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Contemporary outcomes of flail chest injuries: An update from ACS-TQIP (2017-2023)
Lucine Gabriel1, Hari Ramesh, Randilu Amarasinghe
1Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia (L.G., H.R., R.A., M.G., S.k.); Department of Orthopedic Surgery, University of Arizona College of Medicine, Phoenix, AZ (N.D.).
Background:
Flail chest represents one of the most severe forms of blunt thoracic injury and is associated with significant morbidity and mortality. Much of the understanding of flail chest epidemiology, and outcomes came from Dehghan et al. (2014). Since then, flail chests management has undergone substantial evolution. Given these changes, we sought to examine the outcomes of flail chest that accurately reflects current clinical practice.
Methods:
This is a retrospective study analyzing the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) 2017 to 2023 data on flail chest patients. Propensity-score matching was performed to compare clinical outcomes in patients SSRF versus no SSRF. Multivariable analysis was performed to compare the outcome of flail chest patients with concomitant head injury or pulmonary contusion. Our primary outcome is in-hospital mortality, with mechanical ventilation, hospital and Intensive Care Unit (ICU) length of stay (LOS), and the rate of pneumonia, sepsis, and tracheostomy.
Results:
A total of 41,542 patients with flail chests were identified, 19,170 after matching. Overall, 29.08% required mechanical ventilation, 4.99% tracheostomy, 6.24% in-hospital mortality, 3.66% VAP incidence, and 2.22% ARDS. SSRF patients had a significantly lower rate of in-hospital mortality compared with nonoperative patients (3.3% vs. 9.2%, p<0.01). However, SSRF was associated with a longer hospital LOS (11.9 vs. 7.2 days, p<0.01), ICU LOS (8 vs. 5 days, p<0.01), and higher rate of unplanned ICU admission (7.5% vs. 4.4%, p<0.01) in flail chest patients.
Conclusions:
Compared with Dehghan et al. (2014), our analysis demonstrates significant improvements: mechanical ventilation rate decreased from 59% to 29.08%, tracheostomy from 21% to 4.99%, and mortality from 16% to 6.24%. These reductions in morbidity and mortality reflect a decade of optimized critical care and standardized management in flail chest trauma. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).
Level Of Evidence:
Level III (Prognostic/ Epidemiological).
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Flail chest is a severe and potentially life-threatening condition characterized by the fracture of three or more adjacent ribs in multiple places. It is most commonly caused by direct impacts and trauma, such as motor vehicle accidents or injuries from a steering wheel impact. It can also occur due to falls in elderly individuals with osteoporosis, or assaults involving sharp objects.
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