Skip to Content

Module 4: Thoracic Injuries

Segment 2: Thoracic Cage Injuries

References labeled PEDS contain a pediatric element or primary focus.

Topic: General thoracic cage/chest wall injuries

Topic: Rib fractures

  • Aamir J, Alade B, Caldwell R, et al. Sternal fractures and thoracic injury: an analysis of 288 sternal fractures attending a major trauma centre. Eur J Orthop Surg Traumatol. 2023;33(6):2619-2624. doi: 10.1007/s00590-023-03479-0 https://pubmed.ncbi.nlm.nih.gov/36735092/.
  • Abu-Zidan FM, Alao DO, Cevik AA. Point-of-care ultrasound (POCUS) diagnosis of rib fractures. World J Emerg Surg. 2025;21(1):1. doi: 10.1186/s13017-025-00665-9 https://pubmed.ncbi.nlm.nih.gov/41350734/.
  • Al Ma’ani M, Hejazi O, Sarani B, et al. Outcomes of rib fixation versus nonoperative management in flail chest: Does body mass index change the equation? J Trauma Acute Care Surg. 2026;100(1):47-53. doi: 10.1097/ta.0000000000004800 https://pubmed.ncbi.nlm.nih.gov/41114706/.
  • Altamimi A, Musawa I, Alshahrani MA, et al. Minimally invasive total thoracoscopic fixation versus open fixation for multiple Rib fractures: Systematic review and meta-analysis of clinical outcomes. Injury. 2026;57(7):113336. doi: 10.1016/j.injury.2026.113336 https://pubmed.ncbi.nlm.nih.gov/42102768/.
  • Ang D, Nathens A, Nayduch D, et al. A multicenter randomized controlled trial on the surgery of fractured ribs: The SOFRIB trial. Ann Surg. 2026;doi: 10.1097/sla.0000000000007053 https://pubmed.ncbi.nlm.nih.gov/41881849/.
  • Aryan N, Grigorian A, Nahmias J, et al. Impact of obesity on outcomes of surgical stabilization of rib fractures. J Trauma Acute Care Surg. 2026;100(1):54-59. doi: 10.1097/ta.0000000000004788 https://pubmed.ncbi.nlm.nih.gov/41198081/.
  • Bankhead-Kendall B, Radpour S, Luftman K, et al. Rib fractures and mortality: Breaking the causal relationship. Am Surg. 2019;85(11):1224-1227. doi:  https://pubmed.ncbi.nlm.nih.gov/31775963/.
  • Barry R, Thompson E. Outcomes after rib fractures in geriatric blunt trauma patients. Am J Surg. 2018;215(6):1020-1023. doi: 10.1016/j.amjsurg.2018.03.011 https://pubmed.ncbi.nlm.nih.gov/29548528/.
  • Bauman ZM, Phillips J, Tian Y, et al. It doesn’t hurt as long as I don’t move: Aligning pain assessment in patients with rib fractures with mobilization needed for recovery. J Trauma Acute Care Surg. 2024;97(6):856-860. doi: 10.1097/ta.0000000000004446 https://pubmed.ncbi.nlm.nih.gov/39405440/.
  • Bauman ZM, Tian Y, Doben AR, et al. Chest Wall Injury Society guidelines for surgical stabilization of rib fractures: Indications, contraindications, and timing. J Trauma Acute Care Surg. 2025:10.1097/TA.0000000000004750. doi: 10.1097/ta.0000000000004750 https://pubmed.ncbi.nlm.nih.gov/40802491/.
  • Bauman ZM, Todd SJ, Raposo-Hadley A, et al. Impact of sternal fixation on patient outcomes: A case matched review. J Trauma Acute Care Surg. 2023;94(4):573-577. doi: 10.1097/ta.0000000000003824 https://pubmed.ncbi.nlm.nih.gov/36730841/.
  • Bresgen TU, Salinaro F, Barcella B, et al. Acute pain management of rib fractures: a narrative review. Injury. 2025;56(12):112857. doi: 10.1016/j.injury.2025.112857 https://pubmed.ncbi.nlm.nih.gov/41223579/.
  • Bui A, Gregorevic K, Read D, et al. Risk stratification in older adults with rib fractures: Performance of the STUMBL score. Injury. 2026:113601. doi: 10.1016/j.injury.2026.113601 https://pubmed.ncbi.nlm.nih.gov/42629302/.
  • Carmona A, Nicolas M, Tusman G, et al. Cryoanalgesia in patients undergoing surgical stabilization of rib fractures: A comparative study. J Surg Res. 2025;doi: 10.1016/j.jss.2025.11.061 https://pubmed.ncbi.nlm.nih.gov/41407571/.
  • Chen C, Sehgal A, Battle C, et al. Acute management of adults following chest wall injury: An assessment of institutional clinical practice guidelines across the UK and synthesis of care recommendations. Injury. 2025;56(5):112077. doi: 10.1016/j.injury.2024.112077 https://pubmed.ncbi.nlm.nih.gov/39665971/.
  • Choi J, Zamary K, Barreto NB, et al. Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures. PLoS One. 2020;15(9):e0239896. doi: 10.1371/journal.pone.0239896 https://pubmed.ncbi.nlm.nih.gov/32986770/.
  • Collis J, Farquharson B, Chan S, et al. The implementation of a rib fracture pathway at a small district general hospital to improve patient care. Cureus. 2023;15(5):e38863. doi: 10.7759/cureus.38863 https://pubmed.ncbi.nlm.nih.gov/37303343/.
  • Craxford S, Owyang D, Marson B, et al. Surgical management of rib fractures after blunt trauma: a systematic review and meta-analysis of randomised controlled trials. Ann R Coll Surg Engl. 2022;144:1-e124. doi: 10.1308/rcsann.2021.0148 https://pubmed.ncbi.nlm.nih.gov/34928718/.
  • Dehghan N, Nauth A, Schemitsch E, et al. Operative vs nonoperative treatment of acute unstable chest wall injuries: A randomized clinical trial. JAMA Surg. 2022;157(11):983-990. doi: 10.1001/jamasurg.2022.4299 https://pubmed.ncbi.nlm.nih.gov/36129720/.
  • Fields AC, Castillo-Angeles M, Bryan MR, et al. Rib fracture injury guidelines for patients over the age of 65: Should these patients routinely be admitted to the intensive care unit? J Surg Res. 2025;315:443-450. doi: 10.1016/j.jss.2025.09.051 https://pubmed.ncbi.nlm.nih.gov/41086662/.
  • Forrester JD, Bauman ZM, Cole PA, et al. Chest Wall Injury Society recommendation for surgical stabilization of nonunited rib fractures to decrease pain, reduce opiate use, and improve patient reported outcomes in patients with rib fracture nonunion after trauma. J Trauma Acute Care Surg. 2023;95(6):943-950. doi: 10.1097/ta.0000000000004083 https://pubmed.ncbi.nlm.nih.gov/37728432/.
  • Forrester JD, Tung JT, Knight AW, et al. Chilling the nerve, easing the pain?: A randomized clinical trial evaluating surgeon-administered bedside percutaneous cryoneurolysis for rib fracture pain. J Trauma Acute Care Surg. 2026;100(6):863-870. doi: 10.1097/ta.0000000000004885 https://pubmed.ncbi.nlm.nih.gov/41604277/.
  • Franssen A, Daemen JHT, Luyten JA, et al. Treatment of traumatic rib fractures: an overview of current evidence and future perspectives. J Thorac Dis. 2024;16(8):5399-5408. doi: 10.21037/jtd-23-1832 https://pubmed.ncbi.nlm.nih.gov/39268098/.
  • Gabriel L, Ramesh H, Amarasinghe R, et al. Contemporary outcomes of flail chest injuries: An update from ACS-TQIP (2017-2023). J Trauma Acute Care Surg. 2026;doi: 10.1097/ta.0000000000005097 https://pubmed.ncbi.nlm.nih.gov/42296258/.
  • Haberal MA, Demirci H, Çolak MA. Association of four or more rib fractures with complications in isolated blunt chest trauma. Am J Emerg Med. 2026;106:124-128. doi: 10.1016/j.ajem.2026.05.010 https://pubmed.ncbi.nlm.nih.gov/42114385/.
  • Hoepelman RJ, Beeres FJP, Heng M, et al. Rib fractures in the elderly population: a systematic review. Arch Orthop Trauma Surg. 2023;143(2):887-893. doi: 10.1007/s00402-022-04362-z https://pubmed.ncbi.nlm.nih.gov/35137253/.
  • Hopper W, Roberts J, Halvorson E, et al. Intercostal nerve cryoablation in surgical stabilization of rib fractures: Does the benefit depend upon patient acuity? J Trauma Acute Care Surg. 2026;doi: 10.1097/ta.0000000000005138 https://pubmed.ncbi.nlm.nih.gov/42468042/.
  • Huelskamp MD, Mboulla Nzomo M, Horst N, et al. The impact of injury severity and age on short-and long-term mortality and hospital length of stay after surgical stabilisation of rib fractures (SSRF): a German population-based propensity-score matched investigation. World J Emerg Surg. 2026;21(1) doi: 10.1186/s13017-026-00682-2 https://pubmed.ncbi.nlm.nih.gov/41772696/.
  • Hylands M, Gomez D, Tillmann B, et al. Surgical stabilization of rib fractures for flail chest: Analysis of center-based variability in practice and outcomes. J Trauma Acute Care Surg. 2024;96(6):882-892. doi: 10.1097/ta.0000000000004254 https://pubmed.ncbi.nlm.nih.gov/38196120/.
  • Ikarine I, Altawil L, Kartiko S, et al. Intercostal nerve cryoablation as an adjunct to surgical stabilization of rib fractures: A systematic review, meta-analysis, and GRADE assessment. J Surg Res. 2026;322:61-69. doi: 10.1016/j.jss.2026.03.044 https://pubmed.ncbi.nlm.nih.gov/41965210/.
  • Ingoe HM, Eardley W, McDaid C, et al. Epidemiology of adult rib fracture and factors associated with surgical fixation: Analysis of a chest wall injury dataset from England and Wales. Injury. 2020;51(2):218-223. doi: 10.1016/j.injury.2019.10.030 https://pubmed.ncbi.nlm.nih.gov/31690496/.
  • Jensen S, Sanderfer VC, Porter K, et al. Surgical stabilization of rib fractures in the geriatric trauma population is associated with equivalent outcomes to a younger cohort: A propensity-matched analysis. Injury. 2024;doi: 10.1016/j.injury.2024.111593 https://pubmed.ncbi.nlm.nih.gov/38762943/.
  • John TS, Adrian C, Patrick G, et al. To fix or let them flail: the who, what and when of rib fixation. Trauma Surg Acute Care Open. 2025;10(Suppl 1):e001801. doi: 10.1136/tsaco-2025-001801 https://pubmed.ncbi.nlm.nih.gov/40400729/.
  • Kelley KM, Burgess J, Weireter L, et al. Early use of a chest trauma protocol in elderly patients with rib fractures improves pulmonary outcomes. Am Surg. 2019;85(3):288-291. doi:  https://pubmed.ncbi.nlm.nih.gov/30947776/.
  • Koushik SS, Bui A, Slinchenkova K, et al. Analgesic techniques for rib fractures—A comprehensive review article. Curr Pain Headache Rep. 2023;27(11):747-755. doi: 10.1007/s11916-023-01172-9 https://pubmed.ncbi.nlm.nih.gov/37747621/.
  • Kwon J, Zakhary B, Coimbra BC, et al. Early surgical stabilization of multiple rib fractures and flail chest is associated with better outcomes compared with nonoperative management. J Trauma Acute Care Surg. 2025;doi: 10.1097/ta.0000000000004770 https://pubmed.ncbi.nlm.nih.gov/40828411/.
  • Lauer KV, O’Rourke AP, Austin-Nash KE, et al. Should we be scoring pain differently for rib fractures? A comparison of two scoring systems. Injury. 2025;doi: 10.1016/j.injury.2025.112625 https://pubmed.ncbi.nlm.nih.gov/40750533/.
  • Li C, Juan YS, Hu HL, et al. Impact of frailty on outcomes after multiple rib fractures and flail chest undergoing surgical stabilization of rib fractures: a propensity score-matched analysis of the Nationwide Inpatient Sample 2005-2020. Am J Surg. 2025;249:116572. doi: 10.1016/j.amjsurg.2025.116572 https://pubmed.ncbi.nlm.nih.gov/40834660/.
  • Lucena-Amaro S, Cole E, Zolfaghari P. Long term outcomes following rib fracture fixation in patients with major chest trauma. Injury. 2022;doi: 10.1016/j.injury.2022.04.020 https://pubmed.ncbi.nlm.nih.gov/35513938/.
  • Maghsoudi T, Bower K, Locklear T, et al. How timing of regional anesthesia impacts outcomes in traumatic rib fracture patients: A Trauma Quality National Improvement Program–based study. J Surg Res. 2026;322:104-112. doi: 10.1016/j.jss.2026.03.058 https://pubmed.ncbi.nlm.nih.gov/41965207/.
  • Mukherjee K, Schubl SD, Tominaga G, et al. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2023;94(3):398-407. doi: 10.1097/ta.0000000000003830 https://pubmed.ncbi.nlm.nih.gov/36730672/.
  • Nasef H, Chin B, Nunes N, et al. Surgical stabilization of rib fractures in adult trauma patients with flail chest with or without severe traumatic brain injury: A national analysis. Injury. 2026;57(10):113602. doi: 10.1016/j.injury.2026.113602 https://pubmed.ncbi.nlm.nih.gov/42628226/.
  • Neupane I, Wice M, Monteiro JFG, et al. Impact of geriatric trauma co-management on 1-year mortality in older adults with multiple rib fractures. R I Med J (2013). 2023;106(4):19-24. doi:  https://pubmed.ncbi.nlm.nih.gov/37098142/.
  • Orduño Villa NY, Bhatt H, Hernandez J, et al. Cost-benefit analysis of rib fixation for multiple rib fractures in US trauma patients. J Trauma Acute Care Surg. 2026;100(1):33-39. doi: 10.1097/ta.0000000000004764 https://pubmed.ncbi.nlm.nih.gov/40802492/.
  • Ozgur GK, Akcam TI, Arkoc K, et al. Comparative evaluation of external chest wall fixator treatment effectiveness in patients with rib fractures. Injury. 2025;56(10):112675. doi: 10.1016/j.injury.2025.112675 https://pubmed.ncbi.nlm.nih.gov/40829526/.
  • Peuker F, Hoepelman RJ, Beeres FJP, et al. Nonoperative treatment of multiple rib fractures, the results to beat: International multicenter prospective cohort study among 845 patients. J Trauma Acute Care Surg. 2024;96(5):769-776. doi: 10.1097/ta.0000000000004183 https://pubmed.ncbi.nlm.nih.gov/37934655/.
  • Pieracci FM, Majercik S, Ali-Osman F, et al. Consensus statement: Surgical stabilization of rib fractures. Rib fracture colloquium clinical practice guidelines. Injury. 2017;48(2):307-321. doi: 10.1016/j.injury.2016.11.026 https://pubmed.ncbi.nlm.nih.gov/27912931/.
  • Rafaqat W, Panossian VS, Yi A, et al. Long-term functional recovery after rib fractures: The impact of frailty. J Trauma Acute Care Surg. 2024;doi: 10.1097/ta.0000000000004489 https://pubmed.ncbi.nlm.nih.gov/39621411/.
  • Sarani B, Pieracci F. Contemporary management of patients with multiple rib fractures: What you need to know. J Trauma Acute Care Surg. 2024;97(3):337-342. doi: 10.1097/ta.0000000000004338 https://pubmed.ncbi.nlm.nih.gov/38548709/.
  • Schubl SD, Greig CJ, Doben A. Intrathoracic surgical stabilization of rib fractures: What you need to know. J Trauma Acute Care Surg. 2026;100(3):359-365. doi: 10.1097/ta.0000000000004832 https://pubmed.ncbi.nlm.nih.gov/41701566/.
  • Sermonesi G, Bertelli R, Pieracci FM, et al. Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper. World J Emerg Surg. 2024;19(1):33. doi: 10.1186/s13017-024-00559-2 https://pubmed.ncbi.nlm.nih.gov/39425134/.
  • Shiroff AM, Wolf S, Wu A, et al. Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis. J Trauma Acute Care Surg. 2023;94(4):538-545. doi: 10.1097/ta.0000000000003828 https://pubmed.ncbi.nlm.nih.gov/36730674/.
  • Simmonds A, Smolen J, Ciurash M, et al. Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review. J Trauma Acute Care Surg. 2023;94(4):532-537. doi: 10.1097/ta.0000000000003809 https://pubmed.ncbi.nlm.nih.gov/36949054/.
  • Singleton JM, Bilello LA, Canham LS, et al. Chest computed tomography imaging utility for radiographically occult rib fractures in elderly fall-injured patients. J Trauma Acute Care Surg. 2019;86(5):838-843. doi: 10.1097/ta.0000000000002208 https://pubmed.ncbi.nlm.nih.gov/30676527/.
  • Surgeons ACo. Best practices guidelines: Management of chest wall injuries. 2025. ACS Trauma Quality Programs. https://www.facs.org/media/qdgliayt/2025_tr_bestpracticesguidelines_chest-wall.pdf.
  • Tignanelli CJ, Rix A, Napolitano LM, et al. Association between adherence to evidence-based practices for treatment of patients with traumatic rib fractures and mortality rates among US trauma centers. JAMA Netw Open. 2020;3(3):e201316. doi: 10.1001/jamanetworkopen.2020.1316 https://pubmed.ncbi.nlm.nih.gov/32215632/.
  • Todd K, L’Huillier JC, Jalal K, et al. Age or frailty: What predicts outcomes in geriatric patients with rib fractures? J Surg Res. 2026;321:173-185. doi: 10.1016/j.jss.2026.02.026 https://pubmed.ncbi.nlm.nih.gov/41887162/.
  • Tsigaras ZA, Kimmel LA, Lodge M, et al. Outcomes of conservatively managed traumatic thoracic vertebral and rib fractures in older adults at a major trauma centre. Trauma. 2026;28(1):30-37. doi: 10.1177/14604086251387179 https://journals.sagepub.com/doi/abs/10.1177/14604086251387179.
  • Van Wijck SFM, Pieracci FM, Smith EF, et al. Rib fixation in patients with severe rib fractures and pulmonary contusions: Is it safe? J Trauma Acute Care Surg. 2022;93(6):721-726. doi: 10.1097/ta.0000000000003790 https://pubmed.ncbi.nlm.nih.gov/36121283/.
  • Velez DR, Adamska N, Dickinson A, et al. Evolving outcomes after rib fractures in geriatric patients: Revisiting historical data in the modern era. J Surg Res. 2026;321:461-466. doi: 10.1016/j.jss.2026.03.025 https://pubmed.ncbi.nlm.nih.gov/41934834/.
  • White LD, Riley B, Seidel D, et al. Rib fracture-related morbidity and mortality for older persons in the era of fascial plane blocks: A cohort study. Trauma. 2024;26(1):43-48. doi: 10.1177/14604086221125725 https://journals.sagepub.com/doi/abs/10.1177/14604086221125725.
  • Wu C-J, Lai C-Y, Ting Y-L, et al. Paradoxical motion of the chest wall. J Emerg Nurs. 2025;51(1):27-29. doi: 10.1016/j.jen.2024.09.009 https://pubmed.ncbi.nlm.nih.gov/39800445/.
  • Zangbar B, Mehta R, Prabhakaran K, et al. Rib fractures in frail geriatric patients: Does surgical stabilization improve outcomes? J Trauma Acute Care Surg. 2026;100(1):40-46. doi: 10.1097/ta.0000000000004761 https://pubmed.ncbi.nlm.nih.gov/40828196/.

Topic: Ventilation problems/tissue O2 cascade

  • Angus DC, Seymour C, Bibbins-Domingo K. Caring for patients with acute respiratory distress syndrome. JAMA. 2023;330(4):368-371. doi: 10.1001/jama.2023.6812 https://pubmed.ncbi.nlm.nih.gov/37329332/.
  • Cipulli F, Miori S, Balzani E, et al. Noninvasive ventilation failure in thoracic trauma: A retrospective study on predictive scores, ventilatory strategies and pain management’. J Crit Care. 2025;89:155137. doi: 10.1016/j.jcrc.2025.155137 https://pubmed.ncbi.nlm.nih.gov/40505205/.
  • Gattinoni L, Taccone P, Carlesso E, et al. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. Am J Respir Crit Care Med. 2013;188(11):1286-93. doi: 10.1164/rccm.201308-1532CI https://pubmed.ncbi.nlm.nih.gov/24134414/.
  • Taniguchi H, Utsumi S, Kajiyama T, et al. Noninvasive respiratory support strategies in chest trauma: A systematic review and network meta-analysis. J Trauma Acute Care Surg. 2026;doi: 10.1097/ta.0000000000004987 https://pubmed.ncbi.nlm.nih.gov/41989256/.