Invited Commentary

Contemporary Management of Flail Chest

P. GEOFF VANA, M.D.,* DANIEL C. NEUBAUER, B.S.,† FRED A. LUCHETTE, M.D., M.SC.,*†

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

527
528 THE AMERICAN SURGEON
The parenchymal injury related to pulmonary contu-
sion causes respiratory dysfunction, capillary hemor-
rhage, local and regional inflammation, increased
capillary permeability, and migration of neutrophils
into the extravascular space. The sum effect of these
alterations is an increase in alveolar consolidation and
reduced compliance, which result in increased right-
to-left shunt and hypoxia.18, 19 When inflammation
and edema are severe, the contusion also affects un-
injured lung tissue in the contralateral hemithorax.
Davis and colleagues20 measured protein content in
bronchoalveolar lavage fluid using a porcine model of
pulmonary contusion. They found delayed but signif-
icant capillary leakage and increasing infiltration of
protein and neutrophils in lavage fluid from the non-
injured contralateral lung.
The mortality rate for the combination of flail chest
and pulmonary contusion is in excess of 40 per cent
compared with a mortality rate of 16 per cent for blunt
thoracic injury alone without pulmonary contusion.21
The cumulative effect of the combination of both in-
juries is increased hospital length of stay and greater
incidence of mechanical ventilation and long-term
morbidity resulting from chronic pain or chest wall
deformity.22, 23 When Trinkle and colleagues24 hy-
pothesized that pulmonary contusion was the principal
injury that accounted for the respiratory insufficiency
seen with flail chest, the standard of care was finally
altered to address the physiologic changes arising from
this injury. Almost 40 years later, pulmonary contusion
continues to be recognized as the primary pathophysi-
ology accounting for the increased mortality and mor-
bidity related to flail chest, and it takes priority over the
flail chest in patient management.
Diagnosis
Physical examination often leads to the initial di-
agnosis of rib fractures because the awake and in-
teractive patient notes localized pain during palpation
of the thorax at the fracture site. However, the first and
second ribs are difficult to assess for fracture on clin-
ical examination as a result of their anatomic location.
Similarly, 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. 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, which are
also the ribs involved with flail chest. 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
June 2014 Vol. 80
pressure that occurs with diaphragmatic excursion.
During expiration, the flail segment elevates above
the intact chest wall as a result of the relative positive
pressure in the pleural space. This motion may not be
initially apparent on inspection of the chest as a result of
splinting of the fractured ribs by the intercostal muscles,
which will minimize movement of the flail segment
during respiration. However, eventually the chest wall
musculature fatigues, unmasking the flail segment by
visualization of the paradoxical motion. Chest radiog-
raphy has a sensitivity of only 50 per cent for identifying
a displaced rib fracture, and it is also unreliable for
identifying a flail segment.25–27 The availability of
computed tomography (CT), which is significantly
more sensitive for detecting fractured ribs, makes CT
the imaging modality of choice for evaluating injured
patients with major thoracic injuries. With liberal use
of thoracic CT scan, treatment and management plans
are changed in 20 per cent of severely injured pa-
tients.27, 28 In addition to revealing rib fractures,
thoracic CT scan also allows for the diagnosis of pul-
monary contusion and assessment of the severity of in-
jured lung parenchyma (Fig. 1). A pulmonary contusion
can be diagnosed as a lung consolidation in the setting of
overlying chest wall trauma on CT.12 Patients with a
pulmonary contusion compromising greater than 20 per
cent of their total lung volume are at very high risk for
adverse events, including pneumonia and acute res-
piratory distress syndrome, which may influence their
flail chest management.12
History of Management
Jones and Richardson first described flail chest in
1926.1 Subsequently, the deformity of the chest wall
resulting from flail chest was referred to as ‘‘stove in
chest’’ until the arrival of the first automobiles, at
which time the incidence of flail chest increased and
FIG. 1. Pulmonary contusion.
No. 6 CONTEMPORARY MANAGEMENT OF FLAIL CHEST
the phrase ‘‘steering wheel injury’’ was used to describe
it.2, 3 The disruption of the chest wall resulting in flail
chest was initially viewed as mechanical instability with
the focus of treatment on minimizing the movement of
the flail segment. As a result, numerous strategies were
developed in an effort to stabilize the chest wall. Until
the 1930s, these approaches took the form of strapping
the chest with various materials or exerting compres-
sion externally with sandbags.23 Treatment during the
next two decades used mechanical devices, including
surgically applied wires, hooks, and even screws. The
Hudson method involved the passage of long metal
pins under the pectoralis muscles and the serratus
anterior muscles. The pins were then attached to bows
and suspended from overhead traction frames. Coun-
terweights were adjusted to minimize the movement of
the flail segment of the chest wall to reduce pain and in
an attempt to restore the thoracic volume to normal.
However, none of these treatments altered the high
mortality rate associated with the condition.29, 30
With the arrival of volume-cycled ventilators in the
1950s, Avery and colleagues31 introduced the concept
of internal pneumatic stabilization for the management
of flail chest. The authors recognized the impact of
pulmonary edema and atelectasis on outcomes, but they
considered these to be secondary to the paradoxical
motion of the flail segment that caused increased dead
space, ineffective ventilation, and hypercarbia. The
concept of the dead space air ‘‘pendulating back and
forth’’ between the alveoli and tracheobronchial tree
was used to explain the pathophysiology of flail chest.
They concluded that mechanical ventilation allowed
for internal splinting of the chest wall and correction
of dead space. Although the theory of Pendelluft was
never proven, the attractiveness of the explanation con-
veniently justified routine use of mechanical ventilation
for patients presenting with flail chest for the next two
decades.32, 33 The mortality from flail chest was initially
lowered by the use of mechanical ventilation, but ven-
tilator-associated complications began to increase, ne-
gating the initial improvements in patient prognosis.16
Eventually, Shackford and colleagues32 described
the high incidence of barotrauma, ventilator-associated
pneumonia, and tracheal injury with routine use of
mechanical ventilation for treating flail chest.
As the understanding of the pathophysiology behind
flail chest injury progressed, researchers found that the
paradoxical motion was not the primary cause of
morbidity and mortality. Maloney34 demonstrated that
the hypoxia was the result of a pulmonary right-to-left
shunt related to the underlying pulmonary contusion,
not a result of the paradoxical movement of the flail
segment. This finding led to introduction of ‘‘selective
management’’—identifying which patients required
management of the pulmonary contusion versus those
? Vana et al. 529
needing pain control alone for the flail chest injury.
Trinkle and colleagues24 found that conservative man-
agement aimed at treating the underlying contusion, and
not just the flail segment, resulted in better outcomes for
patients sustaining thoracic trauma. They hypothesized
that management should be focused on the contusion
and consist of intravenous fluid restriction, diuretics,
aggressive respiratory therapy, and pain control. The use
of mechanical ventilation was limited solely to treating
the sequelae of pulmonary contusion: right-to-left ar-
teriovenous shunting, influx of inflammatory factors,
increased capillary permeability, and increased alveolar
filling leading to respiratory distress.35 They concluded
that the routine use of mechanical ventilation to treat
flail chest, although common in many hospitals, was
actually ‘‘a triumph of technique over judgment.’’11, 24
This study advanced the management of flail chest,
encouraging the use of more selective mechanical
ventilation based on failure to maintain oxygenation,
ventilation, and pulmonary hygiene. This strategy was
supported by the findings from two prospective ran-
domized studies. Both Richardson and colleagues and
Bollinger demonstrated a significant reduction in mor-
bidity and mortality when intubation was avoided in
patients with flail chest and pulmonary contusion.17, 30
During the last two decades of the 20th century, the
focus of treatment of flail chest has been directed at
maintaining adequate ventilation and pulmonary hy-
giene. Numerous studies have demonstrated the ben-
efit of using regional analgesia administered through
an epidural catheter rather than systemic narcotics in
these patients.36–38 Alternatives include the delivery of
long-acting local anesthetics as intercostal nerve blocks
or into the paravertebral18, 19, 39 or intrapleural space.38
Nonsteroidal anti-inflammatory drugs such as ketorolac
are also beneficial adjunctive analgesics. The next ad-
vance in management of flail chest came with improved
strategies for stabilizing fractured ribs.
Current Management
Nonoperative
Selective management therapies target the underlying
pulmonary contusion and attempt to mitigate the com-
plications associated with the flail segment, including
pain, atelectasis, and compromised pulmonary hygiene.
To treat the underlying pulmonary contusion, the goal of
fluid resuscitation is to maintain euvolemia by pre-
venting hypovolemia and fluid overload.5, 16, 24 Clear-
ing pulmonary secretions and preventing infection is
done through maintaining adequate pulmonary clear-
ance with such techniques as suctioning, inspiratory
spirometry, and intermittent positive-pressure (non-
invasive) ventilation to clear secretions and guard
530 THE AMERICAN SURGEON
against respiratory failure and the need for mechan-
ical ventilation and possible tracheostomy.29
Adequate analgesia is the primary therapy that has
been shown to allow for effective pulmonary mechanics,
minimizing atelectasis while maintaining clearance of
secretions.6, 9 There are several analgesic modalities that
have been demonstrated to provide adequate control of
chest wall pain. These range from oral and intravenous
narcotics, continuous or patient-controlled regional an-
esthesia, and epidurals. Systemic narcotics should be
avoided because they may actually cause reduced
pulmonary clearance of secretions and thus increase the
risk of atelectasis and hypoxia requiring intubation.
Regional anesthesia can be very effective for not only
providing adequate pain control, but also optimizing
diaphragm functioning with a reduced risk of hypo-
tension. Unfortunately, regional blocks are limited by
the half-life of the agents and require repeated ad-
ministration.9, 37, 38 Epidural administration of anal-
gesia is very effective at reducing pain and can be
used for several days or weeks while the rib fracture
pain is resolving. A common complication seen with
the use of epidural catheters is hypotension from the
sympathetic blockade that results from the use of
local anesthetic. A rare complication is the development
of infection of the epidural space with abscess forma-
tion. If not diagnosed early, the infection may spread
to the spinal cord, leading to paralysis. Despite the
known risk of complications associated with epidural
catheters for analgesia in flail chest, they are the
preferred method for analgesia in this setting as a re-
sult of their effective control of pain and fewer of the
neurologic effects associated with oral or parenteral
narcotics.6, 9, 37
Despite the development of ‘‘selective management,’’
mechanical ventilation continues to have a role in the
management of patients with flail chest and pulmonary
contusion. Mechanical ventilation is indicated in pa-
tients who have persistent hypoxia despite adequate
analgesia and hemodynamic stability.16, 17 Advances
in ventilator technology have yielded methods of ven-
tilating patients with flail chest that are better tolerated
than continuous mechanical ventilation (CMV) or con-
tinuous positive pressure ventilation. Cullen and col-
leagues40 studied CMV and synchronized intermittent
mechanical ventilation (SIMV) with positive end expi-
ratory pressure (PEEP). They found SIMV combined
with PEEP to be the superior mode of ventilation. Use
of SIMV allowed patients to breathe spontaneously
and avoid hypocapnia, whereas concurrent use of PEEP
increased functional residual capacity by minimizing
alveolar collapse during expiration. This strategy also
enabled recruitment of previously collapsed pulmonary
regions, decreasing intrapulmonary shunting and im-
proving global ventilation–perfusion.40
June 2014 Vol. 80
The combination of effective analgesia and pul-
monary hygiene, coupled with treatment of the un-
derlying pulmonary contusion, allows for maintenance
of pulmonary function and avoidance of mechanical
ventilation.
Operative
It is argued that the high rate of morbidity associated
with flail chest with pulmonary contusion outweighs
the benefits of surgical fixation of the flail segment.41
Although approximately 68 per cent of patients re-
quiring mechanical ventilation secondary to flail chest
are reportedly extubated by postinjury Day 3, surgical
fixation has become a more common and acceptable
practice.16 The most common indications for surgical
stabilization are failure to wean from mechanical ven-
tilation, inability to provide adequate pain control, and
the need for restoration of volume loss. These losses
occur when the fractured rib edges are not in apposition
and thoracic volume is subsequently reduced.22, 42–44
However, there is no current consensus regarding the
timing of operative fixation or the approach to use for
exposure of multiple consecutive fractured ribs. Most
surgeons prefer to fixate fractures involving the lateral
and anterior surfaces of the ribs as a result of easier
dissection and exposure through a single posterolateral
thoracotomy incision. The effect of a concomitant pul-
monary contusion on pulmonary function should also be
considered when selecting patients for surgical stabili-
zation. Several studies have shown that rib fixation does
not provide short-term benefits when the patient re-
quires prolonged mechanical ventilation for manage-
ment of a pulmonary contusion.42, 45–47
The operation proceeds with the patient placed in the
lateral decubitus position, and a posterolateral thora-
cotomy incision is made to allow exposure of the
specific ribs requiring fixation. The serratus anterior
and latissimus dorsi muscles may be retracted anteriorly
and posteriorly, respectively, to avoid excessive division
of the muscles for exposure of the fracture site. Alter-
natively, several small incisions may be made overlying
the fractured segments to avoid muscle division. The
intercostal muscles are separated at the superior border
to avoid the neurovascular bundle running inferiorly and
also to enable entrance into the pleural cavity for
alignment of fractured segments and visualization of
the lung during fixation. The ends of the fracture ribs
should be cleared of soft tissue to ensure ideal alignment
and apposition of the fracture edges, which is necessary
for optimal healing.
There are numerous systems available for fixation,
ranging from cables and Kirschner wires to intra-
medullary rods, small fragment plates, and fixators
(Fig. 2).22, 43, 48–55 One of the original devices described
No. 6 CONTEMPORARY MANAGEMENT OF FLAIL CHEST
for stabilizing fractured ribs, the Judet strut, has been
used with some success to bridge the fractured ribs in-
volved in a flail segment. The Judet strut is a malleable
metal plate that can be molded around the superior and
inferior edges of the rib. The plate is secured to the rib
with spurs that are molded to penetrate one cortex of the
bone. During positioning and manipulating the spur,
there is a high risk of incorporating the neurovascular
bundle along the inferior edge of the rib and injuring
or impinging the neurovascular bundle. If the inter-
costal nerve is injured, this may be a source for chronic
pain.42, 56–58
Similar to the Judet strut is the U-plate. The U-plate
eliminates the possibility for neurovascular bundle
injury by its application because it is affixed to only the
superior aspect of the rib. In contrast to the Judet strut,
its application does not require dissection of the sur-
rounding intercostal muscles and periosteum. The plate
is fixated with locking screws placed through both
cortices at the middle of the rib.59
Most surgeons use metal plating systems for fixation
that are manufactured in generic sizes, similar to those
used for facial fractures. These systems take various
forms, including tubular plates, dynamic compres-
sion plates, and low-contact dynamic compression
plates.41, 42, 44, 47, 49–54, 60, 61 The plates are malleable
so they can be configured to the shape of the specific rib
anatomy. Furthermore, reconstructive plates are thin
enough to allow for physiologic movement without
placing stress on the individual plates during the re-
spiratory cycle and future activity.
Absorbable plates have been successfully used both
in flail chest deformities after trauma and in non-
traumatic thoracotomy.62–66 Implanted using absorbable
? Vana et al. 531
sutures, these plates are designed to slowly transfer the
stress and physiologic load to the bone as it heals. The
absorbable polymer struts may decrease pain after sur-
gical fixation, potentially eliminating the need for a
subsequent operation to remove hardware as a result of
chronic pain.67 Although the absorbable fixation de-
vices are more expensive, animal models reveal that
these plates promote faster healing with greater bone
strength. Research has also demonstrated that outcomes
with absorbable fixation devices are superior to those
with nonoperative management when comparing post-
operative residual angulation and alignment.68, 69
Another option for fixation is intramedullary struts
or rods. Their use for rib fixation is founded on the
principles that have allowed its almost universal use in
surgical fixation of long bones of the extremities. The
original material used in the construction of these
smaller intramedullary devices was associated with
a high failure rate as a result of loss of fracture re-
duction. The underlying cause of the failure of these
early rods and struts was believed to be rotational
stress.42, 43, 50, 70, 71 Advancements in technology and
further research have provided improvements in the
design, including the use of contoured titanium to in-
crease stability and minimize movement of the rib with
rotation and a single unicortical locking screw to de-
crease displacement.
When selecting surgical candidates for fixation of
a flail chest wall segment, surgeons should weigh long-
term risks and benefits carefully. The short-term out-
comes of surgical fixation versus those for nonoperative
management of flail chest have been reviewed over the
last 50 years, but much of the literature is limited to
retrospective studies examining a small number of
FIG. 2. Fixation devices. (Left, top to bottom)
Wire fixation devices, Judet struts, U-plates, rib
plates. (Right, top to bottom) Intramedullary fixation
devices, Kirschner wire, rib splint. Used with per-
mission from Fitzgerald DC, Denard PJ, Phelan D,
et al. Operative stabilization of flail chest injuries:
review of literature and fixation options. Eur J Trauma
Emerg Surg 2010;36:427–33.87
532 THE AMERICAN SURGEON
patients and a wide variety of outcomes as measures
of morbidity.
One of the early studies that evaluated the long-term
morbidity that resulted from severe chest wall injury
was performed by Livingston and Richardson in 1990.72
They prospectively studied results of pulmonary func-
tion tests (PFTs) in 28 survivors of major thoracic
trauma at 6 and 12 months after injury, comparing
them with those of a historic cohort group. None of
the patients received surgical fixation of the chest
wall. Both groups required mechanical ventilation for
an average of three weeks. Two weeks after discharge,
PFT results ranged from 40 to 50 per cent of predicted
values. Over the next year, there was continued im-
provement in PFTs to 65 to 90 per cent of predicted
values. The authors concluded that recovery from severe
chest injury occurs rapidly in most patients, long-term
respiratory disability is uncommon, and recovery of
pulmonary function justified the major commitment
of intensive care unit (ICU) resources required for
recovery.72
More recently, operative stabilization of flail chest
has been advocated as a method to reduce the duration
of critical care support traditionally required for these
severe chest wall injuries. Voggenreiter and colleagues60
evaluated the efficacy of operative management in the
setting of pulmonary contusion. Patients without a pul-
monary contusion who had early fixation of the flail
segment required significantly fewer days of mechan-
ical ventilation than those managed nonoperatively
(6.5 ± 7.0 days vs 26.7 ± 29.0 days; P < 0.02). Patients
who had progressive paradoxical motion of the flail
segment during weaning also benefitted from operative
stabilization of the chest wall. However, the group that
also had a concomitant pulmonary contusion that un-
derwent early fixation of the fractured ribs did not
benefit from the procedure.60
In a prospective study completed over 10 years,
Lardinois and colleagues73 studied pulmonary function
in patients who had undergone early fixation (average,
within 2.8 days of injury) of anterolateral flail chest
injuries with reconstruction plates. Most (85%) patients
were liberated from mechanical ventilation within seven
days after stabilization. At six months, PFTs demon-
strated resolution of clinically significant pulmonary
restriction.73 The long-term benefit of early stabilization
was also reported by Mouton and colleagues.59 Within
their 1997 study, 95 per cent of patients with flail chest
achieved 100 per cent working capacity at the time of
follow-up assessment (mean, 28 months). The majority
(86%) returned to preoperative sports activity levels
without experiencing chest wall or shoulder girdle pain
or dysfunction.59
Solberg and colleagues74 reported a unique approach
to flail segments with posterior fractures after a lateral
June 2014 Vol. 80
impact implosion force. Once again, early fixation
resulted in early extubation (mean, 1.9 days), reduced
ICU length of stay (5.7 vs 16.7 days; P < 0.01), and
lower incidence of pneumonia and sepsis.
Granetzny and colleagues75 randomly assigned 40
patients with flail chest to either nonoperative man-
agement or fixation of the ribs with Kirschner wires 24
hours after admission. The nonoperative group in this
Egyptian study was managed with various methods of
external stabilization (packing and strapping). The
group managed with early fixation demonstrated a sig-
nificantly shorter duration of mechanical ventilation
(2 vs 12 days), ICU length of stay (9.6 vs 14.6 days), and
hospital length of stay (11.7 vs 23.1 days).75 Two
months after discharge, the group that had undergone
early fixation had significantly better PFT measure-
ments, fewer chest infections, and lower incidence of
chest wall deformity and scoliosis compared with the
nonoperative group.75
In 2002, a Japanese study by Tanaka and colleagues21
also examined the value of operative management in
patients with flail chest with or without pulmonary
contusion. After 5 days of mechanical ventilation, pa-
tients were randomly assigned to either undergo fixation
or continue management with internal pneumatic sta-
bilization. There was a significant reduction in mean
days of ventilation (10.8 vs 3.4; P < 0.05), ICU length of
stay (16.5 vs 26.8 days; P < 0.05), and incidence of
pneumonia (24 vs 77%; P < 0.05) in the operative
group. The decreased stay and need for additional in-
terventions also resulted in a significant reduction in the
hospital cost ($13,455 ± $5,840 for the surgical group vs
$23,423 ± $1,380 for the group receiving pneumatic
stabilization).21
Finally, a recent prospective study from Australia by
Marasco and colleagues76 randomly assigned 46 pa-
tients with flail chest to either surgical fixation using
polylactide copolymer plates or continued mechanical
ventilation within 48 hours of admission. Importantly,
they did not exclude patients with an associated pulmo-
nary contusion. Surgical fixation resulted in a signifi-
cantly shorter ICU stay (11.8 vs 14.9 days; P < 0.03) and
reduced need for noninvasive ventilation (3 vs 50 hours;
P < 0.01). In contrast to the studies by Granetzny and
Tanaka, there was no difference between the two groups
in the incidence of pneumonia, need for tracheostomy,
or hospital length of stay. At 3-month follow-up, there
was no difference in PFT results or quality of life. There
was an average cost savings of $14,443 for those who
underwent surgical rib fixation.76
When combined, these three studies included a total
of 123 patients with flail chest, of whom 61 received
some form of operative stabilization of the flail seg-
ment. Although each study examined different out-
comes and criteria for fixation, they all demonstrated
No. 6 CONTEMPORARY MANAGEMENT OF FLAIL CHEST
FIG. 3. Thoracic trauma algorithm.
a significant reduction in ventilator days and ICU
length of stay with operative stabilization of the chest
wall.
Conclusion
Thoracic trauma continues to be a major cause of
morbidity and mortality in the polytrauma patient, ac-
counting for 10 to 15 per cent of all injuries and ranking
second only to head injury as the leading cause of
trauma-related death.4, 6, 37 The majority of flail chest
injuries, with or without pulmonary contusion, can be
adequately treated with nonoperative interventions.
Multiple studies have concluded that regional analgesia
delivered by an epidural catheter or administered into
the paravertebral space will relieve pain adequately to
avoid the need for intubation and mechanical venti-
lation; however, some patients will progress to acute
respiratory failure despite these measures and require
intubation.38, 39, 77 Multiple studies have demonstrated
that early operative stabilization of the flail segment
reduces morbidity for patients without an associated
pulmonary contusion.75, 76, 78–80
On the basis of our review of the literature, we pro-
pose an algorithm for the management of flail chest
(Fig. 3). Patients with signs and symptoms of a signifi-
cant injury should be evaluated with dynamic helical CT
scan. All patients with a flail segment should be initially
admitted to a critical care unit for early administra-
tion of regional anesthesia and monitoring of their pul-
monary function during ongoing resuscitation because
? Vana et al. 533
these patients are at great risk for rapid decom-
pensation within the first 24 to 48 hours.40, 81 When
pain relief is not adequately achieved with nonoperative
management, the patient should be considered for
early surgical stabilization of the flail segment. Other
indications for operative fixation of the flail ribs in-
clude severe rib displacement with loss of apposition
of the rib edges, significant reduction in the pleural
cavity volume, and overriding rib fractures.49, 50, 82, 83
Early operative fixation (within 2 to 5 days) avoids
the need for intubation. In the intubated patient, sur-
gical stabilization of the unstable chest wall has been
shown to reduce ventilator days, ICU and hospital
length of stay, incidence of pneumonia, and hospital
cost while preventing long-term reduction in pulmo-
nary function. Although patients with a concomitant
pulmonary contusion do not generally experience the
same short-term benefit of reduced ventilator days
and hospital length of stay, they may reap long-term
improvement in pulmonary function from undergoing
surgical restoration of thoracic volume and chest wall
mechanics.22, 43, 45, 76, 81, 84–86
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