The modified Ravitch approach for the management of severe anterior flail chest with bilateral sternochondral dislocations: a case report
© The Author(s). 2018
Received: 6 October 2017
Accepted: 4 January 2018
Published: 19 January 2018
The management of flail chest continues to evolve as scientific evidence and surgical experience accumulates. Flail chest injuries that span the sternum present a rare and complicated injury pattern that can be challenging to manage both medically and surgically. Our patient is a 69-year-old involved in a high-speed motor vehicle crash with respiratory failure secondary to an anterior flail chest. Tomographic examination confirmed a sternal fracture with bilateral sternochondral dislocations and multiple rib fractures. The rib fractures created a lateral flail segment which extended towards the right side. An open Pectus exposure with a right anterolateral extension (modified Ravitch approach) and osteosynthesis plates accomplished stabilization of the chest wall, and contributed to weaning from mechanical ventilation.
Flail chest continues to present significant therapeutic challenges to both clinicians and their patients. While evidence continues to accumulate regarding the treatment of multiple, sequential rib fractures, certain combinations of chest wall instability lack specific recommendations and guidelines for their management, mostly due to their low incidence. One such presentation is the sternochondral dislocation associated with sternal body fracture.
In this article, we present the management of such an injury. The case report was written following the recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals (contained in the ICJME statement, http://www.icmje.org/), the work of the Equator Network (http://www.equator-network.org/) and the SCARE checklist .
A 69-year-old white male with a history of chronic obstructive pulmonary disease, hypertension and rheumatoid arthritis on steroids was brought to the emergency department after a head on collision at 50 miles per hour. He was in respiratory distress with obvious chest wall deformity. Prehospital interventions included a needle decompression on the right side. On arrival, his airway was patent, with bilateral diminished breath sounds and saturating 97% on 100% nonrebreather mask. He was tachypneic with obvious paradoxical movement of the right side of his chest wall with retraction upon inspiration bilaterally. Significant subcutaneous emphysema was noted, and the abnormal chest motion extended towards the right anterior-lateral chest wall (Additional file 1: Video S1). He was normotensive with a heart rate in 90 s. His presenting GCS was 15, with no obvious neurologic deficits. There was no any evidence of abdominal or pelvic tenderness, and the remainder of his primary survey was notable only for some lower extremity bruising. Chest tubes were placed bilaterally, after the patient was intubated and sedated for persistent respiratory distress and agitation with impending respiratory collapse. Output from the right chest tube was 120 mL and from the left chest tube 120 mL. The chest tubes were placed based on the enormous amount of subcutaneous emphysema, but very small pneumothorax and hemothorax on initial chest X-ray.
Chest and abdominal X-rays were obtained and showed subcutaneous emphysema and an endotracheal tube in adequate position. The patient was subsequently taken to CT scan for imaging (Fig. 1) with 3D reconstructions (Fig. 2) which revealed significant chest wall deformity with multiple fractures. The imaging demonstrated separation of the right 3rd to 5th costochondral junctions, separation of the left 2nd costochondral junction, and an oblique fracture of the proximal sternum with a 1.5-cm gap of displacement, and multiple rib fractures bilaterally. The right hemithorax had fractures of the anterior lateral 1st to 8th ribs and the left hemithorax had anterior-lateral fracture of ribs 2–6. The patient had an anatomic flail chest just from the right ribs 3–6 breaking in more than one place, but also a clinical and anatomic flail from the bilateral anterior lateral rib fractures and sternal fracture (Additional file 1: Video S1).
Additional file 1: Video S1. (MP4 2931 kb)
After approximation of the sternum was complete, the displaced ribs were stabilized using rib plates (Zimmer Biomet, Warsaw IN). The reconstruction of the ribs was accomplished with fixation of the 4th, 5th, and 6th ribs on the right side with plates that bridged both the anterior and lateral fractures. The second left and third right costochondral cartilage were also significantly displaced from the sternum, and the approximation of the joint was achieved using a Biomet LJ plate (Zimmer Biomet, Warsaw IN) bent to fit the bone and cartilage on either side.
Follow-up and outcome
Flail chest is a severe, life-threatening complication of thoracic trauma. The condition is defined as three or greater consecutive ribs fractured in two places, with or without a sternal component, with associated paradoxical motion of the chest wall segment. This affected segment is in discontinuity with the rest of the chest wall, leading to collapse on inspiration and expansion upon expiration . Clinical significance of the flail segment can vary based on size and anatomic location. Morbidity associated with the condition includes mechanical ventilation, pneumonia, chest wall deformation, and chronic pain. Associated pulmonary contusions can further complicate patient conditions. A higher overall morbidity has been attributed to anterior flail segments as compared to lateral. Mortality rates vary between studies depending on associated injuries, but have been noted to range from 5 to 36% .
Current conservative management guidelines focus on avoidance of hypotension and hypoxia along with adequate pain control. Goal-directed fluid resuscitation should be used in the setting of hypotension, and epidural anesthesia is considered first-line treatment for pain in the setting of flail chest with pulmonary contusion. Mechanical ventilation is not used prophylactically, but should be employed in the setting of respiratory failure .
Although this conservative management is generally agreed upon, the role for surgical fixation in the setting of flail chest and the timing of therapy continues to evolve. Current indications for surgical fixation include (1) thoracotomy for other thoracic injuries, (2) unsuccessful weaning from mechanical ventilation, (3) severe chest wall instability, (4) persistent pain, and (5) progressive loss of pulmonary function [4, 5]. A randomized control trial by Tanaka et al. demonstrated statistically shorter periods of mechanical ventilation, ICU days, lower incidences of pneumonia, and less need for tracheostomy. Furthermore, several studies have found improvement in long-term pulmonary function tests and decrease in pain when compared to non-operative management [5, 6]. Of the abovementioned indications for surgical intervention, our patient displayed three. His chest wall instability was the cause for his severe pain induced agitation as well as a strong contributing factor in his failure to wean from mechanical ventilation. This particular clinical association has been described before .
The typical incisions for surgical stabilization of rib fractures involve a classic antero-lateral or posterior lateral thoracotomy or a vertical axillary thoracotomy for exposure of the fractured ribs. For decades, Kirschner wires and Judet plates were used with variable success. With the development of rib stabilization systems that used modern principles of osteosynthesis, there has been an explosion of systems of rib fixation hardware that both restore anatomical contour of the chest and provide the creation of a rigid construct for bone healing. While literature on the surgical fixation of lateral flail chest continues to accumulate, reports on the surgical approach to sternochondral disjunction are quite rare. A few case reports or small series have been published documenting the use of the Nuss procedure using a retrosternal bar for sternal stabilization . Our patient’s condition was quite complex, involving a transverse displaced sternal fracture with bilateral sternochondral disjunction as well as lateral flail segments. A simple lateral fixation or Nuss procedure would not be adequate for chest wall stabilization. A modified Ravitch procedure, an operation typically reserved for complex or recurrent cases of pectus excavatum , was employed in this situation. The key steps in this procedure involve the creation of myocutaneous flaps, subperichondral cartilage resection, and transverse sternal osteotomy with fixation to bring the sternum to a more anterior position, as originally described by Ravitch in 1949 .
Our surgical approach modifies this classic technique, which we found useful for several reasons. The transverse inframammary incision with a midline cephalad extension allows adequate access to both the sternal fracture as well as the lateral flail segments, all of which required surgical fixation to restore chest wall stability. Our modification to the Ravitch procedure also involves both reduction and fixation of the sternochondral cartilage and repositioning of the sternal fragments, both of which had been forcefully displaced as a result of the blunt trauma. The reconstruction of the sternal fracture was achieved with an H-plate, providing 8 sites of bicortical fixation along the fracture. This method of fixation has been shown to provide superior stabilization in comparison to sternal wires, which are used in the classic operation [11, 12]. The myocutaneous flaps we created provide additional coverage to the implanted hardware and reinforcement of the area, to prevent a possible pulmonary hernia.
In summary, the management of flail chest continues to evolve as scientific evidence and experience accumulates. For certain subgroups of patients, surgical stabilization has been shown to improve outcomes. Anterior flail segments are rare and often more complex in comparison to lateral segments and thus can present challenges to surgical fixation. We have used a modified Ravitch procedure to successfully repair a severe sternal displacement with an associated flail segment. This technique can be safely and effectively used to provide adequate chest wall stabilization in rare, complex anterior injuries to improve recovery of pulmonary function in patients’ refractory to non-operative management.
No sources of funding were required for this case report.
A patient perspective was not directly obtained for this case report, but elements pertaining to this were collected from the treating clinicians: The patient has no specific recollection of his initial injury or his arrival to the emergency department, but both he and his spouse recall the attempts at weaning from mechanical ventilation, including the pain it elicited in his chest as the support was removed. They also shared how much easier it was to breathe after the operation and how the “cracking and rubbing” sensation over his breast bone (that was gone after surgery) was their major source of anxiety and pain.
GE carried out the literature search and review and drafted the manuscript. ECO helped with the video production, conceived the project, and proofread the manuscript. ESS helped drafting the manuscript and helped with the literature search. All authors read and approved the final manuscript.
Consent for publication
As per existing policies and in accordance with current rules and regulations pertaining the protection of human subjects during research (including the Helsinki declaration) and applicable Federal Law pertaining the management of patient information, informed consent was obtained from the patient for surgical treatment, the acquisition of pictorial material and other elements related to his medical care and the possible use of this materials for teaching purposes, including publication on a scientific journal. The consent is included in the Medical Record of the patient, and a copy may be made available to the Editor upon request.
The authors declare that they have no competing interests.
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- Agha RA, Fowler AJ, Saetta A, Barai I, Rajmohan S, Orgill DP, for the SCARE Group. The SCARE statement: consensus-based surgical case report guidelines. Int J Surg. 2016 Oct;34:180–6. https://doi.org/10.1016/j.ijsu.2016.08.014. Epub 2016 Sep 7View ArticlePubMedGoogle Scholar
- Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin. 2007 Feb;17(1):25–33. https://doi.org/10.1016/j.thorsurg.2007.02.005.View ArticlePubMedGoogle Scholar
- Kilic D, Findikcioglu A, Akin S, Akay TH, Kupeli E, Aribogan A, Hatipoglu A. Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location. Thorac Cardiovasc Surg. 2011 Feb;59(1):45–8. https://doi.org/10.1055/s-0030-1250597.View ArticlePubMedGoogle Scholar
- Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward T 3rd, Rodriguez A, Smith L. Eastern Association for the Surgery of Trauma: management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S351–61. https://doi.org/10.1097/TA.0b013e31827019fd.View ArticlePubMedGoogle Scholar
- Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52(4):727–32. discussion 732.PubMedGoogle Scholar
- Caragounis EC, Fagevik Olsén M, Pazooki D, Granhed H. Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study. World J Emerg Surg. 2016;11:27. https://doi.org/10.1186/s13017-016-0085-2. eCollection 2016.View ArticlePubMedPubMed CentralGoogle Scholar
- Lanier ST, Wetterau M, Smith-Singares E, Bilfinger T, Vosswinkel J, Shapiro MJ, Dagum AB. Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: a case report. Can J Plast Surg. 2011 Winter;19(4):145–7.View ArticlePubMedPubMed CentralGoogle Scholar
- Lee SK, Kang DK. Nuss procedure for surgical stabilization of flail chest with horizontal sternal body fracture and multiple bilateral rib fractures. Journal of Thoracic Disease. 2016;8(6):E390–2. https://doi.org/10.21037/jtd.2016.04.05.View ArticlePubMedPubMed CentralGoogle Scholar
- Sultan I, Yang SC. Congenital chest wall anomalies. In: Yuh DD, Vricella LA, Yang SC, Doty JR. eds. Johns Hopkins textbook of cardiothoracic surgery, 2nd Edition. New York, NY: McGraw-Hill; 2014. http://accesssurgery.mhmedical.com/content.aspx?bookid=963&Sectionid=55168775. Accessed 29 Nov 2016.
- Ravitch MM. The operative treatment of pectus excavatum. Ann Surg. 1949;129:429–44.View ArticlePubMedPubMed CentralGoogle Scholar
- Marasco S, Saxena P. Surgical rib fixation—technical aspects. Injury. 2015;46(5):929–32. https://doi.org/10.1016/j.injury.2014.12.021. Epub 2015 Jan 10.View ArticlePubMedGoogle Scholar
- Schulz-Drost S, Oppel P, Grupp S, et al. Surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling. JoVE. 2015;95:52124. https://doi.org/10.3791/52124.Google Scholar