Chest Injury Trauma patients often present with some degree of chest injury and pulmonary contusions. Taking care of patients with significant chest wall injury can be particularly challenging. If multiple ribs are involved or even if the same ribs are broken in several places (flail chest) the chest wall mechanics are significantly impaired. Extubating or taking these patients off the ventilator can be significantly delayed.

Pain control becomes one of the top priorities in chest injured patients. Often though, even with adequate pain control via epidural analgesia and intravenous opioids, patients continue to fail coming off of mechanical ventilation.

Chest wall stabilization or surgical restoration of the chest wall anatomy is still controversial yet is becoming more popular in some trauma centers.

The images above demonstrate extensive damage to the chest wall bilaterally. The patient essentially presented with flail chest on both sides. (upper image) The bottom image is a chest XR after the patient underwent chest wall stabilization. Multiple metal plates were used to reconstruct the chest wall anatomy.

At what point to consider this surgery and who benefits from it most remains a subject of debate. In my personal clinical experience, extensive and especially bilateral rib fractures should be considered for surgical reconstruction. Younger patients do better with the surgery, yet the image above is of an 85 (yes, 85) year old patient.

I was able to take this patient off the ventilator 3 days after the procedure. The bottom line - more evidence is needed for this to become a mainstream treatment, yet the benefit of chest wall reconstruction in individual cases often outweighs the risk.

I am a big proponent of the chest wall stabilization for patients with severe chest trauma and flail chest. In my experience, it facilitates weaning from the ventilator, pain control and improves activity. Should it become the standard of care?

Severe chest wall injury and flail chest – those are very difficult injuries to treat. The greatest challenge is to wean those patients off mechanical ventilation and keep them off the ventilator. Pain control is a problem as well – often patients end up having epidural catheter for analgesia. The recovery is long and painful for the patients with severe chest wall injury. Not surprising, the functional capacity is diminished for many months after the discharge from the Hospital. There is a lot of literature out there about the treatment options of these injuries. In my practice, I have seen great benefits from a chest wall stabilization procedure (click on image above). In my experience it was easier to wean the patients off the ventilator, pain was better controlled and the patients, in general, did better from activity standpoint. Those are the observations from my practice. I do believe in this treatment modality and I hope to see it becoming the standard of care.