Flail Chest

Flail chest injuries: A review of outcomes and treatment practicesfrom the National Trauma Data Bank

Niloofar Dehghan, MD, Charles de Mestral, MD, PhD, Michael D. McKee, MD, Emil H. Schemitsch, MD,and Avery Nathens, MD, MS, PhD, MPH, Toronto, Ontario, Canada

BACKGROUND: Flail chest injuries are associated with severe pulmonary restriction, a requirement for intubation and mechanical ventilation,and high rates of morbidity and mortality. Our goals were to investigate the prevalence, current treatment practices, andoutcomes of ail chest injuries in polytrauma patients.

METHODS: The National Trauma Data Bank was used for a retrospective analysis of the injury patterns, management, and clinicaloutcomes associated with ail chest injuries. Patients with a ail chest injury admitted from 2007 to 2009 were included in theanalysis. Outcomes included the number of days on mechanical ventilation, days in the intensive care unit (ICU), days in thehospital, and rates of pneumonia, sepsis, tracheostomy, chest tube placement, and death.

RESULTS: Flail chest injury was identied in 3,467 patients; the mean age was 52.5 years, and 77% of the patients were male. Signicanthead injury was present in 15%, while 54% had lung contusions. Treatment practices included epidural catheters in 8% andsurgical xation of the chest wall in 0.7% of the patients. Mechanical ventilation was required in 59%, for a mean of 12.1 days.ICU admission was required in 82%, for a mean of 11.7 days. Chest tubes were used in 44%, and 21% required a tracheostomy.Complications included pneumonia in 21%, adult respiratory distress syndrome in 14%, sepsis in 7%, and death in 16%. Patientswith concurrent severe head injury had higher rates of ventilatory support and ICU stay and had worse outcomes in every categorycompared with those without a head injury.

CONCLUSION: Patients who have sustained a ail chest have signicant morbidity and mortality. More than 99% of these patients were treatednonoperatively, and only a small proportion (8%) received aggressive pain management with epidural catheters. Given the highrates of morbidity and mortality in patients with a ail chest injury, alternate methods of treatment including more consistentuse of epidural catheters for pain or surgical xation need to be investigated with large randomized controlled trials. (J TraumaAcute Care Surg. 2014;76: 462Y468. Copyright * 2014 by Lippincott Williams & Wilkins)

LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level IV.KEY WORDS: Flail chest; rib fracture; thoracic trauma; chest wall fixation.

R ib fractures are common injuries and occur in up to 39% ofpatients with blunt chest trauma.1 These fractures areroutinely treated nonoperatively, and most heal without majorcomplications. However, a number of these injuries can resultin a mechanically unstable chest wall or ail chest, which isassociated with high rates of short-term mortality and long-term morbidity.1,2

A ail chest is dened as three or more consecutive ribfractures, in two or more locations, creating a ail segment.3

This denition also applies to three or more bilateral consec-utive rib fractures, and three or more rib fractures associatedwith a sternal fracture because both of these also lead to thecreation of a mechanically unstable ail segment.4 A ail chestcan lead to chest wall instability, asynchronous movement ofthe ail segment, and paradoxical chest motion. It also leads to

deformity of the chest wall and loss of thoracic volume.4 Thesein turn lead to decreased lung volume, atelectasis, chesttightness, dyspnea, and chronic pain.1,2,4,5

The current treatment of ail chest injuries consists ofnonsurgical management via intubation and intermittent posi-tive pressure ventilation (internal pneumatic splint), analgesia,pulmonary toilet, and chest physiotherapy.1,4,6 However, evenwith aggressive nonoperative management, patients with severechest wall injuries remain at risk for many complications. A ailchest injury causes compromised respiratory function with poorpulmonary toilet or inability to clear secretions, which typicallyrequires mechanical ventilatory support. Prolonged mechanicalventilation can in turn result in barotrauma and increases therisk for pneumonia, sepsis, extended time in the intensive careunit (ICU), and death.1,2,4,5,7,8 Even in the presence of extra-thoracic injuries in these polytrauma patients, pneumonia andthe resultant sepsis remain two of the most common causes ofdeath in patients with ail chest injuries.4

A better understanding of the present-day burden of ailchest injuries will provide useful information on the poten-tial utility of different treatment strategies. A contemporarydescription of practice patterns and in-hospital outcomes ofpatients with ail chest injuries is currently lacking in the lit-erature. This is relevant, given the increased interest in surgicalxation of selected cases. The purposes of this study were to

ORIGINAL ARTICLE

J Trauma Acute Care SurgVolume 76, Number 2462

Submitted: July 7, 2013, Revised: November 10, 2013, Accepted: October 14, 2013.From the Division of Orthopaedics (N.D., M.D.M., E.H.S.), Department of Surgery,

St. Michaels Hospital; Division of General Surgery (C.D.M.), Department ofSurgery, and Department of Surgery (A.N.), Sunnybrook Health SciencesCentre, University of Toronto, Ontario, Canada.

This study was presented at the Canadian Orthopaedic Association Annual Con-ference 2013.

Address for reprints: Niloofar Dehghan, MD, 55 Queen St East, Suite 800, Toronto,Ontario, Canada, M5C 1R6; email: [email protected].

DOI: 10.1097/TA.0000000000000086

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

determine the prevalence of ail chest injuries in the traumapatient population and to describe current treatment practices,both nonsurgical and surgical, as well as the morbidity andmortality of patients with these injuries.

PATIENTS AND METHODS

Study DesignWe designed a retrospective cohort study of patients with

ail chest injuries identied in the National Trauma Data Bank(NTDB), to characterize the prevalence of this injury as wellas injury patterns, current management, and in-hospital mor-bidity and mortality. Certain patient subgroups were compared.The subgroups were dened based on the presence of severehead injury or the presence of lung contusions because thesehave been reported in the literature to require longer durationof ventilatory support and have worse outcomes comparedwith patients without such injuries.1,2,4,9

Data Source and SettingThe NTDB is the largest aggregation of US/Canadian

trauma registry data and was used in this study. Data fromNTDB version 10.1, years 2007 to 2009, were used.

CohortThe cohort included adults (Q16 years of age) sustaining

a ail chest injury following blunt trauma, treated at a Level 1or 2 trauma center. Flail injury was identied based on thefollowing Abbreviated Injury Scale (AIS) diagnosis codes:450260.3 (ail injuryVunilateral or not further specied),450262.3 (ail injury without lung contusion), 450264.4 (ailinjury with lung contusion), and 450266.5 (bilateral ail injury).

At the patient level, patients who were dead on arrival ordied in the emergency department were excluded owing tolimited opportunity for injury ascertainment or intervention.At the center level, facilities with the following criteria wereincluded for analysis: trauma center Level 1 or 2, facilities with90% or more of patients having at least one AIS code, facilitiescoding for a minimum of 100 patients, those that code com-plications, and facilities that code at least one exploratorylaparotomy. We wished to exclude centers that did not con-sistently code procedures. We therefore identied and excludedcenters where no patient underwent either of the two mostcommonly coded operative procedures in NTDB, namely, openreduction and internal xation of the femur and open reductionand internal xation of the tibia (ICD-9 procedure codes 79.35and 79.36). To derive more valid estimates of in-hospital com-plications, we also excluded centers unlikely to accurately codecomplications. In doing so, we excluded centers that did notcode at least one pneumonia or urinary tract infection during the3-year study period.

Patient CharacteristicsThe patient characteristics examined included age, sex,

the presence of an associated severe head injury, and thepresence of a lung contusion. A severe head injury was denedas a head injury with AIS score of 3 or greater and a motorGlasgow Coma Scale (GCS) score of 4 or less. The presence ofa lung contusion was identied based on the AIS diagnosis

coding listed earlier (450264.4: ail injury with lung contu-sion); however, there was no denition or grading system withregard to the extent of contusion present.

Management, Morbidity, and MortalityWe examined the duration of mechanical ventilation,

ICU stay, and total hospital stay. We also calculated the pro-portion of patients who received a chest tube, tracheostomy, orepidural catheter. Procedures were captured based on ICD-9procedure codes. The frequency of complications and mortalitywere also calculated. The selected complications were obtainedfrom the complications eld of the NTDB and included pneu-monia, adult respiratory distress syndrome (ARDS), and sepsis.

Statistical AnalysisManagement and in-hospital morbidity and mortality

were compared across subgroups and dened based on thepresence or absence of severe head injury and the presence orabsence of lung contusion. W2 or Fishers exact test was usedfor categorical variables, and t test or Kruskal-Wallis test wasused for continuous variables. A two-tailed > G 0.05 wasconsidered statistically signicant.

RESULTS

We identied 354,945 patients with an Injury SeverityScore (ISS) of 9 or greater following blunt trauma treatedat 199 Level 1 and 2 trauma centers (representing 980% oftrauma centers for that period). Of these patients, 3,467 (1%)experienced a documented ail chest injury. The followingdata pertain to the 3,467 patients identied with a ail chestdiagnosis.

Entire CohortThe average age at the time of injury was 52.5 years,

with 77% male and 23% female patients. The mean ISS was30.4, and the most common mechanism of injury was motorvehicle collision (79%). Other causes included fall (16%) andother blunt injury (5%). A severe head injury was present in15% of patients, while 54% had documented lung contusions.

Overall, intubation and mechanical ventilation were re-quired in 59% (1762/2984, data unavailable for 483 patients),for a mean of 7.2 days overall (SD 11, median 1, interquartilerange (IQR) 0Y12). The mean duration of mechanical venti-lation was 12.1 days for the 59% who required intubation andmechanical ventilation (SD 12, median 9, IQR 3Y18). ICUadmission was required in 82% of patients (2767/3377, dataunavailable for 90 patients), for a mean of 9.6 days overall(median 5, SD 12, IQR 1Y15). The mean length of ICU staywas 11.7 days for the 82% who required ICU admission (SD12, median 8, IQR 3Y17). Mean length of hospital stay overallwas 16.6 days (SD 16, median 12, IQR 6Y22) (Figs. 1, 2).

Chest tubes were used in 44% (1,542 of 3,467), and 21%(714 of 3,467) of the patients required a tracheostomy. In-hospital complications included pneumonia in 21% (713 of3,467), ARDS in 14% (480 of 3,467), sepsis in 7% (255of 3,467), and death in 16% (544 of 3,467) of the population(Fig. 1). Epidural catheters were used in 8% (263 of 3,467) of

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* 2013 Lippincott Williams & Wilkins 463


the patients, and surgical xation of the chest wall was per-formed in only 0.7% (24 of 3,467) of the patients.

Patients With Severe Head InjurySevere head injury (dened as head AIS score Q 3 and a

motor GCS score e 4) was present in 15% (523 of 3,467) ofthe patients. When comparing the outcomes of patients withsevere head injury with those without a documented severehead injury, there were statistically signicant higher rates ofcomplications and poor outcomes in all categories.

Compared with those without a severe head injury, pa-tients with a severe head injury had statistically signicantincrease in rates of need for mechanical ventilation (88% vs.54%, p G 0.00001) and ICU stay (89% vs. 81%, p G 0.00001).

They also had more days on a mechanical ventilator (11.2 vs.6.5, p G 0.001), more days in the ICU (13.4 vs. 8.9, p G 0.001),and more days in the hospital (21.4 vs. 15.8, p G 0.0005).(Fig. 2, Tables 1 and 2)

With regard to other outcomes, patients with a severehead injury compared with thosewithout severe head injury alsohad higher rates of chest tube use (51% vs. 43%, p G 0.001),tracheostomy (34% vs. 18%, p G 0.0001), pneumonia (31% vs.19%, pG 0.0001), ARDS (17%vs. 13%, pG 0.016), sepsis (11%vs.7%, p G 0.001), and death (40% vs. 11%, p G 0.0001) (Fig. 3).These patients were also less likely to receive an epiduralcatheter for pain management (1% vs. 9%, p G 0.0001), whilethere was no difference between rates of surgical xation be-tween the two groups (Fig. 3, Table 1).

Figure 1. Outcomes, morbidity and mortality for 3,467 patients identied with ail chest injury.

Figure 2. Number of days on mechanical ventilation, ICU stay, total hospital stayVbased on injury pattern.

J Trauma Acute Care SurgVolume 76, Number 2Dehghan et al.

464 * 2013 Lippincott Williams & Wilkins


Patients With Pulmonary ContusionOf the 3,467 patients, 54% (1,880 of 3,467) had a doc-

umented lung contusion. When comparing patients with pul-monary contusion with those without contusion, there was astatistically signicant increase in the rate of mechanicalventilation (61% vs. 56%, p G 0.005), time on the ventilator(7.3 days vs. 7.0 days, p G 0.016), need for ICU admission(84% vs. 80%, p G 0.003), days spent in the ICU (9.9 days vs.9.2 days, p G 0.0032), and total days in the hospital (17.1 days vs.16.1 days, p G 0.018). Patients with pulmonary contusionsalso had higher rates of chest tube placement (47% vs. 42%,p G 0.003) and pneumonia (22% vs. 19%, p G 0.013). Whilethese were statistically signicant, the magnitude of the differ-ence was not as great as when comparing patients with presenceor absence of severe head injury. There were no differences withregard to the rate of tracheostomy, ARDS, sepsis, or death. Therewere also no differences between the two groups with regardto use of epidural catheters for pain or surgical xation of thechest wall (Tables 1 and 2).

Treatment ModalitiesVEpidural Catheters,Surgical Fixation of the Chest Wall

Epidural catheters were used in 8% (283 of 3,467), andonly 24 of the 3,467 patients underwent surgical xation oftheir ail chest (0.7%).

DISCUSSION

The current treatment of severe chest wall injuries con-sists of nonsurgical management via intubation and intermit-tent positive pressure ventilation (internal pneumatic splint),analgesia, pulmonary toilet, and chest physiotherapy.1,4,6 Pa-tients with severe chest wall injuries have been reported to havehigh rates of morbidity and mortality, and studies have shownthat only 43% of such patients return to their previous full-timeemployment.10 Many patients complain of chronic pain, sub-jective dyspnea, chest tightness, and chest wall deformity10,11

and have low scores on the SF-36.12

TABLE 1. Complications and Outcomes for Patients with Flail Chest Injury - Based on Injury Pattern

All patientsNo SevereHead Injury

With SevereHead Injury

No PulmonaryContusion

With PulmonaryContusion

Outcomes Percentage n Percentage n Percentage n p Percentage n Percentage n p

No. patients 100 3,467 85 2,944 15 523 46 1,587 54 1,880

Mechanical ventilation 59 1,762 54 1,369 88 393 0.00001* 56 778 61 984 0.005*

ICU admission 82 2,767 81 2,306 89 461 0.00001* 80 1,229 84 1,538 0.003*

Chest tube 44.5 1,542 43.3 1,276 50.9 266 0.0014* 41.8 663 46.8 879 0.003*

Tracheostomy 20.6 714 18.2 535 34.2 179 0.0001* 20.9 332 20.3 382 0.66

Pneumonia 20.6 713 18.8 553 30.6 160 0.0001* 18.7 297 22.1 416 0.013*

ARDS 13.8 480 13.2 390 17.2 90 0.0156* 13.1 208 14.5 272 0.25

Sepsis 7.4 255 6.7 198 10.9 57 0.0008* 6.8 108 7.8 147 0.25

Death 15.7 544 11.4 337 39.6 207 0.0001* 16.1 255 15.4 289 0.57

Epidural use 7.6 263 8.7 257 1.1 6 0.0001* 6.7 107 8.3 156 0.08

Open reduction andinternal xationchest wall

0.7 24 0.6 18 1.1 6 0.17 0.4 7 0.9 17 0.10

*Statistical signicance, p G 0.05

TABLE 2. Days on Mechanical Ventilation, ICU Stay, Total Hospital StayVBased on Injury Pattern

All PatientsNo SevereHead Injury

With SevereHead Injury

No PulmonaryContusion

WithPulmonaryContusion

Outcomes Mean SD Mean SD Mean SD p Mean SD Mean SD p

Day on mechanical ventilation

Ventilated patients only 12.1 11.0 12.0 11.9 12.7 12.1 0.60 12.4 12.1 11.9 11.9 0.91

All patients 7.2 12.0 6.5 10.6 11.2 12.1 0.001* 7.0 11.0 7.3 11.0 0.016*

Days in ICU

Patients admitted to ICU only 11.7 11.8 11.0 11.6 15.0 13.4 0.0001* 11.5 11.9 11.8 12.1 0.242

All patients 9.6 12.0 8.9 11.3 13.4 13.5 0.001* 9.2 11.6 9.9 11.9 0.0032*

Days in hospital 16.6 16.0 15.8 14.6 21.4 21.7 0.0005* 16.1 15.6 17.1 16.3 0.018*

*Statistical signicance, p G 0.05




This study of 3,467 patients with a ail chest injurydemonstrated high rates of morbidity and mortality. Morethan 80% of patients required ICU admission, for a mean of11.7 days. Mechanical ventilation was used in a large pro-portion (59%) of patients, and those on a mechanical ventilatorhad a mean of 12.1 ventilation days. Long-term mechanicalventilation has many complications. Prolonged mechanicalventilation in patients with chest trauma has been reportedto result in high rates of pneumonia, barotrauma, sepsis, ICUstay, and death.1,2,4,5,7,8 Decreasing the number of days onmechanical ventilation may result in decreased morbidityand mortality and may dramatically decrease medical costs.The average hospital cost of mechanical ventilation/ICU stayfor trauma patients in the United States is approximately$3,500 per day;13 decreasing the length of stay by even a fewdays can produce dramatic savings in health care expenses.

There have been a number of studies demonstratingthe benet of surgical xation of severe chest wall injuries,2,5,7,8,14

including fewer days on mechanical ventilation,5,7Y9 decreasedlength of ICU stay,2,5,7,8 fewer chest infections,5,7,8 and lesschronic pain,2 while improving long-term respiratory func-tion15,16 and promoting earlier return to work.8 There are threepreviously published randomized controlled trials on this top-ic.5,8,17 Tanaka et al.8 demonstrated that patients with surgicalxation were extubated a mean of 2.5 days postoperatively,compared with 18.3 days in the nonoperative group. Granetzkyet al.5 reported 2 days of mechanical ventilation in the surgicalgroup, compared with 12 days in the nonsurgical group. How-ever, these randomized controlled trials have been criticizedfor small sample size, outdated methods of surgical xation(K-wires, Judet struts, absorbable plates), and vague inclusion/exclusion criteria. We believe there is a need for a large, multi-center, well-designed, randomized controlled trial in this area,to better assess the benets of surgical xation versus non-operative care for trauma patients with ail chest injuries.

Given the increased interest in surgical xation in recentyears,18,19 we sought to determine if this translated into more

patients being treated with surgical intervention. Contraryto our expectations, a very small proportion of patients weretreated with surgical xation (24 of 3,467, or 0.7%). This couldbe caused by the fact that the data were collected from 2007to 2009, and it is possible that xation rates have increasedsince that time. It could also mean that despite numerous re-cent published series of surgical xation of ail chest injuries,nonoperative treatment is still the overwhelming choice oftreatment.

The optimal nonoperative treatment of patients withail chest includes adequate pain management, via use ofepidural catheters, intercostal nerve blocks, or patient-centeredanalgesia.6 The use of epidural catheters seems to be the mostpreferred method, with improved outcomes and lower com-plications compared with other methods.6,20Y22 Compared withintravenous narcotic use, epidural catheters allow for improvedsubjective pain perception, pulmonary functions tests, lowerrate of pneumonia, as well as decreased length of time on amechanical ventilator or ICU stay.6,20,21 They also have lowerrate of complications such as respiratory depression, somno-lence, and gastrointestinal symptoms.6 Epidural catheters havealso been compared with intrapleural catheters in a previousrandomized controlled trial and have shown to decrease painand improve tidal volume and negative inspiratory pressures.22

While we were unable to assess the number of patients treatedwith intercostal nerve blocks or patient-centered analgesia, wewere able to examine the use of epidural catheters for patientswith ail chest injuries, and we were able to determine thatthese were seldom used (8%). While coding validity remainsunknown, such a low number raises the possibility of underuse.

The literature supports the suspicion that patients withail chest injury, with concurrent severe head injury or pul-monary contusion, have poor outcomes. In addition, the lit-erature on surgical xation of such injuries consistently reportssevere head injury and pulmonary contusion as exclusioncriteria for surgical xation. The reason suggested is that theprimary early benet of surgical xation is decreased time on

Figure 3. Outcome for patients with ail chest, based on head injury.




mechanical ventilation; however, patients with head injuryand pulmonary contusion may require long-term mechanicalventilation and do not attain the benets of early extubation.Based on the results of this study, we can conrm that patientswith a ail chest and severe head injury have poor outcomesin all categories compared with patients without severe headinjury. These patients had an increased rate of need for me-chanical ventilation and time on a ventilator and had higherrates of chest tube placement, pneumonia, ARDS, and sepsis.Tracheostomy was performed almost twice as often, and thedeath rate was more than 3.5 times higher than patients withouta severe head injury. Further research in this area is warrantedto help improve outcomes of this subset of patients with ailchest injuries.

With respect to the impact of pulmonary contusion, therewere statistically signicant differences, of a much smallermagnitude compared with the effect of head injury. This maybe caused by variability in coding this injury and a lack of aclear denition for pulmonary contusion. Whether these werediagnosed based on radiologist reports of imaging or moreobjective tests such as bronchoalveolar lavage is unknown.Many patients with blunt chest injuries have pulmonary con-tusions, but the severity of this entity may determine outcome.Patients with extensive pulmonary contusion may have worseoutcomes compared with those without. However, includingall patients with contusions, whether small or extensive, andusing less than optimal criteria result in difculty in the in-terpretation of results. There is currently no widely used classi-cation of pulmonary contusions, and there is a need for amore consistent method of diagnosis and classication of theseinjuries.

The limitations of this study are its retrospective nature;there were missing data for some of the outcomes, and the va-lidity of coding remains unknown. Given the heterogeneity ofhead injuries and coding uncertainty around pulmonary contu-sions, multivariable analyses of these conditions were not per-formed. The strengths are that we have attempted to restrict ouranalysis to centers that code accurately and have been able toidentify one of the largest populations of patients with ail chestinjuries in the literature to date.

CONCLUSION

Patients who have sustained a ail chest have signicantmorbidity (ICU admission, 82%; mechanical ventilation, 59%;need for chest tube, 44%; tracheostomy, 21%; ARDS, 14%;sepsis, 7%) and a high rate of mortality (16%). Patients withconcurrent severe head injury have signicantly worse out-comes compared with those without a severe head injury on allparameters studied. Patients with concurrent pulmonary con-tusion also had poor outcomes, although the magnitude of thisdifference was less than that seen with the presence of severehead injury.

More than 99% of patients with ail chest injuries weretreated without surgical intervention, and only a small propor-tion (8%) received aggressive pain management with epiduralcatheters. Given the high rates of morbidity and mortality inpatients with ail chest injuries, alternate methods of treatment

need to be investigated, such as more consistent use of epiduralcatheters for pain or surgical xation. Previous small random-ized trials have suggested improvementswith surgical xation ofthese injuries, although this practice is neither widely acceptednor practiced in North America, with only 0.7% of ail chestsbeing surgically treated. More research in this area is warrantedto help improve patient outcomes. A large multicenter ran-domized controlled trial comparing modern surgical techniquesversus nonoperative care for trauma patients with ail chestinjuries is required.

AUTHORSHIP

N.D. and A.N. performed the literature search. N.D., C.D.M., andM.D.M. designed this study. C.D.M. collected the data. N.D. andC.D.M. analyzed and interpreted the data. All authors participated inwriting and critically revision.

DISCLOSURE

The authors declare no conicts of interest.

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