Benyan A. S., Medvedchikov-Ardia M. A.

Samara State Medical University, Ministry of Health of the Samara Region, Samara Regional Clinical Hospital n.a. V.D. Seredavin

The severity of a closed chest injury is equally determined by damage to the bone frame and intrapleural organs. The main strategic aim of treatment in the acute period of trauma is removal of life-threatening conditions. The modern organization of medical care and the use of high-tech interventions can reduce the mortality rate in severe chest trauma to 1-4 % in patients with isolated trauma and up to 8-15 % in patients with polytrauma. At the same time, there is a high frequency of unsatisfactory long-term results associated with such late complications and consequences as chest deformities, false costal joint, pulmonary hernia, and restrictive respiratory dysfunction [3]. In the clinical picture of all these conditions, chronic persistent pain syndrome and respiratory failure prevail. The same syndromes underlie the decrease in working capacity and disability in 14-30 % of patients with post-traumatic chest pathology [2].
Post-traumatic deformity of the chest occurs as a result of a significant displacement of fragments of rib fractures in case of multiple and floating nature of fractures. The pathophysiological effect of this condition consists, in addition to a violation of the biomechanics of external respiration, also in a decrease in the volume of the pleural cavity and, as a result, in a decrease in the respiratory surface of the lung, as well as in traumatization of the lung parenchyma by rib fragments [5].

Here we present a clinical case of a patient with posttraumatic deformation of the chest and intrapleural complications. The study was conducted in compliance with Helsinki declare – Ethical Principles for Medical Research with Human Subjects (2013), and the Rules for clinical practice in the Russian Federation confirmed by the Order of the Health Ministry of RF on 19 June 2003, No. 266. All participants in the study gave informed consent to participate in the study.


Patient B., aged 54, was admitted to the Department of Thoracic Surgery, Samara Regional Clinical Hospital on October 18, 2017. He had post-traumatic deformity of the chest.
The anamnesis included polytrauma, and a closed chest injury after a traffic accident 6 months ago. According to the presented note, multiple fractures of the ribs, hemopneumothorax on the left, closed abdominal trauma, and closed fractures of the bones of the extremities were diagnosed. The severity of the thoracic injury determined its dominant character in the structure of all injuries. In the acute period of injury, the patient underwent drainage of the pleural cavity and conservative treatment of rib fractures. After the end of the course of inpatient treatment, the patient was not consulted by a thoracic surgeon, and dynamic monitoring at the outpatient stage was not carried out.

The main clinical symptom complex upon admission to the department of thoracic surgery was chronic pain syndrome caused by displacement of the ribs and pathological mobility of the chest wall in the area of closed chest injury. The intensity of the pain syndrome according to the visual analog scale (VAS) was assessed by the patient at 6 points. In addition, the patient also noted periodic cough with recurrent hemoptysis and the appearance of shortness of breath with moderate physical exertion. This was confirmed in the study of the function of external respiration, which registered a decrease in the vital capacity of the lungs (VC) up to 79 % and functional vital capacity (FVC) up to 62 %.

The patient had hypersthenic physique at the moment of examination.
The left half of the chest is deformed in the projection of the III-VII ribs between the mid-clavicular and middle axillary lines. The deformation is represented by flattening. With deep palpation in this area, pathological mobility of the ends of the ribs is determined. Auscultation during deep breathing reveals a "click" symptom. The respiratory rate is 18 per minute. With a slight physical exertion (rise to the 1st floor, a 6-minute walk test), mixed dyspnea develops up to 24 per minute.
Computed tomography revealed some post-traumatic changes in the left hemithorax − a decrease in the volume of the left pleural cavity, displacement of fragments of the ribs III-VI with invasion into the lung parenchyma, consolidated fractures of the ribs I, II, VII, VIII, and fibrous changes in the lung. To improve the topical diagnosis of fracture lines and the extent of displacement of fragments during computed tomography, a radiopaque grid was used to mark the surgical field (RF patent for utility model No.
152847, June 20, 2015). Its use allowed projection of abnormal zone onto skin surface, and planning of the length and configuration of soft tissue incision (Fig. 1).

Figure 1. Computed tomography of the chest with 3D reconstruction and radiopaque grid. Marking the skin incision line for access to rib fractures

Aclinical diagnosis was made: “Closed chest injury dated April 14, 2017. Multiple fractures of the ribs on the left with displacement of fragments. Post-traumatic deformity of the chest. Chronic recurrent pulmonary hemorrhage due to traumatization of the lung parenchyma by fragments of the ribs”. Taking into account the totality of the revealed pathological changes, indications for surgical treatment were put forward. The surgical intervention plan included thoracoscopy to eliminate costal-pulmonary invasion and subsequent restoration of the rib cage by internal fixation.
Description of the surgical operation.
Surgery was performed on October 26, 2017, under endotracheal anesthesia with separate lung intubation. At the first stage, 2-port thoracoscopy was performed, during which the adhesive process in the pleural cavity and traumatization of the lung parenchyma with fragments of ribs IV-V were confirmed (Fig. 2). After pneumolysis and elimination of invasion of costal fragments into the lung parenchyma, the wound surface of the upper lobe, which had a wedge-shaped shape with a cone-shaped recess and dimensions of 3 × 4.5 cm, was sutured with interrupted U-shaped sutures. At this point, the intrapleural stage was completed, the pleural cavity was drained with one drain to a passive underwater drainage system.

Figure 2. Intraoperative photo. Damage to the lung from broken ribs

Next, a projection incision of the soft tissues was performed in the area of the "safety triangle". The dissection of the soft tissues was performed according to the principle of saving large muscle masses: m. pectoralis major and m. latissimus dorsi. After the displacement zone of the ribs IV, V, VI was identified, the edges of these ribs were mobilized, the fragments displaced into the pleural cavity and responsible for lung injury were resected. The defect of the bone rib tissue after resection did not exceed 1 cm. Further, bone osteosynthesis of the ribs IV, V, VI was performed using the Matrix Rib Fixation System (Fig. 3). The surgical wound was sutured in layers with drainage of the subpectoral space. The postoperative period proceeded well. Infectious intrapleural and wound complications were not noted. The patient was discharged on the 8th day after the operation with recovery.

Figure 3. Intraoperative photo. Bone titanium plates fixed to the ribs

Long-term follow-up took place 1.5 and 6 months after discharge. Satisfactory condition, no complaints. Postoperative pain is assessed by VAS at 2 points. He notes an increase in physical activity, plans to start working. Spirometry revealed an increase in external respiration parameters: VC – 96 %, FVC – 92 %.


The presented clinical case of surgical treatment of the patient with post-traumatic complications and consequences of a closed chest injury shows the variety of pathophysiological mechanisms and methods of surgical correction. Typical thing is the use of conservative methods of treatment of rib fractures in the acute period of injury, despite multiple fractures. J. D. Richardson et al.  believe that the refusal of surgical fixation of rib fractures can also be one of the predisposing risk factors for the formation of deformities and false costal joints [4]. In addition, there was no systematic follow-up to assess the likelihood of developing late complications. L.W. Kong et al. note that in 30 % of patients with a closed chest injury in the long term, late complications and consequences of a closed chest injury are recorded, which lead to disability or cause a change in occupation [2].
The clinical picture and pathological changes detected during the operation indicate further ineffectiveness of conservative measures. Therefore, in the absence of absolute contraindications, it is necessary to make a decision in favor of surgical treatment. The planned nature of the operation allows careful approach to the issues of planning the surgical access and choosing the method of rib fixation.
Preoperative navigation contributes to a better topical diagnosis of the area of the surgical incision and, accordingly, to minimization of surgical trauma [5]. Marking the surgical field is not only an element of the WHO surgical safety checklist, but also an essential auxiliary step in ensuring navigation, which is a key one in chest wall surgery, and especially rib surgery. The radiopaque grid used in our clinic for marking the surgical field allows us to project the lines of rib fractures onto the skin of the chest with the highest degree of accuracy, and, respectively, to plan the incision line, taking into account the tactics of preserving large muscle masses.
The main principle of modern surgical treatment of patients with post-traumatic chest deformity and late intrapleural complications is the combination of rib fixation technology and thoracoscopy. Minimization of additional dissection of the intercostal and other auxiliary respiratory muscles and fixation of the instability of the bone frame contribute to the rapid restoration of the biomechanics of external respiration. In cases of significant displacement of fragments or the formation of a false joint, preference should be given to methods of bone osteosynthesis of the ribs, which provide more rigid fixation [6].

Reducing the intensity of the pain syndrome and reducing respiratory failure are the main criteria for the effectiveness of the operations performed [1]. Follow-up in the long-term period confirmed a significant improvement in the function of external respiration and a decrease in the degree of pain syndrome according to VAS.


The use of internal fixation technologies in the treatment of patients with long-term consequences and late complications of a closed chest injury makes it possible to eliminate the main pathological syndromes and increase exercise tolerance. The key elements of surgical tactics are the definition of indications for surgery, navigation when projecting a surgical approach, the choice of a method for fixing and replacing a chest wall defect, thoracoscopy in the presence of concomitant intrapleural pathological syndromes. An important organizational decision to ensure early detection and timely treatment of patients with this post-traumatic pathology will be the creation of a register to regularly monitor the main parameters of the respiratory function and assess the return to work.

Funding and conflict of interest information

The study was not sponsored.
The authors declare the absence of obvious and potential conflicts of interest related to the publication of this article.


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      Morgan-Jones RL, Mackie IG. Non-union of a fracture of the 8th rib. Injury. 1996; 27(2): 147-148. doi: 10.1016/0020-1383(95)00194-8
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