title: Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability.
abstract: OBJECTIVE
  Stabilizing techniques of flail chest injuries usually need wide approaches to the chest wall. Three main regions need to be considered when stabilizing the rib cage: median-anterior with dissection of pectoral muscle; lateral-axillary with dissection of musculi (mm) serratus, externus abdominis; posterior inter spinoscapular with division of mm rhomboidei, trapezius and latissimus dorsi. Severe morbidity due to these invasive approaches needs to be considered. This study discusses possibilities for minimized approaches to the shown regions.
  
  
  METHODS
  Fifteen patients were stabilized by locked plate osteosynthesis (MatrixRib®) between May 2012 and April 2014 and prospectively followed up. Flail chest injuries were managed through limited incisions to the anterior, the lateral, and the posterior parts of the chest wall or their combinations. Each approach was 4-10 cm using Alexis®retractor.
  
  
  RESULTS
  One minimized approach offered sufficient access at least to four ribs posterior and laterally, four pairs of ribs anterior in all cases. There was no need to divide latissimus dorsi muscle. Trapezius und rhomboid muscles were only limited divided, whereas a subcutaneous dissection of serratus and abdominis muscles was necessary. A follow-up showed sufficient consolidation.
  
  
  RESULTS
  pneumothorax (2) and seroma (2).
  
  
  CONCLUSIONS
  Minimized approaches allow sufficient stabilization of severe dislocated rib fractures without extensive dissection or division of the important muscles. Keeping the arm and, thus, the scapula mobile is very important for providing the largest reachable surface of the rib cage through each approach.
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany. stefan.schulz-drost@uk-erlangen.de.|Department of Pediatric Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany. stefan.schulz-drost@uk-erlangen.de.
authors.forename: S
authors.initials: S
authors.lastname: Schulz-Drost
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Grupp
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Pachowsky
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
authors.forename: P
authors.initials: P
authors.lastname: Oppel
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Krinner
authors.affiliation: Department of Orthopedic and Trauma Surgery, St. Theresien Krankenhaus, Mommsenstr. 24, Nuremberg, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Mauerer
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
authors.forename: F F
authors.initials: FF
authors.lastname: Hennig
authors.affiliation: Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Langenbach
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001860:Bone Plates; D005260:Female; D005409:Flail Chest / Q000503:physiopathology / Q000601:surgery*; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D056888:Patient Positioning / Q000379:methods*; D011030:Pneumothorax / Q000517:prevention & control / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control / Q000601:surgery*; D011446:Prospective Studies; D016896:Treatment Outcome
keywords: Approach chest wall; Flail chest injury; Matrix rib; Muscle sparing approach; Rib fracture