Surgical stabilization of rib fractures in patients with open flail chest results in improved clinical outcomes: a report of three cases

Introduction

Thoracic trauma is the second leading cause of trauma-related death. Additionally, commissurotomy, a standard treatment in such cases, can often result in complications and increased mortality (1). The modern flail chest was first described by Cohen (2) in 1955 as having three or more consecutive ribs fractures in two or more places (2-4). Flail chest severely affects thoracic stability and respiratory function. Surgical stabilization of rib fractures (SSRF) has significant benefits over non-surgical treatment (3,5-7), including reduced chest pain and dyspnea, fewer intensive care unit (ICU) and hospital days, and reduced chances of tracheotomy, pneumonia, chest deformity, mortality, and sepsis. The Eastern Association for Trauma Surgery guidelines recommend rib fracture fixation as a treatment option for the flail chest (8). Currently, SSRF for treating flail chest is accepted by surgeons (3,5-8). However, there is a controversy about whether to perform rib fracture fixation during open flail chest. Some people believe that rib fixation in an open flail chest is prone to severe consequences due to hardware infection and does not support rib fixation. Open chest wounds are at high risk of secondary injury and infection. However, adequate chest wall stability is essential to safeguard thoracic organs and sustain respiratory function (9-11).

Since July 2013, our center has consecutively treated three patients with open flail chest. All of them underwent emergency green-channel procedures for chest wall defect repair or foreign body removal, with concurrent partial rib fixation, and achieved favorable postoperative recovery (Table 1).

Emergency green-channel: the emergency green-channel refers to our hospital’s standardized emergency trauma green channel, which is a routine management protocol for critically injured patients. Under this management mode, pre-hospital resuscitation, imaging examination, multidisciplinary consultation and preoperative preparation are completed in a priority manner to accelerate surgical intervention. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0104/rc).

Case presentation

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Case 1 (admitted on February 7, 2022)

A 37-year-old male, struck a barrier in the middle of the road while driving a small car, resulting in an approximately 8 cm steel pipe scraping the right side of his face and penetrating the left side of his chest (Figure 1A-1D). Rescuers trimmed the excess steel pipe protruding from his body before extracting him from the vehicle. He was initially taken to a local county hospital, receiving rehydration, blood transfusion, wound dressing, and compression for hemostasis. Approximately 8 hours post-injury, he was transferred to Department of Emergency of The Affiliated Hospital of Inner Mongolia Medical University, presenting with coma, craniofacial trauma, right maxillary and mandibular fractures with partial tissue loss, tooth loss, partial tongue loss, open wound in the left hypochondriac region, open fractures of the sternum and clavicle, left hemopneumothorax, and left lung contusion. The patient’s critical condition precluded imaging studies. Immediate surgical intervention was implemented through the emergency pathway.

Figure 1 Representative case illustrating SSRF in open flail chest (Case 1). (A) The patient is in a prone position with a right-sided facial injury and a steel tube penetrating the left thoracic cavity. (B) Open wound on the left back. (C) Dorsal view of CT rib 3D reconstruction on the third postoperative day (postoperative 3D reconstruction of CT scanning), partial 6^th rib defect with internal fixation of the 7^th and 8^th ribs. (D) Anterolateral view of CT rib 3D reconstruction on the third postoperative day with partial 2^nd anterior rib defect. Sternal stalk with comminuted fracture of the medial head of the clavicle. (E) The chest radiograph was reviewed 12 months after surgery, and the thoracic morphology was normal, with most of the left second anterior rib and the 6^th rib missing. (F) The chest was healed 19 months after surgery. 3D, three-dimensional; CT, computed tomography; SSRF, surgical stabilization of rib fracture.

The patient had severe oral injuries. Tracheotomy was performed after facial wound debridement under local anesthesia, and general anesthesia was administered following tracheotomy and endotracheal intubation. The thoracic wound was debrided, and the left posterior lateral incision into the chest was explored, revealing a comminuted fracture of the medial head of the left clavicle, a comminuted fracture of the sternal stalk, a fracture of the sternal body, multiple fractures of the left 1^st to 8^th ribs, of which the 2^nd, 5^th, 6^th, and 7^th ribs were comminuted, and the 2^nd, 5^th, and 6^th ribs were partially missing. The steel tube pierced the thoracic cavity from below the left sternoclavicular joint and penetrated the posterior chest wall below the left scapula obliquely in front of the left pulmonary hilum and heart. After verifying the anatomical locations of vital organs and the steel pipe, the surgical team cautiously removed the steel pipe without provoking any bleeding. The thoracic cavity was then cleared of bone fragments, dirt, and clots, followed by several rounds of flushing. The upper and lower lobes of the left lung were severely contused, with some small branches of the pulmonary arteries and veins ruptured and thrombosed. The lung tissue was repaired with absorbable sutures.

Severe fractures were observed in the left 5^th, 6^th, 7^th, and 8^th posterior ribs, with the left 6^th rib comminuted to the degree that precluded fixation, necessitating the removal of small fragments of the broken rib bone. Surgical fixation was performed on the left 7^th and 8^th posterior ribs (Figure 1E). The fractured ends of the remaining ribs were stabilized with intercostal “8” sutures using Prolene sutures (9). The fracture of the 5^th rib was first secured with a suture “8” suture and then additionally stabilized with an intercostal “8” suture to the adjacent 4^th rib. The 2^nd anterior rib exhibited a crushed fracture and severe rib defect that could not be fixed, leading to the removal of fragmented bone. After sternal reduction, adequate stability was achieved; therefore, no hardware was used for sternal fixation, and only suture fixation was applied, and relative stability was achieved at the site of the comminuted fracture of the sternum and medial clavicle head. Drainage was installed in the chest cavity before closing the chest. Following thoracic surgery, the patient underwent additional facial surgery.

Due to postoperative coma, the patient was given ventilator-assisted breathing. Ventilator support was discontinued 45 days after the surgery, and the patient regained consciousness 62 days post-operation. After 6 months, the patient regained independent mobility. A chest radiograph performed 12 months postoperatively showed normal thoracic morphology (Figure 1E). At the 19-month postoperative follow-up visit, the chest was healed (Figure 1F), and the tracheotomy tube was functioning properly without complications, displaying regular activity and no evidence of hardware infection or chest wall deformity.

Case 2 (admitted on September 11, 2017)

A 53-year-old male sustained injuries at his workplace due to an accidental fall into a mixer. The patient remained conscious and was promptly admitted to the local county hospital for initial wound care. Approximately 5 hours post-incident, he was transferred to Department of Emergency of The Affiliated Hospital of Inner Mongolia Medical University, presenting with a traumatic right thoracic injury, right-sided hemopneumothorax, a comminuted fracture of the right femur, a fractured right toe, and skin avulsions on both lower extremities. Immediate surgical intervention for debridement of the open wounds was performed. The patient presented with total avulsion of the skin and parietal pleura of the chest wall, leaving a minor portion of soft tissue attached at the chest apex. The fractured 3^rd and 4^th ribs with a cut end revealed right lung tissue (Figure 2A-2C). Thoracic wound debridement was performed, and thoracoscopic exploration revealed a right upper mediastinal hematoma, with no lung injuries or air leaks identified. Measures for intra-thoracic hemostasis, clot, and debris removal, and thoracic cavity irrigation were undertaken. Only the 4^th rib fractures was addressed, while the remaining fractures were managed with intercostal “8” sutures using Prolene sutures (9). The 3^rd and 5^th ribs were secured with intercostal “8” sutures spanning across the neighboring 4^th and 6^th ribs, respectively. After securing the suture ligation, the repaired chest wall’s stability was confirmed. Antibiotic beads, a closed chest drain, and subcutaneous drainage strips were placed within the chest cavity, followed by wound suturing: subsequent treatment involved debridement and suturing of open wounds in both lower extremities. Tracheal intubation was removed postoperatively, and a chest radiograph on the 3^rd post-operation indicated satisfactory recovery (Figure 2D). The patient received two subsequent orthopedic procedures for right femoral shaft fracture and left foot fracture respectively and was discharged 45 days postoperatively. No signs of hardware infection or chest wall deformities were observed during a 72-month postoperative follow-up (Figure 2E,2F). The patient demonstrated the ability to engage in light physical labor.

Figure 2 Representative case illustrating SSRF in open flail chest (Case 2). (A) Open injury to the right chest wall with whole chest wall avulsion, rib fracture, and right lung exsanguination. (B) Preoperative chest CT, open hemopneumothorax in the right chest, mediastinal hematoma, significant rib fracture dislocation, and blood accumulation in the left chest cavity. (C) Dorsal view of CT rib 3D reconstruction on the preoperation, significant rib fracture dislocation. (D) On postoperative 3^rd day, a rib plate of the 4^th anterior rib is seen on the chest X-ray. (E) 3D reconstruction of the CT rib at 63-month postoperative follow-up, with visible internal fixation devices and old fracture breaks. (F) Healing of the right chest at 72 months postoperatively. 3D, three-dimensional; CT, computed tomography; SSRF, surgical stabilization of rib fracture.

Case 3 (admitted on July 16, 2013)

A 23-year-old male was admitted to Department of Emergency of The Affiliated Hospital of Inner Mongolia Medical University half an hour after a car accident. A foreign body penetrated his left upper chest, resulting in an open chest injury and coma. Preliminary diagnosis: hemorrhagic shock, open flail chest, left main bronchus rupture, left lung contusion, open left hemopneumothorax, open fracture of the left clavicle and fracture of the upper left humerus, sternoclavicular joint, and acromioclavicular joint dislocation. As observed on emergency surgery, the penetrating wound’s entrance, located on the patient’s upper left chest, had an open wound approximately 20 cm long, revealing a left clavicle fracture, broken ribs, mediastinal hematoma, and exposed left lung tissue and pericardium (Figure 3A). Some of the soft tissue edges of the skin were ischemic and necrotic (Figure 3B). The ~8 cm long penetrating injury exit wound was located on the patient’s back. The wound was debrided, and an incision was made on the left posterolateral side to eliminate clots and debris from the thoracic cavity. The surgical team discovered an intraoperative rupture at the root of the left main bronchus, which was repaired intermittently using an absorbable thread. Additional lung tissue repairs included a 10 cm tear in the upper lobe and a 5 cm tear in the lower lobe of the left lung, using absorbable sutures. A rupture of the adventitia of the descending aorta about 7 cm long was left untreated. The manubrial and clavicle fractures were fixed internally. Fractures occurred in the left anterior first to third ribs and left posterior sixth to eighth ribs; only the second and third ribs were fixed with hardware, and the rest of the fractures were fixed with intercostal “8” sutures using Prolene thread (9). The chest wall was then stabilized after fixation.

Figure 3 Representative case illustrating SSRF in open flail chest (Case 3). (A) Left open thoracic trauma with visible left clavicle fracture and rib fracture, blackened necrosis at the margin of the broad-tipped triangular flap, and exposed left lung tissue (B) Postoperative chest wound by the 2^nd day, the triangular flap edge became black, necrotic, and large. SSRF, surgical stabilization of rib fracture.

Postoperatively, antibiotic therapy was applied, and a chest drain was placed in a closed position within the thoracic cavity. Subcutaneous drainage strips were installed in the chest wall wound before suturing. The patient, devoid of neurological complications, emerged from the coma and resumed spontaneous breathing. Following a 45-day stay, the patient was released from the hospital. A follow-up evaluation conducted 122 months postoperative showed no signs of hardware infection or chest wall deformity, leading clinical staff to express satisfaction with the patient’s recovery and the treatment results.

Discussion

Open flail chest is a rare and challenging condition to manage (10). The primary objective of treatment is to restore chest wall functionality and protect the wound with soft tissue to ensure proper lung function (9). In theory, an open and infected wound from an open flail chest could result in hardware infection during the postoperative period. Nevertheless, the precise level of risk remains unknown. There is a lack of clinical data on the safety of hardware fixation for open flail chest. The literature, however, does report a 1.8–5% incidence of postoperative hardware infection after SSRF (1,5,12-14), with Staphylococcus aureus being the most prevalent infecting organism (12,13).

Since 2013, our team has managed three consecutive patients presenting with open flail chest, resulting in satisfactory recovery with no postoperative hardware infections. The emphasis on preventing hardware infection is paramount in treating open flail chest, requiring comprehensive management of patients. All patients received local application of antibiotic microspheres combined with intravenous antibiotic treatment for 3 to 5 days. The cases described herein were promptly treated with anti-shock therapy upon arrival at the emergency department. Contaminated open wounds were secured, injuries were meticulously assessed, and emergency surgeries were expedited through the green channel to minimize the gap between injury occurrence and surgical intervention; all 3 cases underwent surgery within 8 hours post-injury. Pneumonia is identified as a significant risk factor for postoperative hardware infection (14). Early implementation of SSRF following admission significantly curbs the incidence of pulmonary complications, such as pneumonia (5,15). Pieracci et al. (15) proposed that, when feasible, SSRF should be performed within 24 hours of admission and that each additional day of hospitalization prior to SSRF correlates with a 31% surge in the probability of pneumonia (P<0.01). Fortunately, none of our three patients developed pneumonia. Additionally, Junker et al. (14) highlighted that risk factors for hardware infection include: chest tube insertion through the fracture line preoperatively, preoperative pneumonia diagnosis, soft tissue injury near the fracture, or patients necessitating open chest following SSRF. Statistically significant risk factors encompassed high body mass index (BMI) and admission with hemorrhagic shock (P<0.05) (14). Within these parameters, all three cases in our cohort exhibited a low BMI, with one presenting in shock at admission.

Prior to this multiple-case investigation, only two case reports documented successful SSRF in patients with traumatic rib fractures with thoracic infections but without subsequent implant infection. The first report featured a patient with an abscessed chest harboring multiple bacterial and fungal infections (16), while the second detailed a patient with mediastinal fungal colonization (17). However, these two papers lacked explicit surgical details. Our experience suggests that the potential risk of implant-associated infection should be thoroughly assessed. To mitigate this, implant usage should be minimal during rib fracture repair, ensuring chest wall stability. Prolene sutures in an “8” configuration (9) should be employed for securing the fracture. Subsequently, an extra “8” Prolene suture should span the intercostal space. Lastly, an 8” suture should be placed across the rib to secure the fracture to the adjacent rib. The usual ratio of rib fixation roots to fracture roots is 0.6 (15), and in the three patients of this study, it was found to be 0.25, 0.25, and 0.33, respectively.

We carefully preserved the rib periosteum in each of the three patients to prevent ischemic necrosis and secondary infection of the bone fragments in shattered fractures. In some situations, thoracoscopic exploration is a safe, dependable, less invasive approach that allows for the comprehensive examination of the pleural cavity and foreign body removal (18). We highlight the criticality of debriding the wound and pleural cavity to preempt infection. This involves meticulous wound debridement, removal of inactivated tissue and rib fragments from the thoracic cavity, and elimination of foreign contaminants that may have entered the thoracic cavity. Damaged lung tissue that can be conserved should be repaired and preserved to the maximum extent feasible because an inflated lung can decrease dead space and offer effective protection against the formation of thoracic abscesses.

Further investigations with increased case numbers are required to verify the practicability of SSRF in open chest scenarios and to refine the comprehensive management strategy to prevent implant infection more effectively.

Conclusions

For selected patients with open flail chest, when the time from injury to surgery is no more than 8 hours, the open wound contamination is mild, and thorough debridement is performed, chest wall reconstruction and internal fixation surgery may be relatively safe. This approach can help save patients’ lives in the early stage and may lead to favorable long-term outcomes. However, caution should be exercised when considering primary surgery for patients with open contaminated wounds and an injury-to-surgery time exceeding 8 hours. Admittedly, our conclusions need to be validated with more cases.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0104/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0104/prf

Funding: This work was supported by the Inner Mongolia Key R&D & Achievement Transformation Program (No. 2026YFDZ0125) and the Inner Mongolia Science and Technology Program (No. 2019GG105).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0104/coif). All authors declare that the study received financial support from the Inner Mongolia Key R&D & Achievement Transformation Program (No. 2026YFDZ0125) and the Inner Mongolia Science and Technology Program (No. 2019GG105). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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