From the Guidelines
Surgical stabilization of rib fractures (SSRF) is the recommended treatment for patients with flail chest, as it reduces morbidity, mortality, and improves quality of life by decreasing ventilator days, ICU stay, pneumonia rates, and improving long-term pulmonary function 1.
Treatment Approach
The treatment of flail chest should prioritize SSRF, especially in patients with severe flail chest, those with 3 or more displaced rib fractures, significant chest wall deformity, or those requiring mechanical ventilation.
- Initial management includes adequate pain control with opioids and NSAIDs, as well as regional anesthesia techniques such as epidural analgesia or intercostal nerve blocks.
- Oxygen supplementation should be provided to maintain oxygen saturation above 92%.
- For patients with respiratory compromise, non-invasive positive pressure ventilation (NIPPV) like CPAP or BiPAP should be initiated early.
- If respiratory failure develops, intubation and mechanical ventilation may be necessary.
Benefits of SSRF
The benefits of SSRF in patients with flail chest include:
- Reduced duration of mechanical ventilation 1
- Lower pneumonia and tracheostomy rates 1
- Shorter ICU stay 1
- Improved long-term pulmonary function 1
- Reduced morbidity and mortality 1
Indications for SSRF
SSRF should be considered in all flail chest patients, as well as in non-flail chest patients with multiple severely displaced rib fractures or respiratory failure despite mechanical ventilation 1.
- SSRF is most beneficial in patients with anterolateral flail chest and respiratory failure without severe pulmonary contusion, in patients with pulmonary contusion and persistent chest wall instability or weaning failure, and in non-intubated patients with deteriorating pulmonary function 1.
From the Research
Treatment Options for Flail Chest
The treatment for flail chest, which is defined as the fracture of three or more ribs in two or more places, can vary depending on the severity of the injury and the patient's overall condition. The current treatments of choice include:
- Conservative treatment, consisting of respiratory assistance with endotracheal intubation and mechanical ventilation, as well as pain control 2
- Operative fixation of fractured ribs, which may lead to better outcomes in selected patients, particularly those with severe ventilatory restriction due to chest wall paradox alone 3
- Surgical stabilization of the chest wall, which can be achieved through various techniques, including compression osteosynthesis and plate fixation procedures 3, 4
- Epidural analgesia, which can be used in conjunction with surgical stabilization to reduce pain and improve outcomes 2, 5
Indications for Surgical Stabilization
Surgical stabilization of flail chest is typically indicated in patients with:
- Severe ventilatory restriction due to chest wall paradox alone 3
- Flail chest combined with intra-thoracic lesions that require thoracotomy 3
- Flail chest combined with lesions that require a prone position for surgical exploration 3
- Respiratory distress patients when the unstable chest wall interferes with mechanical ventilation or with underlying organs 3
Benefits of Surgical Stabilization
Surgical stabilization of flail chest has been shown to have several benefits, including:
- Improved pulmonary function, with less restrictive impairment of pulmonary functions 4
- Reduced need for mechanical ventilation, with shorter durations of ventilatory support 2, 4
- Reduced length of stay in the intensive care unit (ICU) and hospital 2
- Improved pain management, with reduced need for analgesics 2, 5