Eur J Trauma Emerg Surg (2010) 36:427–433

DOI 10.1007/s00068-010-0027-8

REVIEW ARTICLE

Operative stabilization of flail chest injuries: review of literature

and fixation options
D. C. Fitzpatrick • P. J. Denard • D. Phelan •

W. B. Long • S. M. Madey • M. Bottlang

Received: 5 April 2010 / Accepted: 26 April 2010 / Published online: 3 June 2010
Ó The Author(s) 2010. This article is published with open access at Springerlink.com

Abstract bending. Intramedullary rib splints allowed less-invasive

Background Flail chest injuries cause significant mor- fixation of posterior fractures where access for plating was
bidity, especially in multiply injured patients. Standard limited.
treatment is typically focused on the underlying lung injury Conclusion Operative treatment can provide substantial
and involves pain control and positive pressure ventilation. benefits to patients with flail chest injuries and respiratory
Several studies suggest improved short- and long-term compromise requiring mechanical ventilation. The use of
outcomes following operative stabilization of the flail anatomically contoured rib plates and intramedullary
segments. Despite these studies, flail chest fixation remains splints greatly simplifies the procedure of flail chest
a largely underutilized procedure. fixation.
Methods This article reviews the relevant literature con-
cerning flail chest fixation and describes the different Keywords Flail chest
Rib fracture

implants and techniques available for fixation. Addition- Surgical stabilization
Rib plate
Rib splint
ally, an illustrative case example is provided for descrip-
tion of the surgical approach.
Results Two prospective randomized studies, five com- Introduction
parative studies, and a number of case series documented
benefits of operative treatment of flail chest injuries, Flail chest injuries carried a dismal prognosis prior to the
including a decreased in ventilation duration, ICU stay, development of modern medical interventions. In the first
rates of pneumonia, mortality, residual chest wall defor- half of the 1900s, management of these severe thoracic
mity, and total cost of care. Historically, rib fractures have injuries included non-operative treatments such as external
been stabilized with external plates or intramedullary taping, patient positioning and traction by way of towel
implants. The use of contemporary, anatomically con- clips attached to the flail segment [1, 2]. These techniques
toured rib plates reduced the need for intraoperative plate limited paradoxical motion at the fracture site but required
the patient to remain supine for prolonged periods of time,
which often led to more serious complications.
D. C. Fitzpatrick
Slocum Center for Orthopedics and Sports Medicine, Several reports describing internal fixation of flail chest
Eugene, OR, USA injuries appeared in the 1950s. Common surgical tech-
niques included simple wire suture fixation of the fracture
P. J. Denard
ends and rush rod fixation of the flail segment [3, 4]. In the
Department of Orthopedics, Oregon Health and Science
University, Portland, OR, USA late 1950s the medical treatment of the underlying lung
injury by ‘internal splinting’ of flail chest segments using
D. Phelan
W. B. Long
S. M. Madey
M. Bottlang (&) positive pressure ventilation became popular [5]. The use
Biomechanics Laboratory, Legacy Clinical Research and
of positive pressure ventilation resulted in improved patient
Technology Center, 1225 NE 2nd Avenue, Portland,
OR 97215, USA outcomes relative to early non-operative and operative
e-mail: mbottlan@lhs.org fixation [5]. However, this technique requires prolonged
428 D. C. Fitzpatrick et al.

time on the ventilator, resulting in secondary chest infec- pressure mechanical ventilation. Only fractures occurring
tions and persistently high mortality rates of 10–36% in between ribs 4 and 10 were stabilized. Patients in each
some series [6–9]. Additionally, positive pressure ventila- group had identical extubation criteria. They found sig-
tion is not always able to reduce and stabilize the bony nificant differences in the number of days requiring
injury, resulting in painful fracture nonunion or symp- mechanical ventilation (10.8 vs. 18.3), number of days in
tomatic chest wall deformity in 64% of patients in one the ICU (16.5 vs. 26.8), and pneumonia (22% vs. 90%)
study [7]. In contrast, operative repair of severe chest wall between the surgical and non-surgical groups, respectively.
injury is associated with low long-term morbidity and pain They also found a difference in the rate of return to work at
[10]. These factors led a number of surgeons to advocate 6 months (61% vs. 5%) and the total cost of care ($13,455
for primary internal fixation of severe flail chest injuries. A vs. $23,423). Patients in the non-surgical group had greater
small number of reports were published beginning in the complaints of chest tightness, thoracic pain and dyspnea at
1960s with generally improved results relative to non- 6 and 12 months after surgery.
surgical historical control groups. More recently, two A second randomized, prospective study by Granetzny
comparative studies noted a reduction in mortality of 38 et al. [11] compared outcomes in 20 patients treated using
and 78% due to surgical stabilization [11, 12]. surgical fixation with intramedullary k-wires and 20
Despite these seemingly superior results, operative fix- patients treated non-surgically with adhesive plaster
ation of flail chest injuries remains an underutilized inter- strapping. They found a significant difference in the
vention [13]. This underutilization is secondary to multiple number of days of ventilator use (2 vs. 12), the number of
factors including the lack of familiarity with the few days in the ICU (9.6 vs. 14.6), residual chest wall defor-
comparative studies of operative and non-operative treat- mity (1 vs. 9), pneumonia (10% vs. 50%) and wound
ment, surgical specialization in which fracture surgeons are infection rates (10% vs. 0%) between the operative and
not comfortable operating in the chest and thoracic sur- non-operative groups, respectively. They also noted sig-
geons are not familiar with modern fracture fixation prin- nificantly improved pulmonary function tests performed at
ciples, and the lack of appropriate fixation hardware to 2 months post-injury in the operative group.
simplify the surgery and optimize outcomes. Mayberry Lardinois et al. [8] prospectively evaluated 66 patients
et al. [14] surveyed a series of 405 cardiothoracic, trauma, who required surgery out of 732 total patients with a flail
and orthopedic surgeons concerning their views on chest chest injury. All patients had anterolateral flail segments
wall fixation. They found that most surgeons felt chest wall involving greater than 4 ribs. Indications for fixation
fixation was indicated in some cases, but that very few had included respiratory failure (n = 28), progressive dis-
experience using the technique. They also found that most placement of the flail segment (n = 15), failure to wean for
surgeons were unfamiliar with the literature concerning pulmonary reasons (n = 21) and thoracotomy due to
chest wall fixation and that there was an unfamiliarity of associated injuries (n = 2). Pulmonary contusion involving
fixation techniques and instrumentation by the surgeons on average 30% of the lung volume was present in 80% of
who typically operate on the chest. This article attempts to the patients. Fixation was performed using stainless steel
address these two issues by distilling the modern literature 3.5 mm reconstruction plates. They found that immediate
regarding flail chest fixation as well as reviewing the fix- extubation was possible in 47% of patients, and the mean
ation options for stabilization of flail chest segments. ventilator time was 2.1 days. They also found a return to
Finally, our preferred technique of fixation is presented work rate at 2 months post-surgery of 100%. Plate removal
with an illustrative case. was required in 11% of patients because of hardware
related pain.
Many experts believe that the underlying lung injury,
Literature review rather than the bony injury, is the major contributor to the
morbidity and mortality following flail chest injuries.
There are two level one studies comparing operative and Voggenreiter et al. [15] attempted to address this issue by
non-operative treatment of flail chest injuries [11, 12]. retrospectively comparing the outcomes of surgical fixation
Tanaka et al. [12] selected 37 patients out of 148 with flail of the flail segment in 10 patients with and 10 patients
chest who met strict inclusion criteria for a prospective, without underlying pulmonary contusion. They also eval-
randomized study of surgical versus internal pneumatic uated 18 matched patients without pulmonary contusion
stabilization. All patients required mechanical ventilation treated non-surgically. Pulmonary contusion was diagnosed
and had six or more consecutive rib fractures. All patients on bronchoscopy. Inclusion criteria were flail chest with
were initially treated with positive pressure ventilation. At the need for thoracotomy (n = 6), flail chest and respira-
5 days post-injury, 18 patients were randomized to fixation tory failure without pulmonary contusion (n = 9), para-
with Judet struts and 19 patients continued with positive doxical chest wall motion (n = 3) and severe deformity of
Operative stabilization of flail chest injuries 429

the chest wall (n = 2). Fractures were fixed with Judet (1.2%), four draining wounds without infection, two
struts or 3.5 mm plates. The results were focused on short- pleural empyemas, one wound hematoma, one persistent
term outcomes, namely the number of ventilator days, pleural effusion and one case of osteomyelitis. They noted
pneumonia and mortality. They found significant differ- eight hardware failures and nine patients requiring hard-
ences in the number of ventilator days (30.8 vs. 6.5) and ware removal.
rates of pneumonia (40% vs. 10%) and mortality (30% vs. It is important to also understand that the inclusion
0%) between the surgical patients with and without pul- criteria for these studies were fairly strict and that not all
monary contusion. They also found significant differences flail chest patients require surgical treatment. Common
in ventilator days (6.5 vs. 26.7) and pneumonia (10% vs. inclusion criteria were flail segments of 3–4 ribs or greater
27%) between the surgical and non-surgical patients with one of the following associated conditions: failure to
without pulmonary contusion. They suggested that patients wean for pulmonary reasons, massive chest wall deformity
with flail chest and no contusion have better outcomes if with paradoxical chest wall motion, and respiratory failure
surgical stabilization is performed early, while patients despite the use of adequate peridural anesthesia. More
with flail chest and pulmonary contusion should be fixed controversial indications included fixation of rib fractures
only if paradoxical motion or progressive collapse is noted. ‘on retreat’ from surgery for associated injuries, pain
Nirula et al. [16] retrospectively compared 30 flail chest without respiratory failure and fixation in the setting of a
patients treated surgically with 30 non-surgical patients pulmonary contusion without paradoxical motion or mas-
matched base on age, Injury Severity Score and chest sive deformity.
Abbreviated Injury Score. Indications for surgery included
severe flail chest, pain, bleeding and failure to wean. They
used Adkins Struts and wires to fix the flail segments. The Implants
primary outcome measures of ICU days and total hospital
days did not show a statistically significant difference Stabilization with plates
between the groups. However, the number of ventilator
days measured from the time of surgery to extubation was Over the past three decades, a considerable number of
significantly lower in the operative group (2.9) relative to specialized rib plates have been introduced, emphasizing
the non-operative group (9.4). the persistent desire for operative stabilization of the chest
Ahmed and Mohyuddin [17] compared 26 patients wall (Fig. 1). Early rib plates were applied with sutures or
treated surgically with k-wire fixation of one rib of the flail circlage wires. In 1972, Paris et al. [23] introduced rib
segment with 38 patients treated non-surgically using struts that were up to 40 cm long to span and suspend flail
positive pressure ventilation. The rib was stabilized ‘on- rib segments. These struts were applied along the rib,
retreat’ after other surgical interventions including treat- between ribs or across ribs using sutures, and were rou-
ment of a hemothorax, treatment of a major air leak, or tinely removed upon fracture healing. Vecsei et al. [24]
associated abdominal and orthopedic injuries. No statistical introduced a low-profile plate for circlage fixation that did
analysis was performed and the groups were not matched not require routine removal. Because the flat cross-sec-
or randomized. They reported improved outcomes in the tional profile of 1 mm 9 14 mm precluded in-plane con-
number of ICU days (21 vs. 9), the number of ventilator touring, these plates were only available up to a length of
days (15 vs. 3.9), the number of patients requiring trache- 8 cm and did not allow bridging of a flail segment. A
otomy (37% vs. 11%), the rate of chest infection (50% vs. subsequent generation of rib plates utilized claws that were
15%), sepsis rate (24% vs. 4%) and the mortality rate (29% tightened to the rib with forceps to simplify plate fixation
vs. 8%) between the non-operative and operative groups, and to reduce the risk of injury to intercostal neurovascular
respectively. structures posed by circumferential suture fixation [19, 25].
A number of case series studies have also been pub- The Judet plate (1973) had clawed end sections and a flat
lished which support the trends seen in these five com- central section of 5.3 cm length suitable for spanning a
parative and two prospective studies [13, 18–21]. In single fracture [25, 26]. The Labitzke claw plate was the
general, there is a decrease in the number of days requiring first rib plate specifically designed to accommodate in-
mechanical ventilation, number of days in the ICU, and the plane bending [27]. It was sufficiently flexible to closely
rate of chest infection, all favoring operative fixation of the conform to the conical surface over long rib sections.
flail segment. While the Labitzke plate could span both fractures of a flail
Nirula et al. [22] collected information on 650 rib rib segment, its high flexibility necessarily limited the
fracture repairs reported in the literature to determine the ability to rigidly suspend a flail segment. Stating the fun-
complication rates associated with surgical fixation. Com- damental need for rigid spanning of a flail segment, San-
plications included eight superficial wound infections ches-Lloret introduced 13–19 cm long rib struts with
430 D. C. Fitzpatrick et al.

single fracture flail bridging

Paris
wire circlage

Vecsei

Judet

Labitzke
clamping

Sanchez-Lloret

U-plate
screw fixation

Fig. 2 Intramedullary fixation of rib fractures with Kirschner wires

anatomical rib plate [34], Rehbein plates [40], and contemporary rib splints [38, 39]

compared to flexible claw plates. For plate contouring of

standard plates, Oyarzun et al. [31] recommended that the
Fig. 1 Evolution of rib plates (drawings to scale in cross-sectional rib fracture should be reduced first, a template should be
and frontal view): early plates were applied with sutures and circlage
wires. To simplify plate application, a subsequent plate generation contoured to the rib surface, and a plate should be con-
had ‘‘claws’’ that allowed clamping of the plate onto the rib surface. toured to the template using bending irons, pliers, or a
Contemporary rib plates are applied with screws that securely lock bending press. This complexity frequently required a team
into the plate. Rib plates can be categorized into short implants for approach, whereby the general/thoracic surgeon provided
fixation of a single fracture site (Vecsei et al. [24], Judet [26], U-plate
[29]), and long implants that also permit bridging and suspension of a the operative exposure and collaborated with the ortho-
flail segment (Paris et al. [23], Labitzke [19], Sanchez-Lloret et al. paedic service for plate fixation [13]. More recently, ana-
[28]). Anatomical rib plates [32] made of flexible titanium can be tomic rib plates were introduced with the goal of reducing
used for bridging fixation of multiple fractures or can be shortened as or eliminating the need for templating and pre-bending of
needed for fixation of a single fracture
the plate [32]. By their anatomically contoured nature, they
also facilitate direct reduction of the rib fragments to the
clawed end sections to bridge fractures on each side of the plate. This can reduce surgical complexity and time,
flail rib segment with a single implant [28]. The circular especially when multiple ribs require stabilization, as in the
mid-section of the struts accommodated contouring but case of a flail chest. Specific to flail chest stabilization,
lacked the low profile of plates. For minimally invasive anatomic rib plates support the use of long plates that
fixation of a single fracture, Sales et al. [29] recently enable strong yet low-profile bridging and suspension of a
introduced a U-plate with a length of less than 5 cm. flail segment.
Despite introduction of specialized plates, standard 1/3
tubular and 3.5 mm reconstruction plates remain the most Intramedullary stabilization
frequently used plates for rib fracture fixation, likely
because of their broad availability. These standard plates Intramedullary implants have also been used as splints to
accommodate in-plane contouring and provide sufficient hold the flail segment in a more anatomic position and
stability to suspend a flail segment. However, these plates prevent paradoxical motion without obtaining rigid fixation
can be too stiff and may cause stress concentrations that (Fig. 2). Intramedullary fixation has several benefits rela-
contribute to screw pullout in osteoporotic ribs [9, 15, 27, tive to plate fixation, including less surgical dissection
30]. Furthermore, Labizke [19] stated that these plates required for insertion and less prominent hardware, which
require bending and twisting, making their application limits the need for removal at a later time. Kirschner wire
more technically demanding and more time-intensive (k-wire) fixation of ribs is reported in multiple studies over
Operative stabilization of flail chest injuries 431

Fig. 3 a CT scan performed

immediately post injury
showing two levels of displaced
rib fractures with volume loss
relative to the contralateral
hemithroax. b Post-operative
CT scanogram showing the four
rib plates on the anterolateral rib
fractures and the four splints
used to stabilize the posterior
fractures. The use of splints for
the posterior fractures allows
relative stability of the fractures
without the need for excessive
dissection

the past 50 years with generally good results [9, 17, 33, well as the use of modern flail chest fixation techniques
34]. Authors have noted rotational instability of the frac- using newer anatomically contoured implants.
tures, caused by the small circular cross section of the A 70-year-old man was admitted to the emergency ward
k-wires [30, 33]. Another reported problem with intramed- following a high-speed motor vehicle collision. On evalu-
ullary k-wire fixation is the potential for loss of fracture ation in the emergency room he complained of chest pain
reduction with migration of the wire resulting in pain or but was hemodynamically stable with an oxygen saturation
additional injury to the surrounding tissues [17, 25, 35, 36]. of 92% on room air. Physical examination revealed com-
The Rehbein plate, an intramedullary plate with a rectan- fortable respirations without paradoxical chest wall motion.
gular cross section designed to provide improved rotational Radiographs and a computed tomography (CT) scan of the
stability was introduced in 1972 [37]. One end of the plate chest revealed segmental fractures of the left 3rd through
was designed to be left out of the canal and was sutured to 10th ribs with a hemopneumothorax (Fig. 3a). A chest tube
the rib to limit migration. More recently, a pre-contoured was placed and he was admitted to the intensive care unit
rib splint was introduced for intramedullary fixation of rib for observation. Associated injuries included right 3rd
fractures [38]. Similar to the Rehbein plate, this splint has a through 5th rib fractures, a sternal fracture, left renal lac-
rectangular cross section, but it is pre-contoured to fit the eration, grade I splenic laceration, a pelvic ring injury, and
rib and is fixed to the rib with a locking screw to eliminate a T3 spinous process fracture. Total injury severity score
migration and to provide angular stability. Biomechanical was 21.
analysis of this implant showed significant benefits relative On post-injury day (PID) 1 the patient developed pro-
to simple k-wire fixation [39]. Specifically, rib splint con- gressive respiratory distress. He was unable to maintain
structs were 48% stronger than Kirschner wire constructs. adequate oxygenation and required mechanical ventilation.
Rib splints furthermore prevented the complications of His pulmonary status continued to worsen and on PID four
cut-out and migration seen with Kirschner wires. There- he required an increase in the FIO2 from 70 to 100. Chest
fore, rib splints are an attractive intramedullary solution for radiographs showed increased atelectasis of the left lower
less-invasive stabilization of rib fractures, especially in lobe. A volumetric chest CT was obtained which showed a
case of posterior rib fractures where access for plating is left lung volume of 914 cm3 compared to 1,760 cm3 on the
limited. right. The increasing ventilatory requirements and decreased
lung volume prompted the decision to stabilize the chest
wall. On PID five an open reduction and internal fixation of
Case example the left 5th through 9th ribs was performed with the Ma-
trixRIBTM Fixation System (Synthes CMF, West Chester,
The following case example is provided to illustrate PA). Intramedullary rib splints stabilized the posterior
rational indications for surgical fixation of rib fractures as fractures of the 5th and 7th through 9th ribs (Fig. 3b).
432 D. C. Fitzpatrick et al.

However, several studies suggest a substantial benefit to

patients with flail chest injuries and respiratory compro-
mise requiring mechanical ventilation. Despite this evi-
dence, the procedure remains mostly underutilized. The
goal of this work is to better inform the reader of the lit-
erature regarding chest wall fixation, given the fact that
many surgeons are not aware of the published reports on
flail chest fixation.
The use of anatomically contoured titanium plates and
splints greatly simplifies the procedure of flail chest fixa-
tion. The pre-contoured plates are used for complex frac-
tures and are long enough to allow bridging fixation of
multiple fractures, including the entire flail segment, if
desired. Because they are thin and manufactured from
titanium, they are able to flex with respiration, limiting the
risk of hardware or fixation failure secondary to repetitive
loading. Additionally, the plates are low profile and prevent
hardware irritation to minimize the need for removal after
the fractures heal.
Rib splints are used for simple fractures, especially
posterior fractures of the flail segment where access for
plating is limited. Use of the splint for the posterior frac-
tures reduces the need to elevate the latissimus dorsi,
allowing fixation with less surgical dissection. Rib splints
provide stable but flexible fixation of the fracture frag-
Fig. 4 a Two months postoperative CT focusing on one rib splint. ments. Use of a combination of plates and splints is com-
There is abundant callus formation confirming healing of the fractures mon in our practice and allows the greatest possible
by means of secondary bone healing. The chest volume is returned to
normal. b One year postoperative CT rendering combination of fixation options to fix these complex chest
wall injuries.

Anterolateral fractures of these ribs were secured using Conflict of interest statement One or more of the authors receive
consulting/royalty payments from Synthes CMF related to technology
anatomical rib plates with three locking screws on each side
discussed.
of the fracture. No plate contouring was required. Operative
time was 140 min. Open Access This article is distributed under the terms of the
The patient was extubated on postoperative day seven Creative Commons Attribution Noncommercial License which per-
and discharged 19 days after surgery. A 2-month postop- mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
erative CT scan showed intact hardware and fixation, as
well as abundant formation of fracture healing callus at the
fracture sites (Fig. 4a). At 3 months post-injury he required
no narcotic pain medications and was swimming for References
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