[Evolution of Opinions on Chest Wall Stabilisation and Our Experience]

PURPOSE OF THE STUDY Rib fractures represent one of the most common fractures sustained by 10-40% of all patients with blunt chest trauma, their incidence increases with age. In the current literature, however, new indication criteria continue to emerge. The purpose of this study is to assess the indication criteria, the timing of surgery and the use of individual plates in dependence on fracture location in our patients after the chest wall stabilisation in a retrospective analysis. MATERIAL AND METHODS Our group of patients (n = 349) included the patients who were hospitalised in the Trauma Centre of the University Hospital Olomouc from 1 January 2015 to 31 January 2019, of whom 16 patients were indicated for a surgery. In case of polytrauma, spiral CT was performed, while all patients with a more serious wall chest trauma underwent 3D CT chest wall reconstruction. The surgical approach was chosen based on the fracture location, most frequently posterolateral thoracotomy was opted for. The type of plates was chosen based on the location and type of the fracture. The most common was the lateral type of fracture. RESULTS The most common indication for surgery was multiple rib fractures with major chest wall disfiguration with the risk of injury to intrathoracic organs, present hemothorax or pneumothorax. The age of patients ranged from 44 to 92 years. 8 patients sustained a thoracic monotrauma, the remaining patients suffered multiple injuries, mostly craniocerebral trauma, pelvic or long bone fractures or parenchymal organ injury. The patients were indicated for surgery between 1 hour and 7 days after the hospital admission, on average 3 plates per patient were used and the most commonly used type of plate was the newly modified Judet plate made by Medin. All the patients underwent a surgical revision of pleural cavity, in 3 patients diaphragmatic rupture was found despite a negative preoperative CT scan. The duration of mechanical ventilation in polytrauma patients was 16 days, in thoracic monotrauma patients it was 2 days. CONCLUSIONS Prevailing majority of patients with a blunt chest trauma with rib fractures is still treated non-operatively, which is confirmed also by our group of patients. Nonetheless, correctly and early indicated stabilisation of the chest wall based on accurate indication criteria is of a great benefit to the patients. The aim of each and every trauma centre should be to develop a standardised protocol for the management of blunt chest trauma (the so-called "rib fracture protocol"), which comprises precisely defined criteria for patient admission, multimodal analgesia, indications for surgery, comprehensive perioperative and postoperative care and a subsequent rehabilitation of patients. Key words: rib fracture protocol, chest wall stabilisation, flail chest.