Systematic Review of Systematic Reviews for Effectiveness of Internal Fixation for Flail Chest and Rib Fractures in Adults

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Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical fixation of rib fractures as evidenced by systematic reviews.

A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or multiple rib fractures.

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR) and Science
Citation Index were last searched 17th March 2017. Risk of bias was assessed using the ROBIS tool. The primary outcome was duration of mechanical ventilation.

Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials, 19 non-randomised studies). Length of mechanical ventilation was shorter in the fixation group compared to the non–operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI [-5.54, -3.5] to -7.5 days, 95% CI [-9.9, -5.5]. Pneumonia, length of hospital and ICU stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of multiple rib
fracture population; due to limited evidence the benefits with surgery are uncertain.

Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence isrequired before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, multiple rib fractures.
Original languageEnglish
Article numbere023444
Number of pages17
JournalBMJ Open
Issue number4
Publication statusPublished - 1 Apr 2019

Bibliographical note

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.


  • flail chest
  • internal fixation
  • length of hospital stay
  • mechanical ventilation
  • meta-analysis
  • mortality
  • multiple rib fractures
  • pneumonia
  • rib fracture
  • systematic review

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