Document Type: Original Article


Department of General and Thoracic Surgery, University Hospital “SS. Annunziata” , Chieti, Italy


Objective: Thoracic trauma may be a life-threatening condition. Flail chest is a severe chest injury with high mortality rates. Surgery is not frequently performed and, in Literature, data are controversial. The authors report their experience in the treatment of flail chest by an extracortical internal-external stabilization technique with Kirshner’s wires (K-wires).

Methods: From 2010 to 2015, 137 trauma patients (109 males and 28 females) with an average age of 58.89 ±19.74 years were observed. Seventeen (12.41%) patients presented a flail chest and of these, 13 (9.49%) with an anterior one. All flail chest patients underwent early chest wall surgical stabilization (within 48 hours from the injury).

Results: In the general population, an overall morbidity of 21.9% (n = 30 of 137) and a 30-day mortality rate of 5.1% (n = 7 of 137) were observed. By clustering the population according to the treatment (medical or interventional vs surgical), significant statistically differences between the two cohorts were found in morbidity (12.65% vs. 34.48%, P = 0.002) and mortality rates (1.28% vs. 10.34%, P = 0.017). In patients undergoing chest wall surgical stabilization, with an average Injury Severity Score of 28.3 ± 5.2 and Abbreviated Injury Score (AIS) of 8.4 ± 1.7, an overall morbidity rate of 52.9% (n = 9) and a mortality rate of 17.6% (n = 3) were found. Post-surgical device removal, in local anesthesia or mild sedation, was performed 42.8 ± 2.9 days after chest wall stabilization and no cases of wound infection, dislodgment of the wires or osteosynthesis failure were reported. Moreover, in these patients, an early postoperative improvement in pulmonary ventilation (ΔpaO2 and ΔpCO2: +9.49 and -5.05, respectively) was reported.

Conclusion: Surgical indication for the treatment of flail chest remains controversial and debated both due to an inadequate training and the absence of comparative prospective studies between various strategies. Our technique for the surgical treatment of the anterior flail chest seems to be anachronistic, but the aspects described, both in terms of technical features and of outcome and benefits (health, economic), allow to evaluate the effectiveness of this approach.


Main Subjects

1. Clark GC, Schecter WP, Trunkey DD. Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion. J Trauma 1988; 28(3): 298-304. doi:


2. Cannon RM, Smith JW, Franklin GA, Harbrecht BG, Miller FB, Richardson JD. Flail chest injury: are we making any progress? Am Surg 2012; 78(4): 398-402.

3. Jayle CP, Allain G, Ingrand P, Laksiri L, Bonnin E, Hajj-Chahine J, et al. Flail chest in polytraumatized patients: surgical fixation using Stracos reduces ventilator time and hospital stay. Biomed Res Int 2015; 2015: 624723. doi:10.1155/2015/624723.

4. Fowler TT, Taylor BC, Bellino MJ, Althausen PL. Surgical treatment of flail chest and rib fractures. J Am Acad Orthop Surg 2014; 22(12): 751-60. doi:10.5435/JAAOS-22-12-751.

5. Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward T 3rd, et al. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73(5 Suppl 4): S351-61. doi: 10.1097/TA.0b013e31827019fd.

6. Gunduz M, Unlugenc H, Ozalevli M, Inanoglu K, Akman H. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J 2005; 22(5): 325-9. doi: 10.1136/emj.2004.019786.

7. Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: an underused procedure? Am Surg 2007; 73(6): 591-6.

8. Landercasper J, Cogbill TH, Lindesmith LA. Long-term disability after flail chest injury. J Trauma 1984; 24(5): 410-4.

9. Mayberry JC, Ham LB, Schipper PH, Ellis TJ, Mullins RJ. Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. J Trauma 2009; 66(3): 875-9. doi: 10.1097/TA.0b013e318190c3d3.

10. Cataneo AJ, Cataneo DC, de Oliveira FH, Arruda KA, El Dib R, de Oliveira Carvalho PE. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev 2015; (7): CD009919. doi: 10.1002/14651858.CD009919.


11. Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative

management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg 2013; 258(6): 914-21. doi: 10.1097/SLA.0b013e3182895bb0.

12. Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg 2006; 72(4): 307-9.

13. Mayberry JC, Kroeker AD, Ham LB, Mullins RJ, Trunkey DD. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg 2009; 75(5): 389-94.

14. Avery EE, Benson DW, Morch ET. Critically crushed chests; a new method of treatment with continuous mechanical hyperventilation to produce alkalotic apnea and internal pneumatic stabilization. J Thorac Surg 1956; 32(3): 291-311.

15. Ginsberg RJ, Kostin RF. New approaches to the management of flail chest. Can Med Assoc J 1977; 116(6): 613-5.

16. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002; 52(4): 727-32.

17. Fitzpatrick DC, Denard PJ, Phelan D, Long WB, Madey SM, Bottlang M. Operative stabilization of flail chest injuries: review of literature and fixation options. Eur J Trauma Emerg Surg 2010; 36(5): 427-33. doi: 10.1007/s00068-010-0027-8.

18. Lardinois D, Krueger T, Dusmet M, Ghisletta N, Gugger M, Ris HB. Pulmonary function testing after operative stabilisation of the chest wall for flail chest. Eur J Cardiothorac Surg 2001; 20(3): 496-501.

19. Richardson JD, Adams L Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg 1982; 196(4): 481-7. doi: 10.1097/00000658-198210000-00012.

20. Tzelepis GE, McCool FD, Hoppin FG Jr. Chest wall distortion in patients with flail chest. Am Rev Respir Dis 1989; 140(1): 31-7. doi: 10.1164/ajrccm/140.1.31.

21. Paris F, Tarazona V, Blasco E, Canto A, Casillas M, Pastor J, et al. Surgical stabilization of traumatic flail chest. Thorax 1975; 30(5): 521-7. doi:10.1136/thx.30.5.521.

22. Judet R. Osteosynthese costale. Rev Chir Orthop Reparatrice Appar Mot 1973; 59(Suppl 1): 334-5. [in French].

23. Sanchez-Lloret J, Letang E, Mateu M, Callejas MA, Catalan M, Canalis E, et al. Indications and surgical treatment of the traumatic flail chest syndrome. An original technique. Thorac Cardiovasc Surg 1982; 30(5): 294-7. doi: 10.1055/s-2007-1022410.

24. Sales JR, Ellis TJ, Gillard J, Liu Q, Chen JC, Ham B, et al. Biomechanical testing of a novel, minimally invasive rib fracture plating system. J Trauma 2008; 64(5): 1270-4. doi: 10.1097/TA.0b013e31804a7fd5.

25. Ramponi F, Meredith GT, Bendinelli C, Söderlund T. Operative management of flail chest with anatomical locking plates (MatrixRib). ANZ J Surg 2012;82(9):658-9.

doi: 10.1111/j.1445-2197.2012.06159.x.

26. Bottlang M, Walleser S, Noll M, Honold S, Madey SM, Fitzpatrick D, et al. Biomechanical rationale and evaluation of an implant system for rib fracture fixation. Eur J Trauma Emerg Surg 2010;36(5):417-26. doi: 10.1007/s00068-010-0047-4.

27. Bemelman M, van Baal M, Yuan JZ, Leenen L. The role of minimally invasive plate osteosynthesis in rib fixation: a review. Korean J Thorac Cardiovasc Surg 2016; 49(1): 1-8. doi: 10.5090/kjtcs.2016.49.1.1.

28. Engel C, Krieg JC, Madey SM, Long WB, Bottlang M. Operative chest wall fixation with osteosynthesis plates. J Trauma 2005; 58(1): 181-6.

29. Shah TJ. On internal fixation for flail chest. J Thorac Cardiovasc Surg 1996; 112(3): 849-50.

30. Helzel I, Long W, Fitzpatrick D, Madey S, Bottlang M. Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures. Injury 2009; 40(10): 1104-10. doi: 10.1016/j.injury.2009.06.004.

31. Granhed HP, Pazooki D. A feasibility study of 60 consecutive patients operated for unstable thoracic cage. J Trauma Manag Outcomes 2014; 8(1): 20. doi: 10.1186/


32. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013; 216(5): 924-32. doi: 10.1016/j.jamcollsurg.2012.12.024.

33. Nolasco-de la Rosa AL, Mosiñoz-Montes R, Matehuala-García J, Román-Guzmán E, Quero-Sandoval F, Reyes-Miranda AL. Unstable thorax fixation with bioabsorbable plates and screws. Presentation of some cases. Cir Cir 2015;

83(1): 23-8. doi: 10.1016/j.circir.2015.04.019. [in Spanish]

34. Liovic P, Šutalo ID, Marasco SF. Fixation of a human rib by an intramedullary telescoping splint anchored by bone cement. Comput Methods Biomech Biomed Engin 2016; 19(12): 1297-305. doi: 10.1080/10255842.2015.1131979.

35. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg 2012; 215(2): 201-5. doi:10.1016/j.jamcollsurg.2012.02.023.