Interest in fixation or bracing of an unstable chest wall existed long before the advent of mechanical ventilation. Jones and Richardson described a percutaneous technique where traction was applied to the fractured ribs [2]. Cohen described traction of the flail segment using percutaneous towel clips [3]. An even more enterprising device, the “Cape Town Limpet,” a sink plunger type of device was reported by Schrire in 1962 [4]. Significant complications from these external traction devices resulted from the prolonged bed rest required [5].

Several reports describing internal fixation of rib fractures were published in the 1950s and 1960s. Wire sutures and rush rod fixation were suggested [6, 7], but neither gained traction in clinical practice.

In the late 1950s, clinical practice was greatly affected following the introduction of positive-pressure ventilation to internally splint the unstable chest wall [8]. Mortality from flail chest was initially lowered, leading to widespread adoption of this intervention for the next two decades; however, ventilator-associated complications arose such as barotrauma, ventilator-associated pneumonia, and tracheal injury were often encountered [9].

As the understanding of the pathophysiology of severe chest wall injury matured, researchers proposed that concomitant pulmonary contusion, not the paradoxical motion of the flail segment, was primarily responsible for the morbidity and mortality associated with such injuries [10]. Two prospective randomized studies guided clinicians to use selective mechanical ventilation techniques based on failure to maintain oxygenation, ventilation, and pulmonary hygiene [11, 12]. Research focus shifted to focus on the underlying pulmonary contusion.

Few investigators continued to study operative rib fixation in severe chest injury, and none used prospective or randomized methodology. However, severe chest wall injuries continued to carry relatively high morbidity and mortality, despite the improvements conferred by selective mechanical ventilation. In the last 20 years, several comparative studies and a few randomized trials have suggested that significant further improvements can be made in the care of these patients with operative rib fixation. This has become a much more viable treatment option given newly available, rib-specific fixation products such as DePuy/Synthes’^® MatrixRIB™ System.

Three studies were conducted prior to 1995 and will be mentioned briefly as they were included in recent meta-analyses. In 1972, Ohresser et al. [13] retrospectively reported significant improvements in dyspnea at 1 year after severe closed chest injury for patients treated with operative osteosynthesis (implant not described) when compared to the nonoperative group. In 1981, Kim et al. [14] retrospectively compared 18 patients with flail chest treated with Judet clasps to 45 patients with flail chest treated with mechanical ventilation alone. The operative group had fewer deaths and fewer ventilator days. In 1985, Borrelly et al. [15] retrospectively compared 79 patients treated with osteosynthesis using Judet clasps or sliding staples to 97 patients treated with ventilation alone for chest instability. The operative group had a significantly lower incidence of sepsis and spent fewer hospital days. All three studies used variable definitions of “flail chest,” “severe chest injury,” and “chest instability,” and all were conducted in France.

In the modern literature, two studies have investigated wire fixation for flail chest injury. In 1995, Ahmed and Mohyuddin [16] compared 26 flail chest patients treated with K-wire internal fixation to 38 patients treated with endotracheal intubation and intermittent positive-pressure ventilation alone. Significant improvements noted in the operative group included fewer days on mechanical ventilation, fewer ICU days, fewer cases of chest infection and sepsis, fewer tracheostomies, and lower overall mortality rate. The second trial investigating wire fixation was randomized and controlled and will be discussed later in this chapter.

In 1997, a Ukrainian study by Karev [17] compared 40 patients with flail chest treated operatively to 93 patients treated nonoperatively. A variety of unspecified extramedullary osteosynthesis implants were used, typically at the end of other emergency surgical procedures. This indication is otherwise referred to as “thoracotomy for other indications” and essentially means that rib fixation was performed “on the way out.” Operatively managed patients had fewer days on mechanical ventilation, a lower incidence of pneumonia, and a decreased incidence of mortality.