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C OPYRIGHT Ó 2011 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Operative Treatment of Chest Wall Injuries:
Indications, Technique, and Outcomes
By Paul M. Lafferty, MD, Jack Anavian, MD, Ryan E. Will, MD, and Peter A. Cole, MD

Investigation performed at University of Minnesota-Regions Hospital, St. Paul, Minnesota

ä Most injuries to the chest wall with residual deformity do not result in long-term respiratory dysfunction unless they
are associated with pulmonary contusion.

ä Indications for operative fixation include flail chest, reduction of pain and disability, a chest wall deformity or
defect, symptomatic nonunion, thoracotomy for other indications, and open fractures.

ä Operative indications for chest wall injuries are rare.

Operative management of chest wall injuries is a controversial
topic. This was highlighted by a recent survey of 238 members
of the Eastern Association for the Surgery of Trauma, ninety-
seven members of the Orthopaedic Trauma Association, and
seventy thoracic surgeons1. The majority of the respondents
(82% of the general surgeons, 66% of the orthopaedic sur-
geons, and 71% of the thoracic surgeons) responded that op-
erative repair of rib fractures was indicated in selected patients.
Fewer (17% of the general surgeons, 32% of the orthopaedic
surgeons, and 23% of the thoracic surgeons) responded that
operative repair of rib fractures was rarely or never indicated.
Only 21% of the trauma surgeons, 16% of the orthopaedic
surgeons, and 52% of the thoracic surgeons indicated they had
ever performed or assisted in open reduction and internal
fixation (ORIF) of rib fractures. Twenty-two percent (eighty-
nine) of all 405 respondents indicated that they were familiar
with a randomized trial of surgical repair of flail chest1.
In 2004, over 300,000 people were treated for rib fractures
in the U.S.2, with 102,000 patients being admitted to U.S. hos-
pitals3. Because the majority of patients with rib fractures are not
admitted to the hospital4, the true incidence may be higher than
estimated. Fractures of consecutive ribs have been found to be
independent markers of injury severity, resulting in increased
morbidity and mortality5-7. An estimated 25% of annual trau-
matic deaths result from chest trauma. Rib fractures have been
detected in up to 39% of patients (548 of 1417) who have sus-
tained blunt chest trauma and up to 10% of trauma admissions
overall (711 of 7147). Flail chest is present in up to 6% of pa-
tients (eighty-two of 1417) who have sustained blunt chest
trauma4,8-15. These injuries are potentially fatal, with in-hospital
mortality rates of up to 12% (eighty-four of 711) for patients
with multiple rib fractures and up to 33% (thirty of ninety-two)
for patients with a flail chest8,16-18. Nonoperative management,
consisting of pulmonary toilet, pain control, and selective ven-
tilatory support, is the standard treatment for these injuries at
most institutions. Operative intervention is controversial19, al-
though several reports indicate that patients who underwent
ORIF of flail chest injuries or multiple rib fractures required a
shorter duration of ventilator support, were less likely to develop
infections and septicemia, and were less likely to require tra-
cheostomy than patients managed nonoperatively20-22.
The orthopaedic surgeon is often consulted about con-
comitant fractures and is often the specialist who follows the
patient for the longest period of time. Thus, it is paramount
that orthopaedic surgeons be aware of the short and long-term
sequelae of these chest wall injuries as well as the potential
benefit of ORIF of fractured ribs in the setting of massive chest
wall trauma.
Diagnosis
Up to 54% of rib fractures (208 of 388) are missed on routine
chest radiographs7,23-25. Oblique radiographs or special rib views
increase sensitivity but are not routinely ordered. Nuclear scans
can also detect occult rib fractures26. Computed tomography

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member
of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am. 2011;93:97-110 d doi:10.2106/JBJS.I.00696

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(CT) scans, which are now commonly performed during the
routine workup for trauma patients, have been shown to be the
most sensitive imaging study for detecting rib fractures24.
Epidemiology, Morbidity, and Mortality
A recent biomechanical study demonstrated that the main
loading modes during impacts causing rib fractures are local
bending and shearing 27, resulting in the typical short oblique
fracture pattern seen. Mortality rates of up to 33% (thirty of
ninety-two) have been reported for patients with flail chest
injuries18,28-33. In a retrospective study of 388 patients with at
least one rib fracture identified on CT scans, Livingston et al.24
found that the mortality rate associated with rib fractures was
lower than previously reported. The authors theorized that this
was due to previous investigators relying on chest radiographs
to detect rib fractures7,13,34, which led them to miss the rib injury
in 54% (208) of 388 cases24,35,36. The study by Livingston et al.
revealed a fourfold increase in the mortality of patients with
even a single rib fracture on chest radiographs. Using chest
radiograph data, they found that mortality increased incre-
mentally with five or more fractures and that there were large
increases in mortality when there were seven or more fractures.
However, with use of the more sensitive CT data, this curve
shifted. Mortality incrementally increased with two or three
fractures, and large increases in mortality were not observed
until nine or more fractures were present. In that study, the
mean number of rib fractures per patient was 4.2, with 21%
(eighty-one) of the 388 patients having a single rib fracture and
17% (sixty-six) having six or more rib fractures. Ribs 4 through
9 were the most often injured. The vast majority of fractures
were posterolateral, and there was a slight left-sided propensity.
Fig. 1
A young female patient with a deformity of the posterior aspect of the thorax secondary to
multiple malunited rib fractures.
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Nearly half (187) of the patients in the study had pulmonary
contusions associated with the fractures.
Several studies have demonstrated a direct correlation be-
tween the number of rib fractures and intrathoracic injury, mor-
bidity, and mortality 5,14,15,34. A study of 105,683 trauma patients
revealed that the presence of three or more rib fractures increased
the relative risk of splenic injury to 6.2 and the relative risk of liver
injury to 3.6 but did not predict the presence of aortic injury12. Up
to 55% of patients (391 of 711) with rib fractures have been found
to require immediate surgery or admission to the intensive-care
unit, primarily because of associated injuries8.
Studies have shown that many patients treated non-
operatively for chest wall injuries have several long-term
morbidities (Fig. 1). When patients with rib fractures were
compared with chronically ill patients, the former group was
found to be significantly (p < 0.001) more disabled at thirty
days in all categories of the Short Form-36 Health Status Survey
except emotional stability (they showed equivalent disability
in that category) and their perception of general health (they
showed significantly less disability in that category). Patients
who have had a flail chest often report long-term dyspnea and
chest pain and have abnormal test results on spirometry32.
The morbidity and mortality rates for patients with chest
wall injuries are higher at the extremes of age5,7,10,11,13,14,18,37,38.
Ribs may become brittle with advancing age. With a less
compliant chest wall, less energy is required to cause fractures.
A recent study of 181,331 adults in the National Trauma Data
Bank showed that ‘‘the odds ratio for death for younger pa-
tients (aged 18-45) was 1.4 (95% CI 1.3-1.6) if rib fractures of
at least AIS 3 or greater were present. For older patients (over
64 years) the odds ratio was 2.5 (95% CI 2.3-2.8). In other
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words, regardless of the presence or absence of concomitant
trauma, crash-injured patients with rib fractures of at least AIS
3 have a significantly increased risk of in-hospital mortality,
and of two patients having similar non-rib trauma, one with
AIS 31 rib fractures has a substantially higher expected risk of
death than one without. This effect is more dramatic for older
patients.’’18 Bulger et al.7 found that elderly patients who had
sustained blunt chest trauma with rib fractures had twice the
mortality and thoracic morbidity compared with younger pa-
tients with similar injuries. In their study, for each additional
rib fracture in an elderly patient, mortality increased by 19%
and the risk of pneumonia increased by 27%. Rib fractures in
children are of particular concern. The chest wall of a child is
more pliable because of a lack of calcification, which allows
plastic deformation. Hence, children can have substantial in-
trathoracic trauma in the absence of rib fractures39, and pedi-
atric rib fractures themselves indicate very high-energy injury
mechanisms. Therefore, rib fractures are considered to be more
of a marker of severe trauma in children than in adults8,12,40. The
likelihood of rib fractures noted in a child being the result of a
nonaccidental injury decreases with increasing age. Rib frac-
tures in children less than three years of age have been found
to be highly predictive of child abuse5,38,40,41, with 82% (fifty-
one) of sixty-two children who were seen with rib fractures
when they were less than three years of age being victims of
abuse 38 . It is rare for children to have more than three rib
fractures12.
Pulmonary Contusion
Rib fractures are often associated with pulmonary contusions8.
Multiple rib fractures have been found to predispose patients to
pulmonary insufficiency and compromised ventilation. Fur-
thermore, in patients with a flail chest injury, paradoxical chest
wall motion and pain can result in low tidal volumes, sub-
stantial alveolar collapse, arteriovenous shunting, and hypox-
emia, necessitating prolonged mechanical ventilation20, all of
which can result in severe complications such as pneumonia
and sepsis 28,29,42-44. The presence or absence of pulmonary
contusion has been found to be an important factor guiding the
decision regarding whether to proceed with ORIF. Patients with
pulmonary contusion do not seem to benefit as much as do
those without it20,22,45,46. Perhaps this is because most injuries to
the chest wall do not result in long-term respiratory dysfunc-
tion unless pulmonary contusion is associated. Fibrosis and
scarring of the contused lung have been proposed as reasons for
respiratory derangements detectable by spirometric testing46.
Nonoperative Management
Nonoperative treatment is appropriate for the vast majority of
rib fractures, and operative management should be considered
for very few cases. Healing usually occurs spontaneously
without placement of orthopaedic implants. Advantages of
nonoperative treatment include avoidance of potential surgical
complications such as infection, injury to intercostal neuro-
vascular structures, lung injury, and the need for subsequent
operations to remove implants. However, nonoperative man-
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agement of rib fractures has been associated with substantial
pain and discomfort20. The mainstays of nonoperative man-
agement include conventional pain control methods (oral an-
algesia, intercostal blocks, patient-controlled analgesia systems,
pleural infusion catheters, and epidural analgesia), aggressive
pulmonary toilet, and mechanical ventilation7. Fractured ribs
managed nonoperatively are subjected to continued displace-
ment during breathing in the healing phase. This may lead to
symptomatic malunion or nonunion, requiring later operative
intervention30,47,48. Long-term problems continue to be rare, with
the vast majority of rib fractures healing uneventfully.
Operative Management
Proposed Benefits of Operative Fixation
Reported short-term benefits of ORIF of rib fractures and flail
chest include accelerated restoration of pulmonary func-
tion20,28,42,44,45,49,50, reduced morbidity associated with prolonged
mechanical ventilation6,21,28,29,42,44,49,51, and shortened stays in the
intensive-care unit and the hospital20,42,52. These advantages
typically lead to a shorter recovery time and a faster return to
work. Early restoration of chest wall integrity and respiratory
pump function after ORIF may prove to be cost effective
through the prevention of prolonged mechanical ventilation
and restriction-related work capacity. Reported long-term
benefits of ORIF include a decreased likelihood of clinically
relevant long-term pain, respiratory dysfunction, and skeletal
deformity28,50,53. There is also a theoretical advantage of im-
proved lung functional reserve following ORIF secondary to
restoration of greater lung volumes.
Although surgery is rarely utilized, a review of the liter-
ature indicates that there are occasional situations where op-
erative management of rib fractures should be considered. All
indications are currently considered relative; there are no ab-
solute indications based on available studies. Treatment must
be individualized on the basis of the patient’s fracture pattern,
overall medical condition, and functional status (Table I)19.
Flail Chest
Flail chest is variably defined in the literature. The most
commonly cited definition is unilateral fractures of four con-
secutive ribs, with each rib fractured in two or more places.
Clinically, flail chest is diagnosed when an incompetent seg-
ment of chest wall is large enough to allow paradoxical motion
of the chest wall with respiration25,29,48 (Figs. 2-A, 2-B, and 2-C).
A sternal flail chest occurs when the sternum becomes disso-
ciated from the hemithoraces as a result of bilateral, multiple,
anterior cartilage or rib fractures. Two recent randomized trials
indicated that selected patients with flail chest may benefit from
ORIF in both the short and the long term42,54. Several non-
randomized, cohort-comparison trials have also generally
confirmed these findings, with the caveat that flail chest repair
is not advisable for patients with substantial pulmonary con-
tusions 20,22,45. In the Eastern Association for the Surgery of
Trauma (EAST) Practice Management Guideline for ‘‘Pulmonary
Contusion—Flail Chest,’’ ORIF for severe unilateral flail chest or
for patients requiring mechanical ventilation when thoracot-
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Fig. 2-A
Fig. 2-B
omy is otherwise indicated was considered to be a Level-III
recommendation55. Level-III recommendations are defined by
EAST as being supported by Class-III studies (retrospectively
collected data). EASTstates that this type of recommendation is
useful for educational purposes and in guiding future clinical
research only. They cited the low numbers of patients ran-
domized, the strict exclusion criteria in the study by Tanaka
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Two-dimensional axial CT scan (Fig. 2-A) and three-dimensional recon-
struction of a CT scan (Fig. 2-B) showing a flail chest injury in a fifty-one-
year-old woman who was involved in a motorcycle collision. Note the
substantial reduction in lung volume of the left hemithorax on the axial
view.
et al.42, and the absence of trials comparing operative repair
with ‘‘modern’’ nonoperative treatments as reasons for the
Level-III designation.
Chest Wall Deformity or Defect
Chest wall defects or deformities can result from severely dis-
placed rib fractures with or without soft-tissue loss. Paradoxical
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Fig. 2-C
Oblique radiographs made after the patient underwent ORIF of four ribs with locking 2.4-mm reconstruction plates as well
as ORIF of the scapular and clavicular fractures.

motion may be noted if a flail segment is present. Many pa-
tients, especially those who are young and have adequate pul-
monary reserve, do not require endotracheal intubation.
Minimal to moderate-size tissue defects can be caused by
penetrating missiles, shotgun injury, or impalement by sur-
rounding objects. In these cases, repair of both rib fractures and
soft tissues may be indicated to restore chest wall competency
(Fig. 3).
Acute Pain and Disability
It has been hypothesized that certain patients experiencing
persistent, unrelenting pain with breathing, coughing, or mo-

TABLE I Potential Indications and Considerations for Operative Fixation of Rib Fractures*

Operative Indications Other Considerations

Flail chest Failure to wean from ventilator

Paradoxical movement visualized during weaning
No substantial pulmonary contusion
No substantial brain injury
Reduction of pain and disability Painful, movable consecutive rib fractures
Failure of narcotics or epidural pain catheter
Fracture movement exacerbating pain, inhibiting respiratory effort
Minimal associated injuries
Chest wall deformity/defect Chest wall crush injury with collapse of the structure of the chest wall and
marked loss of thoracic volume
Severely displaced, multiple rib fractures or tissue defect that may result in permanent
deformity or pulmonary hernia
Severely displaced fractures substantially impeding lung expansion or fractured ribs impaling
the lung
Patient expected to survive other injuries
Symptomatic rib fracture nonunion Radiographic evidence of fracture nonunion
Patient reports persistent, symptomatic fracture movement
Thoracotomy for other indications in the
setting of rib fractures
Open rib fracture

*The content in this table was obtained, and modified, from: Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications,
technical issues, and future directions. World J Surg. 2009;33:14-22. With kind permission from Springer Science1Business Media.
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Fig. 3
Anteroposterior chest radiograph showing severely displaced fractures (arrows) of
consecutive ribs (1 through 12) resulting in a substantial right-sided chest wall
deformity as well as a comminuted displaced intra-articular fracture of the right
scapula in a fifty-four-year-old man who was involved in a motor-vehicle collision.

bilization may benefit from ORIF30,47,49. This suggestion has not
been confirmed by cohort-comparison or randomized trials. It
has been suggested that, if their pain were alleviated by acute
ORIF, patients could possibly return to work and their usual
activities sooner56.
traumatic indications such as tumor resection also may result
in rib fractures that can be surgically repaired. Stabilizing the
fractured ribs prior to closure after completion of the primary
procedure may increase patient comfort and improve pulmo-
nary care.

Nonunion Open Fractures

A small percentage of rib fractures do not heal and may develop
into a symptomatic nonunion. Fibrous tissue and pseudar-
throsis are characteristic histological findings. Patients with
nonunion have reported pain, tenderness, a sensation of
‘‘jabbing’’ into the lung with deep respiration, clicking with
motion of the ipsilateral shoulder girdle 47,48, or pain with
sneezing and other bodily motions involving a Valsalva ma-
neuver. In the past, rib nonunions have been treated with rib
resection or cancellous bone-grafting19, although resection does
not always guarantee lasting relief of pain. More recently, ORIF
has been employed to treat rib nonunion30,37,47,48,57-59.
Thoracotomy for Other Indications
A patient who undergoes a thoracotomy for another indication
such as an open pneumothorax, pulmonary laceration, re-
tained hemothorax, or diaphragmatic laceration may be a
candidate for ORIF of rib fractures. Thoracotomy for non-
Although, to our knowledge, no published study has addressed
the treatment of open rib fractures, it is reasonable to apply
standard principles of open fracture management to these
injuries. The goals of treatment of open rib fractures are to
prevent infection, allow the fracture to heal, and restore
function. We believe that the standard principles of imparting
stability to open extremity fractures after irrigation and de-
bridement may be equally relevant to the treatment of chest
wall injuries in order to decrease pain and the risk of infection
and nonunion.
Preoperative Planning
The geometry and character of human ribs are unique among
the bones of the body and contribute to the challenge of rib
fracture fixation. Human rib thickness ranges from 8 to 12 mm
with a relatively thin (1 to 2-mm) cortex surrounding soft
marrow60. Individual ribs do not have good tolerance to stress
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and do not provide good cortical screw purchase. Rib fractures
may be oblique or even comminuted, further complicating the
challenge of obtaining reliable fixation. In addition, the inter-
costal nerve lies in a groove under the inferior surface of the
rib, and iatrogenic injury from manipulation of the fractured
ribs or placement of orthopaedic implants may lead to post-
thoracotomy pain syndrome49,61. Three-dimensional CT recon-
structions may be useful to completely define all rib fractures
and the extent of their displacement and to help plan the
surgical approach37,49,62. If possible, chest tubes are removed
from the pleural space at least a day before ORIF to minimize
the potential for bacterial contamination. Antibiotics are rou-
tinely given perioperatively.
Operative Technique: Our Preference
Mayberry et al.1 found that 33% (seventy-nine) of 238 trauma
surgeons, 48% (forty-seven) of ninety-seven orthopaedic trauma
surgeons, and 91% (sixty-four) of seventy thoracic surgeons
considered themselves competent to perform the surgery. We
recommend that a thoracic surgeon be present to assist with the
operative approach if the orthopaedic surgeon is unfamiliar or
inexperienced with thoracic approaches.
The patient is placed in the lateral decubitus position. A
standard thoracotomy incision is made overlying the fractured
ribs. Dissection is carried sharply through skin, subcutaneous
tissues, and fascia. The serratus anterior muscle is retracted
anteriorly and the latissimus dorsi muscle is retracted poste-
riorly, to the extent necessary as determined by how anterior or
posterior the incision is placed. Muscle-sparing techniques,
such as division of the latissimus dorsi muscle in line with its
fibers, can provide adequate exposure of up to three rib frac-
tures through an incision 10 to 15 cm in length. Alternatively,
instead of making one larger incision, the surgeon can make
multiple smaller incisions that avoid muscle division. The in-
tercostal muscles are incised over the superior border of the rib
at the desired level. By entering the pleural cavity, this approach
provides excellent visualization during ORIF. The ability to
reduce the rib from inside the thoracic cavity via manipulation
is important, given that the fractured ribs displace toward the
midline. Throughout the procedure, the lung is observed and
protected.
Single-lung ventilation is useful to improve exposure and
avoid injury to the lung parenchyma on the intrathoracic side
of the dissection. However, the presence of a pulmonary con-
tusion may limit tolerance of single-lung ventilation. In addi-
tion to the lung affected by contusion, there can be impairment
of the noncontused lung due to the systemic inflammatory
response syndrome initiated by the trauma in some patients. If
there is no evidence of contralateral lung injury, single-lung
ventilation is likely to be successful52,63.
Early ORIF reduces the extent of thoracic wall dissec-
tion necessary for mobilization and excision of callus. The
ends of the fractured ribs are cleared of their soft-tissue at-
tachments for a distance of 1 to 2 mm with use of an elevator.
Curets and pituitary rongeurs are used to carefully clean any
debris from the fracture site. Care must be taken to avoid
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violating the intercostal neurovascular bundles located on
the inferior aspect of the ribs. When there is a nonunion, the
medullary canal is reestablished with an appropriately sized
drill bit in oscillate mode to avoid cortical penetration. The
fracture ends are mobilized and reduced with use of a com-
bination of bone reduction clamps and dental picks. Uni-
cortical drill holes are useful to create purchase points for
reduction tools during mobilization, reduction, and fixation.
Displaced rib fractures tend to shorten and overlap; thus,
gaining compression is not generally an issue once reduction
is obtained.
Plates may be applied directly over the periosteum of the
rib. The fractured ribs adjacent to the thoracotomy site are
typically plated first. The senior author (P.A.C.) chooses a plate
of sufficient length to allow at least six cortices of fixation on
both sides of the fracture. As is the case for long-bone fractures,
osteoporotic bone may require longer plates or locking con-
structs to help prevent fixation failure. Given that the fracture
site will experience immediate continuous motion with respi-
ration, we recommend the use of locking plates. This fixation
option allows use of shorter plates and less surgical exposure.
The choice of implants as well as relative screw configurations
depend on many factors such as the bone quality and whether
the surgeon desires secondary or primary healing. If precon-
toured plates are not available, the senior author recommends
using a template to contour a 2.7-mm locking reconstruction
plate or 3.0-mm mandibular locking plate of appropriate
length. The fractured ends of the ribs should be placed under
compression before screws are placed, with bone graft possibly
added in cases of nonunion. The ribs on both sides of the
thoracotomy are sequentially approximated. It is unnecessary
to plate all of the fractured ribs in a large thoracic segment, but
enough of them must be plated to provide internal splinting to
the remaining ribs and to help restore thoracic contour (Figs.
2-A, 2-B, and 2-C). Ribs anterior to the scapula are difficult to
access safely and generally should be left unfixed given the
added muscular protection and stabilization from the peri-
scapular musculature. Additionally, deformity of the upper ribs
results in less lung-volume loss. At the conclusion of fixation,
the pleural cavity can be filled with saline solution and the lung
can be reinflated to check for air leaks. If a leak exists, a chest
tube should be placed. Wound drains are used at the discretion
of the operating surgeon, on the basis of an assessment of the
wound. A layered muscular closure with absorbable suture is
then executed. The chest tube is left in place until the lung is
fully reinflated, no evidence of pneumothorax is present on
radiographs of the chest, and the drainage and air leak have
ceased64.
Fixation Options
Fixation must be able to tolerate up to 25,000 breathing cycles
per day as well as coughing. Both rigid and nonrigid systems
have been developed. Potential disadvantages of both rigid and
nonrigid internal fixation systems include interference with
CT and MRI (magnetic resonance imaging) studies, stress-
shielding, palpable implants, and the potential need for another
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operation for implant removal due to pain or loosening of
implants29,56,65.
Metal Plates
The use of metal plates is the standard choice for operative fix-
ation of rib fractures29,31,37,45,51,64-66. Generic 3.5-mm and 2.7-mm
reconstruction plates, one-third tubular plates, dynamic com-
pression plates, and low-contact dynamic compression plates
contained in standard small and mini-fragment implant sets have
been utilized, as have plates designed for maxillofacial sur-
gery29,43,47,59,64,65,67. These maxillofacial plates may be 2.4, 2.7, or
3.0 mm and are made of titanium or stainless steel. Recently,
there has been a move toward using locking plates with either
bicortical or unicortical screws, especially in patients with os-
teopenic bone or in whom there is poor screw purchase58,65,68.
Generic small and mini-fragment plates have the disadvan-
tage of requiring extensive contouring 51,58,59,68. Because of the
complex geometry of ribs, intraoperative contouring of plates
can be difficult. Furthermore, the use of generic plates has
been accompanied by screw loosening and pullout in several
reports31,43,45,67.
Recently, investigators have attempted to address these
deficiencies. Mohr et al.69 performed a study to establish a
biometric foundation to generate specialized, anatomically
contoured implants for rib fixation. These implants theoreti-
cally should improve maintenance of reduction and stability,
decrease the incidence of implant loosening, shorten the op-
erative time, and consequently decrease the risk of infection
and nonunion or failure of the implant. Precontoured plates
are relatively thin, which minimizes stress-shielding while al-
lowing physiologic motion during respiration. The clinical
superiority of precontoured plates has not been proven, mak-
ing the added cost of these specialized implants difficult to
justify at the present time.
Absorbable Plates
Absorbable polymers have been successfully used in the fixa-
tion of maxillofacial, tibial, and rib fractures49,60,70-77; in the
reconstruction of chest wall deformities 78 ; and in rib re-
approximation after thoracotomy for nontraumatic indica-
tions 79-82 . Plates made of absorbable polymer are typically
applied with use of absorbable suture material. The plates may
be applied on either the interior or the exterior surface of the
rib and may be secured by placing the suture either around the
rib or through drill holes. These implants retain sufficient ri-
gidity until adequate healing has taken place, resorbing at a rate
that slowly transfers mechanical load to bone. This may min-
imize the problem of stress-shielding, which has been reported
with metal implants73,83, and eliminate the potential need for a
second operation for implant removal49. Findings in animal
models have supported the concept that fractures heal faster,
with stronger bone after healing, with use of absorbable
plates84,85. In a rabbit model, rib fracture reduction was main-
tained to a greater degree with polylactide plate fixation of ribs
than with nonoperative treatment, resulting in improved bone
healing86. Antibiotics could be added to absorbable plates87,88.
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Although they have not been reported with the treatment of
rib fractures, there are concerns about complications, such as
foreign-body reactions, swelling, fluid accumulation, and cyst
formation, related to bioabsorbable materials utilized in frac-
ture fixation elsewhere in the body 74,89-93. For these reasons, the
use of bioabsorbable materials for fracture fixation in other
locations has been largely abandoned. Absorbable implants are
also more costly than standard metal implants.
Intramedullary Fixation
Intramedullary fixation of rib fractures has been used suc-
cessfully but is technically demanding and carries the risk of
implant dislodgment and migration 20,53,55,94,95 as well as poor
rotational stability65. Recently, anatomically contoured titanium
intramedullary struts designed for rib fracture fixation have
been introduced and have improved rotational stability. A
broad flat design and the addition of a single unicortical lock-
ing screw to hold the strut suggest that this implant design may
lessen the risk of dislodgment and migration (Figs. 4-A, 4-B,
and 4-C).
Judet Struts
The Judet strut is a bendable metal plate that grasps the rib with
tongs both superiorly and inferiorly without transfixing
screws45,96-100. Fixation of this plate around the inferior margin
of the rib can potentially crimp the intercostal neurovascular
bundle, causing intercostal nerve injury and subsequent
chronic pain. One variation of the strut that has been reported
is a self-gripping, elastic band that envelops the rib28.
U-Plates
U-plates are applied in a manner similar to that used to apply
the Judet strut, but they do not have the potential for crimping
of the intercostal nerve because the plate is placed along the
superior border. U-plates can be placed with minimal dissec-
tion of the rib in the extrapleural space, with preservation of the
periosteum. They are secured by locking screws placed through
the midsubstance of the rib with use of a targeting guide60.
Locking screws engage the exterior and interior aspects of the
plate and do not rely on screw purchase in bone; thus, they may
prove useful in patients with osteoporosis. Sales et al. compared
the stiffness of U-plates with that of 2.4-mm locking plates in a
5-mm-gap model and found U-plate fixation to be more du-
rable60. It is theorized that the smaller size of the U-plate
compared with standard plates may facilitate more minimally
invasive rib fracture repair.
Outcomes
Nonoperative Treatment
Few clinical studies with long-term follow-up of the results of
nonoperative management of rib fractures have been pub-
lished. Kerr-Valentic et al.4 compared forty patients treated
nonoperatively for rib fractures with the chronically ill ref-
erence population in the RAND Medical Outcomes Study and
found that the nonoperatively treated patients were signifi-
cantly (p < 0.001) more disabled at thirty days in all categories
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Fig. 4-A
Fig. 4-A Surgical illustration showing the application of an intramedullary implant. The implant is inserted through a unicortical hole placed on the anterior
aspect of the medial fracture fragment. The arrow indicates the direction of strut insertion. Image courtesy of Synthes, Inc., West Chester, PA. Ó 2009
Synthes, Inc. or its affiliates. Fig. 4-B Intraoperative photograph of rib fixation with use of intramedullary implants. Note that a unicortical locking screw
(arrow) is employed at the base of the implant to prevent migration.
of the Short Form-36 Health Status Survey except emotional
stability (they showed equivalent disability in that category)
and their perception of general health (they showed signifi-
cantly less disability in that category; p < 0.001). The total
mean number of days lost from work/usual activities of daily
living was 71 ± 41. Patients with isolated rib fractures went
back to work/activities of daily living at a mean of 51 ± 39 days
compared with 91 ± 33 days for patients with associated ex-
trathoracic injuries (p < 0.01). Landercasper et al.32 inter-
viewed thirty-two patients at a mean of five years after they
had sustained a flail chest injury and found that 63% reported
dyspnea, 49% experienced chest pain, and 25% experienced
chest tightness. Spirometry results were abnormal in 57%.
Beal and Oreskovich 101 evaluated twenty-two patients who
had sustained a flail chest as their only major injury and found
that 64% had long-term disability. Chest wall pain, deformity,
and dyspnea on exertion were the most frequently reported
symptoms. Bulger et al.7 studied 216 elderly patients (over the
age of sixty-five years) and 168 younger patients and found that
many were unable to return directly home from the hospital,
with the discharge destination significantly affected by age.
Only 56% of the elderly patients and 73% of the younger pa-
tients with rib fractures were discharged to home (p < 0.01).
Other destinations included subacute nursing facilities (16% of
the elderly patients and 8% of the younger patients), short-
term rehabilitation facilities (10% and 8%), and other acute-
care hospitals (18% and 7%). Similarly, Sharma et al.5 found
that 41% (ninety-eight) of 240 elderly patients, 74% (386) of
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Fig. 4-B
522 adult patients, and 87% (forty) of forty-six surviving chil-
dren were discharged to home. These studies indicate that
many patients with rib fractures and flail chest require pro-
longed care.
Operative Treatment
Several studies have demonstrated benefits of ORIF for rib
fractures; however, only two randomized studies have been
published to our knowledge. Tanaka et al.42 randomized thirty-
seven patients at five days after injury to be treated with Judet
struts or internal pneumatic stabilization. Respiratory man-
agement was identical for the two groups. At one month
following injury, patients who underwent ORIF required
significantly less ventilator support (p < 0.05) and had a lower
prevalence of pneumonia (p < 0.05), shorter stays in the
trauma intensive-care unit (p < 0.05), and lower medical costs
(p < 0.05) than patients treated with intubation and mechan-
ical ventilation. Moreover, ORIF improved the percentage of
predicted forced vital capacity during the early phase after
ORIF. Also, the percentage of patients in the ORIF group who
were able to return to their previous employment six months
after injury was significantly higher than the percentage of those
treated with internal pneumatic stabilization (p < 0.05).
More recently, Granetzny et al. 54 reported on a ran-
domized trial of forty patients with flail chest in which an
operatively treated group was compared with patients treated
with external adhesive plaster. Stability of the chest wall oc-
curred in 85% of the patients in the surgical group compared
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Fig. 4-C
Postoperative anteroposterior radiograph made after intramedullary fixation of the ribs
with three implants in a fifty-four-year-old patient with fractures of consecutive ribs that
had resulted in a substantial right-sided chest wall deformity. In this particular design,
the intramedullary implant is secured to the medial fracture fragment by a bicortical
locking screw (arrow).

with 50% of the conservatively treated group. Forty-five per-
cent of the patients in the operatively treated group required
ventilatory support after fixation, for an average of two days,
while 35% of the patients in the conservatively treated group
required ventilatory support, for an average of twelve days.
Chest wall deformity was noted in nine patients in the con-
servatively treated group compared with only one patient in the
operatively treated group. Pulmonary function tests at two
months indicated that the operatively treated group had a
significantly less restrictive pattern (p < 0.001), as indicated by
measurement of forced vital capacity and total lung capacity.
The operatively treated group also had significantly fewer days
of ventilator support, treatment in the intensive-care unit, and
in-patient treatment (p < 0.001) and a lower rate of pneumonia
(p = 0.014).
Mayberry et al.102 recently performed a retrospective re-
view of long-term outcomes of forty-six patients who had
undergone surgical repair of severe acute chest wall injuries.
Indications for the surgery included flail chest with an inability
to be weaned from the ventilator, acute intractable pain, acute
chest wall defects/deformity, acute pulmonary herniation, and
thoracotomy for other traumatic indications. Three patients
had a concomitant sternal fracture repair. Fifteen patients with
a mean age of 60.6 years (range, thirty to ninety-one years)
were surveyed at a mean of 48.5 ± 22.3 months (range, nine-
teen to ninety-six months) postinjury. RAND-36 indices103
indicated equivalent or better health status compared with
reference populations, with the exception of role limitations
due to physical problems when compared with the general
population.
Campbell et al.78 retrospectively reviewed the cases of
thirty-two consecutive patients who had undergone ORIF of
traumatic rib fractures with the Inion biodegradable ortho-
pedic trauma plating system (OTPS) during their index ad-
mission. All patients were followed with a questionnaire
assessing chest symptoms, disability, and quality of life. Wound
infection occurred in 19% of the patients and nonunion of a rib
fracture, in one patient. Patients reported low levels of pain at
rest and with coughing. Chest wall stiffness was experienced by
60% of the patients, while dyspnea at rest was reported by 20%.
Fifty-five percent of the patients returned to work, at a mean of
3.9 ± 3.3 months. All patients reported satisfaction with the
results of the operation.
Nirula et al.22 compared thirty patients who had under-
gone ORIF with thirty controls and found a trend toward fewer
total days of ventilator support in the ORIF group (2.9 days
compared with 9.4 days in the control group). The investigators
concluded that ORIF may reduce ventilator requirements in
trauma patients with severe thoracic injuries.
Karev 21 treated 133 consecutive patients with flail chest
injuries with either ORIF (forty patients) or nonoperative
treatment (ninety-three patients); the two groups were similar
in all respects. Various types of extramedullary ORIF were
performed within twenty-four hours after admission. Non-
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operative treatment included mechanical ventilation, place-
ment of an epidural catheter, and regional analgesia. The in-
vestigators concluded that ORIF should be considered when
extensive flail chest is present, particularly for patients with
severe pulmonary and heart contusion.
Voggenreiter et al.45 specifically examined the effect of
pulmonary contusion on the success of ORIF. Forty-two patients
with flail chest injuries were divided into four groups for anal-
ysis. In group 1, ORIF was performed for flail chest without
pulmonary contusion. In group 2, ORIF was performed for flail
chest with pulmonary contusion. In group 3, flail chest without
pulmonary contusion was not treated with ORIF. In group 4,
flail chest with pulmonary contusion was not treated with ORIF.
In patients with flail chest and respiratory insufficiency without
pulmonary contusion, ORIF permitted early extubation. Pa-
tients with pulmonary contusion did not benefit from ORIF
despite being matched with the other groups for age and injury
severity. These findings indicate that pulmonary contusion can
be considered a relative contraindication to operative fixation
of rib fractures. The results of this study suggest that pulmo-
nary contusion is an independent risk factor for failure, as there
were no significant differences in age, severity of injury, or
extent of injury among the groups.
Ahmed and Mohyuddin20 retrospectively reviewed sixty-
four cases of flail chest over a ten-year period. Twenty-six pa-
tients were treated with ORIF with Kirschner wire fixation, and
thirty-eight were treated with intubation and mechanical ven-
tilation. The average duration of ventilator use in the ORIF
group was 3.9 days, and 80% of the patients were weaned from
the ventilator in an average of 1.3 days. The remaining 20% of
the patients needed ventilator support for a longer duration. For
the patients treated with intubation and ventilation alone, the
average duration of assisted ventilation was fifteen days. The
mortality rate was 8% in the ORIF group and 29% in the in-
tubation group. In the group treated with ORIF, 11% of the
patients ultimately required a tracheostomy compared with 37%
of the patients treated with intubation and ventilation alone. In
the ORIF group, 15% of the patients had a documented chest
infection; 4%, septicemia; and 0%, barotrauma. These compli-
cations occurred in 50%, 24%, and 8% of the cases in the
nonoperatively treated group, respectively. The average stay in
the intensive-care unit was nine days in the ORIF group and
twenty-one days in the group treated with intubation and ven-
tilation alone. The investigators concluded that ORIF for flail
chest resulted in rapid recovery with a decreased rate of com-
plications and better ultimate cosmetic and functional results.
Mouton et al.43 prospectively followed twenty-three pa-
tients for a mean of twenty-eight months after ORIF of rib
fractures. The thirty-day survival rate was 91.3%. Ninety-five
percent of the survivors had a 100% working capacity, and 86%
returned to preoperative sports activities. Lardinois et al.29
performed ORIF on sixty-six patients with anterolateral flail
chest. The thirty-day mortality rate was 11%. Symptoms re-
lated to the chest wall were noted by 11%, requiring removal of
implants in three cases. All patients returned to work, at a mean
of eight weeks. Pulmonary function testing of fifty patients at
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six months postoperatively revealed a restrictive lung pattern.
Smaller retrospective series have also demonstrated successful
results, with acceptable rates of complications, after the treat-
ment of flail chest injuries with titanium and bioabsorbable
plate-and-screw implants19,37,56.
Overview
The vast majority of rib fractures are appropriately managed
nonoperatively. However, operative stabilization should be
considered for certain patients. Patients with multiple rib
fractures treated nonoperatively have been shown to require
longer periods of ventilator support; have longer stays in the
intensive-care unit; and have an increased risk of pulmonary
infection, septicemia, mortality, and requiring a tracheos-
tomy 22,45,50,92,98. Additionally, several reports have demon-
strated that nonunions of rib fractures do occur and that it is
likely that the incidence of nonunion and malunion is
underreported30,37,47,48,54,55.
Operative stabilization of a flail chest is increasingly rec-
ognized as a valid approach to improve pulmonary mechanics in
selected trauma patients20,45,61. Debate centers on patient selection
and the timing of operative intervention. The best indication at
this time for early operative chest wall stabilization appears to
be the presence of flail chest and respiratory failure without
severe pulmonary contusion. Non-intubated patients with
deteriorating pulmonary function in the setting of a flail chest
benefit from stabilization in terms of respiratory dynamics,
better pulmonary toilet, and improved pain control. Finally,
patients with symptomatic malunion or nonunion of rib frac-
tures and flail chest injuries appear to benefit from delayed
ORIF, although clinical series have been small and retrospec-
tive. Pain and prolonged hospitalization are associated with
both increased hospital costs and lost revenue for the patient
because of a delay in return to work.
Larger randomized controlled trials across multiple
centers will be necessary to more definitively determine the
efficacy of these procedures. In the study by Mayberry et al.1,
among the subset of surgeons who were opposed to surgical
repair, 95% of general surgeons, 90% of orthopaedic surgeons,
and 82% of thoracic surgeons indicated that a randomized trial
confirming efficacy would be necessary to change their opin-
ion. We agree with Mayberry et al. that a lack of familiarity with
the published literature and a lack of experience with chest wall
repair are common, and likely contribute to the limited use of
these techniques. Most importantly, in order for optimal proce-
dures to be performed with acceptable complication rates, sur-
geons advocating chest wall repairs will need to further refine
operative techniques and operative indications and adequately
train colleagues. On the basis of the available literature, no formal
recommendation can be made regarding which fixation tech-
nique is best. The technique chosen should be based on the
individual surgeon’s critical analysis of his or her own compe-
tency in this evolving area. Lastly, the cost associated with ORIF
may be offset, in appropriately selected patients, by the decreased
number of days in the intensive-care unit and the hospital, but
this possibility requires additional study. n
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Paul M. Lafferty, MD
Orthopaedic Trauma, Cooper Bone & Joint Institute,
3 Cooper Plaza, Suite 408,
Camden, NJ 08103
Jack Anavian, MD
Department of Orthopaedic Surgery,
Brown University Medical School,
593 Eddy Street,
1st Floor Co-op Building,
Providence, RI 02903
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Ryan E. Will, MD
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3 Philip Pavilion, Tacoma, WA 98405
Peter A. Cole, MD
Division of Orthopaedic Trauma,
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640 Jackson Street, St. Paul, MN 55101.
E-mail address: peter.a.cole@healthpartners.com
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