Perioperative Management Strategies for Fracture Surgery in Patients With Traumatic Pneumothorax: A Retrospective Case Series

Introduction: When patients with traumatic pneumothorax require fracture surgery, clinicians must decide how to manage the pneumothorax perioperatively. Options include chest tube placement for the pneumothorax itself, prophylactic drainage before surgery, proceeding with general anesthesia and positive pressure ventilation (PPV) without drainage, using alternative anesthetic techniques to avoid PPV, or delaying surgery until the pneumothorax improves. Despite the clinical relevance of this scenario, few studies have described how these strategies are selected in actual perioperative practice. Methods: We retrospectively reviewed patients with traumatic pneumothorax who underwent fracture surgery at a community hospital in Japan between January 2013 and December 2024. Patient characteristics, pneumothorax size, associated injuries, chest tube management, anesthetic technique, timing of surgery, and perioperative outcomes were extracted from medical records. Results: Nine patients were identified. Management strategies varied and included early chest tube placement for clinical indications independent of surgery (two cases), prophylactic preoperative chest tube placement (one case), regional anesthesia without PPV (one case), and general anesthesia with PPV without chest tube placement (five cases). Among the five patients who underwent general anesthesia with PPV without chest tube placement, those with minimal pneumothoraces underwent early surgery, whereas those with larger pneumothoraces had surgery delayed until improvement was confirmed. No intraoperative tension pneumothorax occurred. One patient with multiple displaced rib fractures projecting into the thoracic cavity developed postoperative pneumothorax progression requiring delayed chest tube drainage. Conclusions: Perioperative management of traumatic pneumothorax in patients undergoing fracture surgery was highly individualized. Pneumothorax size, rib fracture morphology, pneumothorax trajectory, fracture site, surgical urgency, and the availability of regional anesthetic techniques that avoid PPV should be considered in multidisciplinary decision-making. Further studies are needed to define the risk of clinically significant pneumothorax progression during intraoperative PPV.