Indications for rib fixation

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.