting may allow for a profound reduction in the high morbidity and mortality of flail chest.
