Surgical stabilization of flail chest after trauma: when, why and how to do it?

Chest trauma is the third most common injury in trauma patients. In up to 15% of cases, flail chest (FC) may occur as a consequence of blunt trauma, being defined as three or more adjacent ribs fractured in at least two places. This creates a chest wall segment that moves paradoxically from the chest wall, causing both a fast evolution to respiratory failure and late complications like pneumonia, ARDS, atelectasis, chronic pain and deformity. Non-operative management, as defined by mechanical ventilation associated with adequate pain control, has always been considered the gold standard for FC treatment; surgical fixation for FC, instead, has been routinely performed only in the last years, taking advantage of the simultaneous increase in surgeons’ expertise, new technical improvements of rib-specific fixation systems and publication of encouraging randomized trials. However, the difficulty to select, stratify and compare patients in the setting of multi-systemic traumas makes extremely hard to collect data on the correct management of FC so that no precise guidelines about indications, timing and best technical surgical procedure are currently available and widely accepted. The role of early surgical intervention for FC, which is associated with better post-operative outcomes, has been widely discussed in previous studies; its main advantage, in fact, is to avoid the development of associated hypoventilation and subsequent pneumonia, hypoxemia and pulmonary fibrosis. Moreover, different surgical techniques have been described for fixation of rib fractures, but no consensus has yet been achieved on which of them could be the best procedure, being the choice mostly related to the surgeons’ preferences. The use of metal plates with cortical locking screws is the most preferred choice today, also due to new technical achievement in this field.