Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg K P
Abteilung für Unfallchirurgie, Universitätsklinikum Essen.
Unfallchirurg. 1996 Jun;99(6):425-34.
Between 1988 and 1994, 295 patients with blunt chest trauma were treated. Forty-two patients had flail chest, requiring mechanical ventilation. Open reduction and osteosynthesis (ASIF reconstruction plates or isoelastic rip clamps) of the chest wall were performed in 20 patients. For the purpose of analysis we separated the patients into five groups: group I (n = 10) had chest wall stabilization in flail chest without pulmonary contusion (average ISS 31.0, AIS-thorax 4.1); group II (n = 10) had chest wall stabilization in flail chest with pulmonary contusion (average ISS 37.0, AIS-thorax 4.3); group III (n = 18) had fail chest without pulmonary contusion (average ISS 36.3, AIS-thorax 4.2); group IV (n = 4) had flail chest with pulmonary contusion (average ISS 37.8, AIS-thorax 4.0); group V (n = 29) had pulmonary contusion without flail chest (average ISS 34.5. AIS-thorax 4.1). With open reduction and internal fixation of unstable chest wall segments, the duration of ventilatory support, mortality and pneumonia were significantly reduced to 6.5 (1-25) days in group I (mortality rate 0%, incidence of pneumonia 10%) compared to group III (duration of ventilatory support 26.7 days, mortality rate 39%, incidence of pneumonia 16%). Eighty percent of the patients in group I were extubated within 5 days postoperatively. In group II 4 patients underwent emergency thoracotomy for intrathoracic injuries (3 of them died between 4 h and 31 days) and 2 patients for laceration of the lung. In all these cases the chest wall was stabilized after thoracotomy. One patient was stabilized for a deformation of the chest wall and two for paradoxical movement of the chest wall during weaning from the respirator. The mean duration of ventilation in group II was 30.8 (10-112) days (mortality rate 30%, incidence of pneumonia 30%). No complications related to the osteosynthesis arose during the follow-up. In conclusion, the best indication for early operative chest wall stabilization is flail chest without pulmonary contusion, leading to a significant reduction in the duration of ventilatory support. Secondary stabilization is recommended in patients with pulmonary contusion showing paradoxical movement of the chest wall during weaning from the respirator.
1988年至1994年间，对295例钝性胸部创伤患者进行了治疗。42例患者发生连枷胸，需要机械通气。20例患者进行了胸壁切开复位内固定术（ASIF重建钢板或等弹性肋骨夹）。为了进行分析，我们将患者分为五组：第一组（n = 10）为连枷胸但无肺挫伤的胸壁固定患者（平均损伤严重度评分[ISS] 31.0，胸部简明损伤定级[AIS] 4.1）；第二组（n = 10）为连枷胸合并肺挫伤的胸壁固定患者（平均ISS 37.0，AIS-胸部4.3）；第三组（n = 18）为无肺挫伤的连枷胸患者（平均ISS 36.3，AIS-胸部4.2）；第四组（n = 4）为连枷胸合并肺挫伤的患者（平均ISS 37.8, AIS-胸部4.0）；第五组（n = 29）为无连枷胸的肺挫伤患者（平均ISS 34.5，AIS-胸部4.1）。通过对不稳定胸壁节段进行切开复位内固定，与第三组（通气支持时间26.7天，死亡率39%，肺炎发生率16%）相比，第一组的通气支持时间、死亡率和肺炎发生率显著降低至6.5（1 - 25）天（死亡率0%，肺炎发生率10%）。第一组80%的患者术后5天内拔管。第二组中，4例患者因胸内损伤接受急诊开胸手术（其中3例在4小时至31天内死亡），2例因肺裂伤接受手术。在所有这些病例中，开胸术后胸壁得到固定。1例患者因胸壁变形进行固定，2例因脱机过程中胸壁反常运动进行固定。第二组的平均通气时间为30.8（10 - 112）天（死亡率30%,肺炎发生率30%）。随访期间未出现与内固定相关的并发症。总之，早期手术胸壁固定的最佳适应证是无肺挫伤的连枷胸，这可显著缩短通气支持时间。对于在脱机过程中出现胸壁反常运动的肺挫伤患者，建议进行二期固定。
