Medical Therapy
Internal pneumatic stabilization for flail chest was popularized in the 1950s, but this treatment has subsequently been shown to be unnecessary in most patients without respiratory compromise. In a mid-1970s report, Trinkle et al provided compelling evidence that many patients fared better with adequate pain control and pulmonary toilet (including medical management of their pulmonary injury) than those placed on mechanical ventilation. [15] This remains the standard today. Mechanical ventilation is reserved for patients with persistent respiratory insufficiency or failure after adequate pain control or when complications related to excessive narcotic use occur. Patient-controlled analgesia (PCA) machines, oral pain medications, and indwelling epidural catheters form the mainstay of current treatment.
Two recent clinical reports, one from Turkey (prospective) [16] and one from Japan (retrospective), [17] showed that continuous positive airway pressure (CPAP) by mask may decrease mortality and nosocomial pneumonia in the ICU, but CPAP by mask does not appear to change the length of ICU stay.
Surgical Therapy
Surgical stabilization of the chest was rarely considered necessary in the past, but increasing numbers of reports of positive outcomes in more severe cases are now available in the world literature. Both external (lower efficacy) and internal stabilization have been advocated, usually in reports from outside the United States. As previously noted in traumatic causes, however, severity of respiratory failure is less a result of either the paradoxical motion of the chest wall (tidal volume abnormalities) or chest wall instability. Accordingly, surgical stabilization is still not routinely performed, although many reports show a benefit in decreasing mechanical ventilator days, long-term outcome, and overall lower cost of hospitalization in select patients with severe flail chest. [18, 19, 20, 21, 22]
In general, operative fixation is most commonly performed in patients requiring a thoracotomy for other reasons or in cases of gross chest wall deformity. Flail chest from multiple myeloma, sternal absence, or total sternectomy more frequently responds well to surgical fixation. Underlying pulmonary injury with respiratory insufficiency resulting from changes in tidal volume and minute ventilation in these patients is rare.
A Cochrane Review evaluated the effectiveness and safety of surgical stabilization compared with clinical management for people with flail chest. The study found some evidence from three small studies that showed surgical treatment was preferable to nonsurgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical ventilation, and length of ICU stay. Further studies are needed to confirm these results. [23]
In a retrospective study involving 21 patients with flail chest who were admitted to a level I trauma center between September 2009 and June 2010, Doben et al examined the effectiveness of surgical rib fixation for patients in whom standard therapy had failed. Standard therapy consisted of pain control, aggressive pulmonary hygiene, positive pressure therapy with an acapella device, and frequent chest therapy (chest wall percussion, deep breathing, and coughing exercises). The surgical rib fixation surgeries were performed via a standard anterolateral or posterolateral muscle-sparing thoracotomy incision; ribs were reduced and internally fixated through use of osteosyntheses plates and intramedullary nails. Surgical rib fixation resulted in a significant decrease in ventilator days (4.5 vs 16.0), and the authors concluded that the technique may represent a means to decrease morbidity in patients with flail chest whose pulmonary status is declining. [24]
In a retrospective meta-analysis that included 11 studies with a total of 753 patients with flail chest, Slobogean et al compared the results of surgical fixation with those of nonoperative treatment. Surgical fixation resulted in better outcomes for all pooled analyses, including substantial decreases in ventilator days (mean, 8 days; 95% CI, 5 - 10 days) and the odds of developing pneumonia (odds ratio [OR] 0.2; 95% CI, 0.11 - 0.32). Additional benefits included decreased ICU days (mean, 5 days, 95% CI, 2 - 8 days), mortality (OR, 0.31; 95% CI 0.20 - 0.48), septicemia (OR, 0.36; 95% CI, 0.19 - 0.71), tracheostomy (OR, 0.06; 95% CI, 0.02 - 0.20), and chest deformity (OR 0.11; 95% CI, 0.02 - 0.60). The authors concluded that surgical fixation offers substantial clinical benefits over nonopoerative treatment. [25]
Preoperative Details
Assessment of the severity of underlying pulmonary contusion versus chest wall instability should direct the need for surgical fixation. Preoperatively, a double-lumen endotracheal tube should be considered in patients with flail chest undergoing fixation.
Intraoperative Details
The current literature suggests that both ends of a fractured rib must be stabilized for operative intervention to be most effective. Judet struts, Kirschner (K-) wires, and even prosthetic mesh secured with methylmethacrylate techniques have been described in the literature, but no large randomized prospective trial has been completed to compare the techniques at this time. Because of the increasing interest in surgical stabilization, there are multiple commercially available fixation devices within the last few years.
Postoperative Details
Routine postthoracotomy care with ICU or surgical step-down level observation and close monitoring of respiratory parameters is crucial.
Follow-up
Follow-up chest x-rays and pulmonary function tests determine the resolution of underlying pulmonary pathology and any possible long-term disability as a result of the initial condition.
Future and Controversies
Further improvements in emergency medical systems and the education of prehospital personnel may increase the observed frequency of flail chest in the future. Improvements in noninvasive ventilation techniques like CPAP and pain control may also improve currently observed outcomes. Prevention, including safer automobiles and newer airbag design may affect the incidence and outcome of these multifactorial injuries.
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Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result.
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Multiple left rib fractures, pulmonary contusion, and hemothorax in an elderly man after a motor vehicle accident.
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Axial computed tomography image of the chest in a patient with left posterior rib fractures. The left pneumothorax (white arrows) is associated with a displaced posterior left rib fracture (black arrow). Secondary effects on the left lung include a pulmonary contusion and volume loss.
