Introduction

Tension band wiring for flail chest is now commonly used method for stabilizing a flail chest resulting from multiple rib fractures over plating due to ease of technique and time salvage in emergent conditions. Studies have shown that when patients undergo open reduction with internal fixation (ORIF) of rib fractures they require shorter periods of ventilator support, which in turn reduces morbidity and mortality associated with mechanical ventilation, and reduces risk of contracting infections or septicaemia [4,5]. Complications of ORIF include fracture non-union, infection, pneumothorax, failure of fixation, and post-operative chest wall “rigidity” necessitating wire removal [6-11]. We report this case in view of its rare mode of injury and the life saving immediate fixations of ribs for better chest physiotherapy leading to excellent outcome in a young patient.

Case Report

A 38 year old male suffered cave-in injury and was excavated out of earth using an Earth mover where he suffered massive trauma to the left side of the chest in form of scapular winging and complete scapula-thoracic dissociation as one of the prong got pierced in the thoracic wall. The patient presented with complete lung contusion on the left side with complete tear of subscapularis, lattisimus dorsi, rhomboids and partial tear of the trapezius muscle. He had severe shortness of breath and alarming low oxygen saturation on presentation. X-ray showed fractures of four ribs from 3rd to 6th with flail chest (Figure:1).The patient was managed in the emergency care theatre while stabilizing vitals following the principles of Advanced Trauma Life Saving (ATLS). The patient was revived from hypovolumic shock pre-operatively using crystalloids and blood component transfusion.

After stabilization he was operated under general anaesthesia with tension band wiring for multiple (3rd to 6th) unilateral rib fractures on left side (Figure:2). The wound was thoroughly washed and chest tube was inserted during the repair of the chest wall for pneumothorax and primary closure of the full thickness chest wall flap was done. The surgery was uneventful. During the post-operative period the patient was unable to maintain adequate saturation for the first post-operative week.

The patient improved with simultaneous intravenous antibiotics and regained saturation from 3rd to 6th week postoperatively and chest tube was removed with evidence of loss of column movement for 3 days during the second week post-operatively. There was associated patchy consolidation in the middle and upper lobe of the left lung (Figure:3) which completely resolved by 8th week. There was complete loss of long thoracic nerve function with no neuro-vascular deficit in the left upper limb. Nerve conduction velocity and electro-myographic studies showed normal latency for median, ulnar and radial nerves and a complete recruitment in flexor and extensor group of both arm and the forearm muscles on the 7th postoperative week.

Fig-2.Per-operative photograph showing cerclage wires being used for rib fixations.

Fig-3. Immediate post-operative photograph with ribs fixed with wires with lung contusions.

Fig-4. . Post-operative X-ray showing full lung expansion at three months.

References