Is Traumatic Anterior Stove-In Chest Truly so Rare? A Single Institution Experience

Abstract

Introduction:

The anterior stove-in chest (ASIC) is a rare form of flail chest involving bilateral rib or sternal fractures resulting in an unstable chest wall that caves into the thoracic cavity. Given ASIC has only been described in a handful of case reports, this study sought to review our institution’s experience in the surgical management of ASIC injuries.

Methods:

A retrospective review of patients with ASIC was conducted at our level I trauma center from 1//2021 to 3//2023. Information pertaining to patient demographics, fracture pattern, operative management, and outcomes was obtained and compared across patients in the case series.

Results:

6 patients met inclusion criteria, all males aged 37–78 years. 5 suffered motor vehicle collisions, and 1 was a pedestrian struck by an automobile. The median injury severity score was 28. All received ORIF within 5 days of admission, most commonly for ongoing respiratory distress. Patients 2 and 4 underwent bilateral ORIF of the ribs and sternum while patients 1, 5, and 6 underwent left-sided repair. Patient 3 required ORIF of left ribs and the sternum to stabilize their injuries. 5 of 6 patients were liberated from the ventilator and survived to discharge.

Conclusions:

This study demonstrates successful operative management of 6 patients with ASIC and suggests that early operative intervention with ORIF for affected segments may improve respiratory mechanics, ability to wean from the ventilator, and overall survival. Further research is needed to generate standardized guidelines for the management of this uncommon and complex thoracic injury.

Introduction

Trauma is the leading cause of death among youth and young adults and the fourth leading cause of death overall in the United States.¹ Thoracic trauma and its related complications are responsible for an estimated 25% of all-trauma mortality.² Flail chest, defined as 3 or more ribs broken in at least 2 places, is a relatively uncommon form of thoracic injury, and the most common cause is blunt trauma. It can drastically alter respiratory physiology and mechanics, is often associated with concomitant injury, and leads to pulmonary complications such as pneumothorax, hemothorax, and pulmonary contusion. This disease state has been well-studied, and clear consensus guidelines have greatly improved its overall morbidity and mortality.^3,4 Therefore, patients with these injuries often require hospitalization and are treated based on best practices to improve outcomes.

In contrast, an exceedingly rare and not well-documented subtype of flail chest is the anterior stove-in chest (ASIC). First described in 1956, ASIC refers to a form of flail chest in which a large segment of the anterior chest wall collapses with respiration.^5–7 Since this sentinel article, ASIC has only been described in a handful of case reports, the most recent being published in 2004.^5–8

While uncommon, these studies suggest an even higher morbidity and mortality rate associated with ASIC.^6,7 Similar to flail chest, this is thought to be due to the severe compromise of respiratory mechanics and associated pulmonary complications. In ASIC, a large portion of the chest wall shifts independently because of the ribs and sternum being fractured in multiple locations. This collapse of a large anterior segment of the chest wall further exacerbates the impaired structure and integrity of the chest wall and its functionality. From review of the current literature, ASIC typically occurs after severe blunt force trauma to the chest such as falls from height, contact sports collisions, and motor vehicle collisions (MVCs).^5–8 Furthermore, this handful of studies suggests that geriatric patients are at an increased risk of developing a stove-in chest after blunt chest trauma due to their impaired bone quality and comorbidities.^6–8

Despite the first case being documented more than 70 years ago, the definition of ASIC and the subsequent management remain unclear.^4,5 Given the rare nature and high morbidity and mortality, it is critical to develop consensus guidelines for defining the injury to standardize the management of this complex chest wall injury in order to optimize patient care and improve outcomes. The aim of this study is to evaluate the management of ASIC injuries that were operatively managed at our level 1 trauma center.

Methods

A retrospective cohort review of the institutional trauma registry at a large, academic, American College of Surgeons (ACS)-verified level I trauma center was conducted from January 2021 through March 2023. All patients with chest wall trauma during the study period were reviewed and those meeting criteria for ASIC were included. The diagnosis of ASIC required 2 components:

1. Fracture pattern

   1. Unilateral large segmental flail chest involving >30% of the chest wall.
   2. Unilateral rib fractures with a concomitant sternal fracture.
   3. Bilateral rib fractures of the anterior chest.
2. Respiratory compromise

   1. Paradoxical movement of the chest wall.
   2. Acute oxygen requirement.
   3. Increasing oxygen requirement.
   4. Inability to wean from the ventilator.
   5. Tachypnea from chest wall instability.

All patients meeting criteria and able to make it to the operating room (OR) underwent open reduction internal fixation (ORIF) of involved ribs and/or sternum, and data pertaining to patient demographic information, injury complex and fracture pattern, operative intervention, clinical course, in-hospital complications, mortality, and discharge disposition was obtained. 3D reconstructions were generated from trauma computed tomography (CT) chest imaging and were used to guide operative planning. The operative fixations were all performed by a single attending trauma surgeon and were centered around prioritizing form and function through adequate restoration of chest wall anatomy and respiratory mechanics.

Results

During the study period, 6 patients met inclusion criteria for ASIC (Table 1). All 6 patients were male with a median age of 58 years (range: 37–78). Five presented due to an MVC and the sixth was a pedestrian struck by an automobile. They were severely injured with a median injury severity score (ISS) of 27.5 (range: 24–34). The median time from admission to operative intervention was 3 days (range 2–5). Operative indications included persistent respiratory distress, failure to extubate, and worsening hypoxia. 4 patients underwent unilateral ORIF, 2 underwent bilateral ORIF, and 3 had a concurrent ORIF of the sternum. All operations were successful and without complication.

Table 1.

Demographics, Injury Complex, and Clinical Course of Patients With Traumatic Stove-In Chest.

Case ID	Age	MOI	ISS	Chest Wall Injury Complex	Operative Indication	Operative Intervention	OR Day (HD)	ICU LOS (days)	Hospital LOS (days)	Vent Days	Vent hours Postop
	Sex
1	58 M	MVC	24	L 2nd-9th non-displaced rib fx, L 4th-6th costal cartilage fractures with 2.1 cm defect in the chest wall	Large segment flail chest, failure to extubate	ORIF L ribs 4–6	5	12	22	6	12
2	37 M	MVC	29	Minimally displaced R 1st-8th rib fx, minimally displaced L 1st-7th rib fx	Failed extubation, retained R hemothorax	ORIF R ribs 2–6, L ribs 2–5, ORIF sternum	3	17	23	7	83
3	65 M	MVC	34	Non-displaced fx of R 1st and 2nd rib fx dislocation of L 3rd-5th, 7th-9th, and 11th ribs	Flail chest failure to extubate	ORIF L ribs 2–7, ORIF sternum	4	16	29	14	234
4	58 M	MVC	26	Depressed R anterior 2nd and 8th rib fx, displaced R 3rd-7th rib fx, displaced L anterior 2nd-7th rib fx	Failed extubation, ongoing respiratory distress, flail chest	ORIF R ribs 3–7, L ribs 3–7, ORIF sternum	5	10	16	7	44
5	57 M	MVC	26	Nondisplaced L 3rd and 4th rib fx, minimally displaced L anterolateral 5th-8th rib fx, with segmental fx of 5th and 6th	Flail chest, impending respiratory failure	ORIF L ribs 4–7	2	8	33	4	26
6	78 M	Peds vs auto	33	Mildly displaced L 3rd-6th rib fractures, displaced L posterior 5th-7th and 9th rib fx	Persistent L pneumothorax, failure to extubate, worsening hypoxia	ORIF L ribs 2–8	3	7	7 (hospice)	7	n/a

ASIC: anterior stove-in chest; F: female; Fx: fracture; HD: hospital day; ICU: intensive care unit; ISS: injury severity score; L: left; LOS: length of stay; M: male; MOI: mechanism of injury; MVC: motor vehicle collision; OR: operating room; ORIF: open reduction internal fixation; Peds vs. auto: pedestrian vs auto; R: right; s/p: status post; Vent Days: ventilator days.

The median Intensive Care Unit (ICU) length of stay was 11 days (range: 7–17) with a median ventilator days of 7 (range: 6–14). The median number of hours ventilated after surgery was 44 hours (range: 12–234). The median hospital length of stay was 22 days and all patients were discharged to a rehabilitation facility or home, with the exception of Patient 6, who had other comorbidities that contributed to his ultimate discharge to hospice care. Follow-up was only available for case 4. This patient was seen at 2 months and was off narcotics, back to activities of daily living, and had no complications.

The case series below documents the thoracic injury complex of each patient, their pertinent clinical course, operative intervention, and outcomes. Figure 1 depicts a preoperative chest X-ray, postoperative X-ray, preoperative chest computed tomography 3-D reconstruction, and postoperative chest computed tomography 3-D reconstruction when available (see Legend for reference).

Figure 1.

Pre and post-imaging for patients with traumatic stove-in chest.

Case 1

58M presented after a rollover MVC with L second-ninth non-displaced rib fracture, L fourth-sixth costal cartilage fractures with a 2.1 cm defect in the chest wall, bilateral pneumothoraces, and thoracic spine fractures. He was intubated upon admission and admitted to the SICU for further management. He remained hemodynamically stable and underwent T2-T7 spinal fusion on hospital day 2. Postoperatively, despite multiple attempts, he was unable to wean from the ventilator because of his large segment of flail chest. He was taken to the OR on hospital day 5 and underwent ORIF of L ribs 4–6. He tolerated the procedure without complication and was subsequently extubated 12 hours later on hospital day 6. He developed purulent drainage from soft tissue of the left chest, which was confirmed to be a superficial infection on CT imaging and resolved with a short course of antibiotics. He was ultimately discharged in a stable condition and on room air on hospital day 22 to acute rehab.

Case 2

The patient is a 37M with a history of bilateral upper extremity deep vein thrombosis from a hypercoagulability disorder and on Xarelto. He presented after an MVC with displaced R first–eighth rib fracture, displaced L first-seventh rib fracture, bilateral pulmonary contusions, and a right apical pneumothorax. He remained hemodynamically stable and was taken to the OR with orthopedics on hospital day 2, and while initially extubated postoperatively, he required re-intubation in the PACU due to respiratory distress and significant desaturations. Repeat imaging demonstrated an R retained hemothorax. He was brought to the OR on hospital day 3 and underwent ORIF R ribs 2–6, L ribs 2–5, sternal fixation, and evacuation of retained hemothorax. He tolerated the procedure well and returned to the ICU in a stable condition. He required ventilator support until hospital day 7, when he was successfully extubated, 83 hours after surgery. He was ultimately discharged to acute rehab on hospital day 23.

Case 3

65M presented after an MVC with left hemopneumothorax, non-displaced fracture of R first and second rib, fracture dislocation of L third-fifth, seventh-ninth, and 11th ribs, and a displaced mid body sternal fracture with mediastinal hematoma. He was intubated for respiratory distress and underwent emergent L chest tube before being admitted to the SICU for further management. Due to his continued paradoxical chest wall movement with respirations and inability to wean from the ventilator, he was taken to the OR on hospital day 4 for ORIF L ribs 2–7 and the sternum. Postoperatively a CT chest demonstrated an acute PE in the distal right main pulmonary artery with extension into all 3 lobes. Due to his concomitant injuries, he was unable to be anti-coagulated and an IVC filter was placed. He was subsequently extubated on hospital day 13 (234 hours after surgery), and he was discharged to acute rehab on hospital day 29.

Case 4

58M presented after an MVC with depressed R anterior second and eighth rib fracture, displaced R third-seventh rib fracture, and displaced L anterior second-seventh rib fracture. Bilateral chest tubes were placed emergently for respiratory distress, and he was placed on high-flow nasal cannula and admitted to the SICU for further management. Despite aggressive pulmonary toilet, he acutely decompensated overnight and was intubated for hypoxic respiratory failure. He was then extubated on hospital day 3 but required re-intubation 6 hours later due to worsening tachypnea and increased work of breathing. Due to persistent respiratory insufficiency, paradoxical chest wall movement, and multiple failed extubation attempts, he was taken to the OR on hospital day 5 for ORIF R ribs 3–7, L ribs 3–7, and sternum. He tolerated the procedure well and successfully extubated on hospital day 7, 44 hours after surgery. The remainder of his hospital course was unremarkable, and he was discharged home with outpatient physical therapy on hospital day 16.

Case 5

57M presented following an MVC in which a log hit him through the windshield. He had nondisplaced L third & fourth rib fracture, minimally displaced L anterolateral fifth-eighth rib fracture, with segmental fracture of fifth and sixth ribs, left hemopneumothorax, and a mediastinal hematoma. He was emergently intubated for airway protection. A left chest tube was placed, and he was admitted to the SICU for further management. Due to significant paradoxical movement with respiration secondary to his flail chest and persistent respiratory insufficiency, he was taken to the OR on hospital day 2 for ORIF L ribs 4–7. He tolerated the procedure well and was extubated on hospital day 4, 26 hours after surgery. The remainder of his hospital course was prolonged by pharyngeal dysphagia, acute kidney injury, and severe deconditioning. He was discharged to acute rehab on hospital day 33.

Case 6

78M with a history of lung cancer with multiple resections presented after being involved in a pedestrian vs auto accident where he was subsequently dragged by the car for some distance. He was intubated in the field and airlifted to the trauma center. Upon arrival, a chest tube was emergently placed for a left-sided tension pneumothorax. Despite resuscitation efforts, he remained hemodynamically unstable and was taken emergently to the OR. He underwent an exploratory laparotomy with no significant injuries noted and an emergent left anterolateral thoracotomy with L pulmonary wedge resection, a bronchoscopy, and bilateral chest tube placement. His chest was left open, and he was admitted to the SICU for further resuscitation. His additional injury complex included blunt cardiac injury requiring pressors, left humeral neck fracture, multiple complex facial fractures, and a left wrist soft tissue defect with tendon and bone exposed. Over the next 48 hours, his ventilator requirements were unable to be significantly weaned. Given the severity of his chest wall deformity and emergent nature of the thoracotomy, the decision was made to perform rib fixation during the washout and closure of his chest to help improve chest wall stability. On hospital day 3, he underwent ORIF L ribs 2–8. Postoperatively, he continued to need pressors for his blunt cardiac injury, suffered acute renal failure, and failed to wean from the ventilator. Several days after his definitive surgery, family was identified and informed the team of his past medical history. After multiple discussions with his family, the decision was made to de-escalate care and transition him to hospice.

Technical Details

In this case series, the anterior rib fractures are primarily accessed utilizing a sub-pectus flap. This is accomplished by incising vertically along the lateral border pectoralis major muscle. The fascial attachments between the pectoralis major and serratus anterior are divided. The pectoralis major can be bluntly separated from the chest wall. In doing so, it allows the surgeon to elevate the pectoralis major and gain access to the fractured anterior ribs. If the fractures extend more laterally, windows are placed through the serratus anterior in a muscle-sparing technique. All muscle flaps are closed at the end of the procedure.

In cases requiring sternal fixation, a vertical midline incision is created over the fracture site. This is carried down directly onto the sternum. Once the sternal fracture is identified, the pectoralis major is elevated off of both sides of the sternum creating a landing zone for fixation.

All fractures were reduced, approximated, and fixated to recreate chest wall anatomy. Rib fractures were fixated with either anterior or internal plates. For anterior fixation, at least 3 bicortical self-tapping and self-drilling screws on either side of the fracture are placed. Segmental fractures were secured with additional screws through the flail segment. When the flail segment could not accommodate screws, a 0-Vicryl suture was used to pexy the bone to the plate. Additional screws are added as needed to ensure stability. Internal fixation was accomplished with the standard technique described by Castater et al.(9) Sternal fractures were fixated with at least 4 screws on either side of the fracture in the similar form. Figure 2 depicts the use of a 16-hole ladder plate to fixate the sternal fracture in case 4. In this instance, additional screws were required to ensure stability. When the costal cartilage was involved, anterior plates were contoured to bridge from healthy rib to the sternum. Additional screws were placed in the cartilage to pexy it in place. In scenarios like case 4, both the midline sternal and sub-pectus incisions are leveraged to fixate the chest (Figure 3). The chest wall reconstruction was handled 1 fracture at a time. In doing so, the chest wall slowly regains strength and stability. No additional techniques were required to stabilize the chest in mass prior to fixation.

Figure 2.

Sternal fracture exposure. Midline sternal incision with elevation of bilateral pectoralis major flaps in case 4. A 16-hole ladder plate was utilized to stabilize the fracture.

Figure 3.

Anterior rib fracture exposure. In case 4, a vertical incision along the lateral border of the pectoralis major gains access to the anterior left rib fractures (A). A concomitant sternal incision can be observed in the background (B).

Discussion

Flail chest has long been described as 3 consecutive ribs fractured in 2 or more places and is associated with significantly high morbidity and mortality. Additionally, multiple studies support that early stabilization of the chest wall can reduce these rates.^10,11 However, there is lacking data surrounding ASIC which is traditionally a more damaging subtype of flail chest and often is associated with a more critically ill patient. This study demonstrates the successful operative management of 6 cases of ASIC. To the best of our knowledge, this is the largest review of cases of ASIC in the current literature and the only one to detail operative intervention and outcomes.

The first documented case of ASIC dates back to 1956 and, since then, has only been discussed in a handful of case reports.⁵ Despite the seemingly uncommon nature of ASIC, our institution saw 6 operative cases of it in a single year. This suggests that cases of ASIC are likely under-diagnosed and under-reported in the literature. We speculate this is in part due to the ill-defined nature of this injury complex. There is currently no standard definition for stove-in chest, let alone ASIC, making it challenging to diagnose, document, research, and define best practices for management consistently across institutions. For instance, studies have referred to it as “a collapse of a segment of the chest wall” or “a type of flail chest injury where the segment collapses into the chest.”^3,4 Yet, there has been no consensus on the number of involved ribs, size of the chest wall segment, degree of collapse, or impact on respiratory mechanics needed to accurately define this injury. A collaboration from the Chest Wall Injury Society (CWIS) began the framework for standardization of chest wall injury-related injuries.¹⁰ This was further expanded by a multidisciplinary group of clinicians from CWIS and the American Society of Emergency Radiology (ASER).¹¹ However, both groups refer to anterior flail chest as injuries involving fractures of bilateral ribs. In our study we observed varying fracture patterns causing ASIC, a type of anterior flail chest, including patients that only had unilateral rib fractures. We therefore advocate for establishing a standard consensus definition of anterior flail chest and ASIC in order to better understand its clinical significance and develop best practices for treatment.

Given the paucity of documented cases, there are not established management guidelines. The findings of our single institution experience suggest that early operative intervention with open reduction and internal fixation of the affected ribs and/or sternum may significantly improve respiratory mechanics. Our entire cohort required intubation within 24 hours of their initial injury, experienced challenges with weaning from the ventilator, and worsening respiratory insufficiency during their hospital course. However, all 6 then underwent ORIF within 5 days of their injury and 4 were successfully extubated within 72 hours postoperatively. Case 3 had a pre-existing history of venous thromboembolisms and required a prolonged intubation due to an acute main pulmonary artery embolism.

These results demonstrate that early fixation of the affected segment of ASIC may help stabilize the chest wall in a manner that improves adequate oxygenation and ventilation, as evidenced by their ability to wean from the ventilator shortly after chest wall stabilization. Furthermore, it is well established that operative fixation of flail chest can improve pain control, lead to shorter hospitalizations, and decrease respiratory complications.⁶ It is reasonable to consider the same may hold true for these more complex rib fractures. Often, ORIF of the chest wall is viewed as a rescue procedure only to be performed in patients who have failed nonoperative pain control, multimodal medications, and pulmonary toilet despite multiple studies demonstrating improved outcomes even in high-risk operative patients.^12–17 To date, only 1 article cites failure of pain control as one of many indications for ORIF ribs.¹⁸ In our study, we observed multiple patients failed attempts at extubation before proceeding to surgery. Based on our limited data set and current literature citing improved morbidity and mortality of patients with flail chest that undergo ORIF of the chest, we suggest that patients with this ASIC undergo expeditious ORIF of their chest wall regardless of failure of nonoperative management.

While our single institution experience was successful, further discussion is required to truly define ASIC, and future research is needed to investigate the optimal management and outcomes on a larger scale. Such research has important clinical implications and the potential to help inform future management guidelines.

Limitations

The authors would like to acknowledge the limitations of this study. First, it was retrospective in nature, leading to inherent variables that could not be controlled or accounted for such as initial respiratory support in the trauma bay, pain control regimens, ventilator settings, and standardized operative protocols. Additionally, it was a cohort study and therefore lacked a control group to compare outcomes of nonoperative or alternative management. Unfortunately, follow-up was only available in 1 of the 6 patients, and the data surrounding quality of life was lacking. Further studies would benefit from more granular long-term data. Lastly, it was performed at a single institution, leading to inherent internal biases in practice and limiting its external generalizability.

Glossary

ASIC

anterior stove-in chest

Fx

fracture

ICU

intensive care unit

ISS

injury severity score

L

left

MVC

motor vehicle collision

OR

operating room

ORIF

open reduction internal fixation

R

right

s/p

status post

Appendix

Legend