Abstract

Background: Massive flail chest is an ultra-rare condition and occurs when a remarkable number of adjacent ribs break in at least two points. This entity is highly associated with underlying pulmonary contusion, which may lead to catastrophic pulmonary complications. Considering the importance of this condition, there are controversial data about definitive management of massive flail chest.

Case presentation: We reported a 47-year-old woman brought to our hospital after an auto-pedestrian accident. Due to pneumothorax, we inserted a tube thoracostomy in the right hemithorax. She became gradually unstable, and due to positive findings in imaging studies, the patient underwent splenectomy. She had bilateral multiple rib fractures in several points causing bilateral flail che

Conclusion: Massive flail chest could be treated both surgically or conservatively. However, most clinical data show the cost-effectiveness of operative management, but in some selected cases, it is better to treat the patient in a supportive manner.

Keywords: massive flail chest; Rib fracture;conservative management; chest trauma.

Citation: : Ebrahimian M. Conservative management of bilateral massive flail chest: A case report. Open J Clin Med Images. 2022; 2(1): 1021.

Introduction

Although flail chest is defined as a fracture of 3 or more contiguous ribs in at least two points, the term “Massive Flail Chest” is not clearly described yet. But many sequential ribs must have broken so that the whole underlying lung parenchyma becomes contused. However, conventional flail chest is a common entity among trauma patients. However, a massive flail chest with complete lung contusion is still a rare condition, and there is an intense controversy about its management. Several potential treatments have been described so far [1,2]. Given that underlying pulmonary contusion is a potentially fatal problem, the trauma managers must select the best treatment choice for respective patients.

In the present report, we introduce a case of massive flail chest due to an auto-pedestrian accident managed conservatively

Case presentation

A 47-year-old woman was brought to our emergency department by emergency medical services with a history of an autopedestrian accident 8 hours earlier. She was slightly confused, stable in vital signs, and had a chief complaint of severe back pain. On primary resuscitation, she had bilateral decreased pulmonary sounds, positive chest compression test, and abdominal tenderness in the left upper quadrant was detected. Pulse oxymetry showed reduced oxygen saturation, and Focused Assessment with Sonography in Trauma (FAST) showed moderate free liquid inside the abdomen. Therefore, two 28-Fr tube thoracostomies were inserted bilaterally drained air and blood. Also, a fast-track CT was done in the emergency department showing moderate liquids in the pelvic cavity and multiple lacerations at the posterior surface of the spleen as well as active bleeding (Figure 1a,1b).

On the other hand, the right clavicle, numerous rib fractures, and pulmonary contusion were found on both sides. On the left side, the ribs 1 to 12 were broken. Also, the ribs 6 to 11 were broken at two points. In addition, on the right side, the ribs 1 to 10 were broken at two points and the 11th rib in only one point, altogether causing a massive flail chest (Figure 1c).

The patient was admitted to the intensive care unit (ICU), and resuscitation continued. After two hours, her blood pressure decreased to 70 cmHg, and she was taken to the operating room to perform an emergent laparotomy. After a midline incision and suction of clots and gore, a severely lacerated spleen was found, and a complete splenectomy was performed. There were no other pathologic findings inside the abdomen, and the diaphragm was intact on both sides. Because of severe pulmonary contusion, the patient returned to ICU intubated

The oral regimen was started for her on day two via a nasogastric tube. Figure 2 shows a portable chest x-ray o

On the fifth day of the postoperative period, she could tolerate the weaning process and was extubated successfully. Due to her massive flail chest, conservative therapy was started. Potent analgesic medicines, incentive spirometry, and early ambulation were performed repeatedly. On day 8, the patient was breathless, and CXR showed collapsed lung and remained hemothorax in the right pleural cavity. Thoracostomy tube was changed and re-inserted at another place but couldn’t drain remained hemothorax successfully. Thus, on day 10, a videoassisted thoracoscopic surgery (VATS) was performed, and multiple large clots were extracted from the right-side pleural space. The left clavicle was fixed with plate and screws via an anterior approach. After 36 days of admission, the patient was discharged and showed no complications (Figure 2).

Discussion

As mentioned above, a flail chest is clinically defined as fracture of three or more adjacent ribs in at least two points. However, these fractures alone may not cause any specific clinical problem other than bleeding and pain, but associated pulmonary contusion usually remains problematic. Today, there is a consensus that these patients’ main cause of respiratory insufficiency is related to underlying pulmonary contusion. Therefore, respective treatments are being focused on this problem [1].

Figure 1: Initial imaging studies of the patient: (a,b). Axial and coronal views of CT show lacerated spleen with perisplenic hematoma (blue arrows). (c). multiple contiguous floating ribs (purple arrows) in a portable antero-posterior chest x-ray.

Figure 2: Three-dimensional reconstructed CT of ribs after 2 months. a,b and c depict multiple callus formation at fracture sites on both sides.

Diagnosis is based on clinical and radiological findings. Tachycardia, tachypnea, multiple rib clicking, paradoxical movement, and shortness of breath are more common findings [3]. On the other hand, axial CT has a high diagnostic capability in order to find fractured ribs [4] nad even can predict pulmonary insufficiency [5].

Pulmonary contusion is highly associated with further lung impairments like huge atelectasis and acute respiratory distress syndrome (ARDS). This condition starts with parenchymal destruction and alveolar hemorrhage and finally causes lung insufficiency within hours. It is approximated that contusion may resolve after seven days [5]. The risk of ARDS is related to underlying pulmonary contusion so that more than 20% of lung involvement, is highly predictive for ARDS development [6].

Logically, there are two options for treatment of flail chest: Conservative management and surgical treatment [1,5,7]. However latest literature emphasizes several advantages of surgical therapies, but in some selected cases, conservative management is the best choice. Surgical approaches have better outcomes and in some cases even are cost-effective, especially in patients with multiple rib fractures [8]. On the other hand, non-operative management is associated with more admission days, decreased pulmonary function, increased risk of pneumonia, and need for tracheostomy [9,10]. Also, the surgical method has its respective disadvantages. Operative management may develop surgical complications or need for other operations. Known surgical complications are wound infection, fracture-related infection, nonunion and malunion, bleeding, and the need for blood transfusion [11]. Therefore, it seems that a definitive decision on treatment method entirely depends on the patient’s condition. In some cases, who we can extubate them earlier, conservative management could be a good choice despite global consensus over operative management.

Conclusion

Massive flail chest could be treated both surgically or conservatively. However, most clinical data show the cost-effectiveness of operative management, but in some selected cases, it is better to treat the patient in a supportive manner.

Declarations

Funding sources: The authors didn’t receive any financial support for this report.

Ethical statement: Our institutions ethical committee doesn’t require any ethical approves for case reports.

Authors’ contributions: The authors declared no potential conflict of interests with respect to the research, authorship, and/or publication of this article.

References

1. Bastos R, Calhoon JH, Baisden CE, editors. Flail chest and pulmonary contusion. Seminars in thoracic and cardiovascular surgery; 2008: Elsevier.
2. Edwards JG, Clarke P, Pieracci FM, Bemelman M, Black EA, Doben A, et al. Taxonomy of multiple rib fractures: Results of the chest wall injury society international consensus survey. Journal of trauma and acute care surgery. 2020; 88(2): e40-e5.
3. Balci AE, Ozalp K, Duran M, Ayan E, Vuraloğlu S. Flail chest due to blunt trauma: clinical features and factors affecting prognosis. Ulusal travma ve acil cerrahi dergisi= Turkish journal of trauma & emergency surgery: TJTES. 2004; 10(2): 102-9.
4. Caragounis E-C, Olsén MF, Granhed H, Norrlund RR. CT-lung volume estimates in trauma patients undergoing stabilizing surgery for flail chest. Injury. 2019; 50(1): 101-8.
5. Cohn SM, DuBose JJ. Pulmonary contusion: an update on recent advances in clinical management. World journal of surgery. 2010; 34(8): 1959-70.
6. Miller PR, Croce MA, Bee TK, Qaisi WG, Smith CP, Collins GL, et al. ARDS after pulmonary contusion: accurate measurement of contusion volume identifies high-risk patients. Journal of Trauma and Acute Care Surgery. 2001; 51(2): 223-30.
7. McClure TT, Myers PM, Triplet JJ, Johnson DB, Taylor BC. Surgical treatment of flail chest and rib fractures: a systematic review of the literature. International Journal of Orthopaedics. 2019; 6(2): 1039-44.
8. Swart E, Laratta J, Slobogean G, Mehta S. Operative treatment of rib fractures in flail chest injuries: a meta-analysis and costeffectiveness analysis. Journal of Orthopaedic Trauma. 2017; 31(2): 64-70.
9. Cataneo AJM, Cataneo DC, de Oliveira FH, Arruda KA, El Dib R, de Oliveira Carvalho PE. Surgical versus nonsurgical interventions for flail chest. Cochrane Database of Systematic Reviews. 2015(7).
10. Zhang Y, Tang X, Xie H, Wang RL. Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion. The American journal of emergency medicine. 2015; 33(7): 937-40.
11. Peek J, Beks RB, Hietbrink F, Heng M, De Jong MB, Beeres FJ, et al. Complications and outcome after rib fracture fixation: A systematic review. Journal of Trauma and Acute Care Surgery. 2020; 89(2): 411-8.