Michael D. McKee Emil H. Schemitsch Editors Injuries to t he Chest Wall Diagnosis and Management 123 Injuries to the Chest Wall Michael D. McKee (cid:129) Emil H. Schemitsch Editors Injuries to the Chest Wall Diagnosis and Management Editors Michael D. McKee, MD, FRCS(C) Emil H. Schemitsch , MD, FRCS(C) Division of Orthopedic Surgery Division of Orthopedic Surgery St. Michael’s Hospital St. Michael’s Hospital Toronto , ON , Canada Toronto , ON , Canada ISBN 978-3-319-18623-8 ISBN 978-3-319-18624-5 (eBook) DOI 10.1007/978-3-319-18624-5 Library of Congress Control Number: 2015943668 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2015 This work is subject to copyright. 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Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) This book is dedicated to my parents David and Nancy for their teaching, my partner Niloofar for her support, and my children Sacha, Tyler, Robbin, and Everett for enriching my life every day. Michael D. McKee This book is dedicated to my parents, Emil and Emma Schemitsch, who showed me the importance of books and learning, and to my wife Maureen Schemitsch and our four wonderful children, Laura, Geoffrey, Christine, and Thomas, who support and inspire me. Emil H. Schemitsch Foreword Injuries to the thorax are common and are responsible for up to 25 % of all trauma deaths in North America. However, chest wall injuries are often neglected when considering thoracic injuries. Homer’s Iliad is one of the classic works in Western literature and tells the story of the events related to the siege and battle of Troy. In his lurid description of hand-to-hand combat between the Achaeans and the Trojans, Homer documents 54 thoracic inju- ries in 53 separate warriors. However, rib fractures and chest wall injuries were not listed amongst the plethora of thoracic injuries sustained. C hest wall injuries remain a signifi cant cause of pain, long-term morbidity and mortality after injury. This type of injury can vary in severity from iso- lated rib fractures to severe, bilateral crush injuries leading to respiratory fail- ure. The history of the medical treatment for these injuries mimics the movement of a pendulum. The Edwin Smith Papyrus is an Ancient Egyptian medical text written almost 4,000 years ago and is the oldest known trauma and surgical textbook. This document describes 48 cases of injuries and tumours. One case describes a patient with rib fractures, where the fragments were displaced enough to rupture the overlying skin. The treating physician initiated the trend of non-operative management of rib fractures by stating that this type of injury is generally not treated. T his paradigm has changed several times during the twentieth century. In a classic paper published in 1949, Cameron and colleagues wrote that: p aradoxical respiration due to fl ail chest demands rib immobilization …. We use a single-pointed cervical tenaculum. This instrument has proven most satisfactory in the common type in which the sternum is the mobile fragment. The instrument can be easily introduced into intercostal spaces and a good grip on the sternum obtained … the excursions are [then] materially lessened. However, since the advent of “internal pneumatic stabilization” in the mid 1950s, the pendulum has swung back to the non-operative management of chest wall trauma. Nevertheless, this treatment modality remains associated with signifi cant morbidity and mortality. Approximately 30 % of patients with rib fractures develop pneumonia. Furthermore, trauma patients with more than four rib fractures have a mortality rate of approximately 10 %, and this increases to over 30 % in patients with eight or more fractures. These facts and fi gures give great emphasis to the need for a textbook of this kind. There is renewed interest in chest wall fi xation that has been fuelled both by the availability of new, specialized fi xation equipment and by the vii viii Foreword publication of numerous promising clinical results. Thoracic trauma textbooks focus on treating cardiac and pulmonary injuries. For all surgeons, indeed, for all physicians who treat trauma patients, this defi nitive textbook provides an excellent learning manual as well as a reference source for current knowledge in the management of chest wall trauma. Toronto, ON Homer Tien, MD Pref ace The treatment of severe injuries to the chest wall has traditionally been non- operative, with a focus on ventilatory support, pain control, and complication management. However, it is clear from the literature that, despite optimal nonoperative care, patients who sustain unstable chest wall injuries continue to experience signifi cant morbidity and mortality. This fact, in addition to the development of superior surgical implants and techniques and the positive early clinical experience of select centers with surgical intervention for chest wall stabilization, has led to a renewed interest in this topic. While the litera- ture is still suboptimal in this area, dominated by retrospective reviews and relatively small prospective studies, it is becoming apparent that there is probably a subset of trauma patients who benefi t from early surgical stabili- zation of a mechanically unstable chest wall. However, there is a paucity of information regarding appropriate imaging, patient selection, surgical approach, implant choice, and complication rates/ management regarding surgical fi xation. Additionally, the clinical scene is complicated by the fact that this area is of interest to a number of different surgical specialties including orthopedic surgeons who have extensive expe- rience in fi xation but who rarely operate around the thorax and thoracic/ trauma surgeons who have extensive operative experience in the thorax but may not be facile with the principles and techniques of fi xation. Add into this mix the integral role of the attending intensivist, and it is easy to understand the complexity of this issue. This book is designed to help optimize the treatment of the patient with a severe chest wall injury. With chapters written by intensivists, basic scien- tists, thoracic/trauma surgeons, and orthopedic surgeons from multiple lead- ing academic institutions, it emphasizes the multidisciplinary approach necessary in this area. Readers of this book will also benefi t from the concise, focused chapters and the multiple well-illustrated practical case examples. Whether it is to confi rm established knowledge or to understand principles from clinical areas outside their typical realm of practice, we hope this book, to our knowledge the fi rst of its kind dedicated to chest wall injuries, will be an invaluable resource for practicing clinicians. Toronto, Canada Michael D. McKee Emil H. Schemitsch ix