Fixing the cage: Rib fixation of flail chest

Surgical rib fixation has resurfaced as a treatment for patients with multiple rib fractures or who have a flail segment injury pattern (a chest wall deformity that contains at least two fractures per rib in at least three consecutive ribs) that fail to respond to medical management. As with other fractures of the human skeleton, realigning the broken bones and fixing them to each other improves function, decreases pain, and aids in healing of the fracture.

An evolving procedure

Rib fixation dates back to 1927, when Jones and Jaslow designed rather bizarre contraptions consisting of hooks and forceps drilled into the ribs with attached weights, creating a suspension system to reduce and fixate broken ribs. This trend-setting external fixation technique has been revised multiple times up until the mid-1990s, when the fixation devices were internalized. The modern technique of rib fixation uses the principle of placing plates, screws, and wires to hold the broken rib in place after reduction of the fracture.1

The literature supporting rib fixation lacks large prospective randomized trials that would lead to evidence-based criteria for determining which patients derive the best benefit from surgical stabilization and the resultant long-term outcomes associated with the procedure. A research group at Denver Health, CO, published a comprehensive approach to management of rib fractures in 2015 and provided recommendations for the indications and contraindications of this procedure. Candidates for surgical fixation included patients who have acute respiratory failure requiring mechanical ventilation, uncontrolled pain, and anticipated chronic pain impairment of pulmonary mechanics.2

DeMoya and colleagues added recommendations to include the number of fractures in a flail segment greater than or equal to five and the degree of rib displacement. Patients for whom rib fixation was contraindicated include individuals with active infections (bacteremia, chest wall, or pleural space infections), poor operative candidates, and those individuals who would not benefit from the procedure (patients who require extended ventilation, such as individuals with severe brain injury).2-4 As documented in a consensus guideline in 2017, stabilization is technically easier within 72 hours of injury secondary to difficulty in reducing fractures after callus formation.5


To examine the occurrence of patients with flail chest and rib fixation in the National Trauma Data Bank® (NTDB®) research admission year 2016, medical records were searched using the International Classification of Diseases, 10th Revision Clinical Modification codes. Specifically searched were records that contained a diagnosis code of S22.5 (flail chest) and a procedure code of 21811 (open treatment of rib fracture(s) one to three ribs), 21812 (open treatment of rib fractures four to six ribs), or 21813 (open treatment of rib fractures seven or more ribs). A total of 739 records were found, 715 of which contained a discharge status, including 353 patients discharged to home, 228 to acute care/rehab, 115 to skilled nursing facilities; 19 died (see Figure 1). Of these patients, 76 percent were male, on average 54.8 years of age, had an average hospital length of stay of 17.5 days, an intensive care unit length of stay of 11.7 days, an average injury severity score of 22.5, and were on the ventilator for an average of 10.3 days. Of those tested, 30 percent (154 out of 507) tested positive for alcohol.

Figure 1. Hospital Discharge Status

Figure 1. Hospital Discharge Status

The mainstay treatment for most skeletal fractures involves analgesics, rest, and immobilization/fixation. It would seem counterintuitive to allow a fracture site to move with every breath one takes and expect rapid healing and a prompt return to activities of daily life. More research is needed to see why ribs have been treated nonoperatively and contrary to these basic principles for decades. Fixing the cage may take on a greater role in the treatment of rib fractures during the next few decades.

Throughout the year, trauma data are highlighted through brief reports that are published monthly in the Bulletin. The NTDB Annual Report can be found on the American College of Surgeons website as a PDF file. In addition, the website includes information about how to obtain NTDB data for more detailed study. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB.


Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.


  1. Bemelman M, Poeze M, Blokhuis TJ, Leenen LPH. Historic overview of treatment for rib fractures and flail chest. Eur J Emerg Surg. 2010;36(5):407-415.
  2. Pieracci FM, Rodil M, Stovall RT, et al. Surgical stabilization of severe rib fracture. J Trauma Acute Care Surg. 2015;78(4):883-887.
  3. De Moya M, Nirula R, Biffl W. Rib fixation: Who, what, when? Trauma Surg Acute Care Open. 2017;2(1):1-4.
  4. Brasel K, Moore E, Albrecht R, et al. Western Trauma Association critical decisions in trauma: Management of rib fractures. J Trauma Acute Care Surg. 2016;82(1):200-203.
  5. Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: Surgical stabilization or rib fractures, rib fracture colloquium clinical practice guidelines. Injury. 2017;48(2):307-312.

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