Bronchial rupture associated with flail chest treated by external traction.

A 40-year-old African male was admitted to hospital after being crushed between a reversing lorry and a wall. On examination he was conscious, slightly dyspnoeic but not obviously cyanosed. The pulse rate was 80/min and the arterial pressure was 120/80 mm Hg. The main injury was sited in the left nipple region where a large penetrating wound, 8-10 cm in diameter, communicated with the left pleural cavity. This section of the chest wall was moving paradoxically with respiration. Chest X-rays showed posterior and postero-lateral fractures of the left 4th, 5th, 6th, 7th and 8th ribs The wound was closed under local anaesthesia, an intravenous infusion commenced and the patient was transferred to the operating theatre. An underwater seal-drain was inserted under local anaesthesia in the left mid-axillary line away from the fracture sites. General anaesthesia was induced with thiopentone. Endotracheal intubation was performed following suxamethonium injection. Anaesthesia was maintained with oxygen, nitrous oxide and halo thane. Controlled ventilation was commenced using intermittent suxamethonium for muscle relaxation while a 39FG cuffed tracheostomy tube was inserted. A large leak of gases continued into the underwater seal-drain. It was then decided to proceed with exploratory thoracotomy. The patient was curarized and the inflation pressure of the East-Radcliffe ventilator was increased to compensate for the leak. The operative findings consisted of a left haemopneumothorax and a large tear of the left main bronchus. A smaller bronchial division not anatomically identified was almost completely ruptured. The surrounding lung was severely contused. The bronchial ruptures were repaired with black silk, an airtight occlusion being obtained. An intra-medullary nail was then inserted into the posterior fracture of the 5th rib to achieve stability. During the procedure 3 units of whole blood were transfused. It would have been technically possible to ventilate this patient after operation, but a shortage of trained nursing staff forced us to implement an alternative method of stabilizing the flail segment. Four strong nylon sutures were passed around the fractured ribs. Sufficient traction to prevent flailing was applied to the sutures via a pulley on a Balkan beam. Muscle relaxation was reversed with neostigmine and atropine and the patient was permitted to breathe spontaneously.