What is the treatment for flail chest?

Treatment of Flail Chest

The American College of Surgeons recommends surgical stabilization of rib fractures (SSRF) as the primary treatment approach for flail chest, as it provides better long-term pulmonary function, reduced chest wall deformity, and is more cost-effective despite the added surgical expense. 1

Immediate Stabilization

Upon recognition of flail chest, immediate actions are critical:

• Control paradoxical chest wall movement immediately using a multi-head chest strap or towel clip traction for temporary stabilization 1, 2
• Maintain airway patency and provide adequate oxygen supply to prevent respiratory failure, using high-flow oxygen (10 L/min) as needed 2
• Correct respiratory and circulatory dysfunction to prevent shock, particularly when combined with pulmonary contusion 1

Pain Management

Aggressive pain control is paramount and directly impacts outcomes:

• Implement multimodal analgesia as first-line treatment using intravenous or oral acetaminophen 3, 2
• Consider low-dose ketamine as an alternative to opioids to avoid respiratory depression 3, 2
• Regional anesthetic techniques such as thoracic epidural or paravertebral blocks may be used for severe pain 3
• Inadequate pain control leads to splinting, atelectasis, and pneumonia—a critical pitfall to avoid 2

Despite the importance of epidural analgesia, national data shows only 8% of flail chest patients receive this aggressive pain management approach 4, representing a significant gap in optimal care.

Definitive Treatment: Surgical Stabilization of Rib Fractures (SSRF)

SSRF should be the primary treatment approach for most flail chest patients, with specific indications including:

• All flail chest patients, especially those with anterolateral flail segments with displacement 1
• Respiratory failure without severe pulmonary contusion 1
• Patients with pulmonary contusion and persistent chest wall instability or weaning failure 1
• Persistent severe refractory pain or chest wall deformity 3

Benefits of SSRF:

• Better long-term pulmonary function 1
• Reduced chest wall deformity 1
• More cost-effective despite surgical expense 1
• Faster ventilator wean and shorter ICU time 5

Timing Considerations:

• Early surgical fixation (within 72 hours) provides better outcomes than delayed intervention 3
• Delayed surgical intervention, when indicated, provides poorer outcomes than early SSRF 1
• SSRF is optimal in dedicated centers with multidisciplinary teams that have developed protocols for both operative and non-operative management 1

Mechanical Ventilation

Reserve mechanical ventilation only for patients with signs of respiratory failure, severe associated injuries, or inability to maintain adequate oxygenation despite non-invasive measures 3:

• Do not use mandatory mechanical ventilation for chest wall fixation alone—this outdated approach increases complications 2
• National data shows 59% of flail chest patients require mechanical ventilation for a mean of 12.1 days 4
• Early weaning from mechanical ventilation should be considered to reduce complications 3
• Prolonged mechanical ventilation is associated with pneumonia development and poor outcomes 5

Conservative Management

When SSRF is not indicated or available, conservative management includes:

• Aggressive pulmonary toilet including facemask oxygen, CPAP, and chest physiotherapy 5
• External stabilization methods may be considered as a simple, low-cost approach 6
• More than 99% of flail chest patients nationally are treated nonoperatively 4, though this may not represent optimal care given guideline recommendations

Special Populations: Elderly Patients

Elderly patients (>60 years) require more aggressive management due to higher mortality rates and reduced physiological reserve 3:

• Risk factors predicting increased complications include low oxygen saturation, obesity or malnutrition, pulmonary contusion, smoking or chronic respiratory disease, anticoagulation therapy, and presence of major trauma 3
• Monitor closely for pneumonia, respiratory failure, chest wall deformity, and chronic pain 3
• Rib fractures typically heal within 6-8 weeks, but complete recovery may take up to 2 years in elderly patients 3
• Surgical fixation remains somewhat controversial in elderly patients, though some studies show lower mortality with operative treatment 3

Critical Contraindications and Limitations

The presence of severe pulmonary contusion may limit the immediate benefits of SSRF on ventilator time and ICU stay 1:

• There is no role for surgical stabilization in patients with severe pulmonary contusion 5
• The underlying lung injury and respiratory failure preclude early ventilator weaning in these patients 5
• Supportive therapy and pneumatic stabilization is the recommended approach for this subset 5

Expected Outcomes and Complications

National data reveals significant morbidity and mortality associated with flail chest:

• ICU admission required in 82% for a mean of 11.7 days 4
• Pneumonia develops in 21% of patients 4
• Adult respiratory distress syndrome occurs in 14% 4
• Tracheostomy required in 21% 4
• Overall mortality rate of 16% 4
• Patients with concurrent severe head injury have worse outcomes in every category 4