EXTERNAL STABILIZATION OF THE THORAX IN COMPLEX TREATMENT OF CHILDREN WITH SEVERE CHEST INJURIES: DESCRIPTION OF CLINICAL CASES

Aim. To describe a proposed method of treating children with a traumatic disorder of the thorax. Material and methods. Under the conditions of work in the Tyumen “Center of Medicine of Catastrophes”, doctors of all specialties of the Tyumen region interact with thoracic surgeons. Special attention is given to children with polytrauma. In the Tyumen region for the period 2016–2017, two travels to treat children with multiple floating fractures of the ribs on one side were made. The patients were treated by using an original method of external chest stabilization. We present the advantages of the method in the descriptions of the clinical cases. Results. The chest structure was stabilized by using a V-shaped model of the Cramer tire to increase the area of contact with the chest. The tire was fixed with Kapron thread No 5 by using a large cutting needle, which was wound under the ribs after marking the floating section of the chest. The ribs were stitched for stable areas along the edges and for an unstable fragment of the thorax. Later, the V-shaped model of the Cramer tire was applied and fixed by threads to the chest. This method is simple and acceptable in any hospital and allows early spontaneous breathing with no purulent-septic complications. Conclusions. This method of restoring the skeletal function of the thorax with the help of external fixation of the V-shaped model of the Cramer tire allows reliable minimally invasive stabilization of the chest wall. External stabilization of the thorax allows early transfer of the victims to independent breathing and shortens the duration of treatment in the intensive care unit. The availability and simplicity of the design makes it possible to perform this procedure everywhere. Video thoracoscopic support is needed only if there is a suspicion of a clotted hemothorax.


Background
Chest injuries are one of the most severe forms of trauma and are the primary cause of complications and deaths [1,2]. The prevalence of chest injuries in peacetime traumas remains high and ranks third among all types of traumas. It accounts for 12.5% of all injury cases, and 55.4% of all injury-related deaths, as per autopsies. With multiple unilateral fractures of the ribs, the vital capacity of the lungs on the side of the lesion is reduced by 30%, and the costal valve reduces by 50% [3]. Floating rib fractures occur in 10%-20% of patients with closed chest injury and are associated with a fatality rate of 10%-35% [4].
One of the pathogenetic mechanisms in severe chest injury is the pathological excursion of the floating fragment of the chest wall that results in lung compression, alveolar collapse, and shunting of the blood in a small circle of blood circulation that leads to shock lung syndrome, with severe limitation of the chest respiratory excursion due to pain syndrome. Closed chest injury with floating rib fractures is present in 80%-90% of the cases owing to intrapleural complications, such as pneumothorax and hemothorax, caused by trauma to the intercostal vessels or injury of the lungs by rib fragments [5,6].
In 1951, B.M. Carter et al. reported the use of artificial lung ventilation in severe injury for creating adequate drainage of the tracheobronchial tree by tracheostomy and provide internal support for the lungs by intermittent ventilation [7]. The method of internal pneumatic stabilization has now become widespread and has become the main method for the treatment of patients with floating rib fractures [8].
Anti-shock therapy, drug treatment, infusion therapy, analgesia, and antibacterial therapy are well known and approved, as comprehensively established in the recommendations of the national guidelines for "Intensive therapy" [9]. With respect to the surgical approach, this problem is crosssectoral, involving traumatology, surgery, thoracic surgery, and pediatric surgery. Today, there is lack of consensus regarding the timing and scope of any medical manipulation at this time.
There are reports by the Russian public organization, the Russian Society of Surgeons, about chest injury, where problems associated with the stabilization of the chest are highlighted [10]. Chest stabilization methods are classified as internal and external. While using the internal, pneumatic stabilization method [11], the authors who aimed to identify the optimal method of ventilation succeeded in reducing the hospitalization duration and decreasing the purulent and septic complications [12,13]. Isolated external stabilization of the chest appears to cause severe chest injury; therefore, it is an additional method that provides a stable chest frame during intensive therapy. The trocar is entered through the floating segment of the chest for traction to the plastic panel; alternatively, the injured ribs are fixed to a special splint [14][15][16].
The external method of fixation of the chest frame should restore the shape of the chest and be less traumatic. Currently, several methods for the fixation of the floating segments of the chest frame exist; the main disadvantages of these methods are the complexity of implementation and necessity of certain materials for their use [17]. The search for an opportunity to stabilize the sterno-costal without additional costs for the manufacture of individual devices with maximum comfort for the patient formed the basis of this work.
This study aimed to describe the proposed method for treating children with traumatic disorders of the thoracic frame function.

Material and methods
Doctors from all specialties in the Tyumen region apply to the thoracic surgeon of the Tyumen disaster medicine center, to consult patients remote from the thoracic center whose treatment is associated with staying in the district medical institutions. Among all the consultations, children with polytrauma require a multidisciplinary approach and special focus. The transfer of this category of patients with a recent trauma to the thoracic center is not always possible due to the severity of the condition, and their treatment is conducted on site on arrival of the specialized team. Thus, during 2016-2017, in the Tyumen region, two visits were made to children with severe chest injury, with multiple floating rib fractures on one side. The cause of the injury was a car accident. Both patients were treated with an original method of external chest stabilization. Based on this method, the useful model patent No 174276 "Device for external stabilization of the thoracic frame with floating rib fractures" was registered [18].
Given the small number of observations, the advantages of the used method are presented in the description of clinical cases. Parental consent was obtained for the surgical treatment. The method of surgical aid was approved by the ethical committee at the Tyumen State Medical University. The Department of Scientific Research under the Tyumen State Medical University approved the publication of the medical data and photographs. Parents and patients themselves provided consent for the publication of the data about the disease and the placement of the photographs in the media.

Results and discussion
Case 1. A 17-year-old patient with multiple floating fractures of the ribs 4 and 9 on the left with hemopneumothorax on the left side of the injury site underwent thoracostomy on the left side with evacuation of 300 mL lysed blood. Tracheostomy was performed on day 5 after the trauma; however, it was not possible to wean the patient off the respirator. This patient consulted the thoracic surgeon on the 8 th day after the trauma, following a telephonic consultation with the thoracic surgeon. Objectively, upon examination, the surgeon observed paradoxical respiration with floating. The initial radiographic image on the site of the consultation was as follows: the lungs were straightened, the mediastinum was structural, there were multiple fenestrated fractures of the ribs on the left, and the left pleural cavity was drained. On the 9 th day after the injury, the patient underwent a surgery to stabilize the chest frame; the V-shaped Cramer splint was used as the stabilizing material to increase the contact area with the chest and mold it in the shape of the chest frame. The splint was fixed with a nylon thread no. 5 using a large cutting needle that was inserted under the ribs. The procedure was performed in the intensive care unit on a bed, under intravenous anesthesia. After marking the floating area of the thorax and processing the surgical field, the sutures were overlapped behind the ribs with formation of three conditional lines. The ribs were sutured with stable areas along the edges and the unstable fragment of the chest frame. Thereafter, a V-shaped modeled Cramer splint was applied and fixed to the chest with sutures ( Figure 1).
The post-operative discharge is estimated based on the pleural drainage and presence of hemorrhage. Control radiography of the thoracic organs showed no complications. Two days postoperatively, the patient was weaned from the respirator. During the treatment course, the patient's condition returned to normal; this enabled the removal of the V-shaped modeled Cramer splint on postoperative day 9. The patient was discharged on postoperative day 14 when the chest frame was stabilized, with a satisfactory clinical and radiologic picture.
Case 2. Case 2 was that of a 12-year-old patient with multiple floating fractures of ribs 3 to 10 on the right side and hemopneumothorax on the right. At the injury site, laparotomy was performed with suture of the liver rupture and draining of the right pleural cavity (100 mL of lysed blood was evacuated). This pediatric patient visited the thoracic surgeon on the 4 th day after injury; the consultation was performed on phone, during which, the visit to the thoracic surgeon was fixed. Objectively, upon examination, the surgeon observed paradoxical respiration with floating. The initial radiographic im-age of the site under consultation showed the following: the lung had expanded on the left; on the right, there was homogeneous total shadowing of the right hemothorax with displacement of the mediastinum to the right; there were multiple fenestrated fractures of the ribs on the right; and the right pleural cavity was drained. Sanation fibrobronchoscopy was technically impossible because the endotracheal tubes no. 4 and 5 could not be inserted into the endoscope. Rigid bronchoscopy was also technically impossible. On day 5, the patient underwent the surgery for stabilization of the chest frame. Considering the radiographic image of the chest organs and the presence of an endoscopic stand for endovideosurgical surgeries, diagnostic video-assisted thoracoscopy was performed with laparaports, and carboxythorax was applied at a pressure of 10 mm Hg.
In thoracoscopy, a blood clot with a volume of up to 150 mL was evacuated from the pleural cavity. Further, the right lung was traumatically changed; that is, there was pulmonary contusion. The material for stabilization of the chest frame was the Cramer splint that was V-shaped to increase the contact area with the chest and to mold it in the shape of the chest frame. For fixation, a caprone thread no. 5 with a large cutting needle was used to insert it under the ribs. The procedure was performed in the operating room during video-assisted thoracoscopy under endotracheal anesthesia. After marking the floating area of the chest and processing the surgical field, percutaneous sutures were taken under the ribs with the needle passing along the upper edge of the rib and under the rib in the downward direction; thereafter, the needle was removed through the skin under video-assisted thoracoscopic control ( Figure 2).
Thus, we obtained three conventional ribsuturing lines on the stable areas along the edges and on an unstable fragment of the chest frame. Thereafter, a V-shaped modeled Cramer splint was applied and fixed with threads to the chest. Further,  the pleural cavity was drained with two drains along the pleural cavity. The surgery was completed by the application of a tracheostoma (Figures 3, 4). Control radiography of the chest organs revealed positive dynamics in the form of increased pneumatization of the right lung ( Figure 5).
On day 7, the patient was weaned from the respirator; after 14 days, the V-shaped Cramer splint was removed. The patient was discharged on day 20 after stabilization of the chest frame with a satisfactory clinical and radiologic picture.
Thus, it is necessary to compare the results in a group of similar injury cases to evaluate the results of treatment; however, there are few cases with such injuries in our area. The data of 52 patients with floating fractures of the ribs treated in the M.I. Kalinin Samara regional clinical hospital during 2011 to 2014 can be considered an example [17]. All these patients received complex treatment of severe chest injury and acute respiratory failure; internal pneumatic stabilization was performed with artificial ventilation of the lungs and surgical stabilization of the chest wall frame. Surgical treatment was performed for all patients within 6-72 hours from the moment of eduction from a traumatic shock. With respect to the methods of external stabilization, skeletal traction with the ribs was performed in 14 patients, skeletal traction with fixing of the transpleural ligatures with thoracotomy or videoassisted thoracoscopy in 6 patients, and labor-intensive application of the device for extrafocal fixation of multiple and floating fractures of the ribs and sternum in 7 patients, where the fixation points were the intact collarbone and the pelvic bones that enabled the arrest of respiratory failure within 7-12 days; 25 patients underwent extra-cortical osteosynthesis of 2-5 damaged ribs with the extensible approach, while the duration for the artificial ventilation of the lungs was 2.5 days. Comparing these previous results with our data, we can state that our original method of stabilizing the chest frame is less labor-intensive with regard to installation, does not require special equipment, does not require an extensible approach directly to the ribs, can be performed in the intensive care ward, and involves an average duration of 4.5 days for artificial ventilation.
These clinical observations will draw the attention of surgeons, thoracic surgeons, pediatric surgeons, and traumatologists to the possibility of external fixation of the sternocostal complex in children with severe chest injury and multiple floating rib fractures. A V-shaped modeled Cramer splint (available in all district hospitals) was used as a stabilizer that was fixed to the ribs along three imaginary lines, two of which pass along the stable regions along the edges; the third passes from the middle of the unstable fragment of the thoracic framework. The surgery can be performed both with and without video-assisted thoracoscopic control.

Conclusions
1. The developed method of restoring the frame function of the thorax using an external fixation of the V-shaped modeled Cramer splint enables minimally invasive, reliable stabilization of the chest wall. 2. External stabilization of the chest frame enables early independent breathing in the patients and shortens the duration of treatment in the intensive care unit. 3. The accessibility and simplicity of the design enables the performance of this procedure at any location, including within the framework of specialized assistance "off-premise". 4. Video-assisted thoracoscopic support is necessary only in cases with a suspicion of a clotted hemothorax and ensures control over the fixation of the ligatures to the ribs.

Funding and conflict of interest
The authors declare no conflicts of interest. The study received no external funding.