Indication for thoracotomy and chest wall stabilization.

In multiply injured patients with major blunt thoracic injuries, the continued high mortality is mainly caused by the additive effect of the unstable flail chest associated with pleural and lung injuries upon the pulmonary gas exchange disturbance caused by haemorrhagic shock. A more active approach with early thoracotomy and chest wall stabilization is recommended. Three groups of injuries provide the appropriate indication: 1. Penetrating injuries, ruptures of organs and great vessels, when associated with serial rib fractures, which should be stabilized 'on retreat'. 2. Anterior or lateral wall instability due to double serial rib fractures with concomitant pleural and lung injuries. 3. Flail chest injuries with severe respiratory insufficiency. In all cases the thoracotomy should be performed after resuscitation of the patient on the day of the accident or within 3 days. Screwless elastic self-clasping rib plates were used in 15 multiply injured patients and in 5 isolated thoracic cases with good results and a low complication rate. The mortality was reduced from 64 per cent to 36 per cent in the patients with multiple injuries.