STOVE IN CHEST, FLAIL CHEST AND TRAUMATIC RUPTURE OF DIAPHRAGM.ppt

stove in chest- academic purpose

1. STOVE IN CHEST, FLAIL CHEST AND
TRAUMATIC RUPTURE OF DIAPHRAGM
Dr.A.S.SHIVASARAVANAN,M.D(HOM)
PROFESSOR
DEPARTMENT OF SURGERY
VMHMC
SALEM

2. STOVE-IN CHEST AND FLAIL CHEST
•For practical purposes the two terms ‘stove-in
chest’ and ‘flail chest’ are often used synonymously,
but there is difference between these two terms.
•STOVE-IN CHEST develops from the extensive
localized crushing force which produces multiple rib
fractures. This results in depression of the chest
wall in that region.
• Relative immobility leads to accumulation of
broncho pulmonary secretion.
•This condition, if associated with depressed fracture
of clavicle, becomes a serious condition.

4. FLAIL CHEST
•FLAIL CHEST develops when multiple ribs fracture
anteriorly at or near the costo- chondral junctions and
posteriorly near the angles of the ribs.
•This results in a fragment of the chest wall which
becomes unstable having no bony connection.
•This ‘floating segment’ moves in during inspiration due
to negative pressure in the pleural cavity and moves
out during expiration due to positive pressure in the
pleural cavity.

5. .
•This results in paradoxical movement of this floating
segment of the chest wall.
•This is also known as paradoxical respiration that
means the floating segment moves in the opposite
direction as the movement of the normal chest wall.
• This very badly affects aeration of the lung and
progressive accumulation of carbon dioxide.
• So it ultimately leads to profound hypoxia accentuated
by restriction of breathing produced by severe pain
associated with this type of injury.

6. .
•Three types of flail chest can be seen:-
•In the lateral type, multiple ribs are fractured
anteriorly and posteriorly.
•In anterior type, the anterior ends of a few ribs on
both sides are fractured so that the sternum along
with the anterior fragments of ribs of both sides
becomes the floating segment.
•In posterior type, the multiple ribs are fractured at
their posterior angles on both sides, so that the
spinal column along with the posterior fragments of
the ribs becomes the floating segment. The effect
of paradoxical respiration in this case is minimal.

7. .
•Effects of paradoxical respiration:
•It causes imperfect ventilation which leads to
profound hypoxia.
•With paradoxical respiration, there will be also
mediastinal flutter, in which the mediastinum will
move towards the sound side during inspiration and
moves towards the affected side during expiration.
As the contents of the mediastinum are the heart
and great vessels, their movements will lead to
severe shock.
•Due to paradoxical respiration a portion of inspired
air will flow back to the opposite healthy lung
during inspiration and the same air will reach the
affected lung through the bronchi during expiration.

8. .
•This pendulum movement of air from one lung to
the other will lead to stagnation of air and will
diminish the amount of air entering both the lungs
considerably.
•Paradoxical respiration will also lead to
accumulation of broncho pulmonary secretions due
to tremendous pain and relative immobility of the
affected lung.
•Post traumatic pulmonary insufficiency or wet lung
may also occur due to flail chest.

9. Treatment
•Immediate hospitalization of these patients cannot be
over-emphasized. Administration of relaxant drugs
(this gives quick relief of pain), passage of an
endotracheal tube, insertion of intrapleural drain and
mechanical or manual control of ventilation are the
key stones of the management.
•Modern plastic endotracheal tubes can safely be
retained up to 5 days. But minimum 2 to 3 weeks are
required for consolidation of fractured ribs, so
tracheostomy at a convenient time is always required.
Tracheostomy is extremely needed in this condition
and is considered as ‘routine’ in the management of
patients with flail chest. The utilities of tracheostomy
are:-

10. •It reduces dead space (the unnecessary space
between the nose and the trachea is
eliminated).
•It gives better access for tracheo bronchial
aspiration or toileting.
•It facilitates internal stabilization of the chest
wall through mechanical ventilation. So if
facilitates for immediate tracheostomy are
available, it should be done.

11. Treatment
•Mechanical ventilation is highly effective in
treatment of flail chest. It not only controls
and minimizes paradoxical respiration, but it
acts as an effective ‘internal pneumatic
fixation’ of the floating segment

12. TRAUMATIC RUPTURE OF THE
DIAPHRAGM
•Rupture of the diaphragm may occur from
penetrating injuries or crush injuries to the lower
chest or upper abdomen.
•The abdominal trauma is more often responsible
for rupture of the diaphragm than thoracic
trauma. The ratio is 5:2.
•The crushing injury causes rupture of the
diaphragm due to sudden increase of the intra-
abdominal and intra thoracic pressure.

13. .
•The left hemi diaphragm is ruptured more frequently
by blunt trauma than the right and the ratio is about
9:1.
• The right diaphragm is more protected by the liver,
whereas the left diaphragm is weakened in the
postero-lateral aspect due to the gap for abdominal
aorta and the oesophageal hiatus.
• If the right hemi diaphragm is ruptured, the liver is
usually the only abdominal structure that herniates
through the diaphragm.
•When the left hemi diaphragm ruptures, which usually
extends from the oesophageal hiatus across the cupula
towards the costal margin, the stomach, the spleen,
the left transverse colon and/or omentum may
herniated through the rupture.

14. .
•In case of penetrating
diaphragmatic injuries, the
hole in the diaphragm is
small and herniation
occurs rarely and slowly.
•Immediate diagnosis is the
key of successful
management of this
condition.
• chest X-ray may often
show nothing more than a
blurring of the diaphragm
with or without evidence
of a small haemothorax.

15. .
•Effort should be made to confirm the diagnosis by
contrast studies by pushing air through the
nasogastric tube or by the use of
pneumoperitoneum or by radioisotope liver and
spleen scans.
•The only characteristic feature is that on
auscultation of the chest one may hear bowel
sounds. The confirmative radiographic picture
shows hollow viscera containing air in the pleural
cavity.

16. TREATMENT
•As soon as the diagnosis is confirmed, a
thoracotomy incision is made. The herniated viscera
are put back into the abdomen and the diaphragm
is sutured by interrupted non-absorbable suture
material.
•Thoracotomy is better as-
–Adhesions between abdominal viscera and intrathoracic
structures can be seen easily.
–Reduction of hernia becomes easier.
–Repair of the rupture of the diaphragm is technically
easier from this approach.
–Laparotomy us only indicated when an associated intra-
abdominal injury is suspected.

17. THANK YOU. . .. . .