title: New insights into the pathophysiology of flail segment: the implications of anterior serratus muscle in parietal failure.
abstract: OBJECTIVE
  The wisdom of surgery facing multiple and multi-focal ribs fractures (flail segment) remains controversial. By the present retrospective study, we sought to determine the advisability of surgery as well as the anatomical and biomechanical features of flail segment leading to secondary dislocation.
  
  
  METHODS
  From 1970 to 2000, 127 patients underwent flail segment osteosynthesis. Clinical charts, operative reports and imaging data were reviewed retrospectively. Rib osteosynthesis was carried out with Judet staple and Kirschner wires until 1980, since then it has been undertaken with sliding-staples-struts. Postoperative chest X-ray was carried out to classify the flail segments into anterolateral and posterolateral types according to the location of anterior and posterior rib fractures. Each type was then divided into three subgroups of primary parietal, secondary parietal and retreat indications that were inferred retrospectively from final indications of rib osteosynthesis.
  
  
  RESULTS
  The mean age of patients (ranging in age from 20 to 84 years) was 56+/-14.4 years with a male predominance (108/19). Seventy percent of flail segments was considered as posterolateral. The mean number of rib fractures per patient was 6+/-0.35. Rib osteosynthesis was undertaken with sliding-staples-struts in 70% of patients. The overall hospital mortality was 16%; it was subsequently reduced to 8% since sliding-staples-struts were used. The mean duration of ventilation was reduced from 5.8+/-0.76 days to 2.98+/-0.83 days with sliding-staples-struts. Seventy-seven percent of patients with posterolateral flail segment and primary parietal indication were extubated within the first 48 h postoperatively, whereas 46% of patients from other subgroups required ventilation for more than 5 days. Similarly, 83% of patients of the former subgroup returned to full previous level of activity compared with a rate of 52% for the latter subgroups. The flail segments were dislocated superoposteriorly for both anterolateral and posterolateral types, evoking the action of anterior serratus muscle.
  
  
  CONCLUSIONS
  The anterolateral and posterolateral flail segments are rendered susceptible to secondary dislocation through a complex set of factors, of which the action of anterior serratus muscle is obvious. Restoration of parietal mechanics by early surgical reduction/fixation is a reliable therapeutic option in selected patients and offers encouraging results.
authors.affiliation: Medipole Gentilly-Saint Jacques, 54320 Maxeville, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Borrelly
authors.forename: Mathias Hossain
authors.initials: MH
authors.lastname: Aazami
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001696:Biomechanical Phenomena; D005260:Female; D005409:Flail Chest / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000379:methods*; D006801:Humans; D004204:Joint Dislocations / Q000503:physiopathology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000601:surgery; D018482:Muscle, Skeletal / Q000503:physiopathology*; D012189:Retrospective Studies; D017792:Surgical Stapling; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000601:surgery