An innovative technique of chest wall stabilization and reconstruction in traumatic flail chest: The figure-of-eight suture with polypropylene mesh and musculofascial flap / 中华创伤杂志(英文版)

Surgical stabilization of the flail chest is challenging and has no established guidelines. Chest wall integrity and stability are the main factors that ensure the protection of intrathoracic organs and an adequate respiratory function. Here, we report a novel chest wall reconstruction technique in a 45-year-old man with a traumatic left flail chest and open pneumothorax diagnosed both clinically and radiographically. Rib approximation and chest wall reconstruction was done using intercostal figure-of-eight suture and polypropylene mesh with vascularized musculofascial flap. The patient improved gradually and was discharged after three weeks of total hospital stay. He returned to regular working after a month with no evidence of respiratory distress or paradoxical chest movement. Follow-up visit at one year revealed no lung hernia or paradoxical chest movement. This is a novel, feasible and cost-effective modification of chest wall reconstruction that can be adopted for thoracic wall repair in case of open flail chest, which needs emergency surgical interventions even in resource constraint settings.

The Chinese consensus for surgical treatment of traumatic rib fractures 2021 (C-STTRF 2021) / 中华创伤杂志(英文版)

Rib fracture is the most common injury in chest trauma. Most of patients with rib fractures were treated conservatively, but up to 50% of patients, especially those with combined injury such as flail chest, presented chronic pain or chest wall deformities, and more than 30% had long-term disabilities, unable to retain a full-time job. In the past two decades, surgery for rib fractures has achieving good outcomes. However, in clinic, there are still some problems including inconsistency in surgical indications and quality control in medical services. Before the year of 2018, there were 3 guidelines on the management of regional traumatic rib fractures were published at home and abroad, focusing on the guidance of the overall treatment decisions and plans; another clinical guideline about the surgical treatment of rib fractures lacks recent related progress in surgical treatment of rib fractures. The Chinese Society of Traumatology, Chinese Medical Association, and the Chinese College of Trauma Surgeons, Chinese Medical Doctor Association organized experts from cardiothoracic surgery, trauma surgery, acute care surgery, orthopedics and other disciplines to participate together, following the principle of evidence-based medicine and in line with the scientific nature and practicality, formulated the Chinese consensus for surgical treatment of traumatic rib fractures (STTRF 2021). This expert consensus put forward some clear, applicable, and graded recommendations from seven aspects: preoperative imaging evaluation, surgical indications, timing of surgery, surgical methods, rib fracture sites for surgical fixation, internal fixation method and material selection, treatment of combined injuries in rib fractures, in order to provide guidance and reference for surgical treatment of traumatic rib fractures.

Tórax inestable en paciente pediátrico: reporte de un caso / Flail chest in pediatric patient: case report

El tórax inestable se define por fractura de 3 o más costillas adyacentes, en 2 o más sitios, con movimiento paradojal del tórax afectado. Se presenta en el 2-4 % de los traumas de tórax contusos, con una mortalidad del 10-15 %.El tratamiento se realiza de forma conservadora, mediante analgesia y el uso de ventilación con presión positiva o, quirúrgicamente, mediante osteosíntesis de las fracturas costales.Se presenta el caso de una niña de 9 años con diagnóstico de traumatismo cerrado de tórax y tórax inestable. En la tomografía computada, se evidenciaron fracturas costales de 2da a 7maizquierdas, arcos medios y anteriores. Por inadecuado manejo del dolor, se colocó asistencia ventilatoria mecánica. A las 72 horas, se decidió la resolución quirúrgica mediante osteosíntesis de las costillas 3a-7a. La paciente evolucionó favorablemente. El manejo quirúrgico permitió reducir los días de ventilación mecánica y de internación.

Flail chest is defined by fracture of 3 or more adjacent ribs, at 2 or more sites, with paradoxical movement of the affected chest. It occurs in 2 to 4 % of blunt chest trauma, with a mortality of 10 to 15 %.Treatment is conservative, using analgesia and positive pressure ventilation, or surgical osteosynthesis of rib fractures.We present the case of a 9-year-old girl with blunt chest trauma and flail chest. Computed tomography showed rib fractures from 2nd to 7th left ribs, in middle and anterior arches. Due to inadequate pain management, it was placed in mechanical ventilation. After 72 hours the surgical resolution was decided, osteosynthesis of the 3rd to 7th ribs was performed. The patient evolved favorably. The surgical management allowed reducing days of mechanical ventilation and days of hospitalization.

Blunt trauma related chest wall and pulmonary injuries: An overview / 中华创伤杂志(英文版)

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Clinical Application and Mechanical Analysis of the Treatment of Multiple Rib Fractures and Flail Chest Using Three-wings Rib Plate / 中国医疗器械杂志

This research evaluated the clinical efficacy of three-wings rib plate in the treatment of multiple rib fractures and flail chest with mechanical analysis and clinical verification. The model of rib and three-wings rib plate was reconstructed. The contact simulation with pretension stress was applied to the plate's fixation, and it was found that the bearable stress of the rib fractures after fixation increased from the result which indicated a good fixation efficacy of the plate. Clinical data of 53 cases of rib fractures and flail chest treated with three-wings rib plate in Shanghai Pudong Hospital of Fudan University were retrospectively analyzed. After the operation, the pain of the patients was relieved. Postoperative CT reconstruction of the chest showed good restoration of the rib fractures, which verified the clinical efficacy of three-wings rib plate. The three-wings rib plate showed a high value in clinical use for treatment of rib fractures.

A striking flail chest: a rare manifestation of intestinal disease

No abstract available.

Common Carotid Artery Dissection in Multiple Extracranial Injury: A Case Report / 대한신경손상학회지

Traumatic common carotid artery dissection (CCAD) is rare. To our knowledge, only 14 case reports have described traumatic CCAD previously. Here, we report a case of CCAD in a patient with severe trauma. A 50-year-old man was lying on the road after drinking alcohol when a car drove over him. Computed tomography (CT) revealed multiple rib fractures with hemopneumothorax, lung contusion, flail chest, large amount of hematoma with bladder rupture, and fractures on the C6 spinous process, sacral ala, iliac bone, and pubic ramus. Repair of the bladder rupture, exploratory thoracotomy, and open reduction of multiple rib fractures were performed. Right side hemiparesis was observed on hospital day 4. Brain CT showed a large acute left middle cerebral artery infarction. CT angiography showed focal carotid dissection at the left common carotid artery with intimal flap. The CCAD was located at the C6 level. Clexane (enoxaparin sodium) treatment was initiated. An abdominal CT scan revealed a huge retroperitoneal hematoma and increased amount of hematoma in the prevesical and perivesical space, 10 days later. The patient died two days later. Although traumatic CCAD is rare, this case report provides useful information for trauma surgeons regarding the treatment and diagnosis of similar cases.

Rib Fractures: To Fix or Not to Fix? An Evidence-Based Algorithm

Rib fractures are a common injury resulting from blunt chest trauma. The most important complications associated with rib fractures include death, pneumonia, and the need for mechanical ventilation. The development of new osteosynthesis materials has stimulated increased interest in the surgical treatment of rib fractures. Surgical stabilisation, however, is not needed for every patient with rib fractures or for every patient with flail chest. This paper presents an easy-to-use evidence-based algorithm, developed by the authors, for the treatment of patients with flail chest and isolated rib fractures.

Risk Factors for Pneumonia in Ventilated Trauma Patients with Multiple Rib Fractures

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common disease that may contribute to morbidity and mortality among trauma patients in the intensive care unit (ICU). This study evaluated the associations between trauma factors and the development of VAP in ventilated patients with multiple rib fractures. METHODS: We retrospectively and consecutively evaluated 101 patients with multiple rib fractures who were ventilated and managed at our hospital between January 2010 and December 2015, analyzing the associations between VAP and trauma factors in these patients. Trauma factors included sternal fracture, flail chest, diaphragm injury, traumatic aortic dissection, combined cardiac injury, pulmonary contusion, pneumothorax, hemothorax, hemopneumothorax, abbreviated injury scale score, thoracic trauma severity score, and injury severity score. RESULTS: Forty-six patients (45.5%) had at least 1 episode of VAP, 10 (21.7%) of whom died in the ICU. Of the 55 (54.5%) patients who did not have pneumonia, 9 (16.4%) died in the ICU. Using logistic regression analysis, we found that VAP was associated with severe lung contusion (odds ratio, 3.07; 95% confidence interval, 1.12 to 8.39; p=0.029). CONCLUSION: Severe pulmonary contusion (pulmonary lung contusion score 6–12) is an independent risk factor for VAP in ventilated trauma patients with multiple rib fractures.

Fijación de tórax inestable con placas y tornillos bioabsorbibles. Presentación de serie de casos / Thoracic inestability fixed with bioabsorbable screws and plates

Resumen: Antecedentes: El tórax inestable se trata con ventilación mecánica o inhaloterapia y analgesia. Poco se ha publicado sobre el uso de material bioabsorbible y su evolución en la fijación de tórax inestable. Métodos: Estudio descriptivo de pacientes con tórax inestable sometidos a fijación con placas y tornillos bioabsorbibles en un período comprendido de Febrero de 2009 a Diciembre de 2011. Resultados: Presentamos 18 casos con edades entre 33 y 74 años (media de 53), tres con tórax inestable bilateral; la fijación costal se realizó entre 1 y 21 días del accidente (media de 1.5). Se inició deambulación al día siguiente en 14 casos; la estancia postoperatoria fue de cuatro días (rango de 3 a 14). La frecuencia cardíaca de los pacientes previa a la cirugía era de 90 por minuto (rango 82 a 100) y bajó a 84 después de la fijación (rango 82 a 92); la frecuencia respiratoria preoperatoria era 26 por minuto (rango 22 a 28) y bajó a 22 por minuto (rango 20 a 26) en el postoperatorio. Conclusiones: El uso de material bioabsorbible para osteosíntesis costal no tiene efectos secundarios atribuibles al material en el corto plazo.

Abstract: Background: Flail chest is managed with mechanical ventilation or inhaloteraphy and analgesia. Little has been published on the use of bioabsorbable material and its evolution in flail chest fixation. Methods: This is a descriptive study of patients with unstable chest undergoing fixation with bioabsorbable plates and screws in a period from February 2009 to December 2011. Results: We report 18 cases, aged 33-74 years (mean 53), three with bilateral involvement; rib fixation was performed between 1-21 days of the accident (mean 1.5). They started walking the next day in 14 cases; postoperative stay was four days (range 3-14). The heart rate of patients prior to surgery was 90 per minute (range 82-100) and lowered to 84 after fixation (range 82-92), preoperative respiratory rate was 26 per minute (range 22-28) and below 22 per minute (range 20 to 26) in postoperative period. Conclusions: The use of bioabsorbable material for osteosynthesis of costal fractures did not show side effects in our period of study.

Analysis of Sternal Fixation Results According to Plate Type in Sternal Fracture

BACKGROUND: Sternal fractures are relatively rare, and caused mainly by blunt anterior chest wall trauma. In most cases, sternal fractures are treated conservatively. However, if the patient exhibits problematic symptoms such as intractable chest wall pain or bony crepitus due to sternal instability, surgical correction is indicated. But no consensus exists regarding the most appropriate surgical method. We analyzed the results of surgical fixation in cases of sternal fracture in order to identify which surgical method led to the best outcomes. METHODS: We retrospectively reviewed the medical records of patients with sternal fractures from December 2008 to December 2011, and found 19 patients who underwent open reduction and internal fixation of the sternum with a longitudinal plate (L-group) or a T-shaped plate (T-group). We investigated patients' characteristics, clinical details regarding each case of chest trauma, the presence of other associated injuries, the type of open reduction and fixation, whether a combined operation was performed, and postoperative complications. RESULTS: Of the 19 patients, 10 patients (52.6%) were male, and their average age was 56.8 years (range, 32 to 82 years). Seven patients (36.8%) had isolated sternal fractures, while 12 (63.2%) had other associated injuries. Seven patients (36.8%) were in the L-group and 12 patients (63.2%) were in the T-group. Three patients in the L-group (42.9%) showed a loosening of the fixation. In all patients in the T-group, the fracture exhibited stable alignment. CONCLUSION: Open reduction and internal fixation with a T-shaped plate in sternal fractures is a safer and more efficient treatment method than treatment with a longitudinal plate, especially in patients with a severely displaced sternum or anterior flail chest, than a longitudinal plate.

The Role of Minimally Invasive Plate Osteosynthesis in Rib Fixation: A Review

More than a century ago, the first scientific report was published about fracture fixation with plates. During the 1950's, open reduction and plate fixation for fractures were standardized by the founders of Arbeitsgemeinschaft fur osteosynthesefragen/Association for the Study of Internal Fixation. Since the introduction of plate fixation for fractures, several plates and screws have been developed, all with their own characteristics. To accomplice more fracture stability, it was thought the bigger the plate, the better. The counter side was a compromised blood supply of the bone, often resulting in bone necrosis and ultimately delayed or non-union. With the search and development of new materials and techniques for fracture fixation, less invasive procedures have become increasingly popular. This resulted in the minimally invasive plate osteosynthesis (MIPO) technique for fracture fixation. With the MIPO technique, procedures could be performed with smaller incisions and thus with less soft tissue damage and a better preserved blood supply. The last 5 years rib fixation has become increasingly popular, rising evidence has become available suggesting that surgical rib fixation improves outcome of patients with a flail chest or isolated rib fractures. Many surgical approaches for rib fixation have been described in the old literature, however, most of these techniques are obscure nowadays. Currently mostly large incisions with considerable surgical insult are used to stabilize rib fractures. We think that MIPO deserves a place in the surgical treatment of rib fractures. We present the aspects of diagnosis, preoperative planning and operative techniques in regard to MIPO rib fixation.

Factors Affecting Pneumonia Occurring to Patients with Multiple Rib Fractures

BACKGROUND: Rib fractures are the most common type of thoracic trauma and cause other complications. We explored the risk factors for pneumonia in patients with multiple rib fractures. MATERIALS AND METHODS: Four hundred and eighteen patients who visited our hospital with multiple rib fractures between January 2002 and December 2008 were retrospectively reviewed. Chest X-rays and chest computed tomography were used to identify injury severity. Patients with only a single rib fracture or who were transferred to another hospital within 2 days were excluded. RESULTS: There were 327 male patients (78%), and the median age was 53 years. The etiologies of the patients' trauma included traffic accidents in 164 cases (39%), falls in 78 cases (19%), slipping and falling in 90 (22%), pedestrian accidents in 30 (7%), industrial accidents in 41 (10%), and assault in 15 (4%). The median number of rib fractures was 4.8. Pulmonary complications including flail chest (2.3%), lung contusion (22%), hemothorax (62%), pneumothorax (31%), and hemopneumothorax (20%) occurred. Chest tubes were inserted into the thoracic cavity in 216 cases (52%), and the median duration of chest tube insertion was 10.26 days. The Injury Severity Score (ISS) and rib score had a median of 15.27 and 6.9, respectively. Pneumonia occurred in 18 cases (4.3%). Of the total cases, 33% of the cases were managed in the intensive care unit (ICU), and the median duration of stay in the ICU was 7.74 days. Antibiotics were administered in 399 patients (95%) for a median of 10.53 days. Antibiotics were used for more than 6 days in 284 patients (68%). The factors affecting pneumonia in patients with multiple rib fractures in multivariate analysis included age (p=0.004), ISS (p<0.001), and rib score (p=0.038). The use of antibiotics was not associated with the occurrence of pneumonia (p=0.28). In-hospital mortality was 5.3% (n=22). CONCLUSION: The factors affecting risk of pneumonia in patients with multiple rib fractures included age (p=0.004), ISS (p<0.001), and rib score (p=0.038). Elderly patients with multiple traumas have a high risk of pneumonia and should be treated accordingly.

Evaluation of Lung Injury Score as a Prognostic Factor of Critical Care Management in Multiple Trauma Patients with Chest Injury

PURPOSE: Chest injuries in multiple trauma patients are major predisposing factor for increased length of stay in intensive care unit, prolonged mechanical ventilator, and respiratory complications such as pneumonia. The aim of this study is the evaluation of lung injury score as a risk factor for prolonged management in intensive care unit (ICU). METHODS: Between June to August in 2011, 46 patients admitted to shock and trauma center in our hospital and 24 patients had associated chest damage without traumatic brain injury. Retrospectively, we calculated injury severity score (ISS), lung injury score, and the number of fractured ribs and performed nonparametric correlation analysis with length of stay in ICU and mechanical ventilator support. RESULTS: Calculated lung injury score(<48 hours) was median 1(0-3) and ISS was median 30(8-38) in study population. They had median 2(0-14) fractured ribs. There were 2 bilateral fractures and 2 flail chest. Ventilator support was needed in 11(45.8%) of them for median 39 hours(6-166). The ISS of ventilator support group was median 34(24-34) and lung injury score was median 1.7(1.3-2.5). Tracheostomy was performed in one patient and it was only complicated case and ICU stay days was median 9(4-16). In correlation analysis, Lung injury score and ISS were significant with the length of stay in ICU but the number of fractured ribs and lung injury score were predicting factors for prolonged mechanical ventilator support. CONCLUSION: Lung injury score could be a possible prognostic factor for the prediction of increased length of stay in ICU and need for mechanical ventilator support.

Traumatic rupture of diaphragm with flail chest mimicking tension hydropneumothorax.

Traumatic rupture of diaphragm though not rare, presents as complication of penetrating and blunt injuries of chest and abdomen. Preoperative diagnosis of diaphragmatic injury is difficult because of the complex shape of the thin diaphragmatic muscle, the horizontal in-plane orientation of one diaphragmatic dome, and the often associated traumatic abnormalities in the lung bases. Failure to detect this underlying injury is associated with significant morbidity and mortality because of delayed visceral herniation, strangulation or both. We report a case of left-sided post traumatic rupture of diaphragm presenting as tension hydropneumothroax following a road traffic accident. It was managed as tension hydropneumothorax during initial resuscitation by intercostal tube drainage. Lack of improvement in the clinical condition led to the suspicion of diaphragmatic rupture. The patient was managed successfully by operative repair of diaphragm and manual reduction of hernial contents

Estabilización operatoria con placas y tornillos en costillas para tratar un caso de tórax inestable complicado / Plate ostesynthesis in unstable thorax: case report

Las fracturas costales son uno de los traumas de mayor frecuencia, siendo el 10% de los traumas cerrados. Cuando la lesión es de múltiples arcos costales y es inestable recibe el nombre de tórax inestable. El manejo de éste ha sido controversial durante mucho tiempo. El proceso fisiopatológico generado por el movimiento paradójico de la caja torácica lleva a un desequilibrio en la mecánica respiratoria lo que, asociado a la contusión pulmonar, aumenta la severidad del daño. Con el fin de restablecer la fisiología normal de la mecánica pulmonar, los métodos de tratamiento se han basado en la estabilización neumática interna mediante ventilación mecánica, lo que conlleva a una larga estancia en la UCI y a mayores riesgos adicionales debido al método ventilatorio. La otra alternativa es la estabilización quirúrgica mediante osteosíntesis que permite un proceso de recuperación de la mecánica respiratoria mucho más rápido y una menor estancia hospitalaria; sin embargo, aunque se conocen unas claras indicaciones para la ejecución de este procedimiento, en los diferentes centros de trauma no se realiza este tipo de cirugía de manera rutinaria. En este artículo se reporta el caso de un paciente del HUSJ a quien se le realizó fijación quirúrgica del tórax inestable con mejoría de la función pulmonar, con un periodo de ventilación posoperatorio de 20 horas, una estancia en la UCI de 40 horas y una estancia hospitalaria de 6 días.

Results of treating flail chest by technique of open fixation

Background: Flail chest is a severe condition of thoracic trauma, and it requires diagnosis and treatment as soon as possible. From year 2000, we developed an improved technique of open fixation in order to adapt the situations of Vietnam health settings. Objectives: To report preliminary results of application of improved open fixation technique in Viet Duc Hospital from 2001 to 2006. Subjects and method: This descriptive, prospective and retrospective study involved 19 patients with flail chest due to closed thoracic trauma or multiple traumas, treated by open fixation technique. The parameters included features of patients, characteristics of this technique and postoperative progression.Results: Of 19 patients, there were 16 males and 3 females, mean age: 47.8 years. All patients presented obvious signs of flail chest preoperatively, but only 9 cases were treated by open fixation technique and pleural drainage immediately. This technique canbe applied in all sugical settings with single local anaesthesia, and any kind of common surgical threads. The most suitable initial pulled weight is 2000 g. All cases of flail chest required pleural drainage. All patients had good outcomes with open fixation technique, no death. There were 3 patients with postoperative complications, all were severe multiple trauma patients. Conclusion: Improved open fixation technique applied in Viet Duc Hospital is simple, effective and safe, and can be widely used in all surgical settings.

Decision Making and Emergency Management for Liver Trauma

Liver trauma is one of the most serious injuries, although its incidence is not high, with an excess mortality ratio of 12.3. Liver trauma usually presents as one injury among various injuries involving multiple organs. One should therefore be cautious to focus on the victim itself, and not on the liver, when managing a victim with liver trauma. The principle of decision-making and emergency management for liver trauma is based on the same guideline for multiple trauma victims.Advanced Trauma Life Support (ATLS). ATLS has two stages, a primary survey and a secondary survey. The primary survey is composed of five components: (1) airway management with cervical spine immobilization; (2) breathing and ventilation support; (3) circulation support with hemorrhage control; (4) neurological evaluation; and (5) exposure. The primary survey should include providing immediate interventions for critical conditions such as an airway obstruction, a tension pneumothorax, a flail chest, an open pneumothorax, a massive hemorrhage, and cardiac tamponade. During the primary survey, one can use a non-invasive evaluation method, the Focused Abdominal Sonographic Examination for Trauma (FAST) to screen for hidden blood loss. After the primary survey, one should evaluate all kinds of combined injuries in-detail from head to toe during a secondary survey. By the use of the primary and secondary survey, one can make a decision about further specific management such as to perform or not perform surgery.

Successful use of non-invasive pressure ventilation in a complicated flail chest

The current advanced trauma life support manual states that patients with significant hypoxia namely, SaO2 <90% on room air as a result of pulmonary contusion should be intubated and ventilated within the first hour of injury. Recently, several researchers have shown improved outcomes when patients with acute respiratory failure are managed with non-invasive positive pressure ventilation NIPPV. Trauma patients may also benefit from this therapy. We report a case of 15-year-old boy with isolated flail chest and pulmonary contusion, who was intubated in the emergency room, and was managed successfully with the NIPPV in the intensive care unit ICU despite, having had aspiration pneumonia early in the course of his stay. After initial stabilization, he failed a spontaneous breathing trial. Due to absence of contraindications to the use of NIPPV, the patient was extubated on day 7 from pressure support ventilation of 15 cmH2O and positive end expiratory pressure of 8 cmH2O to immediate NIPPV use. Three days later after a total of 50 hours of NIPPV use in the ICU the patient was successfully discharged home

Uso de fijador externo en la inestabilidad de la pared torácica anterior (volet esternal). Presentación de un caso / Use of the external fixative in the instability of the anterior thoraxic wall (sternal volet). A case report

Se presenta un paciente con inestabilidad de la pared torácica anterior y esternón tratado previamente con un dispositivo creado por los autores en 1995 para el volet costal. Las costillas artificiales externas del dispositivo, diseñado para el cerclaje subperióstico, actúan como elemento de fijación y han conseguido resultados satisfactorios. Se presenta un paciente, que producto de un accidente automovilístico, sufre lesiones en cráneo, tórax, abdomen y extremidades, entre las que resaltan contusión cerebral, lesión hepática, fractura de fémur e inestabilidad de la pared torácica anterior. Esta última requirió de prioridad extrema, pues habría llevado rápidamente al paciente a la insuficiencia respiratoria de no ser solucionado el problema. Se realizó la estabilización externa mediante un equipo que se utiliza en nuestro hospital, reutilizable y aplicable en cualquier inestabilidad torácica independientemente de la localización de esta. El fijador se confecciona con láminas de duraluminio maleables que permiten su adaptabilidad e introduce una forma de tratamiento en las lesiones torácicas bilaterales con inestabilidad esternal, situación compleja en la que puede resultar un instrumento valioso de tratamiento(AU)

A patient is presented with uncertainty of the previous thoracic wall and breastbone tried previously with a device created by the authors in 1995 for the costal volet. The external artificial ribs of the device, designed for the cerclaje subperióstico, act as fixation element and they have gotten satisfactory results. A patient is presented that product of an automobile accident, suffers lesions in skull, thorax, abdomen and extremities, among those that stand out cerebral bruise, hepatic lesion, femur fracture and uncertainty of the previous thoracic wall. This last one required of extreme priority, because it would have taken to the patient quickly to the breathing inadequacy of not being solved the problem. He/she was carried out the external stabilization by means of a team that is used in our hospital, reutilizable and applicable in any thoracic uncertainty independently of the localization of this. The fixer is made with sheets of malleable duraluminio that allow its adaptability and it introduces a treatment form in the bilateral thoracic lesions with uncertainty esternal, complex situation in which can be a valuable instrument of treatment(AU)