The modified Ravitch approach for the management of severe anterior flail chest with bilateral sternochondral dislocations: a case report

Abstract

The management of flail chest continues to evolve as scientific evidence and surgical experience accumulates. Flail chest injuries that span the sternum present a rare and complicated injury pattern that can be challenging to manage both medically and surgically. Our patient is a 69-year-old involved in a high-speed motor vehicle crash with respiratory failure secondary to an anterior flail chest. Tomographic examination confirmed a sternal fracture with bilateral sternochondral dislocations and multiple rib fractures. The rib fractures created a lateral flail segment which extended towards the right side. An open Pectus exposure with a right anterolateral extension (modified Ravitch approach) and osteosynthesis plates accomplished stabilization of the chest wall, and contributed to weaning from mechanical ventilation.

Surgical reconstruction of traumatic flail chest with titanium plaques

“…Although most of the patients with rib fractures are followed in a conservative manner; unavoidable respiratory insufficiency despite aggressive medical treatment, severe chest wall deformity, persistent pain, inability to end mechanical ventilation, thoracotomy needed for another reason are the indications for surgical stabilization [ [2] , [3] , [4] , [5] , [6] , [7] ]. In our case, because of flail chest composing a wide area of the anterior chest wall, stabilization provided a rapid and effective benefit in the early period.…”

“…Except bilateral ribs, fractures on the anterior cartilage area can cause flail on sternum [ 5 ]. In our case, basic factor disturbing the hemodynamics of patient was displaced fractures on the anterior cartilage area and sternum.…”

“…Flail chest is the most critical form of blunt thorax traumas [ [2] , [3] , [4] ]. The pathology is stated as three or more sequential ribs fractured in two places, with or without a sternal component, with accompanying paradoxical movement of the chest wall [ 5 ]. In flail chest, with mediastinal flutter related to the paradoxical movement of the chest wall, related to the pressure on SVC and IVC, hemodynamics can be disturbed and the patient can undergo cardiac arrest [ 6 ].…”

“…In flail chest, with mediastinal flutter related to the paradoxical movement of the chest wall, related to the pressure on SVC and IVC, hemodynamics can be disturbed and the patient can undergo cardiac arrest [ 6 ]. Although in most of the cases of chest wall traumas surgical reconstruction is not needed [ [4] , [5] , [6] , [7] , [8] ], surgical stabilization was shown to be useful in certain subgroup of patients [ 5 ]. Specific guidelines are deficient for the management of certain combinations of chest wall injuries, because of their low incidence.…”

“…Specific guidelines are deficient for the management of certain combinations of chest wall injuries, because of their low incidence. One instance is the sternochondral dislocation accompanying sternal body fracture [ 5 ].…”