Indications for Rib Fixation

  • Tiffany Zens
  • Krista Haines
  • Suresh AgarwalEmail author


There are no clear, absolute, and universally accepted indications or contraindications for operative rib fixation. Furthermore, although the majority of experts believe patients benefit most from early operative fixation, there is no consensus agreement regarding optimal timing of surgery. The most common and well-accepted indication for operative rib fixation is the presence of a flail chest segment in a patient on mechanical ventilation with no underlying pulmonary contusion. This indication is in concordance with the clinical practice guidelines issued by the Eastern Association for the Surgery of Trauma. Additional relative indications supported by the literature and recommended by experts in the field include severe chest wall deformity, symptomatic rib fracture nonunion, acute pulmonary herniation, failure to wean from mechanical ventilation or poor pulmonary mechanics in a patient with severe chest wall trauma, need for acute or chronic pain/symptom control, and thoracotomy for another reason. Surgeons should take into consideration possible contraindications for operative repair including the location of rib fractures and presence of either pulmonary contusion or traumatic brain injury.


Operative rib fixation Indication Contraindication Flail chest Chest wall deformity Symptomatic nonunion Pulmonary herniation Mechanical ventilation Pain 


  1. 1.
    Dehghan 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(2):462–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011;93(1):97–110.CrossRefPubMedGoogle Scholar
  3. 3.
    Swart 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(2):64–70.CrossRefPubMedGoogle Scholar
  4. 4.
    Nirula R, Mayberry JC. Rib fracture fixation: controversies and technical challenges. Am Surg. 2010;76(8):793–802.PubMedGoogle Scholar
  5. 5.
    Kasotakis G, Hasenboehler EA, Streib EW, 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(3):618–26.CrossRefPubMedGoogle Scholar
  6. 6.
    de Jong MB, Kokke MC, Hietbrink F, Leenen LP. Surgical Management of rib Fractures: strategies and literature review. Scand J Surg. 2014;103(2):120–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Mayberry JC, Ham LB, Schipper PH, Ellis TJ, Mullins RJ. Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. J Trauma. 2009;66(3):875–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? J Trauma. 2003;54(6):1058–63. discussion 1063-1054CrossRefPubMedGoogle Scholar
  9. 9.
    Ziegler DW, Agarwal NN. The morbidity and mortality of rib fractures. J Trauma. 1994;37(6):975–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Pate JW. Chest wall injuries. Surg Clin North Am. 1989;69(1):59–70.CrossRefPubMedGoogle Scholar
  11. 11.
    Bottlang M, Long WB, Phelan D, Fielder D, Madey SM. Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study. Injury. 2013;44(2):232–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52(4):727–32. discussion 732PubMedGoogle Scholar
  13. 13.
    Karev DV. Operative management of the flail chest. Wiad Lek. 1997;50(Suppl 1 Pt 2):205–8.PubMedGoogle Scholar
  14. 14.
    Granetzny 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(6):583–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216(5):924–32.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Cataneo AJ, Cataneo DC, de Oliveira FH, Arruda KA, El Dib R, de Oliveira Carvalho PE. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev. 2015;7:CD009919.Google Scholar
  17. 17.
    Nirula R, Allen B, Layman R, Falimirski ME, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg. 2006;72(4):307–9.PubMedGoogle Scholar
  18. 18.
    Mayberry JC, Kroeker AD, Ham LB, Mullins RJ, Trunkey DD. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg. 2009;75(5):389–94.PubMedGoogle Scholar
  19. 19.
    Wu 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(5):7930–6.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Mitchell JD. Blunt chest trauma: is there a place for rib stabilization? J Thorac Dis. 2017;9(Suppl 3):S211–7.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Senekjian L, Nirula R. Rib fracture fixation: Indications and Outcomes. Crit Care Clin. 2017;33(1):153–65.CrossRefPubMedGoogle Scholar
  22. 22.
    Coughlin TA, Ng JW, Rollins KE, Forward DP, Ollivere BJ. Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials. Bone Joint J. 2016;98-B(8):1119–25.CrossRefPubMedGoogle Scholar
  23. 23.
    Schuurmans 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(2):163–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg. 2013;258(6):914–21.CrossRefPubMedGoogle Scholar
  25. 25.
    Mayberry JC, Terhes JT, Ellis TJ, Wanek S, Mullins RJ. Absorbable plates for rib fracture repair: preliminary experience. J Trauma. 2003;55(5):835–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Campbell N, Conaglen P, Martin K, Antippa P. Surgical stabilization of rib fractures using inion OTPS wraps--techniques and quality of life follow-up. J Trauma. 2009;67(3):596–601.CrossRefPubMedGoogle Scholar
  27. 27.
    Nirula R, Diaz JJ, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009;33(1):14–22.CrossRefPubMedGoogle Scholar
  28. 28.
    Fowler TT, Taylor BC, Bellino MJ, Althausen PL. Surgical treatment of flail chest and rib fractures. J Am Acad Orthop Surg. 2014;22(12):751–60.CrossRefPubMedGoogle Scholar
  29. 29.
    Slater MS, Mayberry JC, Trunkey DD. Operative stabilization of a flail chest six years after injury. Ann Thorac Surg. 2001;72(2):600–1.CrossRefPubMedGoogle Scholar
  30. 30.
    Morgan-Jones RL, Mackie IG. Non-union of a fracture of the 8th rib. Injury. 1996;27(2):147–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Ten Duis K, IJpma FF. Surgical treatment of snapping scapula syndrome due to Malunion of rib fractures. Ann Thorac Surg. 2017;103(2):e143–4.CrossRefPubMedGoogle Scholar
  32. 32.
    Takahara K, Uchiyama S, Nakagawa H, Kamimura M, Ohashi M, Miyasaka T. Snapping scapula syndrome due to malunion of rib fractures: a case report. J Shoulder Elb Surg. 2004;13(1):95–8.CrossRefGoogle Scholar
  33. 33.
    Cacchione RN, Richardson JD, Seligson D. Painful nonunion of multiple rib fractures managed by operative stabilization. J Trauma. 2000;48(2):319–21.CrossRefPubMedGoogle Scholar
  34. 34.
    Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: an underused procedure? Am Surg. 2007;73(6):591–6. discussion 596-597PubMedGoogle Scholar
  35. 35.
    François B, Desachy A, Cornu E, Ostyn E, Niquet L, Vignon P. Traumatic pulmonary hernia: surgical versus conservative management. J Trauma. 1998;44(1):217–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Sirmali M, Türüt H, Topçu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management. Eur J Cardiothorac Surg. 2003;24(1):133–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Flagel BT, Luchette FA, Reed RL, et al. Half-a-dozen ribs: the breakpoint for mortality. Surgery. 2005;138(4):717–23. discussion 723-715CrossRefPubMedGoogle Scholar
  38. 38.
    Holcomb JB, McMullin NR, Kozar RA, Lygas MH, Moore FA. Morbidity from rib fractures increases after age 45. J Am Coll Surg. 2003;196(4):549–55.CrossRefPubMedGoogle Scholar
  39. 39.
    Todd SR, McNally MM, Holcomb JB, et al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg. 2006;192(6):806–11.CrossRefPubMedGoogle Scholar
  40. 40.
    Kent R, Woods W, Bostrom O. Fatality risk and the presence of rib fractures. Ann Adv Automot Med. 2008;52:73–82.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Shulzhenko NO, Zens TJ, Beems MV, et al. Number of rib fractures thresholds independently predict worse outcomes in older patients with blunt trauma. Surgery. 2017;161(4):1083–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Chien 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(1):19.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Majercik 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(4):533–538; discussion 538-539.CrossRefPubMedGoogle Scholar
  44. 44.
    Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg. 2016;80(2):187–94.CrossRefPubMedGoogle Scholar
  45. 45.
    Doben AR, Eriksson EA, Denlinger CE, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care. 2014;29(1):139–43.CrossRefPubMedGoogle Scholar
  46. 46.
    Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. 2003;54(3):615–25.CrossRefPubMedGoogle Scholar
  47. 47.
    Fabricant L, Ham B, Mullins R, Mayberry J. Prolonged pain and disability are common after rib fractures. Am J Surg. 2013;205(5):511–5. discussion 515-516CrossRefPubMedGoogle Scholar
  48. 48.
    de Moya M, Bramos T, Agarwal S, et al. Pain as an indication for rib fixation: a bi-institutional pilot study. J Trauma. 2011;71(6):1750–4.PubMedGoogle Scholar
  49. 49.
    Khandelwal 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(6):478–81.CrossRefPubMedGoogle Scholar
  50. 50.
    Landercasper J, Cogbill TH, Lindesmith LA. Long-term disability after flail chest injury. J Trauma. 1984;24(5):410–4.CrossRefPubMedGoogle Scholar
  51. 51.
    Beal SL, Oreskovich MR. Long-term disability associated with flail chest injury. Am J Surg. 1985;150(3):324–6.CrossRefPubMedGoogle Scholar
  52. 52.
    Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? J Am Coll Surg. 2012;215(2):201–5.CrossRefPubMedGoogle Scholar
  53. 53.
    Mouton WLD, Furrer M, Regli B, Ris HB. Long-term follow-up of patients with operative stabilization of a flail chest. Thorac Cardiovasc Surg. 1997;45:242–4.CrossRefPubMedGoogle Scholar
  54. 54.
    Jones KM, Reed RL, Luchette FA. The ribs or not the ribs: which influences mortality? Am J Surg. 2011;202(5):598–604.CrossRefPubMedGoogle Scholar
  55. 55.
    Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg. 1995;110(6):1676–80.CrossRefPubMedGoogle Scholar
  56. 56.
    Voggenreiter 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(2):130–8.CrossRefPubMedGoogle Scholar
  57. 57.
    Kishikawa M, Yoshioka T, Shimazu T, Sugimoto H, Sugimoto T. Pulmonary contusion causes long-term respiratory dysfunction with decreased functional residual capacity. J Trauma. 1991;31(9):1203–1208; discussion 1208-1210.CrossRefPubMedGoogle Scholar
  58. 58.
    Zhang 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(7):937–40.CrossRefPubMedGoogle Scholar
  59. 59.
    Althausen PL, Shannon S, Watts C, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011;25(11):641–7.CrossRefPubMedGoogle Scholar
  60. 60.
    Solberg 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(1):8–13. discussion 13CrossRefPubMedGoogle Scholar
  61. 61.
    Xu 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.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryUW Hospital and Clinics, University of WisconsinMadisonUSA
  2. 2.Division of Trauma and Critical Care Surgery, Department of SurgeryDuke University Medical CenterDurhamUSA

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