| Various types of trauma patients increased year by year with the rapid development of traffic construction, especially the increase of chest trauma and aggravating tendency is obvious. Chest trauma is one of the major cause of mortality and morbidity in patients with different kind of trauma, according to statistical analysis showed that chest trauma ranks second due to trauma and morbidity and mortality of reason after craniocerebral trauma. The most common chest trauma is rib fractures (Rib fractures), accounting for about 85% of blunt chest trauma.The common cause of injury with high traffic accident, falling, crush, indirect direct violence injury. Due to the pathophysiology of rib fracture coexistence is often ignored or underestimated, multiple rib fracture of chest wall instability down, unable to support the normal thoracic integrity, especially flail chest with multiple rib fractures after paradoxical respiration, serious impact on patients with respiratory and circulatory functions lead to respiratory cycle and a series of pathological changes, the patients face to severe threats even to dead and clinical treatment of such patients face many challenges. For rib fracture and peripheral tissue injury can lead to severe pain, patients with radiation protection function, not force a deep breathing, respiratory muscle systolic and diastolic function limit, a spasm state, causing pulmonary ventilation and gas exchange decreased, easy to limit the formation of lung function failure or pulmonary atelectasis, eventually leading to oxygenation levels decreased hypoxemia. Especially after severe multiple rib fractures flail chest floating chest wall is formed, on the inhale floating in depression, thoracic volume decreased, negative intrathoracic pressure decreased, the injured side atelectasis, cause mediastinal swing, ultimately affect the contralateral lung, can effectively expanding the lungs, lung volume reduction and tidal volume decreased significantly, lung compliance decreased, result in the damage to respiratory function; In the injury combined with pulmonary surfactant generated reduction in lung function decline, resulting in more severe ventilation dysfunction. When the flail chest associated with lung injury patients after onset of dyspnea, respiratory failure, circular injured possibility bigger, its existing pathophysiological reasons have the following:(1) Pulmonary capillary wall injury of lung, the alveolar capillary permeability, intravascular fluid migration, causing more extensive edema in Injured Alveolar local and surrounding lung tissue; (2)In patients with dyspnea, difficult to maintain normal levels of oxygen partial pressure, causing pulmonary microvascular contraction, hypoxia, pulmonary arteriolar resistance increased, the formation of pulmonary blood flow reduction;(3) The active substance secreted by alveolar surface type II cell lung contusion area decreased, which decreased pulmonary compliance and pulmonary ventilation/perfusion ratio imbalance, atelectasis, aggravation of hypoxia and carbon dioxide retention.In the past, most surgeons treated of rib fracture and traumatic flail chest were many have adopted conservative treatment, commonly used conservative treatment including:patients lying in bed rest and sedation or analgesia treatment, fixing belts or external fixing traction and prevention of pulmonary infection, hormone therapy, breathing machine ventilation. Although the patient can be cured by conservative treatment. But for patients with multiple rib fractures, especially in rib fracture multiple, fractures exist obvious displacement, accompanied by chest and organ injury, such as in massive hemothorax, pneumothorax, pulmonary contusion, bronchial rupture has many limitations. Such as the use of conservative treatment, patients because of the pain did not dare to early ambulation, lying in bed for a long time, analgesic drug used for a long time, care needs of family or nursing staff for a long time, part of the age of the patients due to long-term bed cause bedsore, pulmonary infection, immunity decreased resistance, restore normal working time is longer, because of long time of rehabilitation and the effects of work and family income, linical study showed that part of multiple rib fractures in patients with flail chest does not appear, in the conservative treatment of may initially due to fracture of violent muscle pain is in spasticity, patients with respiratory activity is not until after the muscle spasm muscle fiber diastole slowly, respiratory muscle activity increased, fracture displacement increase, unstable paradoxical respiration formed flail chest. At the same time, after multiple rib fracture patients because of chest pain could not be drained cough, sputum and airway secretion cannot be ruled out clean, secretions accumulate in the trachea, easy to cause pneumonia and pulmonary atelectasis and other complications. In addition, the fracture due to the fixed unstable displacement of cuttings or easy to damage the intercostal nerves and blood vessels, serious injury to the pleura, lungs and heart and great vessels, causing injury after intercostal neuralgia, pneumothorax or hemothorax progressive; Even in the recovery process due to fracture of chest wall unstable fracture will appear again displacement, pleural volume reduction, thoracic deformity, pleural adhesions, atelectasis and lung function decline; Late or often because of climate or pressure changes with different degrees of pain. The problem of lack of conservative treatment enables us to find a better way to solve all. Although the surgeon explored fixation treatment has been more than 50 years of history of multiple rib fractures, but the indication of surgery is still not clear, surgical treatment also are controversial. With the development and application of medical science and technology development and orthopedic surgery internal fixation materials, equipment, surgeon experience continue to accumulate, internal fixation in the treatment of fracture of rib bone won the good curative effect, especially surgical treatment of multiple rib fractures caused by flail chest has been become a hot research and described in the clinical benefit. But for the choice of whether non flail chest patients conservative treatment or surgical treatment of multiple rib fractures, still continue to debate. According to a survey on different areas of the United States surgeon reported:Agreed to 238 trauma surgeons in 82% of internal fixation for the treatment of multiple rib fractures and in 97 orthopaedic trauma surgeons 66% agreed that in a suitable adaptation syndrome were treated surgically, of the surgical treatment to maintain a cautious attitude; 70 thoracic surgeons in 71% agreed to patients choose selective surgical intervention for the treatment of; in no professional random survey only 22% of doctors agreed to flail chest patients underwent surgical treatment for other forms of rib fracture surgical treatment to objections.Despite a rib fracture surgical treatment and a variety of fixed materials reported in the literature are many, especially flail chest, and expounds its effectiveness, but the vast majority of cases analysis, experience introduction; A system with two different methods of surgical and non-surgical treatment of the comparative research report is very little, and the sample number is few reported. In order to prove whether the internal fixation is more conducive to the recovery of patients with multiple rib fractures, This study will further on multiple rib fracture is associated with chest wall instability and abnormal respiratory activity into flail chest and non flail chest to distinguish and their surgical treatment group and the non operative treatment group, the effects of different treatment comprehensive analysis and comparison, pro bed surgical fixation for the treatment of multiple rib fractures provide theoretical basis and direction.Section IClinical study of internal fixation for the treatment of flail chest with multiple rib fractureObjective Flail chest is caused by severe closed chest trauma after the side of the chest wall or both sides of the chest wall, a plurality of (more than or equal to four) multiple is more than or equal to 2) rib fracture and its local chest wall lose support ribs and softening, thoracic integrity damage, and breathe normally the opposite phenomenon, on the inhale softening region of chest wall in depression, exhale softening in wall appear protruding phenomenon, serious impact on the patient’s respiratory and circulatory function instability and triggered a series of respiratory and circulatory physiology and pathology change, endanger the patient’s life. Due to the harm of flail chest, the treatment of flail chest has been controversial. However, with the development of surgical techniques and fixation materials recently many foreign scholars proposed selectivity on flail chest patients underwent surgical fixation, fixation of displaced and unstable rib fracture, stabilise floating chest wall and intraoperative loose solution for compression of vascularized intercostal nerve, avoid recovery occurred in patients with chronic pain, deformity of thorax, and impaired lung function sequelae; At present there is no systematic comparative study of surgical and non-surgical treatment of two kinds of methods of the specific effect. This study is based on the Fujian provincial hospital emergency center and severe surgery 49 cases of flail chest patients clinical curative effect (which was performed in 26 patients, non-surgical 23 cases) to review analysis: surgical treatment group and non operation group different treatment effect in the treatment of comprehensive analysis compared. It provides a theoretical basis and guidance for clinical surgical fixation for the treatment of multiple rib fractures caused by flail chest.Methods A retrospective analysis of Fujian Province, Fujian Provincial Hospital, emergency surgery center in September 2010 to 2015 March were multiple rib fractures flail chest surgical treatment of 26 cases and May 2007 to 2010 August from multiple rib fracture flail chest surgery in 23 cases of non surgical treatment were retrospectively analyzed. Inclusion criteria:all patients met the diagnostic criteria of flail chest:After blunt chest trauma caused by one side or both sides of the chest wall and a plurality of multiple ribs fracture, local chest wall losing rib support and softening, loss of integrity of the thorax, contrary to normal breathing phenomenon, on the inhale softening region of chest wall in depression, expiratory when softening in wall appeared protrusion of the phenomenon.3D CT diagnosed as unilateral or bilateral multiple ribs fracture, fracture number greater than or equal to 4 root, fracture broken end entirely misplaced rib fracture number is more than or equal to 2 root; a complete clinical data and follow-up data. Exclusion criteria: craniocerebral trauma accompanied with disturbance of consciousness, because of heart and lung function is not full to general anesthesia, combined with respiratory function, previous have thoracic deformity, renal function, sequelae of cerebral vascular diseases, bleeding disorders such as severe cervical injury; no complete clinical data and follow-up; no flail chest and paradoxical respiration. Conservative treatment:external fixation of elastic brassiere, analgesia, tracheotomy, mechanical ventilation, prevention pulmonary infection, combined with hemothorax pneumatosis, feasible thoracentesis or pleural closed drainage. Surgical treatment:in order to reduce damage caused by the operation as far as possible, for the design of operation approach incision, we according to the imaging data of the fracture site is divided into four off section:the costal cartilage segment (including the sternum), anterior is from the collarbone midline to axillary front, the lateral segment of the anterior axillary line to the posterior axillary line, back section after posterior midline to anterior axillary line:According to the different segments of longitudinal incision. In the muscle layer, along the intercostal muscle fibers go direction blunt dissection incision, and fully protect the periosteum of the fracture end, only a few isolated and exposed, carefully separating the periosteum, the rib margin as far as possible not to separate, especially in under the edge, to avoid injuring the intercostal artery and nerve, late or reconstruction plate fixation ribs with AO1/3 tube after operation, according to situation of resettlement hemopneumothorax closed thoracic drainage. All surgical cases were fully communicate with patients and their families, by patients and their families to decide the treatment and signed the consent form. The two group of ICU treatment time, ventilator time, incision of trachea, lung function, chest deformity, return to work time and death situation of comprehensive analysis and comparison.Results The study show that operation group than that in conservative group, significantly reduce mechanical ventilation time (3.92 ±1.09d VS 8.60±1.75d, P= 0.034); to shorten the time of ICU (4.65±1.52d VS 8.39±2.33d, P= 0.016); tracheotomy was significantly reduced (26.9%VS 60.9%, P= 0.017). Postoperative 2-6 months follow-up pulmonary function severity operation group more conservative injury group significantly decreased:normal 76.9% VS43.5%, mild damage 19.2% vs 34.8%, moderate injury 3.8% VS 10.5%, severe injury 0% VS2.2%; Patients with thoracic deformity surgery group than that in conservative group decreased significantly, including:and 46.1% vs 13%, good 38.4% vs 26.1%,15.4% vs 47.8%,0% VS13%; 6 months after operation to return to their daily work rate than conservative group (84.61% vs 56.5%, P= 0.03); surgical treatment group died in 1 case (the cause of death is severe pulmonary infection) and conservative treatment group died,2 cases (1 case of septic shock complicated with multiple organ failure,1 case of ARDS), there were no operative internal fixation loosening, fracture, incision no infection.Conclusion This study by in patients with flail chest surgery group and conservative treatment group effect of the comprehensive analysis and comparison, surgery fixed use time and shorten the time of ICU treatment to reduce mechanical ventilation in patients with flail chest; reduce the incision of trachea; reduce postoperative pulmonary function damage and thoracic deformity rate; increase patients to return to the ratio of the daily work and effect is obvious. So the multiple rib fractures has formed should be given positive surgical internal fixation in patients with flail chest, the treatment effect was better than conservative treatment, through internal fixation to restore the stability of the chest. Early correction of the patients with paradoxical respiration, greatly help the latter part of the recovery of pulmonary function and avoid the occurrence of complications, pulmonary infection and ARDS, improve the quality of life of patients with late, promote the patient a speedy return to pre injury working and living in central, reduce the burden of family and society.Section ⅡClinical study of internal fixation for the treatment of flail chest of multiple rib fracturesObjective Clinically more than 2 rib fracture into multiple ribs fracture (Multiple rib fractures). Multiple rib fractures can also occur in the lateral chest wall, also can be unilateral fracture of multiple ribs, often for single fault, because it did not lead to softening of chest wall, without the occurrence of chest wall floating injury, we put such called non flail chest; In blunt chest trauma in such patients often outpatient without attention, patients with conservative treatment. Recently, however, after long time clinical observation of patients in fracture recovery process due to the relative stability of the chest wall will still appear fracture shift again; existing problems is still rib fracture broken end shift, poor reduction, malunion, appeared the some cases intercostal nerve oppression, resulting in continuous intercostal neuralgia, pain due to exhaustion of cough, expectoration, causing pulmonary infection and atelectasis and other complications. These obviously exposed the problem so that we have been looking for a better way to solve the shortage of conservative treatment, but for non flail chest multiple rib fractures in the conservative treatment or surgical treatment, there are still many arguments, Studies by of 148 cases of non flail chest patients clinical efficacy (including operation 76 cases, surgery was performed in 72 cases) multi aspects analysis:surgical treatment group and the non operative treatment group, the effects of different treatment comprehensive analysis and comparison, the clinical surgical fixation for the treatment of multiple rib bone fold non flail chest to provide theoretical basis and direction.Methods A retrospective analysis of Fujian Provincial Hospital, emergency surgery center in September 2010 to 2015 from March of multiple rib fracture non flail chest surgical treatment of 76 cases and May 2007 to 2010 August were treated with conservative treatment of multiple rib fracture non flail chest 72 cases were retrospectively analyzed. As far as possible to meet the need, all the cases meet we develop a non flail chest diagnostic criteria:one side or both sides of the thorax is more than or equal to 2 single segment of rib fracture did not show a softening of chest wall and paradoxical respiration; complete clinical data and follow-up data of 3D CT diagnosed as unilateral or bilateral multiple single rib fracture, fracture number greater than or equal to 2. Exclusion criteria:craniocerebral trauma accompanied with disturbance of consciousness, because of heart and lung function is not full to general anesthesia, combined with respiratory function, previous have thoracic deformity, renal function, sequelae of cerebral vascular diseases, bleeding disorders such as severe cervical injury; no complete clinical data and follow-up; flail chest and paradoxical respiration. Conservative treatment:external fixation of elastic brassiere, analgesia and prevention pulmonary infection, combined with hemothorax pneumatosis, feasible thoracentesis or pleural closed drainage. In order to reduce damage caused by the operation as far as possible, for the design of operation approach incision needs, we according to the imaging data of the fracture site is divided into four off section:the costal cartilage segment (including the sternum), anterior is from the collarbone midline to axillary front, the lateral segment of the anterior axillary line to the posterior axillary line, back section after posterior midline to anterior axillary line:According to the different segments of 2 root fracture can be done with ribs to more than 3 root fracture incision parallel longitudinal incision. In the muscle layer, along the intercostal muscle fibers go direction blunt dissection incision, and fully protect the periosteum of the fracture end, only a few isolated and exposed, carefully separating the periosteum, the rib margin as far as possible not to separate, especially in under the edge, to avoid injuring the intercostal artery and nerve. Plate or reconstruction plate fixation of rib with AO1/3 tube, postoperative routine placement of thoracic closed drainage. All surgical cases were fully communicate with patients and their families, by patients and their families to decide the treatment and signed the consent form. The two group hospitalization time, pain score, return to daily life time, fracture healing, pulmonary infection and atelectasis by comprehensive analysis and comparison.Results The study show that surgery group than in the conservative group significantly reduced the duration of hospitalization (11.15±2.56d vs 14.88±3.51d, P= 0.005); postoperative 2 months follow-up VAS score surgery group, the pain level was significantly lower than that of lower than the conservative treatment, P= 0.002); 0 painless (76.3% vs 52.8%); 1-3 mild pain pain (19.7% VS%36.1); 4-6 for moderate pain (3.9% vs 11.1%),7 and 10 points for severe pain (0% vs 0%); operation group earlier return to the daily work and life (33.93+9.98 vs 47.90+ 12.47d, P= 0.05). ostoperative 2 months with X-ray surgery group, the overall fracture healing rates were higher, but the operation group, the excellent and good rate than non high operation, two groups of rate ratio (73.7% vs 22.2%), two groups of good rate ratio (23.7% VS 41.7%), two set of medium rate ratio (2.6% vs 33.3%). Two groups of the slip ratio (0% vs 2.8%); surgery group, the lung atelectasis and pulmonary infection rate is low (6.15 vs 2.203%, P= 0.01); (4.62 vs 16.95%,16.95). The two groups were not found in cases of death; no incision infection and internal fixation loosening and fracture. Conclusion multiple rib fractures with high incidence, although some patients in non surgical treatment can be cured, but in the healing process may enable stability to instability of ribs fracture direction, caused by flail chest, but also increase the pulmonary infection and atelectasis probability. The comprehensive analysis and comparison with the research on the non operation group of flail chest patients and non operative group aspects. We consider non flail chest multiple rib fractures suitable surgical treatment, surgery fixed relationship in patients with pain, VAS score low, reduce hospitalization days, reduce complications, the patient was able to earlier return to daily work, internal fixation is safe and stable, also is not found within the fracture fixation loosening, The incision healed well, and surgery related complications, internal fixation for the treatment of multiple rib fractures is a clinical development direction and trend. |
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