Historic overview of treatment techniques for rib fractures and flail chest
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From the beginning of the twentieth century till the current time, an overview is presented of the surgical treatment for rib fractures and flail chest.
Many techniques have been used to stabilize the thorax wall. There has been no follow-up for the most described techniques and the evidence provided is at its best at L3–4. This, together with the noninvasiveness of mechanical ventilation, has made the latter the golden standard.
However, the recent introduction of better and fully dedicated materials provides the possibility of exploring the surgical treatment of chest injuries. The authors make a case for operative treatment of rib fractures and flail chest.
KeywordsThoracic trauma Rib fractures Flail chest History
The history of the application of different treatment techniques for rib fractures mimics the movement of a pendulum. After considerable attention in the 1950s and 1960s, it gradually lost focus until the introduction of plate systems in the 1980s. Thereafter, it again lost interest until the recent introduction of new dedicated materials, initiating a renaissance in the surgical therapy of rib fractures. In the older literature on chest injury, there is a surprisingly good understanding of injury patterns related to chest injury. Current concepts do not differ much from those of 50 years ago. The flail chest as we know it today was described as early as 1955 by Cohen . The synonym “stove in chest” was used earlier, and was first described in 1945 by Hagen . A specific type of flail chest called the “steering wheel injury” chest was described in 1949 by Heroy . This typical injury gained increasing attention due to the ever-growing use of automobiles. The injury was the result of a head-on collision, and was due to the lack of seatbelt restraints such that the casualty smashed into the steering wheel and fractured a series of ribs bilateral to the sternum. A flail chest of the sternum segment or a “floating sternum” was the result. Physiological disturbances of the respiration related to these injuries are described in a surprisingly accurate manner. The typical paradoxical movement with decreased lung compliancy and the increased lung resistance that results in increased breathing effort are described in great detail. Moreover, the impaired venous return due to pressure changes within the chest is described [2, 15]. Williams describes a typical clinical triad related to flail chest: intrabronchial hemorrhage, ineffectual cough and typical anoxia . These early reports feed a progressive awareness that patients with flail chest have a poor prognosis; a high mortality rate of up to 80% is reported [16, 23, 36], leading to numerous ideas and techniques for the chest. Upon analyzing these techniques, they can be divided into two main groups: internal support techniques and external support techniques. The latter group can be divided into conservative, percutaneous and invasive therapies.
Internal support or splinting by mechanical positive pressure ventilation is in fact a relatively modern technique compared to external splinting.
Even though the first description of artificial respiration was provided in 1902 by Hoyt , it was another 49 years before it achieved clinical use. The first publication that deals with positive pressure ventilation for chest injury was from Carter et al. . They describe a technique in which they employ tracheostomy together with intermittent positive pressure ventilation. This method is based on the idea that a tracheotomy enables adequate removal of retained secretions and intermittent mechanical ventilation gives internal support to the lungs and decreases the physical demands on the respiratory muscles.
Avery et al.  was the first to describe continuous mechanical ventilation, thus providing permanent internal pneumatic stabilization for chest injury.
Garzon  was one of the first to discuss the use of a tracheostomy combined with continuous mechanical ventilation. He analyzed a group of 12 patients with flail chest. Nine received tracheotomies and eight mechanical ventilation. As many as four of these 12 patients died as a result of their injuries. The author describes in great detail the pathophysiology of the lung. He proves a relation between lung compliance, airway resistance, breathing workload, lung volumes, pulmonary diffusion, blood gases, shunting, and the extent of the injury.
The first report of external support for a flail chest was from Jones . This appeared 25 years before mechanical ventilation was presented.
External support: nonoperative
The simplest of the reported nonoperative measures is strapping the chest with adhesive tape. The first publications concerning this were from Berry et al. [4, 11, 22]. Hagen  was the first to describe a form of respiratory support with the Drinker respirator (also known as the “iron lung”). This technique uses external splinting, as the working motion of this device is based on a repetitive cycle of creating a vacuum in a metal cylinder and subsequently transferring it to the chest wall of the patient, thus creating inspiration cycles. The patient was positioned in the cylinder for a period of 10 days and weaned for another 11 days.
External support: percutaneous
Heroy  treated flail chest with different techniques. In the case of a steering wheel injury, they applied vitallium alloy screws in the sternum and then applied traction with the patient in the high Fowler’s position. This situation would last for approximately 24 h, after which the screws would generally break out.
Many alternative traction or suspension principles have been described. Some are similar to towel clips or forceps ; others use different techniques, like metal wires around the ribs , and some are even more bizarre, like the placement of a corkscrew in the sternum .
The basic idea behind all of the techniques mentioned here was that traction would lead to the expansion of the lung tissue, thus creating a larger vital capacity for the lungs with less resistance and a reduced risk of atelectasis, pneumonia and respiratory failure. Moreover, stabilizing the chest would reduce the pain, leading to more comfort.
In 1996, an interesting article was published by Gyhra et al. . The authors present the results of a study comparing two different external stabilizing techniques. Adhesive strapping and sandbagging was used in one group, and percutaneous traction through towel clips in the other. It is intriguing to read that old techniques were still being used in 1996, and even being investigated in a comparative study. The results not surprisingly show that the latter had better respiratory parameters.
External support by operative means
Open reduction and internal fixation (ORIF).
Aside from techniques in which anatomical reduction is the goal, many techniques for attaining some sort of internal suspension of the ribs have been described. It is notable that these techniques developed later, possibly due to an increasing awareness that these patients had sustained serious injuries, and each subsequent surgical insult should be either avoided or shortened where possible. The first publication to deal with suspension techniques after open surgery was from a French surgeon, Dor . A technique is described in which the fracture of the ribs is stabilized with K wires.
The technique used by Landreneau et al.  is in fact analogous to the Nussbar® technique, which was initially described and used for the repair of pectus excavatum. Glinz and Carbognani [5, 18] both describe techniques in which they too suspend the chest wall with a metal bar in order to treat flail chest. In 2001, Glavas described  a technique in which the flail segment is bridged with a bone cement (Pallacos®) prosthesis. The prosthesis is made in-house and reaches from the proximal intact rib to the distal intact rib, crossing the flail segment tangentially. The ribs were attached to the prosthesis with sutures or wires. He reports the treatment of 56 patients with good results; however, no fine details are shared.
Regardless of the material used, a similar principle was used in this group of techniques. The surgeons reduced the fracture after open reduction and subsequently created a stable fixation, creating a near-normal chest shape and physiology, and thus enabling normal respiration.
Many different devices have been described. Intramedullary devices have been described by Klassen (bone pegs)  and Cruther and Nolen (rush pins) . Aside from these intramedullary techniques, many surgeons (Hagen, Elkin) [13, 22] have used a simple principle, suturing the fractures with either metal wires or sutures.
Of course, many techniques have employed plates, so many different plates have been designed. Sillar  was the first to report the use of plates to stabilize the chest. The plates were mainly used for sternum fractures; rib fractures were stabilized with parallel K wires through the ribs. Many authors subsequently reported improvised self-made plates and eventually plates dedicated to fixing ribs.
The introduction of Labitzke’s plate system  initiates a period (the 1980s) during which there was renewed interest in rib fixation with plate systems.
Sales et al.  published an article in which a new design of plate that uses both principles (screwing and grasping function) was described. This resulted in the U plate or the RibLoc® plate from Acute Innovations™. As the name suggests, the plate takes the form of a U that slides over the rib; fixation is then obtained with angular stable screws.
In 2008 a dedicated system was introduced to the French scene. It is called the Stratos® system (an abbreviation of “Strasbourg thoracic osteosynthesis system”). It is a fully dedicated system for the treatment of rib fractures and chest wall deformities. The fixation mechanism is analogous to that for the Judet plate. The system is also equipped with bars that can be connected to the plates to bridge or suspend thoracic wall segments. No clinical results have been published thus far.
The most recent system was presented by Synthes™: the Matrix® rib fixation system. It is a fully dedicated plate and splint system solely for the stabilization of ribs. The plates are made of titanium and are designed in such a manner that they mimic the biodynamic characteristics of ribs. The plates and splints are fixed with locking screws.
An interesting aspect of all of the plate systems described here is that there is very limited follow-up in the literature after the initial publication. This suggests that there may have been some problems with the systems. Labitzke describes conventional plates and screws breaking out. Just thinking about the systems and their application introduces potential problems. Labitzke’s plate system with clamps is made of titanium, which has 50% recoil when trying to bend the hooks around the ribs. This may cause insufficient grip around the ribs. Furthermore, the ribs are relatively soft compared to other bones, which may make them prone to breakage when attempting to bend clamps around the ribs.
Neither of these theoretical problems exist with the two most recent systems on the market. For instance, in the RibLoc plate system from Acute Innovations, the plate, which is fabricated from titanium, slides over the ribs without the need to bend it around the rib. It is then fixed with locking screws.
Over the years, many techniques have been used to stabilize the thorax and ribs in order to treat rib fractures and flail chest, as most authors are convinced that the treatment of these conditions is warranted. However, considering the large number of solutions proposed, no definitive solution has been presented yet. Upon reviewing conservative external techniques like strapping or “sand bagging,” it quickly becomes obvious that these techniques were not sufficient. Some simple studies tried to prove this, but if we consider current “evidence-based rules,” none of these studies get above level 3–4.
The summary of invasive techniques provided here highlights the ingenuity of the treating surgeons. Contraptions range from the relatively simple and apparently effective to the bizarre and potentially dangerous. Most of the manuscripts provide no details about any complications, but considering the proposed methods, we would expect them to lead to serious complications like empyema, lung injury, cardiac injury, etc. The fact that none of these techniques has become widely popular confirms that probably all of these expected complications occurred. This has most probably contributed to the popularity of mechanical ventilation as the most popular means of treating thoracic trauma with serial rib fractures, flail chest and pulmonary contusion. This is still seen as the most reliable technique, and remains the gold standard even today. Nevertheless, given recent studies like that of Tanaka et al. , it appears that we can still improve our therapy regimes for rib fractures and flail chest, especially with the introduction of fully dedicated osteosynthesis materials for flail chest and rib fractures.
That these plate systems may offer better therapeutic solutions for flail chest and rib fractures is suggested by recent studies done by Graznetsky et al. [19, 33, 41]. These studies prove (level 2–3) that operative treatment of flail chest leads to a shorter ICU stay, fewer cases of pneumonia and reduced mortality compared to ventilatory support.
Conflict of interest
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