The Journal of Cardiothoracic Trauma

: 2021  |  Volume : 6  |  Issue : 1  |  Page : 4--14

A contemporary algorithm to manage acute rib fractures in the intensive care unit

John Alfred Carr 
 Department of Surgery, Central Michigan University, Saginaw, Michigan, USA

Correspondence Address:
John Alfred Carr
Department of Surgery, Central Michigan University, Saginaw, Michigan


Operative stabilization of both flail and nonflail rib fractures has become very common, with a 76% increase in community hospitals over the past 10 years. This review will explain the rationale and evidence for improved outcomes with operative management of rib fractures, describe the contemporary strategy, and give an algorithm to follow for the management of critical patients in the intensive care unit (ICU) setting with rib fractures. A PubMed and Medline literature search was conducted with the search terms of rib fractures, rib stabilization, rib plating, chest trauma, chest wall, flail chest, nonflail, and ribs. The level of evidence supporting an intervention was evaluated based on the available prospective, randomized trials, nonrandomized trials, retrospective studies, meta-analyses, cohort studies, and reviews. Selected publications of interest on both rib plating and conservative treatment were retrieved and their bibliographies were also reviewed to identify relevant publications. Data from the relevant publications were reviewed, summarized, and the information synthesized. Rib plating has shown improved outcomes in both flail and nonflail rib fractures. Both prospective and retrospective data document a decreased duration of mechanical ventilation, decreased mortality, less pain, decreased incidence of pneumonia, decreased need for tracheostomy, decreased length of ICU and hospital stay, faster return to work, less overall cost, and better pulmonary function at 6 months. The proposed algorithm based on the presented data allows the physician to easily determine which patients are appropriate for rib plating.

How to cite this article:
Carr JA. A contemporary algorithm to manage acute rib fractures in the intensive care unit.J Cardiothorac Trauma 2021;6:4-14

How to cite this URL:
Carr JA. A contemporary algorithm to manage acute rib fractures in the intensive care unit. J Cardiothorac Trauma [serial online] 2021 [cited 2022 Jan 28 ];6:4-14
Available from:

Full Text


With the trauma physician workforce slowly declining in the United States, critical care physicians and thoracic surgeons are being called upon more frequently to manage patients with rib fractures in the intensive care unit (ICU) setting.[1],[2] In the past 10 years, there has been a documented shift in the management of rib fractures from a nonoperative approach, to open reduction and internal fixation with rib plating in a significant number of patients showing improved outcome quality metrics.[3],[4],[5],[6] The surgical and critical care communities have generally agreed that patients with open rib fractures and flail chest require surgery for optimal outcomes.[7],[8],[9],[10] However, over the past 5 years, more patients with rib fractures are now being considered for operative stabilization, while simple, nondisplaced fractures are still being managed nonoperatively.[11],[12],[13],[14],[15],[16] This manuscript will explain the rationale and evidence for improved outcomes with operative management of rib fractures, describe the contemporary strategy, and give an algorithm to follow for the management of critical patients in the ICU setting with rib fractures.

A brief history

The very first recorded operative treatment of flail chest was by Jones and Richardson in 1926.[17] Many attempts to operatively repair broken ribs using plates, screws, pins, and metal hooks continued to be reported from 1940 to 1975.[18],[19],[20],[21],[22],[23] However, the reason that interest for rib stabilization waned in the 1980s and early 1990s was because survival or death of the polytraumatized patient was not dependent on respiratory inhibition from rib fractures. Rather, these patients died from traumatic brain injuries, liver injuries, pulmonary contusions, and multisystem organ failure, with a mortality rate as high as 42%.[24] The rib fractures were at the bottom of the list of priorities. Patients stayed on the ventilator for days and in the hospital for 3–4 weeks at best if they survived, and the inpatient pain management was narcotic-heavy.

However, over the past 5 years, this has certainly no longer been the case. Patients with multiple rib fractures and associated injuries tend to stay in the ICU on average for only 3 days, and have a mortality rate of only 1.6%-6%.[25],[26],[27] Patients are extubated quickly, but respiratory inhibition from rib fracture-induced pain has greatly prolonged the hospital stay after transfer out of an ICU environment.[27],[28] Thus, while the ICU care after chest wall trauma has greatly improved outcomes, expedited discharge home has not been the norm after transfer to the medical floor, where the patients continue to deal with respiratory and pain control issues for days.

Therefore, renewed interest in rib stabilization for pain control and quicker hospital discharge was garnered by multiple reports in the early 2000s showing decreased hospital length of stay, decreased pain, and quicker return to functionality after operative rib fixation.[10],[29],[30],[31],[32],[33] While the initial reports of operative stabilization resulting in improved outcomes and decreased length of stay focused only on patients with flail chest, more recent research has shown these same improved quality metrics in both the flail and nonflail rib fracture patients,[10],[12],[13],[14],[15],[16],[29],[30],[31],[32],[33] which brings us to where we are today.


A comprehensive medical database search of PubMed and Medline was conducted using the search terms of rib fractures, rib stabilization, rib plating, chest trauma, chest wall, flail chest, nonflail, ribs, and combinations thereof. See the PRISMA diagram in [Figure 1] for the breakdown of the articles included. All of the articles identified in the databases using the search terms were initially included. Studies were then excluded if they were too old (published before the year 2000), if rib fractures was not the topic of focus, if they did not report outcomes of interest, if the majority of patients had minor fractures or the majority was not ICU based (for example, rib fractures evaluated and discharged from the emergency department), review articles, commentaries, or case series with fewer than ten patients. Case reports were also excluded. The remaining articles were then assessed for the outcomes of interest which are separately categorized in the Results section. The level of evidence supporting an intervention was evaluated based on the available prospective, randomized trials, nonrandomized trials, retrospective studies, meta-analyses, and case–control or cohort studies and is listed in [Table 1] and [Table 2].{Figure 1}{Table 1}{Table 2}

Grading of the available evidence is as follows: Level 1 (systematic reviews of randomized controlled trials and prospective, randomized trials), Level 2 (prospective, nonrandomized trials, meta-analysis of quasi-experimental studies), Level 3 (one group nonrandomized trials, case–control studies, cohort studies), Level 4 (descriptive studies, large case series, and retrospective group studies), and Level 5 (expert opinion, narrative reviews, and consensus statements). Grades of recommendation are based on the level of evidence as follows: A = Level 1 data, B = Level 2 or 3 data, C = Level 4 data, and D = Level 5 data or inconsistent data. Recommendations are strong for Grade A, moderate for Grades B and C, and weak for Grade D. Since this review is not a meta-analysis, statistical methods were not assigned to the collective data quantitatively as a whole; however, statistical results are reported from specific trials where appropriate.


Duration of mechanical ventilation

The evidence that operative rib stabilization, or rib plating, has decreased the duration of mechanical ventilation in patients with flail chest is vast. There have been three prospective, randomized trials and one prospective, controlled trial showing a decreased time of ventilator support from 2 to 7 days less with rib stabilization compared to best nonoperative management.[30],[31],[34],[35] There have also been 21 nonrandomized studies that show a mean decreased time by meta-analysis of 4 fewer days of mechanical ventilation compared to nonoperative treatment, as reported by Beks [−4.01 days, 95% confidence interval [CI] −5.58 to − 2.45, P < 0.001, [Table 1]].[9],[10],[16],[29],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53]

But what about patients with nonflail rib fractures? There has only been one prospective, randomized trial in patients with nonflail rib fractures.[54] In this study, both the operative and nonoperative patients had broken between 6 and 11 ribs, with a mean of 8 fractures in both groups, but the surgical patients had 6 fewer days of mechanical ventilation on average, compared to the nonoperative group (3.7 + 1.4 vs. 9.5 + 4.3 days, P = 0.037).[54] Three other nonrandomized studies, plus one large multi-institutional study, in patients with multiple, nonflail rib fractures all found a significantly decreased duration of mechanical ventilation, by 3 days on average, in the operative group compared to the conservative treatment group [Table 2].[55],[56],[57],[66] Another large retrospective study in 44,450 geriatric trauma patients older than 65 years with both flail and nonflail rib fractures found that those patients undergoing operative rib stabilization also had, on average, 3 fewer days of mechanical ventilation compared to the nonoperative group (4 vs. 7 days, P = 0.003).[67] And a final, nonrandomized, but prospective study in patients with both flail and nonflail rib fractures also found a statistically significant decrease in duration of mechanical ventilation in those patients who underwent rib stabilization compared to the nonoperative group (P < 0.01).[34]

Need for tracheostomy

The evidence that both flail and multiple, nonflail rib fractures lead to significant pulmonary morbidity shows in the number of recent manuscripts which still promote early tracheostomy for rib fracture patients.[72],[73],[74] However, the majority of these patients included are not receiving rib fixation. In fact, early rib stabilization has been shown to decrease the need for tracheostomy by 30% in two prospective, randomized trials.[30],[31] In the prospective, nonrandomized trial by Pieracci, the patients having rib stabilization had a statistically significant decreased chance of requiring tracheostomy compared to the conservatively treated group (odds ratio, 0.18; 95% CI 0.04–0.78, P = 0.03).[34] Moreover, 16 other nonrandomized and retrospective studies, all showed that rib fixation decreased the need for tracheostomy by as much as 40%.[9],[10],[16],[29],[32],[36],[37],[39],[41],[43],[44],[48],[52],[54],[55],[56],[57]

Incidence of pneumonia

The first prospective, randomized trial to compare the incidence of pneumonia for operative treatment versus nonoperative treatment in 37 patients with rib fractures found an impressive difference of 24% versus 77% (P < 0.05).[30] The second prospective, randomized trial also looking at the incidence of pneumonia in a similar rib fracture population of 46 patients, found a difference in the operative versus nonoperative groups of 48% versus 74% (P = 0.07).[31] The only other prospective, randomized trial to compare the incidence of pneumonia between patients having rib stabilization versus conservative treatment found far fewer cases of pneumonia after surgery once the thoracic cage was stable (48% vs. 80%, P = 0.038).[35] Moreover, a meta-analysis of 20 retrospective studies in patients with both flail and nonflail rib fractures found a 41% risk reduction for pneumonia after rib stabilization (risk ratio: 0.59, 95% CI: 0.42–0.83, P = 0.002).[9],[16],[34],[36],[37],[38],[39],[40],[41],[43],[44],[45],[46],[50],[53],[54],[55],[57],[58],[59],[67]

Intensive care unit length of stay and hospital length of stay

Both ICU and hospital length of stay have been exhaustively analyzed in the flail chest population. Rib stabilization has been shown to decrease ICU length of stay by 10, 3, and 2 days respectively, in three prospective, randomized trials.[30],[31],[35] Multiple additional retrospective studies have also documented a decreased ICU length of stay, with a mean reduction of 2 days, compared to the nonoperative groups (95% CI 0.38–3.61 days, P = 0.02).[9],[16],[29],[34],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[53],[54],[55],[58],[59]

In rib fracture patients without flail chest, ICU length of stay has also been studied, but the evidence is sparse. In the single randomized, prospective study, ICU days were found to be significantly less for the operative versus the nonoperative group by 6 days (8.2 + 4.3 vs. 14.6 + 3.2 days, p = NS).[54] And three retrospective studies have also documented decreased ICU length of stay after rib fixation of 5 days (P = 0.008), 3 days (P = 0.001), and 3 days, respectively.[55],[67],[68] An additional retrospective study also found a statistically significant reduction in ICU length of stay in the operative group, but only if the surgery was performed within 48 h of admission.[57]

In terms of overall hospital length of stay, the vast majority of studies do not show a statistically significant benefit with rib plating.[37],[38],[39],[43],[44],[45],[46],[47],[48],[49],[50],[52],[53],[54],[56],[58],[59] This may be due to other associated injuries, including traumatic brain injuries and orthopedic injuries that often accompany rib fractures and can prolong stay. However, two prospective, randomized trials and five retrospective studies did find an overall decreased length of hospital stay after rib plating.[10],[29],[30],[31],[32],[33],[66] Moreover two additional, well-constructed retrospective studies found a statistically significant decreased overall hospital length of stay of 6 (P = 0.008) and 5 days (P < 0.001), respectively.[57],[67] Hence, in the case of hospital length of stay, the evidence is inconsistent and no definitive conclusion can be drawn.

Surgical complications

The main risks associated with rib plating are implant infection, wound infection, bleeding, and hematoma formation. Nine publications listing surgical complications after rib stabilization included 1174 patients and five reported no complications at all, while the other four reported implant infection necessitating removal of the hardware in 1.5%–5%.[29],[34],[39],[41],[43],[47],[48],[52],[75] Eleven manuscripts reported results of wound infections, and of those, five documented no infections. The other six reported wound infection rates from 2% to 25%.[16],[38],[40],[41],[42],[43],[51],[55],[70]


One prospective, randomized trial and four retrospective studies have proven that operative stabilization of rib fractures is cost effective. The overall cost decreases were due to shorter length of ICU stay and hospital stay.[10],[29],[31],[66],[69]

Quantitative reduction in pain

The major impetus that started the rib plating revolution was the chronic and unrelenting pain. While rib fractures generally take 6–10 weeks to heal, chronic pain that continues beyond 6 weeks occurs in 22%–49% of patients.[76],[77] This chronic pain has been shown to be due to the formation of fibrous nonunion at the fracture site which allows continued motion and inflammation beyond 6 weeks.[60],[78],[79],[80] However, after rib plating, fibrous nonunion occurs in only 1.3% of patients.[71]

Not surprisingly, the first study that looked at narcotic use in 16 rib fracture patients in the immediate postoperative period after rib plating, compared to a nonoperative group of 32 patients, did not find any significant difference in morphine use.[81] Another study which inappropriately matched 67 older trauma patients with flail chest and more severe injuries to a younger, less injured cohort also did not find that rib fracture stabilization reduced pain.[61] However, better studies were needed.

A well-done study that prospectively collected pain scores and quality of life SF-36 data on 39 patients with nonflail rib fractures who underwent rib stabilization and compared the data to 39 nonoperatively managed patients, found that the stabilized patients had significantly better pain control scores at 72 h, 1 week, 2 weeks, 4 weeks, 6 weeks, 3 months and 6 months after surgery as compared to the conservative group (P < 0.001).[13] The operative group also scored significantly better than the conservative group at 1 month and 6 months on the SF-36 (P < 0.05). Moreover, there have been two prospective, randomized trials assessing pain control after rib stabilization.[12],[70] The first was a multicenter, prospective, randomized trial that enrolled 110 patients with nonflail rib fractures into either rib plating or conservative therapy groups and found at 2 weeks after injury that the operative group had significantly lower pain scores (P < 0.01), better disability score (P = 0.03), less narcotic use (P = 0.05), and less pleural space complications (P = 0.02).[12] The second prospective, randomized trial only randomized patients with nonflail rib fractures and high pain scores after 10 days from injury. Pain was then reassessed in the operative and nonoperative groups at 5, 15, and 30 days after randomization. The operative group had significantly less pain and earlier return to normal activity at all time points.[70]

Chronic disability and failure to return to work

It has been thoroughly documented that 35%–76% of patients with more than three rib fractures fail to return to their previous employment or are restricted to lesser employment, within the 1st year.[76],[77],[82],[83] The only prospective, randomized trial that investigated return to work within 6 months found that 61% of the patients having had rib plating returned to their previous employment, compared to only 5% in the nonoperative group.[30] However, after rib plating for both flail and nonflail rib fractures, more recent long-term studies have shown that 79%–92% of patients returned to their previous employment and performance level within 6 months.[16],[60],[61],[62]

Mortality benefit

Research that examined the mortality rates in patients with multiple rib fractures more than 15 years ago before operative rib stabilization was common documented death rates from 10% to 16%, with the most common causes of death being pneumonia, ARDS, and sepsis.[84],[85],[86] With chest stabilization, the 30-day mortality with multiple rib fractures has now plummeted to 1.8%–4.2%, compared to 7.3%–12.4% in the contemporary nonoperative cohorts.[29],[59],[63],[67],[71]

Pulmonary function testing

Rib plating has been shown to quantitatively improve pulmonary function. The first prospective, randomized trial to assess pulmonary function 2 months after injury in patients with multiple rib fractures found that the patients who had rib stabilization had a statistically significantly improvement over the nonoperative patients in total lung capacity (P < 0.001) and forced vital capacity (P < 0.001).[38]

A negative inspiratory force human cadaveric breathing model was creating at the University of Maryland and used to study the respiratory dynamics of the human chest wall with multiple rib fractures and after rib plating and stabilization of those fractures.[87] Both the mean inspiratory volume and the mean peak inspiratory flow rate were cut in half by the presence of five flail rib fractures. When comparing the difference between the fractured, unstable chest wall and the postreduction, stabilized chest wall, a 263% increase in respiratory volume and a 300% increase in peak inspiratory flow were observed (P < 0.02).[87]

Lardinois measured pulmonary function in 66 patients 6 months after rib plating for flail chest and found that 52% had completely normal PFTs. Another 38% all had a forced vital capacity, total lung capacity, and forced expiratory volume in one second within 10%–15% of normal. The remaining 10% had a total lung capacity <85% of predicted; however, all of these patients had returned to work full time without any complaints of dyspnea.[64] Moreover, there have been several other retrospective articles that document that rib stabilization improves pulmonary function testing, normalizes carbon monoxide diffusion testing, and results in normal breathing mechanics.[15],[55],[65],[70]

How many rib fractures would mandate surgery?

The current unanswered questions regarding the operative fixation of rib fractures in the contemporary literature mostly center on the number of rib fractures required as a threshold for surgery and not the presence of any flail segment. However, the problem with a number threshold is that some patients with several rib fractures have surprisingly little pain and appear to function quite well with oral pain medication only. Most physicians would say that these patients would not require surgery at all. On the other hand, some patients with only two rib fractures, or one severely displaced fracture, have severe pain and very limited mobility. This can be especially true in the elderly.[67] It has also been proven that the degree of rib displacement is as predictive of pain and morphine equivalent usage as is the total number of ribs fractured. Every 5 mm increase in displacement predicts a 6% increase in morphine equivalent usage, while every additional rib fracture adds an additional 11% increase in opioid usage.[88] More displacement has also been shown to correlate with increased pulmonary complications.[89] Therefore, a number threshold for surgical decision-making is not valuable by itself, since an elderly patient with two displaced rib fractures may be more disabled and require more oxygen than a 30 years old with four nondisplaced rib fractures.

Thus, the decision to offer these patients' surgical intervention needs to be based on a composite score using the number of ribs fractured, displacement of the fractures, pain score, oxygen requirements, and pulmonary function (spirometry). Two such scoring systems have been proposed: The SCARF score and the RibScore.[90],[91] The RibScore is a radiographic scoring system based on computed tomographic findings, and the SCARF score is a bedside assessment tool based on spirometry, respiratory rate, numeric pain score, and cough. While both tools are useful, neither is comprehensive since the radiographic findings, degree of pain, and pulmonary function must all be taken together to assess the need for operative intervention.

With this in mind, the author created an algorithm that combines all of these variables and yet is simple to follow [Figure 2]. The first step after the initial evaluation is to obtain a computed tomography (CT) scan of the chest to assess the number of rib fractures and the degree of displacement. A plain chest radiograph is not sufficient since such images cannot adequately assess low posterior or very anterior rib fractures, miss 50% of the fractures detected by CT scan, and only have a 40% sensitivity to detect rib fractures.[92],[93] If the radiographic evaluation also shows a traumatic brain injury, liver injury, or other life threatening injuries, these should take priority and the rib fractures can be assessed at a later time. Although repairing rib fractures in patients with traumatic brain injury has been shown to be safe and actually decreases 30-day mortality, the majority of surgeons surveyed from the Chest Wall Injury Society would disqualify such patients from rib stabilization.[11],[94]{Figure 2}

If no other significant injuries are identified, the next step is to assess the rib fractures by number and displacement on CT scan as discussed above. Because significant displacement and more than three rib fractures have been shown to be predictive of increased pain, risk of pneumonia, prolonged mechanical ventilation, and disability with failure to return to work, these patients should be referred for rib plating.[3],[4],[5],[6],[7],[9],[10],[11],[12],[13],[14],[15],[16],[25],[26],[27],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[45],[46],[47],[48],[49],[55],[56],[57],[59],[63],[64],[65],[66],[67],[68],[70],[89] Those patients with three or fewer fractures and no significant displacement (<5 mm) should be evaluated by the SCARF assessment tool to assess pulmonary function, since spirometry has been shown to be predictive of complications and outcome [Table 3].[88],[89],[90],[95],[96],[97],[98]{Table 3}

A SCARF Score of three or higher is predictive of complications, and these patients should also be referred for rib plating. A SCARF score of two or less reassures the physician that this patient will have a successful outcome with only pain control and supplemental oxygen as needed.


The author has been performing rib plating on trauma patients for 12 years in a nonacademic, private practice and has personally witnessed the benefits that patients receive with a stable thoracic cage. But without rib stabilization, rib movement will continue to cause pain and the jagged edges of fractured ribs close to the lung are commonly the cause of recurrent pneumothoraces, both on the hospital ward and after discharge. The four most common reasons for readmission to the hospital after rib fractures are for pain control (5%–10%), recurrent or worsened hemothorax/pneumothorax (10%–38%), pneumonia (6%–14%), and the late development of empyema (14%); all of which are surprisingly high in nonstabilized rib fracture patients.[39],[68],[99],[100],[101] The goal and benchmark for many trauma and ICU patients is decreased length of stay and prevention of complications. And avoiding surgery will prevent surgical complications. However manuscripts that document quality metrics of only hospital length of stay and pain control “success” without rib plating do not tell the whole story when those articles fail to discuss the high readmission rates in such patients. In a review of 158 trauma patients who required readmission to the ICU after initial discharge, 30% were due to complications from rib fractures.[102]

As shown in the data previously presented, rib fracture stabilization clearly decreases the duration of mechanical ventilation, incidence of pneumonia, need for tracheostomy, ICU length of stay, and pain in patients with both flail and nonflail rib fractures. Other than a lack of physicians trained to perform rib plating within an institution, there is no reason that surgery should not be offered to any patient with a significant number of rib fractures when the evidence supporting its use is now overwhelming. Articles such as the recent review in 2020 by Tignanelli which pontificate “evidence-based practices” from the 1990s, and not rib plating, is clearly out of date with contemporary surgical strategy.[103] And as is often the case, articles such as this are written by nonthoracic surgeons who do not perform rib plating as a part of their practice and want to adhere to nonoperative strategies citing “evidence-based practice” from long ago, while ignoring most of the recent evidence out there. A survey of surgeons from the international Chest Wall Injury Society found that 84% of the surgeons would recommend rib plating for three or more displaced fractures in patients without a contraindication for surgery.[11]

Another somewhat concerning statistic is that while rib plating has increased by 76% nationally in the past few years, the greatest utilization of rib plating in trauma patients is not occurring at Level 1 trauma centers, but in the smaller Level 2 and 3 centers, and community hospitals.[104] Smaller trauma centers have been shown to get nonemergent patients into the operating room faster than Level 1 centers, and Level 1 centers have been shown to have longer wait times for urgent cases.[105],[106] This lack of easy access to the OR may translate into a preference for nonoperative management of rib fractures in these centers. However, the exact reason for this rapid growth in the community hospitals is unknown.

Ultimately, it is likely to take another one or two prospective, randomized trials to really drive the benefits of rib plating home. And fortunately, the FixCon trial will give us that data.[107] This trial will examine the benefits of rib plating compared to conservative therapy for patients with three or more simple rib fractures with at least one fracture having some degree of displacement. The primary outcome is the 30-day incidence of pneumonia and the secondary outcomes are duration of mechanical ventilation, pain, length of stay, complications, quality of life, and productivity loss. Follow-up is scheduled from 2 weeks to 12 months. This will be a pivotal trial in expanding the use of rib plating.


Rib plating has already shown great benefits in both flail and nonflail rib fractures. Both prospective and retrospective data document a decreased duration of mechanical ventilation, decreased mortality, less pain, decreased incidence of pneumonia, decreased need for tracheostomy, decreased length of ICU stay, faster return to work, less overall cost, and better pulmonary function at 6 months. The proposed algorithm based on the presented data allows any physician to easily determine which patients are appropriate for rib plating.

Availability of data and material

All data generated and analyzed in this study are included in the article.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Hughes KM, Ewart ZT, Bell TD, Kurek SJ, Swasey KK. Understanding the trauma/acute care surgery workforce. Am Surg 2019;85:638-44.
2Rios-Diaz AJ, Metcalfe D, Olufajo OA, Zogg CK, Yorkgitis B, Singh M, et al. Geographic distribution of trauma burden, mortality, and services in the United States: Does availability correspond to patient need? J Am Coll Surg 2016;223:764-73.e2.
3Martin TJ, Eltorai AS, Dunn R, Varone A, Joyce MF, Kheirbek T, et al. Clinical management of rib fractures and methods for prevention of pulmonary complications: A review. Injury 2019;50:1159-65.
4Liu X, Xiong K. Surgical management versus non-surgical management of rib fractures in chest trauma: A systematic review and meta-analysis. J Cardiothorac Surg 2019;14:45.
5Ingoe HM, Coleman E, Eardley W, Rangan A, Hewitt C, McDaid C. Systematic review of systematic reviews for effectiveness of internal fixation for flail chest and rib fractures in adults. BMJ Open 2019;9:e023444.
6Peek J, Ochen Y, Saillant N, Groenwold RH, Leenen LP, Uribe-Leitz T, et al. Traumatic rib fractures: A marker of severe injury. A nationwide study using the National Trauma Data Bank. Trauma Surg Acute Care Open 2020;5:e000441.
7Senekjian L, Birkas Y, Buhavac M, Dayal S, Mukherjee K, Nygaard R, et al. Stop flailing: The impact of bicortically displaced rib fractures on pulmonary outcomes in patients with chest trauma – An American Association for the Surgery of Trauma multi-institutional study. J Trauma Acute Care Surg 2020;89:658-64.
8Kasotakis G, Hasenboehler EA, Streib EW, Patel N, Patel MB, Alarcon L, et al. Operative fixation of rib fractures after blunt trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017;82:618-26.
9Beks RB, Peek J, de Jong MB, Wessem KJ, Öner CF, Hietbrink F, et al. Fixation of flail chest or multiple rib fractures: Current evidence and how to proceed. A systematic review and meta-analysis. Eur J Trauma Emerg Surg 2019;45:631-44.
10Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: A systematic review. Eur J Trauma Emerg Surg 2017;43:163-8.
11Pieracci FM, Agarwal S, Doben A, Shiroff A, Lottenberg L, Whitbeck SA, et al. Indications for surgical stabilization of rib fractures in patients without flail chest: Surveyed opinions of members of the Chest Wall Injury Society. Int Orthop 2018;42:401-8.
12Pieracci FM, Leasia K, Bauman Z, Eriksson EA, Lottenberg L, Majercik S, et al. A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma Acute Care Surg 2020;88:249-57.
13Zhang JP, Sun L, Li WQ, Wang YY, Li XZ, Liu Y. Surgical treatment ofpatients with severe non-flail chest rib fractures. World J Clin Cases 2019;7:3718-27.
14Griffard J, Daley B, Campbell M, Martins D, Beam Z, Rowe S, et al. Plate of ribs: Single institution's matched comparison of patients managed operatively and non-operatively for rib fractures. Trauma Surg Acute Care Open 2020;5:e000519.
15Li Y, Gao E, Yang Y, Gao Z, He W, Zhao Y, et al. Comparison of minimally invasive surgery for non-flail chest rib fractures: A prospective cohort study. J Thorac Dis 2020;12:3706-14.
16Qiu M, Shi Z, Xiao J, Zhang X, Ling S, Ling H. Potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures. Indian J Surg 2016;78:458-63.
17Jones T, Richardson E. Traction on the sternum in the treatment of multiple fractured ribs. Surg Gynecol Obstet 1926;42:283-5.
18Jaslow IA. Skeletal traction in the treatment of multiple fractures of the thoracic cage. Am J Surg 1946;72:753-5.
19Heroy WW, Eggleston FC. A method of skeletal traction applied through the sternum in “steering wheel” injury of the chest. Ann Surg 1951;133:135-8.
20Constantinescu O. A new method of treating the flail chest wall. Am J Surg 1965;109:604-10.
21Cohen EA. Treatment of the flail chest by towel clip traction. Am J Surg 1955;90:517-21.
22París F, Tarazona V, Blasco E, Cantó A, Casillas M, Pastor J, et al. Surgical stabilization of traumatic flail chest. Thorax 1975;30:521-7.
23Bickford BJ, Grant AF. Surgical management of the stove-in chest injury. Ann R Coll Surg Engl 1956;19:371-82.
24Clark GC, Schecter WP, Trunkey DD. Variables affecting outcome in blunt chest trauma: Flail chest vs. pulmonary contusion. J Trauma 1988;28:298-304.
25Chrysou K, Halat G, Hoksch B, Schmid RA, Kocher GJ. Lessons from a large trauma center: Impact of blunt chest trauma in polytrauma patients-still a relevant problem? Scand J Trauma Resusc Emerg Med 2017;25:42.
26Udekwu P, Roy S, McIntyre S, Farrell M. Flail chest: Influence on length of stay and mortality in blunt chest injury. Am Surg 2018;84:1406-9.
27Butts CC, Miller P, Nunn A, Nelson A, Rosenberg M, Yanmis O, et al. RIB fracture triage pathway decreases ICU utilization, pulmonary complications and hospital length of stay. Injury 2021;52:231-4.
28Kelley KM, Burgess J, Weireter L, Novosel TJ, Parks K, Aseuga M, et al. Early use of a chest trauma protocol in elderly patients with rib fractures improves pulmonary outcomes. Am Surg 2019;85:288-91.
29Ahmed Z, Mohyuddin Z. Management of flail chest injury: Internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg 1995;110:1676-80.
30Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma 2002;52:727-32.
31Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg 2013;216:924-32.
32Swart E, Laratta J, Slobogean G, Mehta S. Operative treatment of rib fractures in flail chest injuries: A meta-analysis and cost-effectiveness analysis. J Orthop Trauma 2017;31:64-70.
33Jiang Y, Wang X, Teng L, Liu Y, Wang J, Zheng Z. Comparison of the effectiveness of surgical versus nonsurgical treatment for multiple rib fractures accompanied with pulmonary contusion. Ann Thorac Cardiovasc Surg 2019;25:185-91.
34Pieracci FM, Lin Y, Rodil M, Synder M, Herbert B, Tran DK, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg 2016;80:187-94.
35Liu T, Liu P, Chen J, Xie J, Yang F, Liao Y. A randomized controlled trial of surgical rib fixation in polytrauma patients with flail chest. J Surg Res 2019;242:223-30.
36Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest- outcomes of patients with or without pulmonary contusion. J Am Coll Surg 1998;187:130-8.
37Majercik S, Wilson E, Gardner S, Granger S, VanBoerum DH, White TW. In-hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures. J Trauma Acute Care Surg 2015;79:533-8.
38Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg 2005;4:583-7.
39Majercik S, Vijayakumar S, Olsen G, Wilson E, Gardner S, Granger SR, et al. Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema. Am J Surg 2015;210:1112-6.
40Solberg BD, Moon CN, Nissim AA, Wilson MT, Margulies DR. Treatment of chest wall implosion injuries without thoracotomy: Technique and clinical outcomes. J Trauma 2009;67:8-13.
41Xu JQ, Qiu PL, Yu RG, Gong SR, Ye Y, Shang XL. Better short-term efficacy of treating severe flail chest with internal fixation surgery compared with conservative treatments. Eur J Med Res 2015;20:55.
42Granhed HP, Pazooki D. A feasibility study of 60 consecutive patients operated for unstable thoracic cage. J Trauma Manag Outcomes 2014;8:20.
43Althausen PL, Shannon S, Watts C, Thomas K, Bain MA, Coll D, et al. Early stabilization of flail chest with locked plate fixation. J Orthop Trauma 2011;25:648-71.
44Zhang Y, Tang X, Xie H, Wang RL. Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion. Am J Emerg Med 2015;33:937-40.
45Ali-Osman F, Mangram A, Sucher J, Shirah G, Johnson V, Moeser P, et al. Geriatric (G60) trauma patients with severe rib fractures: Is muscle sparing minimally invasive thoracotomy rib fixation safe and does it improve post-operative pulmonary function? Am J Surg 2018;216:46-51.
46Wijffels MM, Hagenaars T, Latifi D, Van Lieshout EM, Verhofstad MH. Early results after operatively versus non-operatively treated flail chest: A retrospective study focusing on outcome and complications. Eur J Trauma Emerg Surg 2020;46:539-47.
47Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Fakhry SM, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care 2014;29:139-43.
48DeFreest L, Tafen M, Bhakta A, Ata A, Martone S, Glotzer O, et al. Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest. Am J Surg 2016;211:761-7.
49Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg 2006;72:307-9.
50Velasquez M, Ordoñez CA, Parra MW, Dominguez A, Puyana JC. Operative versus nonoperative management of multiple rib fractures. Am Surg 2016;82:e103-5.
51Zhang X, Guo Z, Zhao C, Xu C, Wang Z. Management of patients with flail chest by surgical fixation using claw-type titanium plate. J Cardiothorac Surg 2015;10:145.
52Balci AE, Eren S, Cakir O, Eren MN. Open fixation in flail chest: Review of 64 patients. Asian Cardiovasc Thorac Ann 2004;12:11-5.
53Jayle CP, Allain G, Ingrand P, Laksiri L, Bonnin E, Hajj-Chahine J, et al. Flail chest in polytraumatized patients: Surgical fixation using Stracos reduces ventilator time and hospital stay. Biomed Res Int 2015;2015:624723.
54Wu WM, Yang Y, Gao ZL, Zhao TC, He WW. Which is better to multiple rib fractures, surgical treatment or conservative treatment? Int J Clin Exp Med 2015;8:7930-6.
55Uchida K, Nishimura T, Takesada H, Morioka T, Hagawa N, Yamamoto T, et al. Evaluation of efficacy and indications of surgical fixation for multiple rib fractures: A propensity-score matched analysis. Eur J Trauma Emerg Surg 2017;43:541-7.
56Wada T, Yasunaga H, Inokuchi R, Matsui H, Matsubara T, Ueda Y, et al. Effectiveness of surgical rib fixation on prolonged mechanical ventilation in patients with traumatic rib fractures: A propensity score-matched analysis. J Crit Care 2015;30:1227-31.
57Iqbal HJ, Alsousou J, Shah S, Jayatilaka L, Scott S, Scott S, et al. Early surgical stabilization of complex chest wall injuries improves short-term patient outcomes. J Bone Joint Surg Am 2018;100:1298-308.
58Dehghan N, Mah JM, Schemitsch EH, Nauth A, Vicente M, McKee MD. Operative stabilization of flail chest injuries reduces mortality to that of stable chest wall injuries. J Orthop Trauma 2018;32:15-21.
59Kane ED, Jeremitsky E, Bittner KR, Kartiko S, Doben AR. Surgical stabilization of rib fractures: A single institution experience. J Am Coll Surg 2018;226:961-6.
60Majercik S, Cannon Q, Granger SR, VanBoerum DH, White TW. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg 2014;208:88-92.
61Marasco SF, Martin K, Niggemeyer L, Summerhayes R, Fitzgerald M, Bailey M. Impact of rib fixation on quality of life after major trauma with multiple rib fractures. Injury 2019;50:119-24.
62Hwee J, Yeo M, Ho M, Aneez D, Pek CH. Results and long-term functional outcomes of rib fracture fixation: A case series in Singapore and a review of indications for surgical fixation. Ann Acad Med Singap 2020;49:93-7.
63Walters ST, Craxford S, Russell R, Khan T, Nightingale J, Moran CG, et al. Surgical stabilization improves 30-day mortality in patients with traumatic flail chest: A comparative case series at a major trauma center. J Orthop Trauma 2019;33:15-22.
64Lardinois D, Krueger T, Dusmet M, Ghisletta N, Gugger M, Ris HB. Pulmonary function testing after operative stabilisation of the chest wall for flail chest. Eur J Cardiothorac Surg 2001;20:496-501.
65Peek J, Beks RB, Kremo V, van Veelen N, Leiser A, Houwert RM, et al. The evaluation of pulmonary function after rib fixation for multiple rib fractures and flail chest: A retrospective study and systematic review of the current evidence. Eur J Trauma Emerg Surg 2021;47:1105-14.
66Otaka S, Aso S, Matsui H, Fushimi K, Yasunaga H. Early versus late rib fixation in patients with traumatic rib fractures: A nationwide study. Ann Thorac Surg 2020;110:988-92.
67Chen Zhu R, de Roulet A, Ogami T, Khariton K. Rib fixation in geriatric trauma: Mortality benefits for the most vulnerable patients. J Trauma Acute Care Surg 2020;89:103-10.
68Fitzgerald MT, Ashley DW, Abukhdeir H, Christie DB 3rd. Rib fracture fixation in the 65 years and older population: A paradigm shift in management strategy at a Level I trauma center. J Trauma Acute Care Surg 2017;82:524-7.
69Coleman JR, Leasia K, Douglas IS, Hosokawa P, Lawless RA, Moore EE, et al. Quantifying the expense of deferring surgical stabilization of rib fractures: Operative management of rib fractures is associated with significantly lower charges. J Trauma Acute Care Surg 2020;89:1032-8.
70Khandelwal G, Mathur RK, Shukla S, Maheshwari A. A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture. Int J Surg 2011;9:478-81.
71Peek J, Beks RB, Hietbrink F, Heng M, De Jong MB, Beeres FJ, et al. Complications and outcome after rib fracture fixation: A systematic review. J Trauma Acute Care Surg 2020;89:411-8.
72Fokin A, Wycech J, Chin Shue K, Stalder R, Lozada J, Puente I. Tracheostomy in trauma patients with rib fractures. Eur J Trauma Emerg Surg 2021;47:965-74.
73Fokin AA, Wycech J, Chin Shue K, Stalder R, Crawford M, Lozada J, et al. Early versus late tracheostomy in trauma patients with rib fractures. J Surg Res 2020;245:72-80.
74Majak P, Næss PA. Rib fractures in trauma patients: Does operative fixation improve outcome? Curr Opin Crit Care 2016;22:572-7.
75Aubert M, Antoine P, Pilichowski P, Contamin C, Peyrin JC, Jacquot C, et al. Flail chests. Study of 224 cases (author's transl). Ann Chir 1981;35:33-9.
76Gordy S, Fabricant L, Ham B, Mullins R, Mayberry J. The contribution of rib fractures to chronic pain and disability. Am J Surg 2014;207:659-62.
77Landercasper J, Cogbill TH, Lindesmith LA. Long-term disability after flail chest injury. J Trauma 1984;24:410-4.
78Kaplan DJ, Begly J, Tejwani N. Multiple rib nonunion: Open reduction and internal fixation and iliac crest bone graft aspirate. J Orthop Trauma 2017;31 Suppl 3:S34-5.
79Hernandez MC, Reisenauer JS, Aho JM, Zeb M, Thiels CA, Cross WW 3rd, et al. Bone autograft coupled with locking plates repairs symptomatic rib fracture nonunions. Am Surg 2018;84:844-50.
80Gauger EM, Hill BW, Lafferty PM, Cole PA. Outcomes after operative management of symptomatic rib nonunion. J Orthop Trauma 2015;29:283-9.
81de Moya M, Bramos T, Agarwal S, Fikry K, Janjua S, King DR, et al. Pain as an indication for rib fixation: A bi-institutional pilot study. J Trauma 2011;71:1750-4.
82Shelat VG, Eileen S, John L, Teo LT, Vijayan A, Chiu MT. Chronic pain and its impact on quality of life following a traumatic rib fracture. Eur J Trauma Emerg Surg 2012;38:451-5.
83Fabricant L, Ham B, Mullins R, Mayberry J. Prolonged pain and disability are common after rib fractures. Am J Surg 2013;205:511-5.
84Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: A review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg 2014;76:462-8.
85Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma 1994;37:975-9.
86Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA, Santaniello JM, et al. Half-a-dozen ribs: The breakpoint for mortality. Surgery 2005;138:717-23.
87Slobogean GP, Kim H, Russell JP, Stockton DJ, Hsieh AH, O'Toole RV. Rib fracture fixation restores inspiratory volume and peak flow in a full thorax human cadaveric breathing model. Arch Trauma Res 2015;4:e28018.
88Bugaev N, Breeze JL, Alhazmi M, Anbari HS, Arabian SS, Holewinski S, et al. Magnitude of rib fracture displacement predicts opioid requirements. J Trauma Acute Care Surg 2016;81:699-704.
89Chien CY, Chen YH, Han ST, Blaney GN, Huang TS, Chen KF. The number of displaced rib fractures is more predictive for complications in chest trauma patients. Scand J Trauma Resusc Emerg Med 2017;25:19.
90Hardin KS, Leasia KN, Haenel J, Moore EE, Burlew CC, Pieracci FM. The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients. J Trauma Acute Care Surg 2019;87:1260-8.
91Chapman BC, Herbert B, Rodil M, Salotto J, Stovall RT, Biffl W, et al. RibScore: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. J Trauma Acute Care Surg 2016;80:95-101.
92Livingston DH, Shogan B, John P, Lavery RF. CT diagnosis of Rib fractures and the prediction of acute respiratory failure. J Trauma 2008;64:905-11.
93Singleton JM, Bilello LA, Canham LS, Levenson RB, Lopez GJ, Tadiri SP, et al. Chest computed tomography imaging utility for radiographically occult rib fractures in elderly fall-injured patients. J Trauma Acute Care Surg 2019;86:838-43.
94Prins JT, Van Lieshout EM, Ali-Osman F, Bauman ZM, Caragounis EC, Choi J, et al. Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI). J Trauma Acute Care Surg 2021;90:492-500.
95Sadler CA, Burgess JR, Dougherty KE, Collins JN. Bedside incentive spirometry predicts risk of pulmonary complication in patients with rib fractures. Am Surg 2019;85:1051-5.
96Schuster KM, Sanghvi M, O'Connor R, Becher R, Maung AA, Davis KA. Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg 2020;89:947-54.
97Sum SK, Peng YC, Yin SY, Huang PF, Wang YC, Chen TP, et al. Using an incentive spirometer reduces pulmonary complications in patients with traumatic rib fractures: A randomized controlled trial. Trials 2019;20:797.
98National Institutes of Health. WGMCC. Pain Intensity Instruments. Available from: [Last updated on 2012 Sep 24; Last accessed on 2021 May 04].
99Baker JE, Skinner M, Heh V, Pritts TA, Goodman MD, Millar DA, et al. Readmission rates and associated factors following rib cage injury. J Trauma Acute Care Surg 2019;87:1269-76.
100Baker JE, Millar DA, Heh V, Goodman MD, Pritts TA, Janowak CF. Does chest wall Organ Injury Scale (OIS) or Abbreviated Injury Scale (AIS) predict outcomes? An analysis of 16,000 consecutive rib fractures. Surgery 2020;168:198-204.
101Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures: Relationship with pneumonia and mortality. Crit Care Med 2006;34:1642-6.
102Christmas AB, Freeman E, Chisolm A, Fischer PE, Sachdev G, Jacobs DG, et al. Trauma Intensive Care Unit 'bouncebacks': Identifying risk factors for unexpected return admission to the Intensive Care Unit. Am Surg 2014;80:778-82.
103Tignanelli CJ, Rix A, Napolitano LM, Hemmila MR, Ma S, Kummerfeld E. Association between adherence to evidence-based practices for treatment of patients with traumatic rib fractures and mortality rates among US trauma centers. JAMA Netw Open 2020;3:e201316.
104Kane ED, Jeremitsky E, Pieracci FM, Majercik S, Doben AR. Quantifying and exploring the recent national increase in surgical stabilization of rib fractures. J Trauma Acute Care Surg 2017;83:1047-52.
105Sunshine JE, Humbert AT, Booth B, Bowman SM, Bulger EM, Sharar SR. Frequency of operative anesthesia care after traumatic injury. Anesth Analg 2019;129:141-6.
106Ahmed K, Zygourakis C, Kalb S, Pennington Z, Molina C, Emerson T, et al. Protocol for urgent and emergent cases at a large academic Level 1 trauma center. Cureus 2019;11:e3973.
107Wijffels MM, Prins JT, Polinder S, Blokhuis TJ, De Loos ER, Den Boer RH, et al. Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): Protocol for a multicenter randomized controlled trial. World J Emerg Surg 2019;14:38.