Chest Wall Injury Research Articles

Embracing a New Horizon in Orthopaedic Surgery: Chest Wall Injury and the Surgical Stabilization of Rib and Sternum Fractures

Embracing a New Horizon in Orthopaedic Surgery: Chest Wall Injury and the Surgical Stabilization of Rib and Sternum Fractures

Injury Patterns and Surgical Approaches

Summary: Effective management of bony and cartilaginous thoracic injury is a vital part of the care of the polytraumatized patient. Commonly because of high-energy accidents including motor vehicle collisions and falls, these patients routinely require multidisciplinary care and surgical intervention. As our understanding of unstable chest wall injuries and pulmonary sequelae of the injury grows, it is imperative that injury patterns and surgical approaches become familiar to the orthopaedic trauma-trained surgeon. Common rib fracture patterns and muscle-sparing surgical approaches are detailed, with the goal of restoring chest wall stability to improve the mechanics of respiration and pain control in these challenging patients.

Comparison of patients who meet criteria for surgical stabilization of rib fractures versus those who actually get rib fixation: A single center review

BackgroundSurgical stabilization of rib fractures (SSRF) has shown benefits for rib fracture patients. However, the incidence of SSRF performed remains low. We compare our institution's rib fracture patients meeting criteria for SSRF versus those actually receiving the operation, hypothesizing a significant portion are not undergoing SSRF. MethodsA retrospective review of rib fracture patients presenting to our Level 1 trauma center from 1/2016 to 4/2023. Patients were categorized as those who met SSRF inclusion criteria versus those who didn't based on the 2023 Chest Wall Injury Society (CWIS) SSRF Guidelines. Basic demographics were obtained. Patients meeting SSRF criteria were divided into those who received SSRF versus those who didn't. Outcomes of interest included type and frequency of SSRF indications and frequency of absolute/relative contraindications. Descriptive statistics were used. Median test and t-test were used for statistical analysis. Statistical significance was set at p < 0.05. ResultsA total of 3,432 patients presented with ≥1 rib fracture(s). Of those, 1,573(45.8 %) met SSRF inclusion criteria. These patients were predominantly male, with mean age of 57.4(±18.5) and a similar Injury Severity Score but significantly higher chest-Abbreviated Injury Score of 3 (Interquartile range 3,4)(p = 0.048). Only 458(29.1 %) patients underwent SSRF, leaving 1,115(70.9 %) managed non-operatively, of which 215(19.3 %) were ventilated and “failure to wean from the ventilator” was the most common (81.4 %) indication for SSRF. Of the 900(80.7 %) non-ventilated patients managed non-operatively, 659 (69.9 %) had ≥two indications for SSRF, 382(34.3 %) had zero relative contraindications and 394(35.3 %) had one relative contraindication for SSRF. Lastly, 52.6 % of patients in this cohort had reported “clicking/popping” of their fractures. ConclusionOnly 29.1 % of patients meeting criteria for SSRF had the operation based on data from our institution. There may be additional opportunity to benefit this cohort of patients meeting SSRF criteria but not undergoing surgery.

Rib Fracture Nonunion

Rib fracture nonunions are uncommon after traumatic chest wall injury. Patients with symptomatic nonunions typically present with persistent rib pain, although some will have dyspnea or popping sensations. Surgical fixation can be considered for symptomatic patients who radiographically demonstrate nonunion 3 months after injury. The surgical approach is still evolving; the most common approach is debridement of the callous and non-viable fracture ends followed by stabilization of the fracture with a plating system. Published reports have found this approach decreased pain and improved the quality of life for most patients. Future studies must delineate who will benefit most from operative management and expand our understanding of patient outcomes after surgery.

Dedicated Chest Wall Injury Program quality review: How to create and incorporate a quality and safety program for surgical stabilization of rib fractures.

Adoption of surgical stabilization of rib fractures (SSRF) in chest trauma necessitates outcomes reviews and process improvement (PI). As volume and complexity increase, such vigilance is imperative. Over 10 years, our center has developed a dedicated PI program based on our trauma PI program. Here, we outline the components of this program, aiming to share best practices and potentially improve SSRF patient outcomes. Over 10 years, our dedicated SSRF PI process has evolved to include bimonthly reviews on case and quality metrics. In 2022, all patients at our single high-volume Level 1 trauma center with flail chest segments were identified, and a PI chart review was conducted. Data collected included management approach (operative vs. nonoperative), postoperative complications, mortality, patient demographics, trauma specific variables (Injury Severity Score, etc.), and rib fracture details. Operative data collected included number of ribs plated, system used, and complication rates for each surgeon and plating system used. Of 82 patients identified, 88% underwent SSRF. Among these, 49% experienced one or more postoperative complications, not all directly related to SSRF procedures. Mortality rate for SSRF patients was 15%, predominantly in those with Injury Severity Score of >25 and mean age of 58 years. Patients who had trauma activations and required emergency department chest tube placement had higher complications. The mean number of ribs stabilized was four. Complications occurred more frequently with posterior fractures. Outcomes were collated and analyzed at SSRF Outcomes Committee. The utilization of SSRF underscores the need for a rigorous quality review process to enhance patient safety and SSRF-specific outcomes. Our program developed over time from and was implemented in fashion similar to the trauma PI processes. The resulting quality initiative has fostered center-specific PI projects and programmatic advancements. Economic and Value-Base Evaluations; Level IV.

When more is more: Utilizing finite element analysis to assess chest wall injury stability after surgical stabilization of all rib fractures versus only a portion of the rib fractures.

Surgical stabilization of rib fractures (SSRF) continues to gain acceptance. Controversary exists around the number of rib fractures needing stabilization. We sought to analyze chest wall stability (CWS) after SSRF using finite element analysis (FEA) modeling in various rib fracture patterns, hypothesizing not stabilizing all fractures leaves the chest wall unstable. FEA thoracic model development was described previously. Two fracture patterns with three case scenarios each were defined for right ribs 4 to 9. Fracture Pattern 1; Case 1-all 6 ribs with lateral fractures and no stabilization; Case 2-all six fractures stabilized; Case 3-only fractures 5 to 7 were stabilized. Fracture Pattern 2; Case 4-all six ribs fractured in a flail pattern (anterior-lateral and posterior-lateral) and no stabilization; Case 5-all 12 fractures stabilized; Case 6-only six anterior-lateral fractures were stabilized. Three assessment criteria were used to quantify thoracic motion: normalized mean absolute error (NMAE), normalized root mean square error (NRMSE), and normalized interfragmentary motion (NIFM). Fracture Pattern 1: Case 1-NMAE and NRMSE analysis demonstrated significant loss of CWS up to 50% with left axial rotation; Case 2-CWS almost completely returned to nonfractured state; Case 3-CWS loss up to 37%. Fracture Pattern 2: Case 4-up to 49% of CWS lost with right axial rotation; Case 5-less than 3% CWS lost; Case 6-over 40% CWS lost. For both fracture patterns, when stabilizing all fractures, NIFM decreased by 95%. In Case 3, NIFM decreased by 56% and in Case 6, NIFM increased by 1% at the non-stabilized fracture line. Stabilizing all rib fractures significantly improves CWS. Not stabilizing both fractures of a flail segment worsens motion at the non-stabilized fractures. Therapeutic/Care Management; Level IV.

A translational study evaluating a ruggedized portable oxygen concentrator versus an oxygen cylinder in simulated polytrauma intubation of swine.

Portable oxygen concentrators (POCs) are medical devices that use filters to selectively remove nitrogen from ambient air to produce concentrated, medical-grade oxygen. This is the first study to evaluate a ruggedized POC's performance during simulated polytrauma intubation. Twenty-seven swine were intubated and anesthetized with ketamine. At T=0, animals were extubated, received a chest wall injury, a tibia fracture, and 20% total blood volume controlled hemorrhage was initiated. At T=10 min, the swine were pre-oxygenated using a bag-valve mask connected to one of three randomized oxygen sources: (1) a ruggedized POC, (2) a M-15 oxygen cylinder, or (3) room air (control). At T=12 min, animals were re-intubated to simulate polytrauma intubation and connected to the test oxygen source for the remainder of the experiment. Surviving animals entered a 2-h period where partial pressure of oxygen (PaO2), oxygen saturation (SpO2), and regional oxygen saturation (rSO2) were monitored. Groups were compared using analysis of variance (ANOVA), Fisher's exact, log-rank analysis, or mixed-effects model as appropriate. All animals survived except one in the POC group. Mixed-effects models revealed differences between groups with regards to PaO2 (p<0.0001) and SpO2 (p=0.006). Based on post hoc analysis, oxygen cylinder PaO2 was superior to both POC and control, but there were no differences between POC and control PaO2. There were statistically and clinically significant differences in SpO2 during periods of pre-oxygenation (T=10‒12 min), intubation (T=12‒14 min), and immediately after intubation (T=14‒20 min). The POC battery was consumed in 43±13 min. In our swine model, a single, ruggedized POC provided inferior amounts of oxygen supplementation compared to an oxygen cylinder and performed no better than room air.

Does PIC score pick correctly? Evaluation of a modified-PIC based admission a single institution retrospective cohort study

IntroductionThe Pain, Inspiratory effort, Cough score (PIC) has been developed and widely adopted to guide clinical prognostication for patients with chest wall injury. To date, the efficacy, accuracy, and safety of a PIC based triage system has not been validated. Therefore, this study sought to evaluate the use of a modified-PIC score to triage and down-grade trauma patients with chest wall injury at a single institution. MethodsA retrospective study was conducted at a large, Level I Trauma Center on patients with chest wall injuries admitted between 1/1/2018–10/31/20,222. On 12/1/2020, our institution implemented a modified-PIC triage tool including the PIC score, age, and severity of chest wall injury. The Pre-PIC (1/1/2018–11/20/2020) and Post-PIC (1/1/2021–10/31/2022) groups were composed based on admission date and outcomes between the two were compared. Results2,627 patients comprised the Pre-PIC group and 2,212 patients comprised Post-PIC. The groups didn't differ significantly in demographics or mechanisms of injury except for COVID status. Post-intervention, a greater proportion of patients were triaged to the intermediate care unit instead of the ICU or floor. There were no significant differences in hospital length of stay (LOS), ventilator days, unplanned ICU admission, or mortality in Pre-PIC vs Post-PIC. ICU LOS, rates of ARDS, and cardiac arrest with return of spontaneous circulation (ROSC) were significantly lower in Post-PIC. Multivariable models demonstrated significantly lower ARDS rates and ICU free days. ICU LOS trended towards significance as well. ConclusionsThis is the largest study, to date, evaluating the impact of a modified-PIC triage system on clinical outcomes. The results suggest a modified-PIC triage system may lead to decreased ICU days, ARDS rates, and rates of cardiac arrest w/ ROSC, potentially improving hospital resource allocation. Further prospective and multi-center studies are needed to validate our understanding on the impact of a chest wall scoring system on triage and outcomes.

Respiratory problems in rowers: outcomes from a systematic assessment of an elite squad

ObjectivesTo characterise the respiratory health of elite rowers using a systematic screening approach to assess respiratory health (SARAH) and identify the associations between SARAH findings and acute respiratory illness (ARI)...

Use of Analgesics and Sedatives in Nontraumatic Patients after Sudden Cardiac Arrest during the Peri-Resuscitation Period in the Emergency Department.

Background: While cardiopulmonary resuscitation (CPR) may be life-saving for patients in cardiac arrest, it simultaneously puts them at risk for skeletal and soft tissue injuries. The prevalence of cardiovascular and thoracic wall injuries related to CPR varies significantly in the literature, from 21% to more than 78%. After restoration of circulation, ischemia-reperfusion brain injury ensues. Sedation is one of the interventions that can reduce its effects on brain cells. The purpose of this study was to analyse the use of analgesics and sedatives in nontraumatic patients after sudden cardiac arrest in the peri-resuscitation period in the emergency department. Methods: This was a retrospective cohort study. An analysis was performed on the electronic health records of 131 patients who underwent CPR, with ages ranging from 24 to 96 years. The study protocol was in accordance with the Declaration of Helsinki. Results: Chest wall injuries were assessed based on the results of X-ray imaging (n = 39; 31%) and computed tomography (n = 87; 69%). Of the 126 cases, 17.5% had rib fractures and 6.3% had rib and sternal fractures. Almost 78% of the patients (n = 102) received sedatives and/or analgesics during the peri-resuscitation period. Monotherapy was used in 85 cases. Among these drugs the most frequently mentioned were midazolam (45.2%), fentanyl (26.8%), and propofol (20.8%). Conclusions: As only two-thirds of the patients received sedation and half received analgesics, there is still room for a broader incorporation of analgesia and sedation into peri-resuscitation care protocols.

Severe Thoracic Trauma Indications and Contraindications for Non-operative and Operative Treatment Strategies

Severe thoracic trauma can occur as a penetrating or blunt mono-injury or as part of a polytrauma. Almost half of all severely injured patients documented in the TraumaRegister DGU were diagnosed with severe chest trauma, defined according to the Abbreviated Injury Scale (AIS) as ≥3. In our own collective, the proportion was even higher with 60%. Emergency surgical treatment with a thoracotomy within the Trauma Resuscitation Unit or within the first hour of admission is an extremely rare intervention in Germany, accounting for 0.9% of severe thoracic injuries. The management of complex polytraumas and extensive pathophysiological reactions to the trauma, as well as knowledge about the development of secondary damage have led to the conclusion that minimally invasive procedures such as video-assisted thoracoscopy (VATS) or inserting a chest drain can resolve most severe thoracic injuries. At <4%, penetrating injuries to the thorax are a rarity. Among blunt thoracic injuries, >6% show an unstable thoracic wall that requires surgical reconstruction. The demographic development in Germany leads to a shift in injury pattern. Low-energy trauma results have lower incidence than higher-grade chest wall injuries with penetrating rib fractures in the pleura, lungs, peri-/myocardium and diaphragm. Sometimes this results in instability of the chest wall with severe restriction of respiratory mechanics, which leads to fulminant pneumonia and even ARDS (Acute Respiratory Distress Syndrome). With this background, surgical chest wall reconstruction has become increasingly important over the past decade. Together with the underlying strong evidence, the assessment of the extend and severity of the trauma and the degree of respiratory impairment are the basis for a structured decision on a non-surgical or surgical-reconstructive strategy, as well as the timing, type and extent of surgery. Early surgery within 72 hours can reduce morbidity (pneumonia rate, duration of intensive care and ventilation) and mortality. In the following article, evidence-based algorithms for surgical and non-operative strategies are discussed in the context on the management of severe thoracic injuries. Thus, a selective literature search was carried out for the leading publications on indications, treatment strategy and therapy recommendations for severe thoracic injury, chest wall reconstruction.

Favourable outcome in survivors of CPR-related chest wall injuries

BackgroundThere is a lack of studies focusing on long-term chest function after chest wall injury due to cardiopulmonary resuscitation (CPR). The purpose of this cross-sectional study was to investigate long-term pain, lung function, physical function, and fracture healing after manual or mechanical CPR and in patients with and without flail chest. MethodsPatients experiencing out-of-hospital cardiac arrest between 2013 and 2020 and transported to Sahlgrenska University Hospital were identified. Survivors who had undergone a computed tomography (CT) showing chest wall injury were contacted. Thirty-five patients answered a questionnaire regarding pain, physical function, and quality of life and 25 also attended a clinical examination to measure the respiratory and physical functions 3.9 (SD 1.7, min 2-max 8) years after the CPR. In addition, 22 patients underwent an additional CT scan to evaluate fracture healing. ResultsThe initial CT showed bilateral rib fractures in all but one patient and sternum fracture in 69 %. At the time of the follow-up none of the patients had persistent pain, however, two patients were experiencing local discomfort in the chest wall. Lung function and thoracic expansion were significantly lower compared to reference values (FVC 14 %, FEV1 18 %, PEF 10 % and thoracic expansion 63 %) (p < 0.05). Three of the patients had remaining unhealed injuries. Patients who had received mechanical CPR in additional to manual CPR had a lower peak expiratory flow (80 vs 98 % of predicted values) (p=0.030) =0.030) and those having flail chest had less range of motion in the thoracic spine (84 vs 127 % of predicted) (p = 0.019) otherwise the results were similar between the groups. ConclusionNone of the survivors had long-term pain after CPR-related chest wall injuries. Despite decreased lower lung function and thoracic expansion, most patients had no limitations in physical mobility. Only minor differences were seen after manual vs. mechanical CPR or with and without flail chest.

Return to work and activity after rib-fixation for acute chest trauma: first application of a validated patient-reported outcomes assessment tool.

Rib fractures present a heavy pain and functional burden in trauma. Our primary aim was to determine return to work in patients with acute rib fractures requiring surgical stabilization of rib fractures. Our secondary outcomes were pain and quality of life. We also document the first application of the Work Productivity and Activity Impairment Instrument, a validated injury-specific patient-reported outcome measure, for chest wall injury in the literature. A retrospective review was conducted on patients with rib fractures requiring surgical fixation in a single centre between 2008 and 2020. After applying inclusion and exclusion criteria to ensure relevance, all eligible patients were asked to complete patient-reported outcome measure questionnaires. Of 1841 trauma patients with rib fractures, 66 underwent surgical fixation. Thirty-nine patients were eligible and 31 completed the questionnaires. Pre-injury and post-injury answers were compared. The number of patients in employment decreased postoperatively from 22 to 16 (P = 0.006). For those who returned to work, there was no difference in hours missed but reduced weekly hours and productivity scores. There were significantly more patients with pain and on pain relief. There was a lower quality of life score postoperatively. Approximately 1 in 5 patients who require surgical fixation for rib fractures will not return to work. This is the first chest wall trauma study that uses the Work Productivity and Activity Impairment Instrument, a validated tool for work productivity outcomes. We recommend this instrument as a reliable tool for investigating return-to-work outcomes in trauma patients.

Haemothorax after primary percutaneous coronary intervention for aborted cardiac arrest with cardiopulmonary resuscitation

Cardiopulmonary resuscitation (CPR) is an irreplaceable option in patients with sudden cardiac arrest. However, lifesaving CPR can also put the patients and treating physicians in a predicament with certain rare and life-threatening complications due to chest wall injuries. Hemothorax is one of such complications which must be diagnosed and treated as early as possible, more importantly in patients with acute coronary syndrome (ACS) as a cause of cardiac arrest, wherein antithrombotic drugs are on board. Possible sources of bleeding in hemothorax can be injury to the internal mammary artery (IMA), intercostal arteries, or rarely azygos vein. Careful evaluation for the source of the bleeder is necessary as often bleeders may be missed out in early phase of evaluation due to associated hemodynamic factors such as low mean arterial pressure, raised intrathoracic pressures, and vasospasm. Here, we report a case of ACS with sudden cardiac arrest revived by CPR and primary percutaneous coronary intervention who eventually developed hemodynamically significant hemothorax due to the right IMA injury as detected by catheter-mediated angiography, which was subsequently sealed by vascular microcoils at either ends of the perforated segment.

Improving the Diagnosis of Rib Fractures in the Emergency Department: A Quality Improvement Project in a District General Hospital in the United Kingdom.

Background Falls in older people are a common presentation in emergency departments (ED) in the United Kingdom. They can lead to multiple injuries, including chest wall injuries (CWIs). Untreated CWI carries significant morbidity and mortality. However, its diagnosis remains challenging during the initial ED encounter. This led to a quality improvement project (QIP) to improve the diagnosis of CWI in patients presenting to William Harvey Hospital, a district general, trauma-unit ED in Willesborough, England. Methods The QIP was run from February 2020 to April 2021 for 14 months. A series of plan-do-study-act (PDSA) cycles were completed to increase the proportion of CWIs diagnosed during the initial ED encounter to 90%. The primary interventions involved designing a new thoracic trauma proforma and the introduction of the modified pain, inspiratory effort, and cough (PIC) score to evaluate and triage patients with CWI. Other interventions included the delivery of an education programme on CWI. The secondary aims were to increase modified PIC score use and to reduce the time between ED presentation and computerised tomography (CT) scanning. Results A total of 147 patients were included in three PDSA cycles. The diagnosis of CWI during the initial ED encounter increased from 61% at baseline to 91%. The median time from ED attendance to the first CT reduced from 477 minutes to 169 minutes. Lastly, following the introduction of the thoracic trauma proforma, the modified PIC score was used in 26% of cases of CWI by the end of the QIP period. Conclusion Our QIP led to improvement in the early diagnosis of CWIs in ED, with significant improvements in door to CT time and the creation of a thoracic injury pathway in the trust leading to multi-specialty improvement of care of such patients.

Response to Comment on: "Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury".

Response to Comment on: "Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury".

Chest wall injury fracture patterns are associated with different mechanisms of injury: a retrospective review study in the United States.

Research on rib fracture management has exponentially increased. Predicting fracture patterns based on the mechanism of injury (MOI) and other possible correlations may improve resource allocation and injury prevention strategies. The Chest Injury International Database (CIID) is the largest prospective repository of the operative and nonoperative management of patients with severe chest wall trauma. The purpose of this study was to determine whether the MOI is associated with the resulting rib fracture patterns. We hypothesized that specific MOIs would be associated with distinct rib fracture patterns. The CIID was queried to analyze fracture patterns based on the MOI. Patients were stratified by MOI: falls, motor vehicle collisions (MVCs), motorcycle collisions (MCCs), automobile-pedestrian collisions, and bicycle collisions. Fracture locations, associated injuries, and patient-specific variables were recorded. Heat maps were created to display the fracture incidence by rib location. The study cohort consisted of 1,121 patients with a median RibScore of 2 (range, 0-3) and 9,353 fractures. The average age was 57±20 years, and 64% of patients were male. By MOI, the number of patients and fractures were as follows: falls (474 patients, 3,360 fractures), MVCs (353 patients, 3,268 fractures), MCCs (165 patients, 1,505 fractures), automobile-pedestrian collisions (70 patients, 713 fractures), and bicycle collisions (59 patients, 507 fractures). The most commonly injured rib was the sixth rib, and the most common fracture location was lateral. Statistically significant differences in the location and patterns of fractures were identified comparing each MOI, except for MCCs versus bicycle collisions. Different mechanisms of injury result in distinct rib fracture patterns. These different patterns should be considered in the workup and management of patients with thoracic injuries. Given these significant differences, future studies should account for both fracture location and the MOI to better define what populations benefit from surgical versus nonoperative management.

Treatment strategy for severe implosion injuries of the lateral chest wall

In the majority of cases implosion injuries to the thoracic wall are caused by blunt, massive force acting on the thorax. Basically, different regions and directions of the acting energy have to be taken into account. In common usage, the term implosion injury has become established, especially for the sequelae of lateral energy impact. Particular attention should be paid to the stability of the shoulder girdle, the underlying hemithorax and its intrathoracic organs.

Comment on: "Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury".

Comment on: "Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury".

Long-term outcome after surgical management of symptomatic non-union rib fractures

IntroductionTraumatic chest wall injuries are common however the incidence of non-union rib fractures is unknown. Previous studies have suggested that surgical management of symptomatic non-union rib fractures could be beneficial in selected patients, although many experience persisting pain despite surgery. The aim of this study is to investigate the long-term outcome after surgical management of symptomatic non-union rib fractures. MethodsThis is a cross-sectional study including adults (≥18 years) managed surgically for symptomatic non-union rib fractures with plate fixation during the period 2010–2020 at Sahlgrenska University Hospital. Patients operated for acute chest wall injury or injury due to cardiopulmonary resuscitation were excluded. Patients answered standardized questionnaires concerning remaining symptoms and satisfaction with surgery, quality of life (QoL, EQ-5D-5 L) and disability (Disability Rating Index, DRI). Lung function, movement of chest wall and thoracic spine, and shoulder function (Boström index) were assessed. ResultsSixteen patients, 12 men and four women, with mean age 61.6± 11.1 were included in the study. The mechanism of injury was trauma in 10 patients and cough-induced injuries in five patients. Lung disease was significantly more prevalent in cough-induced injuries compared to traumatic injuries, 5 vs 1 (p = 0.008). The mean follow-up time was 3.5 years. Ninety-four percent were satisfied with the surgery and reported that their symptoms had decreased, although 69 % had remaining symptoms, especially pain, from the chest wall. Quality of Life was decreased with EQ-5D-5 L index 0.819 (0.477–0.976) and EQ-VAS 69 (10–100). Disability Rating Index was 31.5 (1.3–76.7) with problems running, lifting heavy objects, and performing heavy work. Predicted lung function was decreased with Forced Vital Capacity (FVC) 86.2 ± 14.2 %, Forced Expiratory Volume in 1 second (FEV1) 79.1 ± 10.7 % and Peak Expiratory Flow (PEF) 89.7 ± 14.5 %. Patients with cough-induced injuries had full shoulder mobility. ConclusionsChest wall surgery for symptomatic non-union rib fractures results in decreased symptoms and patient satisfaction in most cases despite remaining symptoms, reduced lung function, chest wall movement, and QoL and persistent disability.