Author		Article		Publication		Year
Ahmed Z, Mohyuddin Z		Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation		J Thorac Cardiovasc Surg. 1995 Dec;110(6):1676-80		1995
Samarrai AR		Costosynthetic stabilization of massive chest wall instability		Int Surg. 1990 Oct-Dec; 75(4):231-3		1990
M.A. Kerr-Valentic, et al.		Rib fracture pain and disability: Can we do better?		J Trauma. 2003 June;54(6):1058-1064		2003
Mohr M, Abrams E, Engel C, Long WB, Bottlang M		Geometry of Human Ribs Pertinent to Orthopaedic Chest-Wall Reconstruction		J Biomech. 2007;40(6):1310-7		2007
Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S		Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients		J Trauma. 2002;52(4):727-32; discussion 32		2002

Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995;110:1676-1680.

A total of 427 patients with major chest trauma were treated in two major hospitals in Abu Dhabi, United Arab Emirates, during a 10-year period. In 64 of 426 patients, flail chest injury was the dominant factor among other injuries that were insignificant. Among 64 cases of flail chest injury, 26 were managed by internal fixation of ribs, whereas the remaining 38 were managed by endotracheal intubation and intermittent positive-pressure ventilation alone.

Of the patients treated by internal fixation 80% (21/26) were weaned from the ventilator within an average of 1.3 days, whereas the remaining 20% (5/26) continued to need assisted ventilation for a longer duration; the total average duration of assisted ventilation for the whole group was 3.9 days. In comparison, among 38 patients with flail chest injury treated by endotracheal intubation and ventilation alone, the average duration of assisted ventilation was 15 days. In the group treated by internal fixation 11% (3/26) of the patients ultimately required a tracheostomy, whereas in the patients treated by intubation and ventilation alone tracheostomy was required in 37% (14/38) of the cases. In the group treated by internal fixation, chest infection was documented in 15% (4/26), septicemia in 4% (1/26), and barotrauma in 0%; in the other group these complications occurred in 50% (19/38), 24% (9/38), and 8% (3/38) of the cases, respectively. The mortality rate was 8% (2/26) in the surgically treated patients, whereas it was 29% (11/38) in the other group. All the deaths in both groups were ascribed to adult respiratory distress syndrome. Average stay in the intensive care unit was 9 days for the patients treated by internal fixation, whereas it was 21 days in the group treated by intubation and ventilation alone.

The treatment of flail chest injury in our series by internal fixation resulted in speedy recovery, decreased complications, and better ultimate cosmetic and functional results and proved to be cost effective.

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Samarrai AR. Costosynthetic stabilization of massive chest wall instability. Int Surg. 1990 Oct-Dec;75(4):231-3.

Operative stabilization of massive chest wall instability is described in 38 patients. 35 patients were young combat casualties with penetrating chest injuries operated upon at front hospitals with limited resources, two patients sustained automobile accidents with blunt thoracic trauma resulting in an extensive flail chest and one patient with elective chest wall resection for soft tissue sarcoma. Intramedullary K-Wires were universally used as costosynthetic stabilizers.

The results were classified as good to excellent in comparison to non operative or other complex operative procedures and a very low mortality rate was achieved as compared to our past experience and the surgical literature.

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M. A. Kerr-Valentic, et al. Rib Fracture Pain and Disability: Can we do better?. J Trauma. 2003 June;54(6): 1058-1064.

OBJECTIVE: The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series.

METHODS: Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0-10). Disability at 30 days was assessed using the SF-36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university-based Level I trauma center.

RESULTS: Forty patients with a mean of 2.7 +/- 1.6 rib fractures were enrolled. Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 +/- 2.1 at 30 days and 1.0 +/- 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p < 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p < 0.001). The total mean days lost from work/usual activity was 70 +/- 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 +/- 39 days compared with 91 +/- 33 days in patients with associated extrathoracic injuries (p < 0.01).

CONCLUSION: Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.

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Mohr M, Abrams E, Engel C, et al. Geometry of human ribs pertinent to orthopedic chestwall reconstruction. J Biomech 2007;40:1310-1317.

Orthopedic reconstruction of blunt chest trauma can aid restoration of pulmonary function to reduce the mortality associated with serial rib fractures and flail chest injuries. Contemporary chest wall reconstruction requires contouring of generic plates to the complex surface geometry of ribs. This study established a biometric foundation to generate specialized, anatomically contoured osteosynthesis hardware for rib fracture fixation.

On human cadaveric ribs three through nine, the surface geometry pertinent to anatomically conforming osteosynthesis plates was characterized by quantifying the apparent rib curvature CA, the longitudinal twist alpha LT along the diaphysis, and the unrolled curvature CU. In addition, the rib cross-sectional geometry pertinent to intramedullary fixation strategies was characterized in terms of cross-section height, width, area, and cortex thickness. The rib surface exhibited a curvature CA ranging from 3.8m-1 in the anteromedial section of rib seven to 17.3 m-1 in the posterior section of rib three. All ribs had in common a longitudinal twist alpha LT, ranging from 41–60 degrees. The unrolled curvature CU decreased gradually from ribs three to five, and increased gradually with reversed orientation from rib six to nine. The cross-sectional area remained constant along the rib diaphysis. However, the medullary canal increased in size from 29.9 mm2 posteriorly to 41.2 mm2 in anterior rib segments.

Results of this biometric rib characterization describe a novel strategy for intraoperative plate contouring and provide a foundation for the development of specialized rib osteosynthesis strategies.

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Tanaka A, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002 Apr;52(4):727-32; discussion 732.

BACKGROUND: We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support.

METHODS: Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukey's test was used to compare the groups.

RESULTS: Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and Pao2/Fio2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19).

CONCLUSION: This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.

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