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Prior to the 1950s, the approach to treating skeletal trauma or deformity of the chest was largely nonoperative. Advances in anesthesia, cardiothoracic surgery, bioprosthetic materials, and mechanical ventilation in the second half of the 20th century reduced the morbidity and mortality of operating in the chest, creating a safer environment for surgical intervention. Potential indications for rib fracture repair include flail chest, non-united rib fractures refractory to conventional pain management, chest wall deformity or defect, and trauma-associated rib fracture and respiratory failure which may be repaired during thoracotomy for other traumatic injury. Several effective repair systems have been developed. These have made plating of ribs and stabilization of the chest wall safe, effective, and easy to perform. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials. In this chapter, we propose a unique classification for flail chest based on vector force applied to the chest wall and its underlying physiologic response to that force.

General Principles

Flail chest has been alternately described as “stoved-in” or “crushed” chest. Nonoperative approaches have included external strapping, placement of sandbags, or positioning of the patient with the injured side down. These methods have been used with relative success to stabilize unilateral flail chest, but for complex injuries, such as bilateral flail chest, mediastinal flail, and large chest wall soft tissue defects, a different strategy is clearly required. External fixation combined with traction was eventually described and largely used during the initial phase of management of flail chest. The prolonged bed rest necessary for fracture union, however, led surgeons to consider internal fixation. Intramedullary “rush nail” fixation was first reported in 1956.1 Another major factor was the introduction of positive pressure mechanical ventilation. Its adoption and success in preventing respiratory failure in patients with multiple rib fractures and flail chest rendered external fixation/traction obsolete.

By the 1960s and 1970s surgeons recognized that select patients with flail chest might benefit from surgical fixation even after brief periods of mechanical ventilation had failed. Sporadic series attempting rib fracture repair using a number of techniques, including plating, wiring, and intramedullary rods, were reported.29 Brunner was the first to successfully repair a case of sternal flail using a substernal stainless steel prosthesis, the same technique used to reconstruct pectus excavatum.10


The indications for surgery in flail chest and rib fracture repair are summarized in Table 137-1. Both acute and chronic problems are amenable to surgery.

Table 137-1Potential Indications for Repair of Rib Fracture

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