Author		Article		Publication		Year
Ahmed Z, Mohyuddin Z		Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation		J Thorac Cardiovasc Surg. 1995 Dec;110(6):1676-80		1995
Bottlang M, Helzel I, Long WB, Madey S.		Anatomically contoured plates for fixation of rib fractures.		J Trauma. 2010 Mar;68(3):611-5.		2010
M.A. Kerr-Valentic, et al.		Rib fracture pain and disability: Can we do better?		J Trauma. 2003 June;54(6):1058-1064		2003
Mohr M, Abrams E, Engel C, Long WB, Bottlang M		Geometry of Human Ribs Pertinent to Orthopaedic Chest-Wall Reconstruction		J Biomech. 2007;40(6):1310-7		2007
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 32		2002
M. Bottlang, S. Walleser, M. Noll, S. Honold, S. M. Madey, D. Fitzpatrick and W. B. Long		Biomechanical rationale and evaluation of an implant system for rib fracture fixation		Eur J Trauma Emerg Surg 2010		2010
Inga Helzel, William Long, Daniel Fitzpatrick, Steven Madey, Michael Bottlang		Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures		Injury, Int J Care Injured 40 (2009) 1104-1110		2009
M. Bemelman, M. Poeze, T. J. Blokhuis and L. P. H. Leenen		Historic overview of treatment techniques for rib fractures and flail chest		Eur J Trauma Emer Surg (2010) 36: 407-415		2010
D. C. Fitzpatrick, P. J. Denard, D. Phelan, W. B. Long, S. M. Madey and M. Bottlang		Operative stabilization of flail chest injuries: review of literature and fixation options		Eur J Trauma Emerg Surg 2010 Apr.		2010

Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995;110:1676-1680.

A total of 427 patients with major chest trauma were treated in two major hospitals in Abu Dhabi, United Arab Emirates, during a 10-year period. In 64 of 426 patients, flail chest injury was the dominant factor among other injuries that were insignificant. Among 64 cases of flail chest injury, 26 were managed by internal fixation of ribs, whereas the remaining 38 were managed by endotracheal intubation and intermittent positive-pressure ventilation alone.

Of the patients treated by internal fixation 80% (21/26) were weaned from the ventilator within an average of 1.3 days, whereas the remaining 20% (5/26) continued to need assisted ventilation for a longer duration; the total average duration of assisted ventilation for the whole group was 3.9 days. In comparison, among 38 patients with flail chest injury treated by endotracheal intubation and ventilation alone, the average duration of assisted ventilation was 15 days. In the group treated by internal fixation 11% (3/26) of the patients ultimately required a tracheostomy, whereas in the patients treated by intubation and ventilation alone tracheostomy was required in 37% (14/38) of the cases. In the group treated by internal fixation, chest infection was documented in 15% (4/26), septicemia in 4% (1/26), and barotrauma in 0%; in the other group these complications occurred in 50% (19/38), 24% (9/38), and 8% (3/38) of the cases, respectively. The mortality rate was 8% (2/26) in the surgically treated patients, whereas it was 29% (11/38) in the other group. All the deaths in both groups were ascribed to adult respiratory distress syndrome. Average stay in the intensive care unit was 9 days for the patients treated by internal fixation, whereas it was 21 days in the group treated by intubation and ventilation alone.

The treatment of flail chest injury in our series by internal fixation resulted in speedy recovery, decreased complications, and better ultimate cosmetic and functional results and proved to be cost effective.

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Bottlang M, Helzel I, Long WB, Madey S. Anatomically contoured plates for fixation of rib fractures. J Trauma. 2010 Mar;68(3):611-5.

BACKGROUND: Intraoperative contouring of long bridging plates for stabilization of flail chest injuries is difficult and time consuming. This study implemented for the first time biometric parameters to derive anatomically contoured rib plates. These plates were tested on a range of cadaveric ribs to quantify plate fit and to extract a best-fit plating configuration.

METHODS: Three left and three right rib plates were designed, which accounted for anatomic parameters required when conforming a plate to the rib surface. The length lP over which each plate could trace the rib surface was evaluated on 109 cadaveric ribs. For each rib level 3-9, the plate design with the highest lP value was extracted to determine a best-fit plating configuration. Furthermore, the characteristic twist of rib surfaces was measured on 49 ribs to determine the surface congruency of anatomic plates with a constant twist.

RESULTS: The tracing length lP of the best-fit plating configuration ranged from 12.5 cm to 14.7 cm for ribs 3-9. The corresponding range for standard plates was 7.1-13.7 cm. The average twist of ribs over 8-cm, 12-cm, and 16-cm segments was 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constant twist of anatomic rib plates was not significantly different from the average rib twist.

CONCLUSIONS: A small set of anatomic rib plates can minimize the need for intraoperative plate contouring for fixation of ribs 3-9. Anatomic rib plates can therefore reduce the time and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates.

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M. A. Kerr-Valentic, et al. Rib Fracture Pain and Disability: Can we do better?. J Trauma. 2003 June;54(6): 1058-1064.

OBJECTIVE: The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series.

METHODS: Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0-10). Disability at 30 days was assessed using the SF-36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university-based Level I trauma center.

RESULTS: Forty patients with a mean of 2.7 +/- 1.6 rib fractures were enrolled. Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 +/- 2.1 at 30 days and 1.0 +/- 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p < 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p < 0.001). The total mean days lost from work/usual activity was 70 +/- 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 +/- 39 days compared with 91 +/- 33 days in patients with associated extrathoracic injuries (p < 0.01).

CONCLUSION: Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.

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Mohr M, Abrams E, Engel C, et al. Geometry of human ribs pertinent to orthopedic chestwall reconstruction. J Biomech 2007;40:1310-1317.

Orthopedic reconstruction of blunt chest trauma can aid restoration of pulmonary function to reduce the mortality associated with serial rib fractures and flail chest injuries. Contemporary chest wall reconstruction requires contouring of generic plates to the complex surface geometry of ribs. This study established a biometric foundation to generate specialized, anatomically contoured osteosynthesis hardware for rib fracture fixation.

On human cadaveric ribs three through nine, the surface geometry pertinent to anatomically conforming osteosynthesis plates was characterized by quantifying the apparent rib curvature CA, the longitudinal twist alpha LT along the diaphysis, and the unrolled curvature CU. In addition, the rib cross-sectional geometry pertinent to intramedullary fixation strategies was characterized in terms of cross-section height, width, area, and cortex thickness. The rib surface exhibited a curvature CA ranging from 3.8m-1 in the anteromedial section of rib seven to 17.3 m-1 in the posterior section of rib three. All ribs had in common a longitudinal twist alpha LT, ranging from 41–60 degrees. The unrolled curvature CU decreased gradually from ribs three to five, and increased gradually with reversed orientation from rib six to nine. The cross-sectional area remained constant along the rib diaphysis. However, the medullary canal increased in size from 29.9 mm2 posteriorly to 41.2 mm2 in anterior rib segments.

Results of this biometric rib characterization describe a novel strategy for intraoperative plate contouring and provide a foundation for the development of specialized rib osteosynthesis strategies.

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Tanaka A, 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 Apr;52(4):727-32; discussion 732.

BACKGROUND: We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support.

METHODS: Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups.

RESULTS: Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and Pao2/Fio2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19).

CONCLUSION: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.

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M. Bottlang, S. Walleser, M. Noll, S. Honold, S. M. Madey, D. Fitzpatrick and W. B. Long. Biomechanical rationale and evaluation of an implant system for rib fracture fixation.

BACKROUND: Biomechanical research directed at developing customized implant solutions for rib fracture fixation is essential to reduce the complexity and to increase the reliability of rib osteosynthesis. Without a simple and reliable implant solution, surgical stabilization of rib fractures will remain underutilized despite proven benefits for select indications. This article summarizes the research, development, and testing of a specialized and comprehensive implant solution for rib fracture fixation.

METHODS: An implant system for rib fracture fixation was developed in three phases: first, research on rib biomechanics was conducted to better define the form and function of ribs. Second, research results were implemented to derive an implant system comprising anatomical plates and intramedullary rib splints. Third, the functionality of anatomic plates and rib splints was evaluated in a series of biomechanical tests.

RESULTS: Geometric analysis of the rib surface yielded a set of anatomical rib plates that traced the rib surface over a distance of 13–15 cm without the need for plate contouring. Structurally, the flexible design of anatomic plates did not increase the native stiffness of ribs while restoring 77% of the native rib strength. Intramedullary rib splints with a rectangular cross-section provided 48% stronger fracture fixation than traditional intramedullary

CONCLUSION: The anatomic plate set can simplify rib fracture fixation by minimizing the need for plate contouring. Intramedullary fixation with rib splints provides a less-invasive fixation alternative for posterior rib fracture, where access for plating is limited. The combination of anatomic plates and intramedullary splints provides a comprehensive system to manage the wide range of fractures encountered in flail chest injuries.

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Inga Helzel, William Long, Daniel Fitzpatrick, Steven Madey, Michael Bottlang. Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures

BACKGROUND: Intramedullary fixation of rib fractures with generic Kirschner wires has been practiced for over 50 years. However, this technique has not been advanced to address reported complications of wire migration and cut-out. This biomechanical study evaluated a novel rib splint designed to replicate the less-invasive fixation approach of Kirschner wires while mitigating their associated complications.

METHODS: The durability, strength, and failure mode of rib fracture fixation with intramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs were loaded to failure to determine their strength and to induce realistic rib fractures. Subsequently, fractures were stabilised with a novel rib splint made of titanium alloy with a rectangular cross-section that was secured with a locking screw. All fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load magnitude to determine their durability. Finally, constructs were loaded to failure to determine their residual strength and failure modes.

RESULTS: Native ribs had a strength of 9.7 _ 5.0 N m, with a range of 3.5–19.6 N m. Fracture fixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out. Dynamic loading caused no significant decrease in construct stiffness (p = 0.85) and construct subsidence remained on average below 0.5 mm. The residual strength of splint constructs after dynamic loading was 1.1 _ 0.24 N m. Constructs failed by splint bending in 44% of specimens and by developing fracture lines along the superior and inferior cortices in 56% of specimens. Regardless of the failure mode, all rib splint constructs recoiled elastically after failure and retained functional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex.

CONCLUSIONS: Rib splints can provide sufficient stability to support respiratory loading throughout the healing phase, but they cannot restore the full strength of native ribs. Most importantly, rib splints mitigated the complications reported for rib fracture fixation with generic Kirschner wires, namely implant cut-out andmigration through the lateral cortex. Therefore, rib splints may provide an advanced alternative to the original Kirschner wire technique for less-invasive fixation of rib fractures.

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M. Bemelman, M. Poeze, T. J. Blokhuis and L. P. H. Leenen. Historic overview of treatment techniques for rib fractures and flail chest

INTRODUCTION: 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.

METHODS: 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.

CONCLUSION: 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.

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D. C. Fitzpatrick, P. J. Denard, D. Phelan, W. B. Long, S. M. Madey and M. Bottlang. Operative stabilization of flail chest injuries: review of literature and fixation options

BACKGROUND: Flail chest injuries cause significant morbidity, especially in multiply injured patients. Standard treatment is typically focused on the underlying lung injury and involves pain control and positive pressure ventilation. Several studies suggest improved short- and long-term outcomes following operative stabilization of the flail segments. Despite these studies, flail chest fixation remains a largely underutilized procedure.

METHODS: This article reviews the relevant literature concerning flail chest fixation and describes the different implants and techniques available for fixation. Additionally, an illustrative case example is provided for description of the surgical approach.

RESULTS: Two prospective randomized studies, five comparative studies, and a number of case series documented benefits of operative treatment of flail chest injuries, including a decreased in ventilation duration, ICU stay, rates of pneumonia, mortality, residual chest wall deformity, and total cost of care. Historically, rib fractures have been stabilized with external plates or intramedullary implants. The use of contemporary, anatomically contoured rib plates reduced the need for intraoperative plate bending. Intramedullary rib splints allowed less-invasive fixation of posterior fractures where access for plating was limited.

CONCLUSION: Operative treatment can provide substantial benefits to patients with flail chest injuries and respiratory compromise requiring mechanical ventilation. The use of anatomically contoured rib plates and intramedullary splints greatly simplifies the procedure of flail chest fixation.


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