Treatment of Flail Chest
The American College of Surgeons recommends surgical stabilization of rib fractures (SSRF) as the primary treatment approach for flail chest patients, as it provides better long-term pulmonary function, reduced chest wall deformity, and is more cost-effective despite surgical expense. 1
Immediate Stabilization
- Control paradoxical chest wall movement immediately, maintain airway patency, and provide adequate oxygen supply to prevent respiratory failure 2, 1
- Consider chest fixation with a multi-head chest strap or towel clip traction for immediate stabilization 3
- Assess for respiratory failure indicators including oxygen saturation <90%, respiration rate >25, and progressive dyspnea 3
Pain Management: The Foundation of Treatment
Aggressive pain control is paramount and may be the single most important factor in patient recovery, as inadequate analgesia leads to splinting, atelectasis, and pneumonia. 4
- Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury 5
- Implement multimodal analgesia with intravenous or oral acetaminophen as first-line treatment 2
- Consider low-dose ketamine as an alternative to opioids 2, 3
- Paravertebral blocks may be equivalent to epidural analgesia when epidural is contraindicated 5
Respiratory Support Strategy
- Avoid obligatory mechanical ventilation in the absence of respiratory failure—this outdated approach increases complications 3, 5
- Reserve mechanical ventilation only for patients with signs of respiratory failure, severe associated injuries, or inability to maintain adequate oxygenation despite non-invasive measures 2
- Consider trial of mask continuous positive airway pressure (CPAP) in alert patients with marginal respiratory status 5
- Apply aggressive chest physiotherapy to minimize the likelihood of respiratory failure 5
- When mechanical ventilation is required, provide positive end-expiratory pressure (PEEP) or CPAP and wean at the earliest possible time 5
Surgical Stabilization of Rib Fractures (SSRF): Primary Treatment
SSRF should be performed in all flail chest patients, particularly those with specific high-risk features. 1
Indications for SSRF:
- 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 pain or severe chest wall instability 4
- Progressive decline in pulmonary function testing 4
- When thoracotomy is required for other concomitant injuries 4
Timing and Setting:
- Early surgical fixation (within 72 hours) shows better outcomes than delayed intervention 2
- SSRF should be performed in dedicated centers with multidisciplinary trauma teams, developed protocols for operative and non-invasive management, experience with muscle-sparing approaches, and advanced imaging capabilities 2, 1
Contraindication:
- There is no role for surgical stabilization in patients with severe pulmonary contusion—the underlying lung injury precludes early ventilator weaning, and supportive therapy with pneumatic stabilization is recommended 4
Fluid Management
- Patients should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion 5
- Diuretics may be used in hemodynamically stable patients with hydrostatic fluid overload or concurrent congestive heart failure 5
Special Considerations for Elderly Patients (>60 years)
- Elderly patients have higher mortality rates and require more aggressive management due to reduced physiological reserve 2, 3
- Monitor closely for pneumonia, respiratory failure, chest wall deformity, and chronic pain 2
- Consider surgical fixation early, though evidence remains mixed for this specific population 2
- Complete recovery may take up to 2 years in elderly patients 2
Critical Pitfalls to Avoid
- Mandatory mechanical ventilation for chest wall fixation alone—this increases complications 3
- Inadequate pain control, which is particularly problematic in elderly patients 3
- Delaying surgical intervention when indicated, as delayed SSRF provides poorer outcomes than early intervention 1
- Using steroids for pulmonary contusion treatment—they should not be used 5