POSTORAD. MED. J. (I962), 38, 460

MANAGEMENT OF STOVE-IN CHEST IN A

PERIPHERAL CLINICSELWYN G. GRIFFIN, M.B., Ch.B.(Liverpool), F.R.C.S.(England)

Thoracic Surgeon, Newcastle Region (Sunderland Area), and Seahamn Hall Hospital

DOUGLAS C. D'NETTO, M.B.(Cal.), F.R.C.S.(E), F.R.C.S.(England)Senior Registrar, The Orthopeedic and Accident Hospital, Sunderland

STOVE-IN chest is a relatively uncommon injury.There have been only three admissions to theSunderland Group of hospitals during the periodI956-60 and this despite the fact that we serve apopulation of 390,ooo, in an area where there is aconsiderable amount of heavy industry, includingshipbuilding and coalmining. Traffic passingthrough the town in the summer months to theseaside and coastal towns is quite heavy. Inaddition, a fourth case was treated in a hospitaloutside the town.

Stove-in chest may be an isolated injury or oneof several sustained by a patient. In itself it is aserious injury and if inadequately treated canprove fatal. Outside special centres a surgeonseldom sees enough cases to learn how to treatthese patients satisfactorily. The treatment givento our four patients, all of whom have survived,has not been ideal but it has depended on thecircumstances under which we work, e.g. insuf-ficient staff for instituting controlled respirationusing a mechanical respirator, etc.

The Nature of the ProblemA stove-in chest results from: (I) Fractures of

the anterior ends of the ribs or costal cartilages onboth sides. This may be associated with a fractureof the sternum. (2) Double fractures of thelateral aspects of the ribs on one side.The patient suffers from pain and respiratory

embarrassment. Shock may be present as aresult of paradoxical respiration and if there hasbeen loss of a large quantity of blood. Controlof the respiratory embarrassment is as urgent andimportant as the replacement of lost blood byadequate transfusion to prevent the patient frompassing into an irrecoverable state.

Respiratory embarrassment results primarilyfrom the paradoxical movement of the flail segmentand is comparable to the problem presented byan open pneumothorax. The flail segment is

.!k

Fiec. I (a).-Fractures of the anterior ends of theribs or costal cartilages on both sides. This isassociated with a transverse fracture of the sternum.

-OI'FiG. I (b).-Double fractures of the lateral aspects of

the ribs on one side.

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sucked in during inspiration and blown out duringexpiration. The result is that expired air, insteadof being exchanged with the atmosphere, isshifted from the lung tissue under the flail segmentinto adjoining lung tissue and into the oppositelung. This results in anoxia and carbon dioxideretention. Associated pressure changes on theaffected side of the chest cause movement of themediastinum towards the opposite side on in-spiration, the reverse occurring in expiration. Thismovement, called mediastinal flutter, interfereswith the filling of the atria, with consequentcirculatory disturbance.The fractures themselves increase the em-

barrassment because pain reduces the expansionof the chest and thus reduces the tidal air.Pulmonary oedema quickly supervenes and may

be present on admission. The cause is not known.It has been suggested that there is a constrictionof the pulmonary vessels in the lung tissue under-neath the flail segment. The resultant anoxiacauses aedema of the alveolar wall. In extensiveinjuries this constriction may cause pulmonaryhypertension with further interference with theexchange of gases in the lungs. The diversion ofextra blood through the normal lung may beanother factor in causing cedema. Unconscious-ness or severe pain, preventing coughing andclearing of the respiratory passages will, by in-creasing anoxia, provoke further cedema. Retainedsecretions quickly become infected with resultantbronchopneumonia (Barrett, I960).Hematoma of the lung, pneumothorax, hamo-

thorax, traumatic diaphragmatic hernia or cardiacinjuries including tamponade, may be present witha stove-in chest and increase respiratory distress.

Finally, if the patient survives, an uncorrecteddeformity may permanently impair his respiratoryfunction.

Case IA patient of 56, a blacksmith's striker in a shipyard,

was admitted on 20. 2.57 at 2.07 p.m., after being caughtin a machine at work. A chronic bronchitic, he hadsustained double fractures of his right ist, 2nd, 3rd and4th ribs. This had resulted in a large anterior flailsegment and paradoxical respiration was obvious. Hispulse rate was go/min. and his blood pressure wasI40/90 mm. Hg.The fracture sites were infiltrated with I % lignocaine

hydrochloride followed by 2%' benzocain in 40(urethane (whose anesthetic action is prolonged) torelieve his pain and a pad and bandage were applied tothe area of paradox in an attempt to control the flailsegment.At 8.30 p.m. he was cold and clammy, dyspnoeic,

wheezing and bubbly. He expectorated a very smallquantity of frothy sputum. His pulse rate was ioo/min.and its volume feeble. His blood pressure was 100oo/7mm. Hg. He was given intravenous injections ofaminophylline and of ephedrine gr. -, but his conditiondeteriorated further.

At 2.30 a.m. he was given a general anesthetic andwith respiratory control his condition improved. Thefractures were exposed through transverse incisions,splitting the pectoral muscles. Displaced fragments ofhis right 2nd, 3rd and 4th ribs were elevated andlengths of stainless steel wire were passed through holesdrilled in the ribs on either side of the fracture sites.The wires were tied and the flail segment was thusstabilized, the right pleural cavity being drained by aMalecot catheter. His bronchial tree was cleared ofsecretion by bronchoscopy, and he was given one pint ofblood.

Following the operation his condition continued toimprove. A B.coli pneumonitis of his right middle andlower lobes responded to a course of streptomycin. Awire in his right 2nd rib snapped and was removed undera local anyesthetic on 14.1.58. He was discharged homeon 15.i.58, returning to work on 11.6.58. The ribsunited with slight flattening.

CommentsThe following points are noteworthy:(i) The rapid deterioration without adequate

treatment in a purely thoracic cage injury.(2) The marked improvement under general

an,asthesia.(3) The maintenance of his general condition

and a satisfactory convalescence after stabilizationof his chest, even without tracheotomy.

(4) The minor residual deformity.Case 2A guard of 60 years on British Railways was admitted

at ii.50 a.m. on 19.8.58, after an engine had crashedinto his guard's van. A chronic bronchitic for severalyears, he had sustained double fractures posteriorlyof his left 6th, 7th and 8th ribs and a single fractureposteriorly of his left gth rib. Anteriorly the costalmargin was fractured with overlying surgical em-physema. He was slightly cyanosed and wheezy butno paradox was seen. A chest X-ray showed no air orblood in the pleura. He was given oxygen and in-jections of morphia gr. -, ephedrine gr. g and 250,000units of penicillin six-hourly.

His condition gradually deteriorated. His cyanosiswas more marked, he became more dyspnoeic and at7 p.m. on 20.8.58 he was semi-comatose. He was coldand clammy with a rapid feeble pulse; his chest was verywet and paradoxical respiration was now obvious over the7th, 8th and 9th ribs antero-laterally. Further chestX-ray (Fig. 2) showed a left pleural effusion.Under local anaesthesia (no anasthetist being in the

hospital) through an incision down to his left 7th, 8thand 9th ribs, his chest was stabilized by bunching theribs together with three deep sutures of No. 3 catgut andone suture of stainless steel wire round the ribs, keepingclose to their deep surfaces to avoid the lung. After thishis chest moved naturally without any suggestion ofparadox. His bronchial tree was cleared of foul greenpus by bronchoscopy. For the first time his colourbecame pink.

Following the operation he was given oxygen andchloramphenicol in addition to penicillin. His conditionimproved through the night and he regained con-sciousness two hours later. His pulse rate fell and itsvolume improved. He was encouraged to cough up hissputum hourly and he did this satisfactorily.

Steady improvement followed with gradual absorptionof a small left pleural effusion. He went home on

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462 POSTGRADUATE MEDICAL JOURNAL Augulst I962

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FIG. 2.-Case 2, 25.8.58. Showing double fracturesof his left 6th, 7th and 8th ribs posteriorly, singlefractures of his gth rib and a left pleural effusion.

I7.9.58 and never attended for a check-up after threeweeks as he felt strong enough to return to work.

Comments(i) Paradoxical respiration may only become

obvious as the patient's condition regresses unlessthe surgeon is looking for it.

(2) Deterioration occurred without adequatetreatment.

(3) An almost moribund patient withstoodcorrective procedures satisfactorily.

(4) Marked improvement followed the stabiliza-tion of his chest and bronchoscopic aspiration.Tracheotomy was again unnecessary.

(5) Although the administration of morphiaprobably did not influence the prognosis, it isbetter to avoid its use unless the patient can still bestimulated to raise his secretion.

Case 3A labourer, aged 33, was crushed beneath a lift at

about 6 p.m. on I.6.59 and admitted at 7 p.m. He wassemicomatose and restless. His breathing was shallowand paradoxical in the upper part of his chest. Hewas cyanosed with a feeble pulse of IIo/min.The flail segment consisted of the sternum and costal

cartilages opposite the 2nd, 3rd and 4th ribs. It wascovered by a pad and bandage. His restlessness wascontrolled by administration of gas and oxygen andmorphia, gr. 1. An endotracheal tube was then passed

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FIG. 3.-Case 3, 2.6.59. Showing double bony fracturesof his left ist and right 2nd ribs and single fracturesof his left 2nd and 3rd ribs. The endotrachealtube is in position. Haematoma in both upperzones.

under pentothal and scoline anaesthesia and administra-tion of oxygen was continued.

X-ray (Fig. 3) showed double fractures of his right2nd and left ist ribs and single fractures of his left 2ndand 3rd ribs. The right Ist, 3rd and 4th costal cartilageswere also fractured.

His condition improved. At i p.m. his depth ofunconsciousness had become lighter. His pulse ratewas Ioo/min. and of better volume. His blood pressurewas 90/60 mm. Hg. An injection of A.T.S. was givenas his chest was covered in abrasions and he was put on acourse of penicillin.The following day he could obey simple commands.

His colour was pink, his paradoxical respiration wasunder control, his pulse rate was 85/min. and its volumewas good. His systolic blood pressure had risen to overIoo mm. Hg. A lesion of the 5th, 6th and 7th cervicalroots of his left brachial plexus and a dislocation of hisright sterno-clavicular joint now became manifest.

His endotracheal tube was removed on 3.6.59. ChestX-ray (Fig. 4) showed paralysis of the left leaf of hisdiaphragm, collapse of the lower lobe of his left lung andsegmental collapse in the middle and lower lobes of hisright lung. Twice at bronchoscopy retained secretionwas removed from his bronchial tree and the collapsedlung tissue re-expanded. It was also noticed that hisleft vocal cord was paralysed. His left recurrentlaryngeal nerve had been damaged at the time of theaccident.He gradually improved. Evidence of voluntary

contraction in the paralysed muscles was noticed on4.6.59. He was discharged home on 11.6.59 after being

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FIG. 4.-Case 3, o1.6.59. Residual shadowing in hisright middle, and lower lobes. Segmental collapseof anterior basal segment of lower lobe of left lungand paralysis of the left leaf of his diaphragm.

fitted with an abduction splint to continue the re-habilitation of his left arm as an out-patient. All hisparalysed muscles recovered and he returned to workon 14.11.59. The only deformity which was presentwas due to an unreduced dislocation of his right sterno-clavicular joint.Comments

(I) His poor general condition on admission as aresult of paradoxical respiration.

(2) Marked improvement occurred after controlof the paradox by administration of an anaestheticand passage of an endotracheal tube.

(3) It was remarkable that a large paradox was somuch under control within two days that it waspossible to remove the endotracheal tube and atracheotomy was unnecessary.Case 4A civilian, aged 3I, attached to the United States Air

Force was admitted to a peripheral hospital at 6 p.m.on 4.9.59 after being involved in a road accident.He was pale and shocked, his pulse rapid and feeble

and his blood pressure 70/50 mm. Hg. He was sufferingfrom gross paradoxical respiration due to fractures of hisright 2nd, 3rd, 4th, 5th and 6th ribs laterally andseparation of his right 2nd, 3rd and 4th chondro-sternaljunctions. The flail segment of chest wall 6 in. indiameter was depressed and there was surgical em-physema over the front of the upper part of his chest.He was covered in abrasions, bleeding from his nose and

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FIG. 5.-Case 4, 4.9.59. Showing collapse of his rightlung, a right hamopneumothorax, a small leftpneumothorax and a broad mediastinum (haema-toma).

coughing up fresh blood. He vomited three times, thevomitus consisting of altered blood.

Chest X-ray (Fig. 5) showed, in addition to thefractured ribs (of which the 3rd was comminuted),collapse of his right lung, a right haemopneumothorax, asmall left pneumothorax and a broad mediastinum.A transfusion of one pint of plasma (which was sub-

sequently followed by nine pints of blood) was startedand the depression in his chest wall was covered by apad and bandage. One of us, called to see him, re-strapped his chest and drained the right haemopneumo-thorax with an intercostal Malecot drain.At 7.30 p.m. his pulse rate was 120/min. but the

volume was good and his blood pressure was 120/80mm. Hg. During the night his condition deteriorated.He became deeply cyanosed, respirations became morelaboured and though his pulse rate remained I20/min.,and the volume was good, his blood pressure rose to130/80 mm. Hg (because of anoxia and carbon dioxideretention).Tracheotomy was performed at i a.m. as a result of

which his condition became less desperate. His breath-ing became less laboured though he still remainedrather cyanosed. As a result of his persistent respiratoryinadequacy, he was restless and confused, i.e. there wasevidence of cerebral anoxia. Again one of us wascalled to the peripheral hospital and it was decided tocarry out a stabilizing operation.At mid-day on 5.9.59 under a general anaesthetic the

flail segment was exposed through an oblique incisionover the front of the right side of his chest, starting overhis right 2nd costal cartilage and extending downwardsand laterally to the anterior axillary fold. His right lungwas punctured and contained a large haematoma. There

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464 POSTGRADUATE MEDICAL JOURNAL August 1962

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FIG. 6.-Case 4, 6.9.59. Showing consolidation andhaematoma of both lungs and mediastinum. Theright lung is now expanded. The tracheotomytube and right Malecot drainage catheter are inposition and the wires approximating the fragmentsof his right 2nd, 3rd and 4th ribs can just be seen.

was a massive haematoma in his superior mediastinum.The rents in the lung were sutured, the flail segment waselevated and stabilized by wiring the fractured fragmentsof his right 2nd, 3rd and 4th ribs and right 2nd, 3rd and4th chondro-sternal junctions together with stainlesssteel wire. Both pleural cavities were drained.At 4.30 p.m. he was no longer cyanosed and though

his chest wall moved much more satisfactorily, minimalparadox was still present. Chest X-ray showed massiveshadowing in the right lung and considerable shadowingin the left lung.On 6.9.59 he was still semi-conscious and restless but

his colour was good and respirations were not laboured.His pulse was I20/min. and of good volume. His bloodpressure was I30/80 mm. Hg. His chest X-ray (Fig. 6)showed that his right lung had expanded though therewas an opacity in the middle lobe. There was a slightresidual left pneumothorax. He was transferred toanother hospital with a positive pressure respirator as hewas still semi-conscious. He remained critically ill forseven days and did not regain full consciousness for fourdays. His condition thereafter steadily improved.He left hospital on 5.10.59. Minimal paradox per-

sisted at the lower end of his sternum on deep breathing;otherwise his chest was satisfactory. His wounds hadhealed and there was no gross residual chest walldeformity. (Chest X-ray, 1.12.59, Fig. 7.)

Comments(i) Deterioration of the patient's condition

occurred without adequate treatment, i.e. tracheo-

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FIG. 7.-Case 4, 1.12.59. Lungs expanded and clear.Mediastinal shadow within normal limits. Thewires are visible.

tomy, stabilization of his chest or positive pressurerespiration.

(2) His definite improvement after tracheotomyfacilitated the next phase in treatment.

(3) The stabilization operation was well with-stood and this procedure allowed repair of the lungtrauma. From this point the patient's conditionimproved steadily.

(4) There was only slight residual deformity.DiscussionThe treatment available for a large stove.in

chest consists of: (i) Positive pressure respirationwith tracheotomy. (2) Stabilization of the chestwall. (3) A combination of the above measures.

For minor cases a combination of strapping withrelief of pain by intercostal block or morphiaderivatives and bronchoscopy is all that isnecessary.

Positive-pressure respiration is very satisfactoryprovided there is adequate staff available to carryit out. This method is impracticable outsidespecial centres because of inadequate staffing.The operation of a mechanical respirator requires acertain amount of skill and cannot be left to thenursing staff, unless they have been speciallytrained. It is easy to carry out positive-pressure

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August I962 GRIFFIN and D'NETTO: Management of Stove-in Chest in a Peripheral Clinic 465

respiration through an endotracheal tube but as thetube cannot be kept in for more than 48 hours atracheotomy then becomes necessary. It requiresmore skill to maintain positive-pressure respirationthrough a tracheotomy and the operation itself isnot without its dangers. Positive-pressure usuallywould have to be continued for several days tostabilize the chest.

Stabilization of the chest wall can be carried outby traction (Proctor and London, I955), or actualrepair of the flail segment by wiring (Bickford andGrant, 1956) or by special nails. We have noexperience of traction. The descriptions in theliterature envisage a certain amount of operativeinterference, complicated appliances and a pro-longed period of traction, i.e. two to three weekswith a certain amount of discomfort to the patient.It has the advantage that no special experience ofthoracic surgery is required. Actual repair of thechest wall can be carried out by a relatively simpleoperation of wiring or suturing the fragmentstogether. Damage to structures inside the thoraxcan be dealt with at the same time. Following theoperation it appears that the patient's conval-escence is usually comfortable and easy to manage.There is very little residual deformity.

Fig. i (a) is reproduced with kind permission of theEditor of the Journal of Bone and Joint Surgery.

Conclusions(I) A minor degree of paradoxical respiration

may easily be missed unless looked for. As thepatient's condition deteriorates it will becomeevident.

(2) Though in one case the nature of therespiratory distress was such that the patient'srespiration could only be controlled by the ad-ministration of an anaesthetic, there was still timein the four cases to assess the patient's conditionand exclude the possibility of other injuries.

(3) Once the patient has been assessed byphysical examination and X-ray and the treatmentof shock, when present, has been started by trans-fusion, the control of the paradoxical respiration isan urgent problem. Pads and bandages are notthe answer. Ideally positive-pressure respirationshould be established with a tracheotomy. Thiswill allow control of his respiration with improve-ment in his general state.

(4) Fixation of a flail segment in ill patientsresulted in immediate improvement in the condi-tion of the three patients in which this simpleoperation was done.

(5) In two out of three cases, where the ribswere wired, a tracheotomy was not necessary.

(6) The cosmetic results in the wired patientswere good. In one the chest wall returned tonormal while in two cases there was slight residualdepression.

REFERENCESBARRETT, N. R. (1960): The Early Treatment of Stove-in Chest, Lancet, i, 293.BICKFORD, B. J., and GRANT, A. F. (1956): Surgical Management of the Stove-in Chest Injury, Ann. roy. Coll. Surg.Engl., 19, 37I.CLARK, D. H. (1961): A Case of Crush Injury of the Chest, Postgrad. med. J., 37, 50.GRIFFITHS, H. W. C. (1960): Crush Injuries of the Chest, J. roy. Coll. Surg. Edinb., 6, 13.PROCTOR, H., and LONDON, P. S. (1955): The Stove-in Chest with Paradoxical Respiration, Brit. J. Surg., 42, 622.

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