Flail Chest Fracture of Ribs 2-9 with Post-CTT Lung Contusion and Subcutaneous Emphysema: A Case Report

Kalih Sarjono; Urip Rahayu

doi:10.37287/ijghr.v6i6.3983

Kalih Sarjono Faculty of Nursing, Universitas Padjadjaran
Urip Rahayu Faculty of Nursing, Universitas Padjadjaran

DOI: https://doi.org/10.37287/ijghr.v6i6.3983

Keywords: flail chest, nursing care, pulmonary contusion, subcutaneous emphysema

Abstract

Flail chest fracture of ribs 2-9 with pulmonary contusion after CTT installation and subcutaneous emphysema is a serious condition that affects the patient's respiratory function and quality of life. Patients often experience difficulty breathing, increased respiratory rate, and severe chest pain. In addition, the presence of a flail chest can increase the risk of complications such as atelectasis, lung infections, and hypoxia. The combination of this disease accompanied by rib fractures 2-9, subcutaneous emphysema, pneumothorax, and hemothorax makes this case unique and rare, so this finding can shed new light on the possible pathogenesis of a disease or its bad effects. The aim of this study is to describe the action in cases of Flail chest fracture of ribs 2-9 with post CTT pulmonary contusion and subcutaneous emphysema. Mr. T, a 23 year old man, was admitted to the Kemuning ICU with various medical diagnoses including flail chest, rib fracture, emphysema subcutis, right pneumothorax, pleural effusion, right hemothorax, right lung contusion, and ARDS. The patient complained of shortness of breath and chest pain after a motorbike accident. Initial actions include GCS monitoring, vital signs, oxygen therapy, fluid therapy, and Chest Tube Thoracostomy (CTT) installation. The patient's condition worsened and required intubation and a ventilator, then a thoracotomy operation and wire installation were performed to stabilize the fracture. After surgery, the patient's condition improved, he was successfully weaned off the ventilator, and pain was managed with intravenous morphine and ketorolac therapy. This case highlights the complexity in flail chest management that requires careful monitoring, interprofessional collaboration, and appropriate treatment strategies to improve the outcomes of patients with this condition.

References

Deng, H., Tang, T. X., & Yao, Y. (2022). The incidence, clinical characteristics, and outcome of polytrauma patients with the combination of pulmonary contusion, flail chest and upper thoracic spinal injury. Injury, 53. https://doi.org/10.1016/j.injury.2021.09.053

Alanwer, K. M., Refat, A. M., & Negm, E. M. (2023). Impact of flail chest injury on morbidity and outcome: ten years’ experience at a tertiary care hospital in a developing country. BMC Anesthesiology, 23(1), 229. https://doi.org/10.1186/s12871-023-02185-y

Apampa, A. A., Ali, A., Kadir, B., & Ahmed, Z. (2022). Safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest in adult populations: a systematic review and meta-analysis. European Journal of Trauma and Emergency Surgery, 48(2), 1025–1034. https://doi.org/10.1007/s00068-021-01606-2

Bakir, M. S., Langenbach, A., Pinther, M., Lefering, R., Krinner, S., Grosso, M., Ekkernkamp, A., Schulz-Drost, S., & DGU, the T. (2022). The significance of a concomitant clavicle fracture in flail chest patients: incidence, concomitant injuries, and outcome of 12,348 polytraumata from the TraumaRegister DGU®. European Journal of Trauma and Emergency Surgery, 48(5), 3623–3634. https://doi.org/10.1007/s00068-021-01819-5

Beks, R. B., Peek, J., & Jong, M. B. (2019). Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg., 45. https://doi.org/10.1007/s00068-018-1020-x

Beks, R. B., Peek, J., Jong, M. B., Wessem, K. J. P., Öner, C. F., & Hietbrink, F. (2019). Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc., 45. https://doi.org/10.1007/s00068-018-1020-x

Brenton, R. (2018). Rapid resolution of severe subcutaneous emphysema with simple percutaneous angiocatheter decompression. J Surg Case Rep, 7.

Chudzik, R., Buczyński, K., Rybojad, P., & Sawicki, M. (2023). Stabilization of after-traumatic flail chest by minimally invasive modified NUSS procedure in patient with starting respiratory insufficiency. Journal of Cardiothoracic Surgery, 18(1), 133. https://doi.org/10.1186/s13019-023-02249-7

Coughlin, T. A., Ng, J. W., Rollins, K. E., Forward, D. P., & Ollivere, B. J. (2016). Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials. Bone Joint J, 98-B. https://doi.org/10.1302/0301-620X.98B8.37282

Dehghan, N., Mah, J. M., & Schemitsch, E. H. (2018). Operative stabilization of flail chest injuries reduces mortality to that of stable chest wall injuries. J Orthop Trauma, 32. https://doi.org/10.1097/BOT.0000000000000992

Dehghan, N., Mestral, C., McKee, M. D., Schemitsch, E. H., & Nathens, A. (2014). Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg, 76. https://doi.org/10.1097/TA.0000000000000086

Divisi, D., Mucilli, F., Leonardo, G. D., Zaccagna, G., Vico, A., & Camplese, P. (2021a). Plates versus struts versus an extracortical rib fixation in flail chest patients: two-center experience. Injury, 52. https://doi.org/10.1016/j.injury.2020.09.018

Divisi, D., Mucilli, F., Leonardo, G. D., Zaccagna, G., Vico, A., & Camplese, P. (2021b). Plates versus struts versus an extracortical rib fixation in flail chest patients: Two-center experience. Injury, 52. https://doi.org/10.1016/j.injury.2020.09.018

Ferreira, R. O. M., Pasqualotto, E., Viana, P., Schmidt, P. H. S., Andrighetti, L., Chavez, M. P., Flausino, F., & de Oliveira Filho, G. R. (2023). Surgical versus non-surgical treatment of flail chest: a meta-analysis of randomized controlled trials. European Journal of Trauma and Emergency Surgery, 49(6), 2531–2541. https://doi.org/10.1007/s00068-023-02339-0

Glaser, J. J., & Rodriguez, C. J. (2022). Open Chest Wounds and Flail Chest BT - Atlas of Emergency Medicine Procedures (L. Ganti (ed.); pp. 141–143). Springer International Publishing. https://doi.org/10.1007/978-3-030-85047-0_26

Gool, M. H., Roozendaal, L. M., & Vissers, Y. L. J. (2022). VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases. Gen Thorac Cardiovasc Surg, 70. https://doi.org/10.1007/s11748-022-01830-6

Guo, Q., Zhang, J., Cai, K., & Zhang, J. (2020). Combining the use of Nuss procedure and rib fixation for severe flail chest: a case report. BMC Surgery, 20(1), 87. https://doi.org/10.1186/s12893-020-00747-2

Helkin, A. W., & Martin, N. D. (2020). Traumatic Rib Fracture in the Absence of Flail Chest: Conservative Therapy or Surgical Fixation? BT - Difficult Decisions in Thoracic Surgery: An Evidence-Based Approach (M. K. Ferguson (ed.); pp. 655–662). Springer International Publishing. https://doi.org/10.1007/978-3-030-47404-1_61

Hoepelman, R. J., Minervini, F., Beeres, F. J. P., Wageningen, B., IJpma, F. F., & Veelen, N. M. (2023). Quality of life and clinical outcomes of operatively treated patients with flail chest injuries: a multicentre prospective cohort study. Front Surg., 10. https://doi.org/10.3389/fsurg.2023.1156489

Ingoe, H. M. A., Coleman, E., Eardley, W., Rangan, A., Hewitt, C., & McDaid, C. (2019). Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open. https://doi.org/10.1136/bmjopen-2018-023444

Keene, D. J., Vadher, K., Willett, K., Mistry, D., Costa, M. L., Collins, G. S., & Lamb, S. E. (2019). Predicting patient-reported and objectively measured functional outcome 6 months after ankle fracture in people aged 60 years or over in the UK: prognostic model development and internal validation. BMJ Open, 9(7), e029813. https://doi.org/10.1136/bmjopen-2019-029813

Li, Z., Zhu, W., Zhang, B., Zhang, Y., Li, H., Lv, B., Zhen, Q., Liu, L., Liu, L., Wu, Y., & Li, S. (2023). A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research. Journal of Cardiothoracic Surgery, 18(1), 359. https://doi.org/10.1186/s13019-023-02445-5

Liu, T., Liu, P., Chen, J., Xie, J., Yang, F., & Liao, Y. (2019). A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients With Flail Chest. Journal of Surgical Research, 242, 223–230. https://doi.org/https://doi.org/10.1016/j.jss.2019.04.005

Lodhia, J. V, Konstantinidis, K., & Papagiannopoulos, K. (2019). Surgical management of multiple rib fractures/flail chest. J Thorac Dis, 11. https://doi.org/10.21037/jtd.2019.03.54

Marasco, S. F., & Abraham, V. (2022). Flail Chest BT - Management of Chest Trauma: A Practical Guide (A. M. Shiroff, M. J. Seamon, & L. J. Kaplan (eds.); pp. 53–61). Springer International Publishing. https://doi.org/10.1007/978-3-031-06959-8_6

Marasco, S. F., Nguyen Khuong, J., Fitzgerald, M., Summerhayes, R., Sekandarzad, M. W., & Varley, V. (2023). Flail chest injury-changing management and outcomes. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc, 49. https://doi.org/10.1007/s00068-022-02152-1

Peek, J., Beks, R. B., Kremo, V., van Veelen, N., Leiser, A., Houwert, R. M., Link, B.-C., Knobe, M., Babst, R. H., & Beeres, F. J. P. (2021). The evaluation of pulmonary function after rib fixation for multiple rib fractures and flail chest: a retrospective study and systematic review of the current evidence. European Journal of Trauma and Emergency Surgery, 47(4), 1105–1114. https://doi.org/10.1007/s00068-019-01274-3

Pieracci, F. M., Agarwal, S., Doben, A., Shiroff, A., Lottenberg, L., & Whitbeck, S. A. (2018). Indications for surgical stabilization of rib fractures in patients without flail chest: surveyed opinions of members of the Chest Wall Injury Society. Int Orthop, 42. https://doi.org/10.1007/s00264-017-3612-1

Rajan, G., Wachtler, C., Lee, S. J. C. S. S. H. S. S.-H. S.-C. S., Wändell, P., Philips, B., Wahlström, L., Svedin, C. G., Carlsson, A. C., Højer, E. G., Kreiberg, M., Dehlendorff, C., Jørgensen, N., Juul, A., Lauritsen, J., Wagner, T., Rosenvilde, J., Daugaard, G., Bandak, M., Hood, K. K., … Fasse, L. (2017). COVID-19 ARDS and Posttraumatic Stress Disorder in Family Members After ICU Discharge. PloS One, 17(1), 47. https://doi.org/10.1186/s13054-024-04815-4

Rashid, Y., Rashid, A., Warraich, M. A., Sabir, S. S., & Waseem, A. (2019). Case Study Method: A Step-by-Step Guide for Business Researchers. International Journal of Qualitative Methods, 18, 1609406919862424. https://doi.org/10.1177/1609406919862424

Saleh, Y., & Alratroot, A. (2020). Crepitus and Subcutaneous Emphysema. N Engl J Med, 328. https://doi.org/10.1056/NEJMicm1907386

Suzuki, M., Masai, K., Asakura, K., Hisida, T., Kato, Y., & Asamura, H. (2021). Successful management of traumatic flail chest by the Nuss procedure: a case report. JACS., 35.

Uchida, K., Miyashita, M., Kaga, S., Noda, T., Nishimura, T., & Yamamoto, H. (2020). Long-term outcomes of surgical rib fixation in patients with flail chest and multiple rib fractures. Trauma Surg Acute Care Open., 5. https://doi.org/10.1136/tsaco-2020-000546

van Gool, M. H., van Roozendaal, L. M., Vissers, Y. L. J., van den Broek, R., van Vugt, R., Meesters, B., Pijnenburg, A. M., Hulsewé, K. W. E., & de Loos, E. R. (2022). VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases. General Thoracic and Cardiovascular Surgery, 70(11), 985–992. https://doi.org/10.1007/s11748-022-01830-6

Zantah, M., Dotan, Y., Dass, C., Zhao, H., Marchetti, N., & Criner, G. J. (2020). Acute exacerbations of COPD versus IPF in patients with combined pulmonary fibrosis and emphysema. Respiratory Research, 21(1), 164. https://doi.org/10.1186/s12931-020-01432-x