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STERNAL TRACTION FOR THE FLAIL CHEST
26 This case was treated along the lines recommended by Hallum and Thomas (1955) and Norburn and Walker (1956) with the addition of isoniaziad 100-150 mg. daily. As in Rabau’s case, the first pregnancy after treatment ended in early abortion. We do not think the postoperative thrombophlebitis was necessarily associated with the tuberculous infection.
Summary A patient with tuberculosis of the fallopian tubes, treated medically, had ’afterwards two pregnancies which resulted in an abortion and a healthy infant. At the time of the cxsarean section both fallopian tubes were free from macroscopic signs of inflammation. Three consecutive operations were followed by venous thrombophlebitis. The third proved fatal because of pulmonary embolism. thank Dr. D. S. Wilson and Lieut.-Colonel D. G. C. with the anaesthesia and radiology; and Miss E. Scott, s.R.N., s.c.M., and her staff -for nursing the We wish
to
Whyte, D.S.O., for their assistance patient.
on
the day after injury, showing
multiple
bilateral rib fractures. were unrecordable, and although there was no cyanosis there was severe respiratory distress. His injuries included compound fractures of the left humerus and left radius and ulna, a fracture of the ascending ramus of the mandible on the right, a fracture of the neck of the right scapula, fractures of the right radius and ulna, a subtrochanteric fracture of the right femur, and finally bilateral fractures of the second to ninth ribs inclusive in the anterior axillary lines (fig. 1). The entire anterior chest wall, an area measuring about 135 sq. in., was involved in paradoxical movement, and he showed the orbital haemorrhages of traumatic asphyxia. After immediate splinting of the limb fractures, strapping the chest, and rapid infusion first of dextran and then of blood, his condition improved enough to allow operation, which was performed under general anaesthesia. First the chest wall was
pressure
REFERENCES Earn, A. A. (1958) J. Obstet. Gynæc. Brit. Emp. 65, 739. Hallum, J. L., Thomas, H. E. (1955) ibid. 62, 548. Norburn, L. M., Walker, A. H. C. (1956) ibid. 63, 173. Rabau, E. (1952) ibid. 59, 743. Stallworthy, J. (1952) ibid. p. 729.
STERNAL TRACTION FOR THE FLAIL CHEST M.B.
G. C. ROBIN Glasg., F.R.C.S., F.R.F.P.S.
ROYAL NATIONAL ORTHOPÆDIC
REGISTRAR,
HOSPITAL, LONDON, W.1
SINCE Jones and Richardson (1926) first described a method of controlling paradoxical respiration after chest trauma by skeletal traction on the sternum, using a gynaecological " bullet forceps", several reports have suggested other methods and instruments found valuable. Butler
Fig. 1-Chest radiograph
and Williams (1948) advocated the use of the ribs; Jaslow (1946) used coat-hanger hooks screwed into the sternum. All three workers employed weight traction. Proctor and London (1955) used " cup hooks" in the sternum fixed to a special bed frame, while Heroy and Egglestone (1951) made drill holes in the sternum and applied a clamp and 10 lb. traction. Ritter and Kaye (1944) used perichondral wires with weight traction. Other workers have advocated open reduction of sternal fractures and fixation with plates (Hendry 1957) or crossed Kirschner wires (McKim 1943), and finally Coleman and Coleman (1950) suggested open reduction of the multiple rib fractures and fixation with wire sutures. Birchfield and Grant (1956) also recommended this method of managing the " stove-in " chest.
(1938)
towel-clips
to grasp
Recently for sternal fixation in a patient with multiple injuries I used an instrument available in most traumatic centres-i.e., a skull calliper-and found it to be both easy to apply and effective.
Fig. 2-Patient in bed with skeletal traction in situ.
Case-report A man, aged 27, was involved in an accident at work in a textile factory on Jan. 6, 1959, when his right hand was trapped in a machine. His arms, head, and trunk were drawn between the rollers, crushing him and at the same time enveloping him in several layers of fabric. The machine had to be reversed to roll him out and he was removed from the wrappings unconscious, deeply cyanosed, and not breathing. After artificial respiration by a workmate he regained consciousness. On arrival in hospital, about half an hour after the accident, he was conscious but grossly shocked. His pulse and blood-
Fig. 3-Diagrammatic
cross-section of anterior chest wall at the
level of the 5th intercostal space.
27
enclosed in circumferential strapping, and then routine toilet and manipulation of the fractures was performed. The limb fractures were immobilised in plaster. After a total transfusion of 9 pints of blood his general condition was good, although, despite the strapping, there was still considerable paradoxical movement of the anterior chest wall. For three days the improvement was maintained, and then a " wet-lung syndrome " supervened and the patient rapidly deteriorated. The respiratory rate rose to 60 per min. and the pulse-rate to 160 per min. The haemoglobin fell from 92% on the morning after injury to 80%, and the white-blood-cell count rose to 25,600 per c.mm. Fixation of the flail chest segment was regarded as essential, and this was carried out as follows: Under local anaathesia, a transverse incision about 5 in. long was made across the sternum at the level of the sixth costal cartilage. The upper part of the rectus abdominis was divided, and the fifth intercostal space on each side was exposed by incising the anterior intercostal membrane. A Crutchfield skull calliper was used to grasp the sternum, the prongs biting into the lateral edges of the bone between the fifth and sixth cartilages on each side. The calliper was then tightened to gain a firm hold and traction of 14 lb. was applied over pulleys (figs. 2 and 3).
patient’s condition improved immediately and dramaThe respiratory rate fell to 30 per min. and the pulserate to 110. The cyanosis cleared, the pain in the chest was relieved, and the patient was able to cough. But the paradoxical movement, though much reduced, was still present, and in fact could not be completely overcome even by pulling manually on the calliper with a much greater force. With this increased pull there was some discomfort from the calliper, but The
tically.
with 14 lb. there were no adverse symptoms. The wound was finally closed round the calliper. Within twenty-four hours, the chest was clinically and radiographically dry, and thereafter the improvement was maintained. On Jan. 17, again under general anaesthesia, with the traction still in place, open reduction of the two forearm fractures was performed. Even at this time temporary removal of the traction was followed by rapid return of respiratory distress, but by mid-February there was radiographic early union of the rib fractures, and the traction was discontinued without return of paradoxical respiration. Since then progress has been uneventful. Apart from slight delay in the left forearm, the limb fractures have united satisfactorily; the patient’s general condition is excellent; and there is no significant deformity of the chest wall.
Discussion " With the increasing number of road accidents, stovein " chests are being seen more commonly, and are usually the result of crushing by the steering-wheel during collision. The injury is frequently anterior and often involves the sternum as well as the ribs. Furthermore, frequently there are other injuries, sometimes very severe. Although Hulman (1957) suggests that, in the management of such injuries, tracheotomy and bronchial aspiration are all that is required and gives physiological reasons for this, and Shefts (1956) states that " tracheotomy is almost mandatory ", there are disadvantages in this method-particularly the loss of the protective function of the upper air passages against infection. Many surgeons, therefore, prefer to avoid tracheotomy if possible. Open reduction of rib fractures, recommended in many centres, has the great disadvantage of converting a closed chest injury into an open one. Coleman and Coleman (1950) and Birchfield and Grant (1956) both confirm that the parietal pleura is always torn below the rib fractures, and recommend routine intercostal drainage after operation. Nevertheless the operation is a major one in a patient who may be in a grave state, as much from other injuries as from the thoracic lesion. Furthermore
the
operation requires expert thoracic surgical skill and nursing, neither of which may be available in the traumatic centre to which the patient is first admitted. Other methods of skeletal traction have disadvantages. Towel clips placed round ribs or pericostal or perichondral wires may, as Shefts (1956) says, injure the internal mammary artery in their application, and " not infrequently the pleura or the lung may be involved ". Even if available, single screws in the sternum, cup hooks, and coat-hanger hooks are not mechanically sound. Clamps fixed to the sternum through drill holes involve the risk of the drill perforating the posterior sternal plate and injuring the mediastinum.
Moreover, with involvement of a large area of chest wall in the paradoxical movement, the forces required to stabilise the flail segment are relatively great. Although Cooper (1957) found 21/2 lb. traction effective, 1n this case not even 14 lb. was enough to control the flail segment completely. In normal quiet respiration the difference in negative pressure in the pleural cavity between inspiration and expiration is said to be 5 mm. Hg, or about 1/10 lb. per sq. in. (Wright 1952). In flail chests, it is probably this decreasing negative pressure that causes the indrawing of the unstabilised segment of the thoracic cage on inspiration. In this patient, therefore, a theoretical traction force of 131/2 lb. should have controlled the anterior chest wall. Nevertheless even a much greater force did not completely prevent some indrawing. the gross respiratory distress of a Presumably, therefore, " patient with a stove-in " chest must result in an intrapleural pressure swing of much more than 5 mm. Hg, and thus the traction force required is consequently increased. Thus very firm skeletal traction is required for adequate management of these cases. The skull calliper allows such firm traction to be applied, and furthermore is simple to apply, with little risk. The dissection required is not deep enough to involve the left pleural reflection, and the application of the clamp directly to the lateral edge of the sternum avoids the internal mammary artery which runs usually half an inch laterally. Its use is therefore advocated in the management of flail chests when the sternal segment of the chest wall is part of the unstable section.
Summary
multiple injuries a skull calliper applied successfully to control paradoxical respiration
In was
a man
with
in the flail chest.
severe
These allowed firm traction
to
be
applied, and, although indrawing of the affected segment was not entirely prevented, the improvement in the patient’s condition was dramatic and immediate. I thank Dr. J. H. Dixon, but for whose skilful anxsthetics this could not have been carried out; Mr. D. M. Dunn, who allowed me to treat this case in the early stages, for his help and encouragement in preparation of this paper; and Miss M. Fishwick for fig. 3, and the photographic department of the Royal National Orthopxdic Hospital for fig. 1. treatment
REFERENCES
Birchfield, B. J., Grant, A. F. (1956) Ann. R. Coll. Surg. Engl. 19, 371. Butler, E. (1938) Surg. Gynec. Obstet. 66, 448. Coleman, F. P., Coleman, C. L. (1950) ibid. 9, 129. Cooper, E. (1957) Brit. med. J. ii, 525. Hendry, L. (1957) ibid. p. 339. Heroy, W. H., Egglestone, F. C. (1951) Ann. Surg. 133, 135. Hulman, S. (1957) Lancet, i, 454. Jaslow, I. A. (1946) Amer. J. Surg. 72, 753. Jones, T. B., Richardson, E. P. (1926) Surg. Gynec. Obstet. 42, 283. McKim, L. H. (1943) Ann. Surg. 118, 158. Proctor, H., London, P. E. (1955) Brit. J. Surg. 42 622. Bitter, H. H., Kaye, B. B. (1944) Amer. J. Surg. 64 191. Shefts, L. M. (1956) The Initial Management of Thoracic and Thoracoabdominal Trauma; p. 70. Springfield, Ill. Williams M. H. (1948) Ann. Surg. 128, 1006. Wright, S. (1952) Applied Physiology; p. 368. London.
Summary A patient with tuberculosis of the fallopian tubes, treated medically, had ’afterwards two pregnancies which resulted in an abortion and a healthy infant. At the time of the cxsarean section both fallopian tubes were free from macroscopic signs of inflammation. Three consecutive operations were followed by venous thrombophlebitis. The third proved fatal because of pulmonary embolism. thank Dr. D. S. Wilson and Lieut.-Colonel D. G. C. with the anaesthesia and radiology; and Miss E. Scott, s.R.N., s.c.M., and her staff -for nursing the We wish
to
Whyte, D.S.O., for their assistance patient.
on
the day after injury, showing
multiple
bilateral rib fractures. were unrecordable, and although there was no cyanosis there was severe respiratory distress. His injuries included compound fractures of the left humerus and left radius and ulna, a fracture of the ascending ramus of the mandible on the right, a fracture of the neck of the right scapula, fractures of the right radius and ulna, a subtrochanteric fracture of the right femur, and finally bilateral fractures of the second to ninth ribs inclusive in the anterior axillary lines (fig. 1). The entire anterior chest wall, an area measuring about 135 sq. in., was involved in paradoxical movement, and he showed the orbital haemorrhages of traumatic asphyxia. After immediate splinting of the limb fractures, strapping the chest, and rapid infusion first of dextran and then of blood, his condition improved enough to allow operation, which was performed under general anaesthesia. First the chest wall was
pressure
REFERENCES Earn, A. A. (1958) J. Obstet. Gynæc. Brit. Emp. 65, 739. Hallum, J. L., Thomas, H. E. (1955) ibid. 62, 548. Norburn, L. M., Walker, A. H. C. (1956) ibid. 63, 173. Rabau, E. (1952) ibid. 59, 743. Stallworthy, J. (1952) ibid. p. 729.
STERNAL TRACTION FOR THE FLAIL CHEST M.B.
G. C. ROBIN Glasg., F.R.C.S., F.R.F.P.S.
ROYAL NATIONAL ORTHOPÆDIC
REGISTRAR,
HOSPITAL, LONDON, W.1
SINCE Jones and Richardson (1926) first described a method of controlling paradoxical respiration after chest trauma by skeletal traction on the sternum, using a gynaecological " bullet forceps", several reports have suggested other methods and instruments found valuable. Butler
Fig. 1-Chest radiograph
and Williams (1948) advocated the use of the ribs; Jaslow (1946) used coat-hanger hooks screwed into the sternum. All three workers employed weight traction. Proctor and London (1955) used " cup hooks" in the sternum fixed to a special bed frame, while Heroy and Egglestone (1951) made drill holes in the sternum and applied a clamp and 10 lb. traction. Ritter and Kaye (1944) used perichondral wires with weight traction. Other workers have advocated open reduction of sternal fractures and fixation with plates (Hendry 1957) or crossed Kirschner wires (McKim 1943), and finally Coleman and Coleman (1950) suggested open reduction of the multiple rib fractures and fixation with wire sutures. Birchfield and Grant (1956) also recommended this method of managing the " stove-in " chest.
(1938)
towel-clips
to grasp
Recently for sternal fixation in a patient with multiple injuries I used an instrument available in most traumatic centres-i.e., a skull calliper-and found it to be both easy to apply and effective.
Fig. 2-Patient in bed with skeletal traction in situ.
Case-report A man, aged 27, was involved in an accident at work in a textile factory on Jan. 6, 1959, when his right hand was trapped in a machine. His arms, head, and trunk were drawn between the rollers, crushing him and at the same time enveloping him in several layers of fabric. The machine had to be reversed to roll him out and he was removed from the wrappings unconscious, deeply cyanosed, and not breathing. After artificial respiration by a workmate he regained consciousness. On arrival in hospital, about half an hour after the accident, he was conscious but grossly shocked. His pulse and blood-
Fig. 3-Diagrammatic
cross-section of anterior chest wall at the
level of the 5th intercostal space.
27
enclosed in circumferential strapping, and then routine toilet and manipulation of the fractures was performed. The limb fractures were immobilised in plaster. After a total transfusion of 9 pints of blood his general condition was good, although, despite the strapping, there was still considerable paradoxical movement of the anterior chest wall. For three days the improvement was maintained, and then a " wet-lung syndrome " supervened and the patient rapidly deteriorated. The respiratory rate rose to 60 per min. and the pulse-rate to 160 per min. The haemoglobin fell from 92% on the morning after injury to 80%, and the white-blood-cell count rose to 25,600 per c.mm. Fixation of the flail chest segment was regarded as essential, and this was carried out as follows: Under local anaathesia, a transverse incision about 5 in. long was made across the sternum at the level of the sixth costal cartilage. The upper part of the rectus abdominis was divided, and the fifth intercostal space on each side was exposed by incising the anterior intercostal membrane. A Crutchfield skull calliper was used to grasp the sternum, the prongs biting into the lateral edges of the bone between the fifth and sixth cartilages on each side. The calliper was then tightened to gain a firm hold and traction of 14 lb. was applied over pulleys (figs. 2 and 3).
patient’s condition improved immediately and dramaThe respiratory rate fell to 30 per min. and the pulserate to 110. The cyanosis cleared, the pain in the chest was relieved, and the patient was able to cough. But the paradoxical movement, though much reduced, was still present, and in fact could not be completely overcome even by pulling manually on the calliper with a much greater force. With this increased pull there was some discomfort from the calliper, but The
tically.
with 14 lb. there were no adverse symptoms. The wound was finally closed round the calliper. Within twenty-four hours, the chest was clinically and radiographically dry, and thereafter the improvement was maintained. On Jan. 17, again under general anaesthesia, with the traction still in place, open reduction of the two forearm fractures was performed. Even at this time temporary removal of the traction was followed by rapid return of respiratory distress, but by mid-February there was radiographic early union of the rib fractures, and the traction was discontinued without return of paradoxical respiration. Since then progress has been uneventful. Apart from slight delay in the left forearm, the limb fractures have united satisfactorily; the patient’s general condition is excellent; and there is no significant deformity of the chest wall.
Discussion " With the increasing number of road accidents, stovein " chests are being seen more commonly, and are usually the result of crushing by the steering-wheel during collision. The injury is frequently anterior and often involves the sternum as well as the ribs. Furthermore, frequently there are other injuries, sometimes very severe. Although Hulman (1957) suggests that, in the management of such injuries, tracheotomy and bronchial aspiration are all that is required and gives physiological reasons for this, and Shefts (1956) states that " tracheotomy is almost mandatory ", there are disadvantages in this method-particularly the loss of the protective function of the upper air passages against infection. Many surgeons, therefore, prefer to avoid tracheotomy if possible. Open reduction of rib fractures, recommended in many centres, has the great disadvantage of converting a closed chest injury into an open one. Coleman and Coleman (1950) and Birchfield and Grant (1956) both confirm that the parietal pleura is always torn below the rib fractures, and recommend routine intercostal drainage after operation. Nevertheless the operation is a major one in a patient who may be in a grave state, as much from other injuries as from the thoracic lesion. Furthermore
the
operation requires expert thoracic surgical skill and nursing, neither of which may be available in the traumatic centre to which the patient is first admitted. Other methods of skeletal traction have disadvantages. Towel clips placed round ribs or pericostal or perichondral wires may, as Shefts (1956) says, injure the internal mammary artery in their application, and " not infrequently the pleura or the lung may be involved ". Even if available, single screws in the sternum, cup hooks, and coat-hanger hooks are not mechanically sound. Clamps fixed to the sternum through drill holes involve the risk of the drill perforating the posterior sternal plate and injuring the mediastinum.
Moreover, with involvement of a large area of chest wall in the paradoxical movement, the forces required to stabilise the flail segment are relatively great. Although Cooper (1957) found 21/2 lb. traction effective, 1n this case not even 14 lb. was enough to control the flail segment completely. In normal quiet respiration the difference in negative pressure in the pleural cavity between inspiration and expiration is said to be 5 mm. Hg, or about 1/10 lb. per sq. in. (Wright 1952). In flail chests, it is probably this decreasing negative pressure that causes the indrawing of the unstabilised segment of the thoracic cage on inspiration. In this patient, therefore, a theoretical traction force of 131/2 lb. should have controlled the anterior chest wall. Nevertheless even a much greater force did not completely prevent some indrawing. the gross respiratory distress of a Presumably, therefore, " patient with a stove-in " chest must result in an intrapleural pressure swing of much more than 5 mm. Hg, and thus the traction force required is consequently increased. Thus very firm skeletal traction is required for adequate management of these cases. The skull calliper allows such firm traction to be applied, and furthermore is simple to apply, with little risk. The dissection required is not deep enough to involve the left pleural reflection, and the application of the clamp directly to the lateral edge of the sternum avoids the internal mammary artery which runs usually half an inch laterally. Its use is therefore advocated in the management of flail chests when the sternal segment of the chest wall is part of the unstable section.
Summary
multiple injuries a skull calliper applied successfully to control paradoxical respiration
In was
a man
with
in the flail chest.
severe
These allowed firm traction
to
be
applied, and, although indrawing of the affected segment was not entirely prevented, the improvement in the patient’s condition was dramatic and immediate. I thank Dr. J. H. Dixon, but for whose skilful anxsthetics this could not have been carried out; Mr. D. M. Dunn, who allowed me to treat this case in the early stages, for his help and encouragement in preparation of this paper; and Miss M. Fishwick for fig. 3, and the photographic department of the Royal National Orthopxdic Hospital for fig. 1. treatment
REFERENCES
Birchfield, B. J., Grant, A. F. (1956) Ann. R. Coll. Surg. Engl. 19, 371. Butler, E. (1938) Surg. Gynec. Obstet. 66, 448. Coleman, F. P., Coleman, C. L. (1950) ibid. 9, 129. Cooper, E. (1957) Brit. med. J. ii, 525. Hendry, L. (1957) ibid. p. 339. Heroy, W. H., Egglestone, F. C. (1951) Ann. Surg. 133, 135. Hulman, S. (1957) Lancet, i, 454. Jaslow, I. A. (1946) Amer. J. Surg. 72, 753. Jones, T. B., Richardson, E. P. (1926) Surg. Gynec. Obstet. 42, 283. McKim, L. H. (1943) Ann. Surg. 118, 158. Proctor, H., London, P. E. (1955) Brit. J. Surg. 42 622. Bitter, H. H., Kaye, B. B. (1944) Amer. J. Surg. 64 191. Shefts, L. M. (1956) The Initial Management of Thoracic and Thoracoabdominal Trauma; p. 70. Springfield, Ill. Williams M. H. (1948) Ann. Surg. 128, 1006. Wright, S. (1952) Applied Physiology; p. 368. London.