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SURGICAL TREATMENT OF LATE COMPLICATIONS OF BLUNT CHEST WALL TRAUMA: CASE OF REPORT
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.
CASE DESCRIPTION
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 %.
DISCUSSION
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.
CONCLUSION
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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