[Thoracic Surgical Aspects of Seriously Injured Patients]. / Thoraxchirurgische Aspekte beim Polytrauma.

The therapy of severely injured patients is demanding and promising only in an interdisciplinary context. From a thoracic surgical perspective, the blunt chest trauma is in the foreground; as it is the 2nd leading cause of death after traumatic brain injury. The first step is to identify the potentially life-threatening injury and its treatment (airway obstruction, prevention of gas exchange, tension pneumothorax, serious bleeding complications in lung-/vascular injuries). Pneumothorax or tension pneumothorax is present in 20% of all polytrauma patients and 50% of all patients with severe chest trauma. In most cases, the use of a chest tube is sufficient in the acute phase (90%). For complex injuries with persistent thoracic haemorrhage and haemodynamic instability of the patient or pleural fistulization with increasing skin emphysema, surgical treatment should be performed at an early interval. Nevertheless, emergency thoracotomy is rarely required at this early stage.

Functional results after chest wall stabilization with a new screwless fixation device.

OBJECTIVES: This is the experience with the Stratos system in two surgical centres for the management of two types of rib fractures: flail chest and multiple dislocated rib fractures with significant chest wall deformity. METHODS: From January 2009 to May 2012, 94 consecutive patients were included. Selected indications were extended anterolateral flail chest (n = 68) and dislocated painful rib fractures (n = 26). The open reduction internal fixation (ORIF) system consists of flexible titanium rib clamps and connecting plates. The postoperative course was assessed. Clinical and functional outcomes were evaluated at 6 months. Functional assessment consisted of measurement of the functional vital capacity (FVC) and magnetic resonance imaging (MRI) examination with determination of the radiological vital capacity (rVC) in patients with a flail chest. RESULTS: The median operation time and length of hospital stay were 122 min and 19 days, respectively, in patients with a flail chest, and 67 min and 11 days, respectively, in patients with dislocated painful rib fractures. The morbidity rate was 6.4% and the overall 30-day mortality rate was 1.1%. Clinical evaluation and pulmonary function testing at 6 months revealed no deformity of the chest wall, symmetrical shoulder girdle mobility in 88% and a feeling of stiffness on the operated side in 19% of the patients operated for a flail chest. Median ratio of FVC was 88%, not suggesting any restriction after stabilization. MRI was performed in 53% (36 of 68) of the patients with a flail chest. The analysis of the rVC showed, on average, no clinically relevant restriction related to the operation, with a mean rVC of the operated relative to the non-operated side of 92% (95% confidence interval: 83, 100). Stabilization of more than four ribs was associated with a lower median rVC than stabilization of four or less ribs. CONCLUSIONS: Our results suggest that stabilization of the chest wall with this screwless rib fixation device can be performed with a low morbidity and lead to early restoration of chest wall integrity and respiratory pump function, without clinically relevant functional restriction. Owing to the simplicity of the fixation technique, indications for stabilization can be safely enlarged to selected patients with dislocated and painful rib fractures.