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Invited Commentary

Contemporary Management of Flail Chest

From the *Department of Surgery and the †Stritch School of Medicine, Loyola University of Chicago,
Maywood, Illinois

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are
the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or
more places, continues to be a clinically challenging problem. The underlying pulmonary contusion
with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to
result in high mortality for these patients. Surgical stabilization of the fractured ribs remains con-
troversial. We review the history of management for flail chest alone and when combined with
pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.

ranks second only to cent volume compression before a rib will fracture.4
head injury as the leading cause of trauma-related
death.1, 2 Chest trauma constitutes 10 to 15 per cent of
Kleinman and colleagues13 used cadavers to study
patterns of rib fractures using blunt forces simulating
all injuries, resulting in approximately 400,000 patients frontal and lateral impact injuries. They observed that
requiring hospitalization each year.2, 3 Specific injuries compressive force, if applied laterally or in an ante-
to the thorax may involve the chest wall, pleura, tra- roposterior direction, causes ribs to fracture not only in
cheobronchial tree, lungs, diaphragm, esophagus, heart, the weaker lateral area, but also posteriorly.13, 14
great vessels, and ribs; fractured ribs are the most The mechanical effects of fractured ribs on pulmo-
common of these injuries. Mortality rates related to rib nary function are rather predictable. The pain that
fractures range from two to 20 per cent.3–5 This wide results from movement at the fracture site leads to
range in mortality rates is partially explained by the splinting of the intercostal muscles. These changes in
influence of successive rib fractures on mortality and by pulmonary mechanics of the chest wall allow for atel-
the varying severity of associated injuries.6–8 ectasis to develop and also impair the patient’s ability to
Flail chest is defined as the fracture of three or more cough and clear secretions.14 Both of these changes
ribs in two or more places and has a reported mortality potentiate the underlying pathophysiology of an asso-
rate between 10 and 15 per cent.9–11 During the past 50 ciated pulmonary contusion. In addition, afferent in-
years, the advances in medical technology and tech- tercostal nerve reflexes cause decreased phrenic nerve
niques have allowed for improved management of flail function and reduced diaphragmatic contractility and
chest, which has reduced morbidity and mortality. An tone.15 Ribs may be fractured bilaterally, and hemo-
associated injury directly related to flail chest is pul- thorax, pneumothorax, or hemopneumothorax may also
monary contusion. Occurring in 30 to 75 per cent of be present, contributing to the development of acute
patients with thoracic trauma, pulmonary contusion is respiratory failure.1, 7
the most common injury associated with rib fractures.
The incidence of pulmonary contusion correlates with
Pathophysiology of Pulmonary Contusion
the magnitude of injury to the chest wall; therefore, the
highest incidence is seen with flail chest.12 This review Pulmonary contusion results from the transfer of
describes contemporary management of flail chest. high energy to the thorax and underlying lung paren-
chyma. One must have a high suspicion for pulmonary
Pathophysiology of Flail Chest
contusion in any patient with respiratory distress after
injury because external signs of chest injury are fre-
Flail chest results when a compressive force is ap- quently not obvious on initial physical examination.
plied to the chest wall. The thorax can withstand 20 per The appearance on chest radiographs is described as
a nonanatomic opacification of the lung parenchyma
Address correspondence and reprint requests to Fred A. Luchette, that may be focal or diffuse; however, this radiographic
M.D., M.Sc., Department of Surgery, 2160 South First Avenue, appearance of pulmonary contusion may not become
Maywood, IL 60153. E-mail: apparent until 24 to 48 hours after the injury.14, 16, 17


The sum effect of these initially apparent on inspection of the chest as a result of alterations is an increase in alveolar consolidation and splinting of the fractured ribs by the intercostal muscles. the contusion also affects un. The cumulative effect of the combination of both in. which is significantly protein and neutrophils in lavage fluid from the non. Jones and Richardson first described flail chest in 1926. the deformity of the chest wall resulting from flail chest was referred to as ‘‘stove in Diagnosis chest’’ until the arrival of the first automobiles. reduced compliance. which are also the ribs involved with flail chest.21 tients. 23 When Trinkle and colleagues24 hy. local and regional inflammation. at Physical examination often leads to the initial di. increased the intact chest wall as a result of the relative positive capillary permeability.18. the imaging modality of choice for evaluating injured The mortality rate for the combination of flail chest patients with major thoracic injuries. musculature fatigues. identifying a flail segment. the flail segment elevates above rhage. 1). unmasking the flail segment by injured lung tissue in the contralateral hemithorax. They found delayed but signif. thoracic CT scan also allows for the diagnosis of pul- juries is increased hospital length of stay and greater monary contusion and assessment of the severity of in- incidence of mechanical ventilation and long-term jured lung parenchyma (Fig.528 THE AMERICAN SURGEON June 2014 Vol. and it is also unreliable for pulmonary contusion. However. visualization of the paradoxical motion. However. and it takes priority over the flail chest in patient management. 19 When inflammation during respiration.25–27 The availability of icant capillary leakage and increasing infiltration of computed tomography (CT). which may influence their this injury. which result in increased right. Similarly. overlying chest wall trauma on CT.1 Subsequently. fractures of the 10th through 12th ribs are associated with less pain as a result of their lack of continuity with the sternum but should raise suspicion for intra-abdominal or retroperitoneal injuries. makes CT injured contralateral lung. which will minimize movement of the flail segment to-left shunt and hypoxia.12 Patients with a pothesized that pulmonary contusion was the principal pulmonary contusion compromising greater than 20 per injury that accounted for the respiratory insufficiency cent of their total lung volume are at very high risk for seen with flail chest. and migration of neutrophils pressure in the pleural space. This motion may not be into the extravascular space. capillary hemor. With liberal use and pulmonary contusion is in excess of 40 per cent of thoracic CT scan. 80 The parenchymal injury related to pulmonary contu. the standard of care was finally adverse events. 28 In addition to revealing rib fractures. which time the incidence of flail chest increased and agnosis of rib fractures because the awake and in- teractive patient notes localized pain during palpation of the thorax at the fracture site.12 continues to be recognized as the primary pathophysi- ology accounting for the increased mortality and mor- History of Management bidity related to flail chest. Pulmonary contusion. treatment and management plans compared with a mortality rate of 16 per cent for blunt are changed in 20 per cent of severely injured pa- thoracic injury alone without pulmonary contusion. Chest radiog- Davis and colleagues20 measured protein content in raphy has a sensitivity of only 50 per cent for identifying bronchoalveolar lavage fluid using a porcine model of a displaced rib fracture. eventually the chest wall and edema are severe. Almost 40 years later. more sensitive for detecting fractured ribs. A pulmonary contusion morbidity resulting from chronic pain or chest wall can be diagnosed as a lung consolidation in the setting of deformity.22. pressure that occurs with diaphragmatic excursion. including pneumonia and acute res- altered to address the physiologic changes arising from piratory distress syndrome. Imag- ing studies facilitate the diagnosis of specific fractured ribs and also associated injuries. The most common ribs that fracture with blunt trauma are the fourth through the ninth. . sion causes respiratory dysfunction.27. 1. During expiration. the first and second ribs are difficult to assess for fracture on clin- ical examination as a result of their anatomic location. pulmonary contusion flail chest management. The paradoxical movement described with flail chest occurs as the in- volved segment of the chest wall retracts during in- spiration as a result of the negative intrapleural space FIG.

and even screws. ventilator-associated pneumonia. ineffective ventilation. it. atelectasis. Avery and colleagues31 introduced the concept domized studies.36–38 Alternatives include the delivery of for internal splinting of the chest wall and correction long-acting local anesthetics as intercostal nerve blocks of dead space.No. 529 the phrase ‘‘steering wheel injury’’ was used to describe needing pain control alone for the flail chest injury. the chest with various materials or exerting compres. Nonsteroidal anti-inflammatory drugs such as ketorolac veniently justified routine use of mechanical ventilation are also beneficial adjunctive analgesics. aggressive respiratory therapy. 30 ventilation.32. including flail chest injury progressed. This strategy was With the arrival of volume-cycled ventilators in the supported by the findings from two prospective ran- 1950s. The maintaining adequate ventilation and pulmonary hy- concept of the dead space air ‘‘pendulating back and giene. an attempt to restore the thoracic volume to normal. and the focus of treatment on minimizing the movement of not just the flail segment. encouraging the use of more selective mechanical However. 3 The disruption of the chest wall resulting in flail Trinkle and colleagues24 found that conservative man- chest was initially viewed as mechanical instability with agement aimed at treating the underlying contusion. They hypothesized developed in an effort to stabilize the chest wall. 24 Clear- shunt related to the underlying pulmonary contusion. paradoxical motion was not the primary cause of To treat the underlying pulmonary contusion. hooks. lowered by the use of mechanical ventilation. was terweights were adjusted to minimize the movement of actually ‘‘a triumph of technique over judgment. and hypercarbia. including the sequelae of pulmonary contusion: right-to-left ar- surgically applied wires. 39 or intrapleural space. 16. these approaches took the form of strapping and consist of intravenous fluid restriction. but they patients with flail chest and pulmonary contusion. 33 The mortality from flail chest was initially strategies for stabilizing fractured ribs.2. pulmonary contusion and attempt to mitigate the com- As the understanding of the pathophysiology behind plications associated with the flail segment. As a result.35 They concluded anterior muscles. This finding led to introduction of ‘‘selective ance with such techniques as suctioning.5. and tracheal injury with routine use of Selective management therapies target the underlying mechanical ventilation for treating flail chest. and pain control. The authors recognized the impact of bidity and mortality when intubation was avoided in pulmonary edema and atelectasis on outcomes. Hudson method involved the passage of long metal increased capillary permeability.16 Current Management Eventually. an epidural catheter rather than systemic narcotics in They concluded that mechanical ventilation allowed these patients. none of these treatments altered the high ventilation based on failure to maintain oxygenation. mortality rate associated with the condition.38 never proven. flail chest. The pins were then attached to bows that the routine use of mechanical ventilation to treat and suspended from overhead traction frames. the motion of the flail segment that caused increased dead focus of treatment of flail chest has been directed at space. Shackford and colleagues32 described Nonoperative the high incidence of barotrauma. 6 CONTEMPORARY MANAGEMENT OF FLAIL CHEST ? Vana et al. the attractiveness of the explanation con. Numerous studies have demonstrated the ben- forth’’ between the alveoli and tracheobronchial tree efit of using regional analgesia administered through was used to explain the pathophysiology of flail chest. 30 considered these to be secondary to the paradoxical During the last two decades of the 20th century. and pulmonary hygiene. ne- gating the initial improvements in patient prognosis. Coun. inspiratory management’’—identifying which patients required spirometry. although common in many hospitals. numerous strategies were patients sustaining thoracic trauma.17. The use sion externally with sandbags. and increased alveolar pins under the pectoralis muscles and the serratus filling leading to respiratory distress. Both Richardson and colleagues and of internal pneumatic stabilization for the management Bollinger demonstrated a significant reduction in mor- of flail chest.’’11.29. The next ad- for patients presenting with flail chest for the next two vance in management of flail chest came with improved decades. 19. The teriovenous shunting. Until that management should be focused on the contusion the 1930s. resulted in better outcomes for the flail segment. 24 the flail segment of the chest wall to reduce pain and in This study advanced the management of flail chest. Maloney34 demonstrated that fluid resuscitation is to maintain euvolemia by pre- the hypoxia was the result of a pulmonary right-to-left venting hypovolemia and fluid overload. influx of inflammatory factors. and intermittent positive-pressure (non- management of the pulmonary contusion versus those invasive) ventilation to clear secretions and guard . diuretics. and compromised pulmonary hygiene. but ven- tilator-associated complications began to increase. ing pulmonary secretions and preventing infection is not a result of the paradoxical movement of the flail done through maintaining adequate pulmonary clear- segment. Although the theory of Pendelluft was or into the paravertebral18. researchers found that the pain.23 Treatment during the of mechanical ventilation was limited solely to treating next two decades used mechanical devices. the goal of morbidity and mortality.

to avoid excessive division in ventilator technology have yielded methods of ven. respectively. These losses gesia is very effective at reducing pain and can be occur when the fractured rib edges are not in apposition used for several days or weeks while the rib fracture and thoracic volume is subsequently reduced. 17 Advances and posteriorly. whereas concurrent use of PEEP and apposition of the fracture edges. If not diagnosed early. the fractured segments to avoid muscle division. A common complication seen with However. continuous or patient-controlled regional an. enabled recruitment of previously collapsed pulmonary ranging from cables and Kirschner wires to intra- regions. and fixators proving global ventilation–perfusion. The serratus anterior tients who have persistent hypoxia despite adequate and latissimus dorsi muscles may be retracted anteriorly analgesia and hemodynamic stability. The effect of a concomitant pul- known risk of complications associated with epidural monary contusion on pulmonary function should also be catheters for analgesia in flail chest. small fragment plates. Despite the thoracotomy incision. Several studies have shown that rib fixation does sult of their effective control of pain and fewer of the not provide short-term benefits when the patient re- neurologic effects associated with oral or parenteral quires prolonged mechanical ventilation for manage- narcotics. Systemic narcotics should be with flail chest with pulmonary contusion outweighs avoided because they may actually cause reduced the benefits of surgical fixation of the flail segment.9.6.22. The combination of effective analgesia and pul- ical ventilation and possible tracheostomy. tilation. they are the considered when selecting patients for surgical stabili- preferred method for analgesia in this setting as a re. Alter- tilating patients with flail chest that are better tolerated natively. of pulmonary function and avoidance of mechanical minimizing atelectasis while maintaining clearance of ventilation. Mechanical ventilation is indicated in pa. surgical providing adequate pain control.16. also to enable entrance into the pleural cavity for ratory pressure (PEEP). medullary rods. Most local anesthetic. alveolar collapse during expiration. 45–47 Despite the development of ‘‘selective management. and anterior surfaces of the ribs as a result of easier tion. leading to paralysis. 43. zation. 80 against respiratory failure and the need for mechan.’’ The operation proceeds with the patient placed in the mechanical ventilation continues to have a role in the lateral decubitus position. inability to provide adequate pain control.41 pulmonary clearance of secretions and thus increase the Although approximately 68 per cent of patients re- risk of atelectasis and hypoxia requiring intubation. 37.29 monary hygiene.40 (Fig. Use the lung during fixation. A rare complication is the development surgeons prefer to fixate fractures involving the lateral of infection of the epidural space with abscess forma. 2). The ends of the fracture ribs of SIMV allowed patients to breathe spontaneously should be cleared of soft tissue to ensure ideal alignment and avoid hypocapnia. 9 There are several analgesic modalities that have been demonstrated to provide adequate control of Operative chest wall pain. of the muscles for exposure of the fracture site. specific ribs requiring fixation. quiring mechanical ventilation secondary to flail chest Regional anesthesia can be very effective for not only are reportedly extubated by postinjury Day 3. there is no current consensus regarding the the use of epidural catheters is hypotension from the timing of operative fixation or the approach to use for sympathetic blockade that results from the use of exposure of multiple consecutive fractured ribs. Unfortunately.16 The most common indications for surgical tension. They found SIMV combined alignment of fractured segments and visualization of with PEEP to be the superior mode of ventilation. 38 Epidural administration of anal. coupled with treatment of the un- Adequate analgesia is the primary therapy that has derlying pulmonary contusion. the need for restoration of volume loss. This strategy also There are numerous systems available for fixation. It is argued that the high rate of morbidity associated esthesia. but also optimizing fixation has become a more common and acceptable diaphragm functioning with a reduced risk of hypo. and a posterolateral thora- management of patients with flail chest and pulmonary cotomy incision is made to allow exposure of the contusion. secretions. the infection may spread dissection and exposure through a single posterolateral to the spinal cord.22. allows for maintenance been shown to allow for effective pulmonary mechanics. and epidurals. intercostal muscles are separated at the superior border leagues40 studied CMV and synchronized intermittent to avoid the neurovascular bundle running inferiorly and mechanical ventilation (SIMV) with positive end expi. These range from oral and intravenous narcotics.6. 9. practice.530 THE AMERICAN SURGEON June 2014 Vol. decreasing intrapulmonary shunting and im. 42–44 pain is resolving. regional blocks are limited by stabilization are failure to wean from mechanical ven- the half-life of the agents and require repeated ad. which is necessary increased functional residual capacity by minimizing for optimal healing.42. Cullen and col. several small incisions may be made overlying than continuous mechanical ventilation (CMV) or con. The tinuous positive pressure ventilation. and ministration. 48–55 One of the original devices described . 37 ment of a pulmonary contusion.

70. animal models reveal that there is a high risk of incorporating the neurovascular these plates promote faster healing with greater bone bundle along the inferior edge of the rib and injuring strength.59 duction. In contrast to the Judet strut. term risks and benefits carefully. Operative stabilization of flail chest injuries: review of literature and fixation options. including the use of contoured titanium to in- sion plates. design. (Right. Kirschner wire. Used with per- mission from Fitzgerald DC. 71 Advancements in technology and used for facial fractures. 42.36:427–33. reconstructive plates are thin When selecting surgical candidates for fixation of enough to allow for physiologic movement without a flail chest wall segment. 50. 2. 60. Furthermore. including tubular plates. 43. Fixation devices. 61 The plates are malleable rotation and a single unicortical locking screw to de- so they can be configured to the shape of the specific rib crease displacement. These systems take various further research have provided improvements in the forms. comes of surgical fixation versus those for nonoperative Absorbable plates have been successfully used both management of flail chest have been reviewed over the in flail chest deformities after trauma and in non.No. anatomy. last 50 years. (Left. Judet struts. and low-contact dynamic compression crease stability and minimize movement of the rib with plates. The volved in a flail segment. 69 Similar to the Judet strut is the U-plate. U-plates.68.87 . During positioning and manipulating the spur. rib splint. with absorbable fixation devices are superior to those costal nerve is injured. rib plates.42. Research has also demonstrated that outcomes or impinging the neurovascular bundle. The plate smaller intramedullary devices was associated with is fixated with locking screws placed through both a high failure rate as a result of loss of fracture re- cortices at the middle of the rib. this may be a source for chronic with nonoperative management when comparing post- pain. surgeons should weigh long- placing stress on the individual plates during the re. Eur J Trauma Emerg Surg 2010. The short-term out- spiratory cycle and future activity. Their use for rib fixation is founded on the injury by its application because it is affixed to only the principles that have allowed its almost universal use in superior aspect of the rib. 49–54. Phelan D. top to bottom) Wire fixation devices. similar to those stress. surgical fixation of long bones of the extremities. The U-plate Another option for fixation is intramedullary struts eliminates the possibility for neurovascular bundle or rods. vices are more expensive. 531 for stabilizing fractured ribs. The underlying cause of the failure of these Most surgeons use metal plating systems for fixation early rods and struts was believed to be rotational that are manufactured in generic sizes. has been sutures. potentially eliminating the need for a inferior edges of the rib. stress and physiologic load to the bone as it heals.62–66 Implanted using absorbable retrospective studies examining a small number of FIG. top to bottom) Intramedullary fixation devices. original material used in the construction of these rounding intercostal muscles and periosteum. et al. 44.67 Although the absorbable fixation de- bone. The Judet strut is a malleable absorbable polymer struts may decrease pain after sur- metal plate that can be molded around the superior and gical fixation. If the inter. the Judet strut. Denard PJ. The its application does not require dissection of the sur. 6 CONTEMPORARY MANAGEMENT OF FLAIL CHEST ? Vana et al. 47. these plates are designed to slowly transfer the used with some success to bridge the fractured ribs in. 56–58 operative residual angulation and alignment. The plate is secured to the rib subsequent operation to remove hardware as a result of with spurs that are molded to penetrate one cortex of the chronic pain. dynamic compres.42. but much of the literature is limited to traumatic thoracotomy.41.

1 days). there their 1997 study. fewer chest infections. was performed by Livingston and Richardson in 1990. However. ICU length of stay (9.59 some form of operative stabilization of the flail seg- Solberg and colleagues74 reported a unique approach ment. and incidence of segment required significantly fewer days of mechan. ICU length of monary contusion who had early fixation of the flail stay (16. resulted in early extubation (mean. and recovery of chest wall deformity and scoliosis compared with the pulmonary function justified the major commitment nonoperative group. there was no difference between the two groups restriction. long-term ments.8 vs 14.455 ± $5. Two weeks after discharge. the group that stabilization).7 ± 29. of whom 61 received or dysfunction. operative stabilization of flail chest patients with flail chest with or without pulmonary has been advocated as a method to reduce the duration contusion.9 days).01). P < 0. in patients who had undergone early fixation (average.75 Two provement in PFTs to 65 to 90 per cent of predicted months after discharge.4.01).840 for the surgical group vs segment during weaning also benefitted from operative $23.60 tients with flail chest to either surgical fixation using In a prospective study completed over 10 years. comparing hours after admission. The authors concluded that recovery from severe early fixation had significantly better PFT measure- chest injury occurs rapidly in most patients. a Japanese study by Tanaka and colleagues21 recovery. 1.532 THE AMERICAN SURGEON June 2014 Vol.443 for those who follow-up assessment (mean. Once again. Patients without a pul. Most (85%) patients cantly shorter ICU stay (11.72 Granetzny and colleagues75 randomly assigned 40 They prospectively studied results of pulmonary func. None of Egyptian study was managed with various methods of the patients received surgical fixation of the chest external stabilization (packing and strapping). pneumonia (24 vs 77%.75 of intensive care unit (ICU) resources required for In 2002. Both groups required mechanical ventilation for group managed with early fixation demonstrated a sig- an average of three weeks. P < 0. was also reported by Mouton and colleagues.7 vs 23.8 days. The nonoperative group in this them with those of a historic cohort group.0 days vs 26. polylactide copolymer plates or continued mechanical Lardinois and colleagues73 studied pulmonary function ventilation within 48 hours of admission. there was continued im.6 days).02).8 days of injury) of anterolateral flail chest nary contusion. they all demonstrated .7 vs 16. nificantly shorter duration of mechanical ventilation PFT results ranged from 40 to 50 per cent of predicted (2 vs 12 days). There was a significant reduction in mean setting of pulmonary contusion. 95 per cent of patients with flail chest was no difference in PFT results or quality of life.05) in the operative ical ventilation than those managed nonoperatively group. the group that had undergone values. At 3-month follow-up.0 days. Over the next year. P < 0.5 vs 26.9 days. P < 0. and values. these three studies included a total without experiencing chest wall or shoulder girdle pain of 123 patients with flail chest. After 5 days of mechanical ventilation.72 also examined the value of operative management in More recently.7 days. patients with flail chest to either nonoperative man- tion tests (PFTs) in 28 survivors of major thoracic agement or fixation of the ribs with Kirschner wires 24 trauma at 6 and 12 months after injury.8 vs 3. 28 months). they did not exclude patients with an associated pulmo- within 2. reduced One of the early studies that evaluated the long-term ICU length of stay (5.21 also had a concomitant pulmonary contusion that un. Surgical fixation resulted in a signifi- injuries with reconstruction plates. hospital length of stay (11.03) and were liberated from mechanical ventilation within seven reduced need for noninvasive ventilation (3 vs 50 hours. P < 0. There achieved 100 per cent working capacity at the time of was an average cost savings of $14.05). pa- of critical care support traditionally required for these tients were randomly assigned to either undergo fixation severe chest wall injuries. In contrast to the studies by Granetzny and strated resolution of clinically significant pulmonary Tanaka.76 (86%) returned to preoperative sports activity levels When combined. 80 patients and a wide variety of outcomes as measures impact implosion force. days of ventilation (10. a recent prospective study from Australia by derwent early fixation of the fractured ribs did not Marasco and colleagues76 randomly assigned 46 pa- benefit from the procedure. P < 0. The majority underwent surgical rib fixation. The decreased stay and need for additional in- (6.380 for the group receiving pneumatic stabilization of the chest wall.73 The long-term benefit of early stabilization in the incidence of pneumonia. PFTs demon. P < 0. Although each study examined different out- to flail segments with posterior fractures after a lateral comes and criteria for fixation.5 ± 7. At six months.05). early fixation of morbidity.6 vs 14. need for tracheostomy. The wall. Importantly.59 Within or hospital length of stay. and morbidity that resulted from severe chest wall injury lower incidence of pneumonia and sepsis. Patients terventions also resulted in a significant reduction in the who had progressive paradoxical motion of the flail hospital cost ($13. Finally.423 ± $1. and lower incidence of respiratory disability is uncommon. days after stabilization. Voggenreiter and colleagues60 or continue management with internal pneumatic sta- evaluated the efficacy of operative management in the bilization.

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