ORIGINAL ARTICLE

OTA Highlight Paper

Early Surgical Stabilization of Flail Chest With Locked

Plate Fixation
Peter L. Althausen, MD, MBA,* Steven Shannon, BS, Chad Watts, BS, Kenneth Thomas, MD,*
Martin A. Bain, MD, FACS, Daniel Coll, P-AC, MHS, Timothy J. OMara, MD,*
and Timothy J. Bray, MD*

Objectives: To compare the results of surgical stabilization with

locked plating to nonoperative care of flail chest injuries.

Design: Retrospective casecontrol study.

Setting: Level II trauma center.
Patients/Participants: From January 2005 to January 2010,

compared with case-matched controls, operatively managed patients

demonstrated improved clinical outcomes. Locked plate fixation
seems to be safe as no complications associated with hardware
failure, plate prominence, wound infection, or nonunion were noted.
Key Words: flail chest, rib fractures, ORIF, surgical stabilization
(J Orthop Trauma 2011;25:641648)

22 patients with flail chest treated with locked plate fixation were
compared with a matched cohort of 28 nonoperatively managed
patients at our institution.

Intervention: Open reduction internal fixation of rib fractures with

2.7-mm locking reconstruction plates.
Main Outcome Measurements: Demographic data, such as
age, sex, injury severity score, number of fractures, and lung contusion
severity, were recorded. Intensive care unit data concerning length of
stay (LOS), tracheostomy, and ventilator days were noted. Operative
data, such as time to OR, operative time, and estimated blood loss,
were recorded. Hospital data, including total hospital LOS, need for
reintubation, and home oxygen requirements, were documented.
Results: Average follow-up period of operatively managed patients
was 17.84 6 4.51 months, with a range of 1322 months. No case of
hardware failure, hardware prominence, wound infection, or nonunion was reported. Operatively treated patients had shorter intensive
care unit stays (7.59 vs. 9.68 days, P = 0.018), decreased ventilator
requirements (4.14 vs. 9.68 days, P = 0.007), shorter hospital LOS
(11.9 vs. 19.0 days, P = 0.006), fewer tracheostomies (4.55% vs.
39.29%, P = 0.042), less pneumonia (4.55% vs. 25%, P = 0.047), less
need for reintubation (4.55% vs. 17.86%, P = 0.34), and decreased
home oxygen requirements (4.55% vs. 17.86%, P = 0.034).

Conclusions: This study demonstrates the potential benefits of

surgical stabilization of flail chest with locked plate fixation. When

Accepted for publication May 13, 2011.

From the *Reno Orthopaedic Clinic, Reno, NV; University of Nevada
Medical School, Reno, NV; Western Surgical Group, Reno, NV; and
Renown Regional Medical Center, Reno, NV.
Presented in part at the Annual Meeting of the Orthopaedic Trauma
Association, 2010, Baltimore, MD.
No funds were received in support of this work.
No benefits in any form have been or will be received from a commercial party
related directly or indirectly to the subject of this manuscript.
Reprints: Peter L. Althausen, MD, MBA, Reno Orthopaedic Clinic, 555 North
Arlington Avenue, Reno, NV 89503 (e-mail: palthausen@sbcglobal.net).
Copyright 2011 by Lippincott Williams & Wilkins

J Orthop Trauma  Volume 25, Number 11, November 2011

INTRODUCTION
Flail chest is an important clinical finding that occurs in
approximately 10% of patients with chest trauma.1 Its presence
alone carries an associated mortality rate of 10%15%.1 The
therapeutic approach to the management of flail chest has
become a matter of recent controversy.2,3 The standard of care
has been selected ventilatory support and tracheostomy when
indicated.4,5 Continuous epidural anesthesia is beneficial and
has been shown to reduce both intensive care unit (ICU) and
total hospital length of stay (LOS).6 Nonoperative treatment
algorithms can be complicated by prolonged ventilatory
support, posttraumatic pneumonia, empyema, respiratory
insufficiency, and chronic pain from fracture nonunion.2,7,8
Long-term disability is reported in over one-third of these
patients.811 These outcomes have resulted in substantial
hospital and societal costs.
Over the past 30 years, the benefits of surgical
stabilization have been reported in several small cases
series.1216 These reports suggest that the pulmonary improvement resulting from open reduction internal fixation shortens
the duration of intubation, decreases ICU LOS, lowers the
incidence of pneumonia, improves pulmonary function
testing, restores chest wall continuity, and allows patients to
return to work more quickly.1216 A recent casecontrol study
by Nirula et al17 demonstrated a trend toward fewer total
ventilator days and no difference in total hospital or ICU LOS.
Tanaka et al4 compared 18 patients treated with surgical
stabilization with 19 patients treated with internal pneumatic
stabilization and found statistically shorter ventilator times
and ICU stays, as well as a lower incidence of pneumonia and
reduced hospital costs. Similar results were reported by
Granetzny et al,18 who demonstrated statistically fewer
ventilator, ICU, and hospital days in addition to fewer cases
of chest infection in operatively managed patients. Despite
these encouraging results, some studies have reported plate
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J Orthop Trauma  Volume 25, Number 11, November 2011

failure, screw loosening, and hardware prominence requiring

removal.1216 With the advent of locking, low profile plates, the
incidence of these complications may be decreased. Our
hypothesis was that patients treated with surgical stabilization
would have fewer cases of hardware failure and shorter ICU
LOS, decreased ventilatory requirements, shorter hospital
LOS, fewer cases of pneumonia or re-intubation, and less need
for tracheostomy.

PATIENTS AND METHODS

After obtaining approval from our institutional review
board, our institutional database was queried to identify
patients with flail chest treated with locked plate fixation from
January 2005 to January 2010. A retrospective clinical and
radiographic review was performed. Patients aged 1965 years
who presented with the diagnosis of flail chest were eligible
for study. Flail chest was defined as fractures of 4 or more ribs
fractured at more than 2 sites.2,4,18 (Fig. 1) Patients with
a visible flail segment or lung herniation were also included for
study. Only patients with a supplemental O2 requirement were
considered for surgical intervention. Data with regard to age,
sex, mechanism, injury severity score (ISS), number of rib
fractures, and severity of lung contusion were collected.
Exclusion criteria included patients with severe spinal cord
injury (loss of diaphragm control), GCS ,8, ICP monitoring,
ARDS, active preexisting infection, preexisting cardiac or
pulmonary conditions, and pregnant women. Number of rib
fractures was determined on review of the admission chest
computed tomography (CT). The presence of an associated
pulmonary contusion was determined by review of the
admission chest radiograph and review of initial CT scans.
These were graded according to the pulmonary contusion
score defined by Balci et al.19 Acute pulmonary herniation was
defined as lung moving between fractured ribs on respiration
and confirmed by CT scan (Fig. 2).
All patients with flail chest at our institution received
multimodal therapy on presentation to the emergency room.
Indications for intubation in the emergency room included the
presence of hypoxia and/or hypercarbia, associated head

FIGURE 1. Three-dimensional CT reconstruction demonstrating flail chest with 9 fractured ribs.

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FIGURE 2. Axial CT scan demonstrating lung herniation.

trauma with unconsciousness, or presence of airway obstruction. Once in the ICU, patients received continuous pulmonary
physiotherapy, mechanical ventilation if needed, continuous
epidural anesthesia, bronchoscopic aspiration, postural drainage, and administration of systemic antibiotics.
Of the patients identified with flail chest injuries
according to standard definitions,2,4,18 indications for surgical
intervention included nonintubated patients with respiratory
failure despite continuous epidural anesthesia and pulmonary
secretion clearance, patients with extensive anterolateral flail
chest and progressive displacement of fractured ribs, intubated
patients with flail chest who failed to wean from the ventilator,
and patients with flail chest who required a thoracotomy due to
associated intrathoracic injury.
Fracture fixation was undertaken using a lateral approach
performed in conjunction with one of our institutions trauma
surgeons. This combined team approach between general
surgery and orthopaedics was always followed up, each serving
as a cosurgeon. It is our belief that the best outcomes will
occur when orthopaedic surgeons trained in the techniques
of osteosynthesis perform fracture fixation while the general
surgeons are present to address any concerns with lung
parenchyma, vascular injury, chest tube placement, and ICU
management. General anesthetic was administered, and selective bronchial intubation was not performed. Selective bronchial intubation means that the endotracheal tube is placed
to leave the operative lung deflated for the duration of the
procedure. The latissimus dorsi muscle was divided, and the
serratus anterior muscle was dissected to obtain visualization
of the ribs. A scapular retractor was often used to gain access to
fractures beneath the scapular body. The fractured ribs were
individually exposed with limited additional periosteal
dissection. Intercostal muscles were not dissected to preserve
respiratory function (Fig. 3). The ribs were treated with
contoured 2.7-mm locking reconstruction plates (Smith &
Nephew, Memphis, TN). Fractures were reduced with standard
techniques using pointed reduction clamps and initial nonlocking screws to obtain compression. Once reduction was
obtained, bicortical locking screws were placed on either side
of the fracture. At least 3 bicortical screws were used on either
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J Orthop Trauma  Volume 25, Number 11, November 2011

Flail Chest Stabilization With Locked Plate Fixation

FIGURE 3. Surgical approach demonstrating thoracotomy,

scapular retractor, and minimal stripping.

side of the fracture line (Figs. 4, 5A, B). All fractures visible
through this approach were addressed with internal fixation.
Far posterior fractures were not treated. Visible segmental
fractures were stabilized with dual plating or a single 14-hole
plate, depending on fracture pattern, location, and accessibility.
A chest tube was then placed, and the wound was closed
in layers. Patients were transferred back to the ICU for
postoperative management.
Chest tubes were discontinued when output was less
than 150 cm3/d and when serial chest radiographs demonstrated no evidence of residual pneumothorax. The patients
were extubated according to strict criteria, including absence
of hypoxia (O2 saturation .92% on room air), stable
hemodynamics, consciousness, respiratory rate ,25 breaths
per minute, spontaneous breathing, tidal volumes .12 mL/kg,
and no obstruction of the airway.
Pneumonia was diagnosed when all the following
criteria were met: continued high fever (.38C) from time

FIGURE 4. Photograph demonstrating rib fixation in place.

q 2011 Lippincott Williams & Wilkins

FIGURE 5. A and B, Postoperative anteroposterior and lateral

radiographs demonstrating rib fixation.

of surgery, leukocytosis, infiltrate on chest radiographs, and

purulent expectorate or endotracheal aspirate from which
known pathogens were grown.
Operative patients were compared with a matched cohort
of nonoperatively managed patients with flail chest at our
institution. Power analysis was conducted to estimate the sample
size required for the study before data collection. With an
alpha level set at 0.05, for multiple linear regression, at least 35
subjects were required to achieve the minimal statistical power
of 0.80. Likewise, to achieve the same power 0.8 for correlation,
the minimal sample size was 29. Therefore, the sample size of
this study (N = 50) is sufficient for statistical analysis.
Patients were matched according to no statistical
difference existing between age, ISS, severity of pulmonary
contusion as defined by Balci et al,19 and number of rib
fractures. ICU data were collected on LOS, time on ventilator,
and need for tracheostomy. Operative data, such as time to OR,
operative time, and estimated blood loss (EBL), were gathered.
Total hospital LOS, need for reintubation, and home oxygen
requirements were recorded. The medical record was reviewed
to identify any complications of care such as posttraumatic
pneumonia, wound infection, plate failure, and nonunion.
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Althausen et al

Data were analyzed using standard statistical methods

by an independent statistician. Multiple linear regression was
applied when comparing means of days on ventilator, ICU
LOS, and hospital LOS between surgical and nonsurgical
groups, respectively, after adjusting age, sex, number of fractured ribs, grade of pulmonary contusion, and ISS. Multiple
logistic regression was used to compare the incidence of
pneumonia, need for reintubation, tracheostomy, and home
oxygen requirements between 2 groups, after adjusting for the
same variables above. Finally, Pearson correlation coefficient
was used for measuring the association between time to
operation and postoperative net ventilator days. The power
analysis was performed using R 2.10.1 for Windows.

RESULTS
The study group consisted of 22 operatively managed
patients and 28 case-matched controls. These groups were
similar in regard to age, sex, ISS, presence and severity of
pulmonary contusion, and number of rib fractures (Table 1).
Average follow-up period of operatively managed patients was
17.84 6 4.51 months, with a range of 1322 months.
Operatively managed patients had surgery from 1 to
5 days after injury, with a mean time to OR of 2.3 days.
Operative times for all fracture cases averaged 55 minutes
from incision to wound closure. EBL averaged 50 cm3. There
were no intraoperative complications. One patient required
reintubation, and 3 patients required tracheostomy. Mean
postoperative ventilator days were 1.81 days, and mean postoperative ICU days were 2.68 days. In contrast, nonoperative
patients spent 9.68 days on the ventilator and 9.68 days in the
ICU. One patient required home oxygen, and only 1 patient
was diagnosed with pneumonia. No cases of hardware failure,
hardware prominence, wound infection, or nonunion were
reported. Regression analysis demonstrated that the correlations between hospital LOS, days on ventilator, ICU LOS, and
time to operation are 0.483 (P = 0.031), 0.477 (P = 0.033), and
0.487 (P = 0.029), respectively (Table 2).
A comparison between operatively and nonoperatively
managed patients (Table 3) demonstrates that operatively treated
patients had shorter ICU stays (7.59 vs. 9.68 days, P = 0.018),
decreased ventilator requirements (4.14 vs. 9.68 days, P = 0.007),
shorter hospital LOS (11.9 vs. 19.0 days, P = 0.006), fewer
tracheostomies (4.55% vs. 39.29%, P = 0.042), less pneumonia
(4.55% vs. 25%, P = 0.047), less need for reintubation (4.55% vs.
17.86%, P = 0.34), and decreased home oxygen requirements
(4.55% vs. 17.86%, P = 0.034).
TABLE 1. Group Demographics

No. Patients
Age (yr)
Sex
ISS
No. rib fractures
Grade of pulmonary contusion

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Nonoperative
Group

22
47.7
5 F, 17 M
25.1
5.9
1.72

28
50.8
6 F, 23 M
24.3
7.3
1.65

N/A
0.445
N/A
0.8
0.186
0.756

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Pearson Coefficient

0.487
0.477
0.483

0.029
0.033
0.031

ICU LOS
Days on ventilator
Hospital LOS

DISCUSSION
Flail chest injuries have been defined by multiple
authors as fractures of 4 or more ribs fractured at more than
2 sites.2,4,18 This is a severe condition in which paradoxical
chest wall motion and rib fracture pain can result in low tidal
volumes, significant alveolar collapse, arteriovenous shunting,
and hypoxemia.13 As a result, flail chest injuries are associated
with high morbidity and mortality. Patients with multiple
rib fractures spend significantly longer intervals in ICUs
than trauma patients without rib fractures, thus resulting in
increased hospital costs and LOS.7 Options for treating
patients with rib fractures include operative and nonoperative
management strategies. Nonoperative management includes
extensive use of analgesics, aggressive pulmonary toilet, and
possible mechanical ventilation for significant flail chests.2,7
Fractured ribs managed nonoperatively are subjected to
continued displacement during the healing phase, which
may result in chest wall deformity, compromised lung volume,
and subsequent respiratory insufficiency.5 Movement at the
fracture site may ultimately lead to malunion or nonunion.20,21
Moreover, nonoperative management of rib fractures is
associated with substantial pain and discomfort for the
patient.811
Operative fixation of rib fractures is neither a new
concept nor a recent development. In the early 20th century,
surgeons recognized the high mortality associated with flail
chest and used external traction devices to stabilize the chest
wall.2229 Numerous complications of bed rest and technical
failures prompted consideration of internal fixation. In the
past 10 years, we have seen a resurgence of internal fixation
options. A variety of different techniques have been used
for the stabilization of rib fractures. These include Judet struts,
intramedullary Kirschner wires or nails,4,13,26 nonabsorbable
plates and screws,8,27,29,30 and most recently, bioabsorbable
plates and screws.31,32 With recent surgical techniques,
the operative fixation of flail chest injuries has been reported
to shorten the duration of mechanical ventilation, decrease the
incidence of pneumonia, decrease hospital LOS, and overall
TABLE 3. Operative vs Nonoperative Patients

Operative
Group

F, female; M, male.

TABLE 2. Association Between Time to Operation

Operative
Patients (Mean)
ICU LOS
Hospital LOS
Days on ventilator
Tracheostomy
Pneumonia
Reintubation
Home O2

7.59
11.9
4.14
13.64%
4.55%
4.55%
4.55%

(7.43)
(7.79)
(6.66)
(3/22)
(1/22)
(1/22)
(1/22)

Nonoperative
Patients (Mean)
9.68
19.0
9.68
39.29%
25%
17.86%
17.86%

(9.18)
(12.64)
(9.18)
(11/28)
(7/28)
(5/28)
(5/28)

P
0.018
0.006
0.007
0.042
0.047
0.034
0.034

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medical expenses.2,4,18 More striking is the reported reduction

in mortality of 29% to 8% attributed to operative stabilization
of rib fractures versus conventional nonoperative management
in some studies.13
Despite these reports, operative stabilization of rib
fractures and flail chest remains a controversial and underused
procedure.32,33 A recent survey of American trauma, orthopaedic, and thoracic surgeons demonstrated a broad range of
opinions regarding the indications for operative repair of rib
and sternal fractures. Among the specific clinical scenarios
posed by this survey for the operative repair of rib fractures,
the presence of a chest wall defect with pulmonary hernia was
the only indication supported by a majority of respondents.
Despite randomized trials published in peer review journals
supporting surgical fixation of flail injuries,2,4,18 a minority of
respondents supported operative fixation for flail chest.
Furthermore, the majority of surgeons surveyed were unaware
of these trials.34

Operative Outcomes
Our operative data are similar to that of other studies.
When performed in a team approach between a general
surgery trauma surgeon and orthopaedic surgeon, rib fixation
becomes a quick and efficient procedure with short operative
times, minimal EBL, and a low complication rate. Standard
locking plate and screw configurations were used, and no
episodes of hardware failure occurred in our series. We believe
that this success stems from the fact that the thoracotomy, lung
decortications, and chest tubes were done by a general surgeon
and fixation was performed by an orthopaedic trauma surgeon,
both adhering to surgical principles from their training. Many
articles have been presented using various fixation devices
from 3.5 plates to absorbable plates to Judet struts.2,4,13,32,35
Locking fixation clearly has the advantage of decreasing screw
loosening or plate and screw disassociation. However, clearly,
many devices can work for fixation. We believe, it is the team
approach and adherence to principles of orthopaedic instrumentation, minimal tissue stripping, protection of intercostal
muscles, pleura, and lung tissue that makes for a successful
outcome.

Early Operative Intervention

During data review, it was observed that patients treated
earlier may have better short-term outcomes. Regression
analysis in our series did show a positive correlation between
hospital LOS, days on ventilator, ICU LOS, and time
to operation. These values are 0.483 (P = 0.031), 0.477
(P = 0.033), and 0.487 (P = 0.029), respectively. These were
all statistically significant findings, suggesting that patients
may benefit from operative intervention as soon as they can be
cleared for surgery. This has not been reported by other authors
and indicates that patients with flail chest treated expeditiously
may have better short-term outcomes.

Hardware Loosening
In our series using locked fixation, no cases of hardware
failure or screw disassociation were reported. In the study of
Lardinois et al,14 radiological evaluation showed disassociation
of screws and plates in 2 patients. Ahmed and Mohyuddin13
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Flail Chest Stabilization With Locked Plate Fixation

performed fixation with Kirschner wires. Several wires

migrated and required subcutaneous removal. In the study
by Mayberry et al32 using bioabsorbable plates, 20% implant
failure and loss of reduction was noted. In another study
using stainless steel nonlocking plates, hardware loosening
was observed.14 In this same study, they also had a case of
prosthesis-related infection and osteomyelitis requiring repeat
surgical intervention. Locking fixation seems to be advantageous in rib fixation as no cases of nonunion, hardware
dissociation, or hardware migration were observed in this
series.

Ventilator Days
Ventilator usage is an important variable in the treatment
of flail chest as it indicates pulmonary stability and need for
ICU care and adds to hospital costs. The most recent study by
Nirula et al2 demonstrated a 6.5 day decrease in ventilator days
in patients treated with operative stabilization. In the study of
Ahmed and Mohyuddin,13 21 of 26 patients with flail chest
treated with ORIF were weaned from the ventilator in 1.3 days.
Of the patients treated with internal fixation, the average
ventilator time was 3.9 days. In comparison, their nonoperative
group managed by endotracheal intubation and ventilation
alone averaged 15 days on the ventilator. In the study by
Lardinois et al,14 immediate postoperative extubation was possible in 47% of patients and median postoperative intubation
was 2.1 days. Voggenreiter et al36 determined that early chest
wall stabilization within 48 hours permits extubation after
a mean ventilator time of 6.5 days. Our results support the
findings of these studies, showing an average ventilator time of
4.14 days of patients treated operatively and an average
ventilator time of 9.68 days in nonoperatively managed
patients. This was a statistically significant difference with
a P-value of 0.007. Immediate postoperative extubation was
possible in 18.18% of patients.

Pulmonary Contusion
When flail chest is combined with pulmonary contusion,
a longer period of mechanical ventilation and higher rate of
pulmonary complications has been noted by other authors.3638
Voggenreiter et al36 compared nonoperatively managed
patients with and without pulmonary contusion and found
that those without injury spent 6.5 days on the ventilator,
whereas patients with pulmonary contusions averaged 30.8
days. This trend was also observed in our study but was not
statistically significant. Surgical stabilization significantly
improved outcomes in these patients.

Tracheostomy
Tracheostomy is often indicated in patients with
pulmonary injury who fail to wean from a ventilator. In our
cohort of operatively treated patients, 3 (13.64%) of 22
patients required tracheostomy, whereas 11 (39.29%) of 28
patients of the nonoperative cohort required this procedure.
This was a statistically significant difference with a P-value of
0.042. In the study of Ahmed and Mohyuddin,13 11% of
operatively treated patients required tracheostomy, whereas
37% of nonoperative patients did. This is a clear advantage of
operative fixation as it avoids a secondary surgical procedure
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and the possible associated complications, such as bleeding

at the time of insertion, obstruction of the tracheostomy tube,
and stomal infection.39

Pneumonia
Ventilator-acquired pneumonia is a common end point
of prolonged intubation that can affect both short-term and
long-term outcomes. Freedland et al38 noted a 100% incidence
of pneumonia in patients requiring ventilator support for more
than 8 days. Tanaka et al4 demonstrated that with surgical
stabilization, the incidence of pneumonia was reduced from
77% to 24%. In our series, only 1 patient treated operatively
(4.55%) had an occurrence of pneumonia. Twenty-five percent
(7 of 28) of our nonoperatively managed patients developed
pneumonia requiring prolonged antibiotic therapy. This is
significant with a P-value of 0.047, demonstrating that surgical
stabilization dramatically decreases the incidence of pneumonia, which subsequently decreases ICU LOS, antibiotic usage,
risk for empyema, and ultimately the costs associated with the
treatment of flail chest.

Intensive Care Unit Days

Average ICU stay in the study by Ahmed and
Mohyuddin13 was 9 days for operatively managed group and
21 days for nonoperative group. Average ICU days in the study
by Lardinois et al14 was 6.8 days. Sirmali et al40 reported an
average of 11.8 days in ICU for all patients with rib fractures,
not just those meeting a diagnosis of flail chest. Mean days for
flail chest patients was 16.8 days, with an 18.7% mortality rate.
Solberg et al3 reported on surgical stabilization of patients with
a variety of chest wall implosion injuries and found that
ICU days were shortened from 16.7 to 5.7 days. Our study
demonstrated a significant difference in the ICU LOS of
operatively and nonoperatively treated patients. Operatively
managed patients spent a mean of 7.59 days in ICU, whereas
nonoperatively managed patients spent 9.68 days. This
was statistically significant with a P-value of 0.018. This
allows beds to be freed up for patients in need, avoids placing
hospital on divert, and decreases overall costs.

Hospital Length of Stay

Due to increasing financial pressures on hospital
systems, hospital LOS has become an important end point.
In a 2006 study, Nirula et al2 found no difference in the total
hospital LOS in operatively and conservatively managed
patients. In contrast, our study demonstrated a significant
difference in the lengths of stay for operatively and
nonoperatively treated patients. Operatively managed patients
had a mean hospital LOS of 11.9 days, whereas nonoperatively
managed patients spent a mean of 19 days in the hospital. This
was a statistically significant difference with a P-value of
0.006. This is much less than that reported by other authors,
such as Lardinois et al,14 whose operatively managed patients
had a median hospital LOS of 17.4 days. Clearly, surgical
stabilization results in decreased resource utilization, more
beds for elective patients, and decreased overall costs.

Hospital Costs
Our study clearly suggests that significant cost savings
may be associated with operative fixation. From the data

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J Orthop Trauma  Volume 25, Number 11, November 2011

presented in this study and those of other recent studies, it

seems logical that shorter ICU stay and hospital lengths of stay,
fewer secondary operations, and fewer ventilator-associated
complications would result in decreased hospital costs. Only
one other study is available for cost comparison of operatively
and nonoperatively treated patients. Tanaka et al4 looked at
the total medical cost of operatively versus nonoperatively
managed patients on the basis of public health insurance
in Japan and found operative patient expense of $5840 and
nonoperative expense of $23,423. In the era of cost containment and limited medical resources, fiscal responsibility
should be a part of medical decision making. Perhaps, this
indicates that surgical intervention should be expanded to
other forms of rib fractures to prevent the additional costs
associated with nonoperative treatment.

Long-term Outcomes
Other studies have demonstrated that rib fracture
patients are significantly more disabled at 30 days postinjury
than patients with chronic medical illness and lose an average
of 70 days of work or usual activity during their acute
recovery.11 Long-term outcome studies of patients with flail
chest injuries indicate that 50%60% of patients develop longterm morbidity, the most common problems being persistent
chest wall pain or deformity, and 20%60% of patients do not
return to full-time employment.9,10 Ten percent of patients
complained of residual chest wall discomfort at 6-month
follow-up, and 50% of patients improved after hardware
removal.12 Mayberry et al11 concluded that operative repair of
severe chest wall injuries is associated with low long-term
morbidity and pain, as well as health status equivalent to the
general population. In contrast, many studies have shown that
patients treated conservatively develop chronic pain and
disability and do not return to work or their preinjury quality of
life.911 Pulmonary function tests at 6 months after surgical
stabilization were normal in more than 50% of patients, with
90% having a total lung capacity greater than 85% predicted.14
Although financial analysis has not been performed on this
finding, operative management has the potential to decrease
the societal costs of chronic pain medicine, disability, and loss
of wages.

CONCLUSIONS
Open reduction and internal fixation of rib fractures is an
effective technique for the treatment of flail chest. The
objective of surgical stabilization is to provide stability for the
injured segments of the chest wall, reduce ventilator time,
decrease ventilator-associated complications, reduce deformity, and decrease chronic pain. This study demonstrates the
potential benefits of surgical stabilization of flail chest with
locked plate fixation. Operative intervention reduces the
duration of ventilator support and improves function. When
compared with case-matched controls, operatively managed
patients demonstrated improved clinical outcomes and
decreased hospital costs. Locked plate fixation seems to be
safe as no complications associated with hardware failure,
plate prominence, wound infection, or nonunion were noted.
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An evidence-based standard of care for the treatment of

rib fractures and flail chest has not been established. In light
of this study and several other small studies, it seems that
nonoperative management may be inadequate, subjecting
patients to longer ICU and hospital LOS and greater risk for
reintubation, tracheostomy, postoperative pneumonia, and
long-term disability. We argue that the greatest benefit from
rib fixation and mitigation of subsequent complications and
morbidity is realized by the prompt identification and
treatment of patients with acceptable indications for surgery.
This is a retrospective study. Like several other recent
studies, it supports the early treatment of flail chest injuries
with surgical stabilization. However, large-scale, multicenter
randomized clinical trials need to be conducted. Adequate
sample size necessary to obtain meaningful comparisons
will have to be determined using known rates of expected
outcomes, and for this to be accomplished, prospective, longterm studies of the duration of pain and disability of rib
fractures treated nonoperatively will be needed.
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11. Mayberry JC, Kroeker AD, Ham LB, et al. Long-term morbidity, pain, and
disability after repair of severe chest wall injuries. Am Surg. 2009;75:389
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12. Paris F, Tarazona V, Blasco E, et al. Surgical stabilization of traumatic flail
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compression osteosynthesisexperimental and clinical results. Thorac
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Althausen et al

Early Stabilization of Flail Chest With Locked

Plate Fixation
Traumatologists interest in the operative fixation of rib fractures in chest wall injury syndromes such as flail chest is in
renaissance. Although operative fixation of rib fractures was first advocated more than 60 years ago, the primitive techniques
used and the advent of internal stabilization by mechanical ventilation led to the procedures virtual abandonment.1
Recently, however, several issues have come to the attention of trauma surgeons that have stimulated this procedures rebirth.
The first is the recognition that many patients with flail chest treated nonoperatively do not liberate from the ventilator in as
timely a fashion as desired. Many develop nosocomial pneumonia, require tracheostomy, and have prolonged intensive care
lengths of stay. The second issue now recognized is that patients with flail chest often develop long-term pain and disability
associated with their chest wall injury, which acute fixation could theoretically alleviate. The third advance centers around the
development of sophisticated fracture fixation techniques, eg, locked plate fixation and rib specific prostheses.2,3 A relative
plethora of contemporary reports now indicates that rib fracture fixation can be performed with low morbidity and virtually no
mortality with improved outcomes compared with nonoperative controls.4 The National Institute for Health and Clinical
Excellence of the United Kingdom recently issued a guidance stating that stabilizing flail chest with metal implants may be
applied routinely.5
This report by Dr. Althausen and colleagues comparing their series of patients with flail chest repair with historical
controls similarly supports the potential benefits of flail chest operative fixation. Unique to this report and emphasized by the
authors are a willingness to intervene early (within 15 days), the exclusive use of locked plate fixation, attention to operative
details such as preserving the periosteum of the fixated ribs, and the cooperative management of the injured patient by
orthopaedic surgeons experienced in fracture fixation with general surgeons experienced in the management of pulmonary
and pleural space complications. The authors appropriately emphasize the technical challenges of fracture fixation in general
and rib fracture fixation in particular. Their excellent results support their expert and cooperative approach, which could be
emulated by trauma centers everywhere. Because rib fracture fixation is technically difficult, general trauma surgeons should
not hesitate to involve their orthopaedic surgeon colleagues in the conduct of this operation. Likewise, orthopaedic trauma
surgeons should be encouraged to add this unique procedure to their operative repertoire. Another option that has produced
excellent results at our trauma center is for the general trauma surgeon to be proctored in the principles of fracture fixation by
an orthopedic trauma surgeon.6 An additional recommendation I often propose to trauma centers is to limit the number of
different surgeons who perform this surgery. Because patients with flail chest are not common at many centers, not all general
or orthopaedic trauma surgeons at a particular center can be expected to gain proficiency. I extend my congratulations to the
authors on their collegial patient management and their superb results.
John Mayberry, MD
Professor of Surgery
Division of Trauma, Critical Care, and Acute Care Surgery
Oregon Health & Science University
Portland, OR

REFERENCES
1. Nirula R, Diaz JJ Jr, Trunkey DD, et al. Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009;33:1422.
2. Sales JR, Ellis TJ, Gillard J, et al. Biomechanical testing of a novel, minimally invasive rib fracture plating system. J Trauma. 2008;64:
12701274.
3. Helzel I, Long W, Fitzpatrick D, et al. Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures. Injury. 2009;40:
11041110.
4. Lafferty PM, Anavian J, Will RE, et al. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011;93:97110.
5. Insertion of metal rib reinforcements to stabilise a flail chest wall (IPG361). National Institute for Health and Clinical Excellence (NICE), 2010. Available
at: http://egap.evidence.nhs.uk/IPG361. Accessed April 26, 2011.
6. Mayberry JC, Kroeker AD, Ham LB, et al. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg. 2009;75:
389394.

J.M. has accepted honoraria for speaking engagements and consulting and has received research grant support from Acute Innovations, LLC, Hillsboro, OR.
Copyright 2011 by Lippincott Williams & Wilkins

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