ORIGINAL ARTICLE

Flail chest injuries: A review of outcomes and treatment practices

from the National Trauma Data Bank
Niloofar Dehghan, MD, Charles de Mestral, MD, PhD, Michael D. McKee, MD, Emil H. Schemitsch, MD,
and Avery Nathens, MD, MS, PhD, MPH, Toronto, Ontario, Canada

Flail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation,
and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, and
outcomes of ail chest injuries in polytrauma patients.
METHODS:
The National Trauma Data Bank was used for a retrospective analysis of the injury patterns, management, and clinical
outcomes associated with ail chest injuries. Patients with a ail chest injury admitted from 2007 to 2009 were included in the
analysis. Outcomes included the number of days on mechanical ventilation, days in the intensive care unit (ICU), days in the
hospital, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death.
RESULTS:
Flail chest injury was identied in 3,467 patients; the mean age was 52.5 years, and 77% of the patients were male. Signicant
head injury was present in 15%, while 54% had lung contusions. Treatment practices included epidural catheters in 8% and
surgical xation of the chest wall in 0.7% of the patients. Mechanical ventilation was required in 59%, for a mean of 12.1 days.
ICU admission was required in 82%, for a mean of 11.7 days. Chest tubes were used in 44%, and 21% required a tracheostomy.
Complications included pneumonia in 21%, adult respiratory distress syndrome in 14%, sepsis in 7%, and death in 16%. Patients
with concurrent severe head injury had higher rates of ventilatory support and ICU stay and had worse outcomes in every category
compared with those without a head injury.
CONCLUSION:
Patients who have sustained a ail chest have signicant morbidity and mortality. More than 99% of these patients were treated
nonoperatively, and only a small proportion (8%) received aggressive pain management with epidural catheters. Given the high
rates of morbidity and mortality in patients with a ail chest injury, alternate methods of treatment including more consistent
use of epidural catheters for pain or surgical xation need to be investigated with large randomized controlled trials. (J Trauma
Acute Care Surg. 2014;76: 462Y468. Copyright * 2014 by Lippincott Williams & Wilkins)
LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level IV.
KEY WORDS:
Flail chest; rib fracture; thoracic trauma; chest wall fixation.
BACKGROUND:

ib fractures are common injuries and occur in up to 39% of

patients with blunt chest trauma.1 These fractures are
routinely treated nonoperatively, and most heal without major
complications. However, a number of these injuries can result
in a mechanically unstable chest wall or ail chest, which is
associated with high rates of short-term mortality and longterm morbidity.1,2
A ail chest is dened as three or more consecutive rib
fractures, in two or more locations, creating a ail segment.3
This denition also applies to three or more bilateral consecutive rib fractures, and three or more rib fractures associated
with a sternal fracture because both of these also lead to the
creation of a mechanically unstable ail segment.4 A ail chest
can lead to chest wall instability, asynchronous movement of
the ail segment, and paradoxical chest motion. It also leads to
Submitted: July 7, 2013, Revised: November 10, 2013, Accepted: October 14, 2013.
From the Division of Orthopaedics (N.D., M.D.M., E.H.S.), Department of Surgery,
St. Michaels Hospital; Division of General Surgery (C.D.M.), Department of
Surgery, and Department of Surgery (A.N.), Sunnybrook Health Sciences
Centre, University of Toronto, Ontario, Canada.
This study was presented at the Canadian Orthopaedic Association Annual Conference 2013.
Address for reprints: Niloofar Dehghan, MD, 55 Queen St East, Suite 800, Toronto,
Ontario, Canada, M5C 1R6; email: Niloofar.Dehghan@Mail.UToronto.ca.
DOI: 10.1097/TA.0000000000000086

462

deformity of the chest wall and loss of thoracic volume.4 These

in turn lead to decreased lung volume, atelectasis, chest
tightness, dyspnea, and chronic pain.1,2,4,5
The current treatment of ail chest injuries consists of
nonsurgical management via intubation and intermittent positive pressure ventilation (internal pneumatic splint), analgesia,
pulmonary toilet, and chest physiotherapy.1,4,6 However, even
with aggressive nonoperative management, patients with severe
chest wall injuries remain at risk for many complications. A ail
chest injury causes compromised respiratory function with poor
pulmonary toilet or inability to clear secretions, which typically
requires mechanical ventilatory support. Prolonged mechanical
ventilation can in turn result in barotrauma and increases the
risk for pneumonia, sepsis, extended time in the intensive care
unit (ICU), and death.1,2,4,5,7,8 Even in the presence of extrathoracic injuries in these polytrauma patients, pneumonia and
the resultant sepsis remain two of the most common causes of
death in patients with ail chest injuries.4
A better understanding of the present-day burden of ail
chest injuries will provide useful information on the potential utility of different treatment strategies. A contemporary
description of practice patterns and in-hospital outcomes of
patients with ail chest injuries is currently lacking in the literature. This is relevant, given the increased interest in surgical
xation of selected cases. The purposes of this study were to
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J Trauma Acute Care Surg

Volume 76, Number 2

determine the prevalence of ail chest injuries in the trauma

patient population and to describe current treatment practices,
both nonsurgical and surgical, as well as the morbidity and
mortality of patients with these injuries.

PATIENTS AND METHODS

Study Design
We designed a retrospective cohort study of patients with
ail chest injuries identied in the National Trauma Data Bank
(NTDB), to characterize the prevalence of this injury as well
as injury patterns, current management, and in-hospital morbidity and mortality. Certain patient subgroups were compared.
The subgroups were dened based on the presence of severe
head injury or the presence of lung contusions because these
have been reported in the literature to require longer duration
of ventilatory support and have worse outcomes compared
with patients without such injuries.1,2,4,9

Data Source and Setting

The NTDB is the largest aggregation of US/Canadian
trauma registry data and was used in this study. Data from
NTDB version 10.1, years 2007 to 2009, were used.

Dehghan et al.

coding listed earlier (450264.4: ail injury with lung contusion); however, there was no denition or grading system with
regard to the extent of contusion present.

Management, Morbidity, and Mortality

We examined the duration of mechanical ventilation,
ICU stay, and total hospital stay. We also calculated the proportion of patients who received a chest tube, tracheostomy, or
epidural catheter. Procedures were captured based on ICD-9
procedure codes. The frequency of complications and mortality
were also calculated. The selected complications were obtained
from the complications eld of the NTDB and included pneumonia, adult respiratory distress syndrome (ARDS), and sepsis.

Statistical Analysis
Management and in-hospital morbidity and mortality
were compared across subgroups and dened based on the
presence or absence of severe head injury and the presence or
absence of lung contusion. W2 or Fishers exact test was used
for categorical variables, and t test or Kruskal-Wallis test was
used for continuous variables. A two-tailed > G 0.05 was
considered statistically signicant.

Cohort
The cohort included adults (Q16 years of age) sustaining
a ail chest injury following blunt trauma, treated at a Level 1
or 2 trauma center. Flail injury was identied based on the
following Abbreviated Injury Scale (AIS) diagnosis codes:
450260.3 (ail injuryVunilateral or not further specied),
450262.3 (ail injury without lung contusion), 450264.4 (ail
injury with lung contusion), and 450266.5 (bilateral ail injury).
At the patient level, patients who were dead on arrival or
died in the emergency department were excluded owing to
limited opportunity for injury ascertainment or intervention.
At the center level, facilities with the following criteria were
included for analysis: trauma center Level 1 or 2, facilities with
90% or more of patients having at least one AIS code, facilities
coding for a minimum of 100 patients, those that code complications, and facilities that code at least one exploratory
laparotomy. We wished to exclude centers that did not consistently code procedures. We therefore identied and excluded
centers where no patient underwent either of the two most
commonly coded operative procedures in NTDB, namely, open
reduction and internal xation of the femur and open reduction
and internal xation of the tibia (ICD-9 procedure codes 79.35
and 79.36). To derive more valid estimates of in-hospital complications, we also excluded centers unlikely to accurately code
complications. In doing so, we excluded centers that did not
code at least one pneumonia or urinary tract infection during the
3-year study period.

Patient Characteristics
The patient characteristics examined included age, sex,
the presence of an associated severe head injury, and the
presence of a lung contusion. A severe head injury was dened
as a head injury with AIS score of 3 or greater and a motor
Glasgow Coma Scale (GCS) score of 4 or less. The presence of
a lung contusion was identied based on the AIS diagnosis

RESULTS
We identied 354,945 patients with an Injury Severity
Score (ISS) of 9 or greater following blunt trauma treated
at 199 Level 1 and 2 trauma centers (representing 980% of
trauma centers for that period). Of these patients, 3,467 (1%)
experienced a documented ail chest injury. The following
data pertain to the 3,467 patients identied with a ail chest
diagnosis.

Entire Cohort
The average age at the time of injury was 52.5 years,
with 77% male and 23% female patients. The mean ISS was
30.4, and the most common mechanism of injury was motor
vehicle collision (79%). Other causes included fall (16%) and
other blunt injury (5%). A severe head injury was present in
15% of patients, while 54% had documented lung contusions.
Overall, intubation and mechanical ventilation were required in 59% (1762/2984, data unavailable for 483 patients),
for a mean of 7.2 days overall (SD 11, median 1, interquartile
range (IQR) 0Y12). The mean duration of mechanical ventilation was 12.1 days for the 59% who required intubation and
mechanical ventilation (SD 12, median 9, IQR 3Y18). ICU
admission was required in 82% of patients (2767/3377, data
unavailable for 90 patients), for a mean of 9.6 days overall
(median 5, SD 12, IQR 1Y15). The mean length of ICU stay
was 11.7 days for the 82% who required ICU admission (SD
12, median 8, IQR 3Y17). Mean length of hospital stay overall
was 16.6 days (SD 16, median 12, IQR 6Y22) (Figs. 1, 2).
Chest tubes were used in 44% (1,542 of 3,467), and 21%
(714 of 3,467) of the patients required a tracheostomy. Inhospital complications included pneumonia in 21% (713 of
3,467), ARDS in 14% (480 of 3,467), sepsis in 7% (255
of 3,467), and death in 16% (544 of 3,467) of the population
(Fig. 1). Epidural catheters were used in 8% (263 of 3,467) of

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Dehghan et al.

Figure 1. Outcomes, morbidity and mortality for 3,467 patients identied with ail chest injury.

the patients, and surgical xation of the chest wall was performed in only 0.7% (24 of 3,467) of the patients.

Patients With Severe Head Injury

Severe head injury (dened as head AIS score Q 3 and a
motor GCS score e 4) was present in 15% (523 of 3,467) of
the patients. When comparing the outcomes of patients with
severe head injury with those without a documented severe
head injury, there were statistically signicant higher rates of
complications and poor outcomes in all categories.
Compared with those without a severe head injury, patients with a severe head injury had statistically signicant
increase in rates of need for mechanical ventilation (88% vs.
54%, p G 0.00001) and ICU stay (89% vs. 81%, p G 0.00001).

They also had more days on a mechanical ventilator (11.2 vs.

6.5, p G 0.001), more days in the ICU (13.4 vs. 8.9, p G 0.001),
and more days in the hospital (21.4 vs. 15.8, p G 0.0005).
(Fig. 2, Tables 1 and 2)
With regard to other outcomes, patients with a severe
head injury compared with those without severe head injury also
had higher rates of chest tube use (51% vs. 43%, p G 0.001),
tracheostomy (34% vs. 18%, p G 0.0001), pneumonia (31% vs.
19%, p G 0.0001), ARDS (17% vs. 13%, p G 0.016), sepsis (11% vs.
7%, p G 0.001), and death (40% vs. 11%, p G 0.0001) (Fig. 3).
These patients were also less likely to receive an epidural
catheter for pain management (1% vs. 9%, p G 0.0001), while
there was no difference between rates of surgical xation between the two groups (Fig. 3, Table 1).

Figure 2. Number of days on mechanical ventilation, ICU stay, total hospital stayVbased on injury pattern.
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Dehghan et al.

TABLE 1. Complications and Outcomes for Patients with Flail Chest Injury - Based on Injury Pattern
No Severe
Head Injury

All patients

With Severe
Head Injury

No Pulmonary
Contusion

With Pulmonary
Contusion

Outcomes

Percentage

Percentage

Percentage

Percentage

Percentage

No. patients
Mechanical ventilation
ICU admission
Chest tube
Tracheostomy
Pneumonia
ARDS
Sepsis
Death
Epidural use
Open reduction and
internal xation
chest wall

100
59
82
44.5
20.6
20.6
13.8
7.4
15.7
7.6
0.7

3,467
1,762
2,767
1,542
714
713
480
255
544
263
24

85
54
81
43.3
18.2
18.8
13.2
6.7
11.4
8.7
0.6

2,944
1,369
2,306
1,276
535
553
390
198
337
257
18

15
88
89
50.9
34.2
30.6
17.2
10.9
39.6
1.1
1.1

523
393
461
266
179
160
90
57
207
6
6

0.00001*
0.00001*
0.0014*
0.0001*
0.0001*
0.0156*
0.0008*
0.0001*
0.0001*
0.17

46
56
80
41.8
20.9
18.7
13.1
6.8
16.1
6.7
0.4

1,587
778
1,229
663
332
297
208
108
255
107
7

54
61
84
46.8
20.3
22.1
14.5
7.8
15.4
8.3
0.9

1,880
984
1,538
879
382
416
272
147
289
156
17

0.005*
0.003*
0.003*
0.66
0.013*
0.25
0.25
0.57
0.08
0.10

*Statistical signicance, p G 0.05

Patients With Pulmonary Contusion

Of the 3,467 patients, 54% (1,880 of 3,467) had a documented lung contusion. When comparing patients with pulmonary contusion with those without contusion, there was a
statistically signicant increase in the rate of mechanical
ventilation (61% vs. 56%, p G 0.005), time on the ventilator
(7.3 days vs. 7.0 days, p G 0.016), need for ICU admission
(84% vs. 80%, p G 0.003), days spent in the ICU (9.9 days vs.
9.2 days, p G 0.0032), and total days in the hospital (17.1 days vs.
16.1 days, p G 0.018). Patients with pulmonary contusions
also had higher rates of chest tube placement (47% vs. 42%,
p G 0.003) and pneumonia (22% vs. 19%, p G 0.013). While
these were statistically signicant, the magnitude of the difference was not as great as when comparing patients with presence
or absence of severe head injury. There were no differences with
regard to the rate of tracheostomy, ARDS, sepsis, or death. There
were also no differences between the two groups with regard
to use of epidural catheters for pain or surgical xation of the
chest wall (Tables 1 and 2).

Treatment ModalitiesVEpidural Catheters,

Surgical Fixation of the Chest Wall
Epidural catheters were used in 8% (283 of 3,467), and
only 24 of the 3,467 patients underwent surgical xation of
their ail chest (0.7%).

DISCUSSION
The current treatment of severe chest wall injuries consists of nonsurgical management via intubation and intermittent positive pressure ventilation (internal pneumatic splint),
analgesia, pulmonary toilet, and chest physiotherapy.1,4,6 Patients with severe chest wall injuries have been reported to have
high rates of morbidity and mortality, and studies have shown
that only 43% of such patients return to their previous full-time
employment.10 Many patients complain of chronic pain, subjective dyspnea, chest tightness, and chest wall deformity10,11
and have low scores on the SF-36.12

TABLE 2. Days on Mechanical Ventilation, ICU Stay, Total Hospital StayVBased on Injury Pattern

All Patients
Outcomes
Day on mechanical ventilation
Ventilated patients only
All patients
Days in ICU
Patients admitted to ICU only
All patients
Days in hospital

No Severe
Head Injury

With Severe
Head Injury

No Pulmonary
Contusion

With
Pulmonary
Contusion

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Mean

SD

12.1
7.2

11.0
12.0

12.0
6.5

11.9
10.6

12.7
11.2

12.1
12.1

0.60
0.001*

12.4
7.0

12.1
11.0

11.9
7.3

11.9
11.0

0.91
0.016*

11.7
9.6
16.6

11.8
12.0
16.0

11.0
8.9
15.8

11.6
11.3
14.6

15.0
13.4
21.4

13.4
13.5
21.7

0.0001*
0.001*
0.0005*

11.5
9.2
16.1

11.9
11.6
15.6

11.8
9.9
17.1

12.1
11.9
16.3

0.242
0.0032*
0.018*

*Statistical signicance, p G 0.05

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465

J Trauma Acute Care Surg

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Dehghan et al.

Figure 3. Outcome for patients with ail chest, based on head injury.

This study of 3,467 patients with a ail chest injury

demonstrated high rates of morbidity and mortality. More
than 80% of patients required ICU admission, for a mean of
11.7 days. Mechanical ventilation was used in a large proportion (59%) of patients, and those on a mechanical ventilator
had a mean of 12.1 ventilation days. Long-term mechanical
ventilation has many complications. Prolonged mechanical
ventilation in patients with chest trauma has been reported
to result in high rates of pneumonia, barotrauma, sepsis, ICU
stay, and death.1,2,4,5,7,8 Decreasing the number of days on
mechanical ventilation may result in decreased morbidity
and mortality and may dramatically decrease medical costs.
The average hospital cost of mechanical ventilation/ICU stay
for trauma patients in the United States is approximately
$3,500 per day;13 decreasing the length of stay by even a few
days can produce dramatic savings in health care expenses.
There have been a number of studies demonstrating
the benet of surgical xation of severe chest wall injuries,2,5,7,8,14
including fewer days on mechanical ventilation,5,7Y9 decreased
length of ICU stay,2,5,7,8 fewer chest infections,5,7,8 and less
chronic pain,2 while improving long-term respiratory function15,16 and promoting earlier return to work.8 There are three
previously published randomized controlled trials on this topic.5,8,17 Tanaka et al.8 demonstrated that patients with surgical
xation were extubated a mean of 2.5 days postoperatively,
compared with 18.3 days in the nonoperative group. Granetzky
et al.5 reported 2 days of mechanical ventilation in the surgical
group, compared with 12 days in the nonsurgical group. However, these randomized controlled trials have been criticized
for small sample size, outdated methods of surgical xation
(K-wires, Judet struts, absorbable plates), and vague inclusion/
exclusion criteria. We believe there is a need for a large, multicenter, well-designed, randomized controlled trial in this area,
to better assess the benets of surgical xation versus nonoperative care for trauma patients with ail chest injuries.
Given the increased interest in surgical xation in recent
years,18,19 we sought to determine if this translated into more
466

patients being treated with surgical intervention. Contrary

to our expectations, a very small proportion of patients were
treated with surgical xation (24 of 3,467, or 0.7%). This could
be caused by the fact that the data were collected from 2007
to 2009, and it is possible that xation rates have increased
since that time. It could also mean that despite numerous recent published series of surgical xation of ail chest injuries,
nonoperative treatment is still the overwhelming choice of
treatment.
The optimal nonoperative treatment of patients with
ail chest includes adequate pain management, via use of
epidural catheters, intercostal nerve blocks, or patient-centered
analgesia.6 The use of epidural catheters seems to be the most
preferred method, with improved outcomes and lower complications compared with other methods.6,20Y22 Compared with
intravenous narcotic use, epidural catheters allow for improved
subjective pain perception, pulmonary functions tests, lower
rate of pneumonia, as well as decreased length of time on a
mechanical ventilator or ICU stay.6,20,21 They also have lower
rate of complications such as respiratory depression, somnolence, and gastrointestinal symptoms.6 Epidural catheters have
also been compared with intrapleural catheters in a previous
randomized controlled trial and have shown to decrease pain
and improve tidal volume and negative inspiratory pressures.22
While we were unable to assess the number of patients treated
with intercostal nerve blocks or patient-centered analgesia, we
were able to examine the use of epidural catheters for patients
with ail chest injuries, and we were able to determine that
these were seldom used (8%). While coding validity remains
unknown, such a low number raises the possibility of underuse.
The literature supports the suspicion that patients with
ail chest injury, with concurrent severe head injury or pulmonary contusion, have poor outcomes. In addition, the literature on surgical xation of such injuries consistently reports
severe head injury and pulmonary contusion as exclusion
criteria for surgical xation. The reason suggested is that the
primary early benet of surgical xation is decreased time on
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J Trauma Acute Care Surg

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Dehghan et al.

mechanical ventilation; however, patients with head injury

and pulmonary contusion may require long-term mechanical
ventilation and do not attain the benets of early extubation.
Based on the results of this study, we can conrm that patients
with a ail chest and severe head injury have poor outcomes
in all categories compared with patients without severe head
injury. These patients had an increased rate of need for mechanical ventilation and time on a ventilator and had higher
rates of chest tube placement, pneumonia, ARDS, and sepsis.
Tracheostomy was performed almost twice as often, and the
death rate was more than 3.5 times higher than patients without
a severe head injury. Further research in this area is warranted
to help improve outcomes of this subset of patients with ail
chest injuries.
With respect to the impact of pulmonary contusion, there
were statistically signicant differences, of a much smaller
magnitude compared with the effect of head injury. This may
be caused by variability in coding this injury and a lack of a
clear denition for pulmonary contusion. Whether these were
diagnosed based on radiologist reports of imaging or more
objective tests such as bronchoalveolar lavage is unknown.
Many patients with blunt chest injuries have pulmonary contusions, but the severity of this entity may determine outcome.
Patients with extensive pulmonary contusion may have worse
outcomes compared with those without. However, including
all patients with contusions, whether small or extensive, and
using less than optimal criteria result in difculty in the interpretation of results. There is currently no widely used classication of pulmonary contusions, and there is a need for a
more consistent method of diagnosis and classication of these
injuries.
The limitations of this study are its retrospective nature;
there were missing data for some of the outcomes, and the validity of coding remains unknown. Given the heterogeneity of
head injuries and coding uncertainty around pulmonary contusions, multivariable analyses of these conditions were not performed. The strengths are that we have attempted to restrict our
analysis to centers that code accurately and have been able to
identify one of the largest populations of patients with ail chest
injuries in the literature to date.

CONCLUSION
Patients who have sustained a ail chest have signicant
morbidity (ICU admission, 82%; mechanical ventilation, 59%;
need for chest tube, 44%; tracheostomy, 21%; ARDS, 14%;
sepsis, 7%) and a high rate of mortality (16%). Patients with
concurrent severe head injury have signicantly worse outcomes compared with those without a severe head injury on all
parameters studied. Patients with concurrent pulmonary contusion also had poor outcomes, although the magnitude of this
difference was less than that seen with the presence of severe
head injury.
More than 99% of patients with ail chest injuries were
treated without surgical intervention, and only a small proportion (8%) received aggressive pain management with epidural
catheters. Given the high rates of morbidity and mortality in
patients with ail chest injuries, alternate methods of treatment

need to be investigated, such as more consistent use of epidural

catheters for pain or surgical xation. Previous small randomized trials have suggested improvements with surgical xation of
these injuries, although this practice is neither widely accepted
nor practiced in North America, with only 0.7% of ail chests
being surgically treated. More research in this area is warranted
to help improve patient outcomes. A large multicenter randomized controlled trial comparing modern surgical techniques
versus nonoperative care for trauma patients with ail chest
injuries is required.

AUTHORSHIP
N.D. and A.N. performed the literature search. N.D., C.D.M., and
M.D.M. designed this study. C.D.M. collected the data. N.D. and
C.D.M. analyzed and interpreted the data. All authors participated in
writing and critically revision.

DISCLOSURE
The authors declare no conicts of interest.

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