Clinical UM Guideline

This document addresses the treatment of rib fracture(s) using an open approach and an internal fixation system. Operative reduction and internal fixation with the use of simple pins, wires or plates, without use of specially designed internal rib fixation devices, is not addressed in this document.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

The use of an internal rib fixation system is considered medically necessary when the following conditions are met:

1. Open treatment of flail chest; and
2. Dependent on mechanical ventilation (that is, requires > 4 hours per day of positive pressure ventilation); and
3. Other causes of ventilator dependency such as severe brain injury are absent.

Not Medically Necessary:

The use of an internal rib fixation system is considered not medically necessary for all other indications.

This document describes clinical studies and expert recommendations, and explains when use of an internal rib fixation system is clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Internal rib fixation systems are used during surgery to stabilize broken ribs. They use plates or similar tools to hold ribs in place to promote healing and help the chest move normally during breathing. This treatment is mainly used for severe rib injuries, especially a condition called flail chest, where part of the chest moves the wrong way during breathing. Studies show this surgery can reduce time in the hospital, time in the intensive care unit (ICU), and time on a breathing machine (ventilator). However, surgery also has risks, such as infection, pneumonia (lung infection), and irritation from the implanted device. This treatment is only considered appropriate in specific, severe cases where breathing is seriously affected and other causes of breathing problems are not present.

What the Studies Show

Rib fractures are common injuries, often caused by trauma such as car crashes. Mild cases are usually treated with pain control and breathing support. Severe cases, like flail chest, can make it hard to breathe and may require a machine to help with breathing. Internal rib fixation surgery aims to stabilize the chest so breathing improves and complications are reduced.

Studies suggest that surgery may lower time on a breathing machine, reduce ICU stays, and lower the need for procedures like tracheostomy. Some studies also show fewer lung complications, such as pneumonia. However, many studies have limits, such as small group sizes, lack of comparison to non-surgical treatment, or lack of random assignment. Some results are mixed, with certain studies showing longer hospital stays or no clear difference in some outcomes. Surgery also has risks, including infection, lung complications, and device irritation that may require removal. Better studies are needed to know if this treatment improves long-term health for all groups.

When is Internal Rib Fixation Clinically Appropriate?

Internal rib fixation systems may be clinically appropriate in these situations:

• The person has flail chest and needs open surgical treatment; and
• The person depends on a breathing machine for more than 4 hours per day; and
• The breathing problem is not caused by another condition, such as severe brain injury

When is this not Clinically Appropriate?

Internal rib fixation systems are not clinically appropriate in scenarios other than those listed above.

For other situations, studies have not clearly shown that this surgery improves health. Some research includes small groups or has design limits, which makes results less certain. Surgery also carries risks, such as infection, pneumonia, and problems with the implanted device.

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure indicated in the Clinical Indications section as not medically necessary.

Summary

While much of the current literature is limited to retrospective studies and small sample sizes, the preponderance of evidence shows benefits from internal rib fixation for individuals with flail chest. These benefits include decreased hospital days, decreased intensive care unit (ICU) days, and decreased days of mechanical ventilation.

Discussion

Rib fractures are one of the most common injuries of the chest. Ribs usually fracture at the point of impact or where they are the weakest (at the posterior angle). Typically, the fifth through ninth ribs are affected. Simple rib fractures can be treated with analgesia and respiratory care (to prevent complications such as pneumonia or atelectasis). Complex rib fractures or multiple rib fractures may require a more aggressive treatment plan. Pain with inspiration and expiration, along with inability to properly inflate and deflate the lungs, may require mechanical ventilation to assist with respiratory effort. With multiple rib fractures, flail chest can occur, causing a paradoxical movement of the chest wall that may alter respiratory effort and hinder breathing.

The chest wall consists of 12 pairs of ribs that protect internal organs such as the heart and lungs. Ribs one to seven connect to both the sternum in the front (anteriorly) and the spine in the back (posteriorly). Ribs 8 to 10 attach to the costal cartilage anteriorly. The lowest two ribs are “floating” and do not connect anteriorly. The first three ribs are relatively protected by the scapula, clavicle, and soft tissue. The middle ribs (numbers 4 to 10) are the most vulnerable and susceptible to injury from blunt trauma. Direct trauma to the chest wall causes most rib fractures. This can be blunt trauma such as a motor vehicle crash or penetrating trauma such as a gunshot.

Rib fractures can be associated with internal injury such as to the abdominal organs, aorta, spleen, liver or lungs, and can be painful, hindering breathing. Once significant accompanying injuries have been ruled out, the cornerstone of rib fracture management is pain control. Pain relief is essential to avoid complications such as pneumonia. Severe injuries can lead to mechanical ventilatory support to assist the individual in breathing.

There are a small number of randomized clinical trials available evaluating the use of surgical fixation compared to non-surgical management for flail chest (Granetzny, 2005; Marasco, 2013; Tanaka, 2002).

Overall, these randomized trials suggest that surgical fixation may improve short-term clinical outcomes compared with non-surgical management. Tanaka (2002) demonstrated reductions in pneumonia, duration of mechanical ventilation, ICU length of stay, and need for tracheostomy in the surgical group, although the study was limited by a small sample size. Granetzny (2005) similarly reported improvements in ventilator days, ICU and hospital length of stay, and short-term pulmonary function in surgically treated individuals; however, the study was also small and used non-standardized conservative management (packing and strapping), which may limit applicability to current care. Marasco (2013) found that surgical fixation was associated with shorter ICU stay, reduced need for non-invasive ventilation, and fewer tracheostomies, though the trial was small, single-center, and had some imbalance in co-interventions between groups.

Additional non-randomized evidence generally supports these findings but is subject to important methodological limitations. Retrospective and observational studies (Althausen, 2011; Zhang, 2015) report improvements in ICU stay, ventilator duration, hospital length of stay, and complication rates with surgical fixation; however, these studies are limited by small sample sizes, retrospective design, potential selection bias, and lack of standardized treatment protocols. A prospective case series (Bottlang, 2013) suggests acceptable clinical and functional outcomes following surgical fixation but lacks a comparator group and is therefore insufficient to establish relative effectiveness.

Meta-analyses (Leinicke, 2013; Slobogean, 2013) report consistent associations between surgical fixation and improved outcomes, including reductions in ventilator days, pneumonia, ICU length of stay, and mortality. However, these analyses are limited by the inclusion of predominantly retrospective studies, heterogeneity in surgical techniques, and variability in non-operative management strategies, reducing confidence in the pooled estimates.

A 2017 meta-analysis by Swart and colleagues reported on 20 studies which compared nonoperative treatment to operative treatment for diagnosis of flail chest. The analysis concluded that operative management was associated with a decrease in mortality, pneumonia, and tracheostomy requirements when compared to non-operative management. They note the retrospective comparative nature of most studies used in the analysis is a major limitation.

In 2019, the results of two large retrospective nonrandomized controlled trials were published. The first (Beks, 2019a), involved 332 participants with flail chest or multiple rib fractures admitted to 1 of the 2 hospitals. One hospital treated all participants nonoperatively and the other hospital with rib fixation with the MatrixRIB^® device (DePuy Synthes, West Chester, PA). There were 92 participants with a flail chest, 37 (40%) undergoing rib fixation and 55 (60%) having non-operative treatment. The remaining 240 participants had multiple rib fractures, 28 (12%) underwent rib fixation and 212 (88%) had non-operative treatment. After propensity score matching for both groups, rib fixation was reported to not be associated with ICU length of stay (for flail chest participants) or with hospital length of stay (for multiple rib fracture participants). Since the operative and non-operative study groups were cared for by different teams in different hospitals, it is possible that variations in care may have confounded the results.

A second study by the same group (Beks 2019b), involved 166 participants who underwent rib fixation with the MatrixRIB device, 66 with flail chest and 99 with multiple rib fractures with an Injury Severity Score (ISS) of 24 and 21, respectively. Overall, the most common complication reported by the authors was pneumonia (n=58, 35%). A sample of 103 participants (62%) were followed for an average of 3.9 years. For this population it was reported that 48% experienced implant-related irritation and 9 had implant removal. Significant variation in the treated injuries, method of rib fixation and duration of follow-up, as well as a significant loss of follow-up, all limit the strength of this study’s conclusions.

Wu and colleagues (2020) published the results of a prospective nonrandomized trial involving 61 participants with multiple bicortical rib fractures with hemothorax caused by severe blunt chest trauma. All participants were ventilator dependent. A total of 21 participants agreed to treatment with the MatrixRIB device and 40 underwent standard non-operative care. The authors reported that the length of ventilator use and hospital stay were significantly shorter in the MatrixRIB group (p=0.002, p=0.011, respectively). There was significant overlap in the confidence limits for these variables. The rate of pneumonia was higher in the non-operative group (p=0.005). This study’s lack of randomization reduces the strength of its findings. The use of individuals whose families refused consent for rib fixation as a control group raises concern over possible selection bias. 

Niziolek and colleagues (2022) hypothesized that implementation of a surgical stabilization of rib fracture program resulted in improved short-term outcomes for those individuals with severe chest wall injuries. The study compared outcomes of those who had surgical stabilization compared to those with non-operative management. For those who underwent surgical stabilization, all were plated using an internal rib fixation system. There were 22 individuals who initially underwent surgical stabilization (the early surgical group). Using those 22 individuals, the authors used a propensity score match to define a non-operative cohort (n=36) which resulted in an approximate 1:1 match. There were 40% of individuals who had early surgical stabilization with requirement for mechanical ventilation compared to 47% of individuals who were treated non-operatively requiring mechanical ventilation. Of those who required mechanical ventilation, those who had early surgical stabilization had a median of 6 days on the ventilator compared to 16 days in the non-operative group. Over a 12-month period, the authors then recruited another 23 participants who received surgical stabilization. When these additional 23 surgical participants were included in the analysis compared to the non-operative group, the risk for acute respiratory distress syndrome was 2% compared to 14%, respectively. The need for tracheostomy was also reduced for the surgical group compared to the non-operative group (9% vs. 33%). There were three incidents of surgical site infections in the surgical group. Other complications including pulmonary, cardiac and infections, as well as readmissions were unchanged between the surgical and non-surgical groups.

Some retrospective studies also report on a comparison of surgical treatment of rib fractures to medical management.

In 2025, Kwon reported on a retrospective cohort study using data from the Trauma Quality Improvement Program (TQIP). The study evaluated outcomes for 3806 individuals who underwent surgical stabilization of rib fractures. These participants had at least three rib fractures following blunt trauma. The study also evaluated outcomes for 3753 similar individuals who received non-operative management. The primary outcomes included in-hospital mortality, total hospital length of stay, ICU length of stay, ICU-free days, duration of mechanical ventilation, and ventilator-free days. Secondary outcomes included pulmonary complications: acute respiratory distress syndrome (ARDS) and ventilator-associated pneumonia. In the flail chest cohort, 330 individuals received surgical treatment compared to 333 who received non-operative treatment. Those who received surgery had a lower mortality rate (4.2% vs.10.1%,p=0.002). Those who received surgery had a longer median hospital stay (14 days vs. 9 days, p<0.001) and a longer ICU stay (8 days vs. 5 days, p<0.001). Those who received surgery had fewer ventilator-free days (21 days vs.18 days, p<0.001), whereas ICU-free days did not differ (p=0.077). ARDS rates were identical (p=0.945), and the increase in ventilator-associated pneumonia after surgery did not reach statistical significance (p=0.055). Strengths of this study include its large, national sample size and use of a contemporary trauma registry, which enhance generalizability, as well as the application of inverse probability weighting and multivariable modeling to reduce confounding and approximate balanced comparison groups. The study also includes clinically relevant subgroup analyses (e.g., flail chest vs. nonflail chest) and evaluates timing of intervention using data-driven methods. However, the retrospective observational design introduces risk of residual confounding and selection bias, as treatment was not randomized. Use of administrative and registry data may result in coding inaccuracies and limits availability of important clinical details (such as specific nonoperative management strategies, ventilatory status, or pain control). Additionally, lack of member-reported outcomes and potential misclassification of flail chest limit assessment of functional benefit and member-centered outcomes, and the findings may not be fully generalizable outside participating trauma centers.

Another retrospective review in 2025 by Qian reported the safety and efficacy of surgical stabilization for those individuals with severe chest trauma and multiple rib fractures. There were 39 total participants with 21 of those who were diagnosed with flail chest. Of those with flail chest, 8 had thoracoscopic surgery and 13 had open surgery. Between the two intervention groups, there were no differences in operation time, intraoperative blood loss, volume of chest tube drainage, ventilator days postoperative, ICU or hospital length of stay. There was a lower incidence of postoperative pleural effusion in the thoracoscopic surgical group. Strengths of the study include direct comparison of two surgical approaches and generally similar baseline characteristics between groups. However, the study is limited by its small sample size, retrospective non-randomized design, potential selection bias due to treatment choice, and short-term follow-up, which limit the strength and generalizability of the findings.

In a 2026 retrospective study, Zhang reported on a new type of rib fracture scoring system for treatment decisions for those with multiple rib fractures. The study included 564 individuals, of whom 290 underwent surgical stabilization and 274 received conservative (non-operative) management. While this study was validating a scoring system for rib fractures, the authors noted those in the surgical treatment group had a lower incidence of pneumonia, reduced ventilator hours, and reduced use of opioids. The interpretation of these findings is limited by the non-randomized design and potential for selection bias and confounding.

A 2026 single-center case series by Jesani reports early experience with intrathoracic surgical stabilization using the RibFix^™ Advantage system (Zimmer Biomet, Jacksonville, FL). The study included 15 consecutive individuals with multiple rib fractures who were treated with surgical stabilization. Indications for surgical management included flail segment, along with severe or refractory chest pain, respiratory compromise, rib clicking, and hemothorax. Many individuals had associated intrathoracic injuries requiring additional procedures (e.g., hemothorax evacuation, diaphragm or lung repair). The median hospital length of stay was 5 days with a range of 3-9 days. There was one postoperative complication of a wound infection treated with antibiotics. The applicability of these findings is limited, as this represents a small, single-center experience performed by highly experienced thoracic surgeons, with no comparator group and heterogeneous injury patterns. Results may not be generalizable to broader populations or settings, and the impact of the procedure independent of concomitant interventions is unclear.

In 2024, the World Society of Emergency Surgery (WSES) and the Chest Wall Injury Society (CWIS) published a position paper for Surgical Stabilization of Rib Fractures (SSRF) (Sermonesi, 2024). This consensus document, based on a systematic review of 287 studies and expert panel input, provides graded recommendations for the management of rib fractures. The authors noted those with flail chest have a higher risk of respiratory failure and mortality and the most current literature suggests surgical treatment should be performed in those with flail chest from traumatic rib fractures.

Previously, if rib fractures required surgical intervention, the most used method was a formal thoracotomy. The addition of intraoperative thoracoscopy and computed tomography have allowed for less invasive approaches with smaller incisions and muscle-sparing techniques.

The United States Food and Drug Administration (FDA) has granted 510(k) clearance to several devices for the fixation and stabilization of rib fractures including those that use an open approach or those that use approaches other than open.

Atelectasis: A collapse of all or part of the lung.

Flail chest: Paradoxical movement of the chest wall, visible with respiration, caused by contiguous rib fractures (generally three or more ribs are fractured with two or more fractures in each rib).

Internal fixation device: A specialized device specifically designed and intended to be used for the repair of rib fractures. Simple pins, wires or plates are not considered devices for the purposes of this document.

Pneumonia: An infection of the lungs which can be caused by a virus or bacteria.

Peer Reviewed Publications:

1. Althausen PL, Shannon S, Watts C, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011; 25(11):641-648.
2. Beks RB, de Jong MB, Houwert RM, et al. Long-term follow-up after rib fixation for flail chest and multiple rib fractures. Eur J Trauma Emerg Surg. 2019b; 45(4):645-654.
3. Beks RB, Reetz D, de Jong MB, et al. Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study. Eur J Trauma Emerg Surg. 2019a; 45(4):655-663.
4. Bottlang M, Long WB, Phelan D, et al. Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study. Injury. 2013; 44(2):232-238.
5. Caragounis EC, Fagevik Olsén M, Pazooki D, Granhed H. Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study. World J Emerg Surg. 2016; 11:27.
6. Coughlin TA, Ng JW, Rollins KE, et al, Management of rib fractures in traumatic flail chest: a meta‐analysis of randomised controlled trials. Bone Joint J. 2016; 98‐B(8):1119‐1125.
7. Doben AR, Eriksson EA, Denlinger CE, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care. 2014; 29(1):139-143.
8. Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005; 4(6):583-587.
9. Jesani H, Gomes-da Silva de Rosenzweig P, Walji HD, et al. Initial experience of intrathoracic rib fixation using RibFix Advantage at a major trauma centre: operative technique and case series. J Thorac Dis. 2025; 17(12):11357-11368.
10. Khandelwal G, Mathur RK, Shukla S, Maheshwari A. A prospective single center study to assess the impact of surgical stabilization in patients with rib fracture. Int J Surg. 2011; 9(6):478-481.
11. 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; 99(6):859-867.
12. Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis. Ann Surg. 2013; 258(6):914-921.
13. Majercik S, Cannon Q, Granger SR, et al. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg. 2014; 208(1):88-92.
14. Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013; 216(5):924-932.
15. Niziolek G, Goodman MD, Makley A, et al. Early results after initiation of a rib fixation programme: a propensity score matched analysis. Injury. 2022; 53(1):137-144.
16. Pieracci FM, Lin Y, Rodil M, et al. A prospective, controlled clinical evaluation of surgical stabilization of severe rib fractures. J Trauma Acute Care Surg. 2016; 80(2):187-194.
17. 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.
18. Qian G, Mao Y, He J, Gao L. Outcomes of internal rib fixation through complete video-assisted thoracoscopic surgery for multiple rib fractures and flail chest in severe chest trauma. Eur J Trauma Emerg Surg. 2025; 51(1):2
19. Slobogean GP, MacPherson CA, Sun T, et al. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg. 2013; 216(2):302-311.
20. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization or internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002; 52(4):727-732.
21. Wu TH, Lin HL, Chou YP, et al. Facilitating ventilator weaning through rib fixation combined with video-assisted thoracoscopic surgery in severe blunt chest injury with acute respiratory failure. Crit Care. 2020; 24(1):49.
22. Xu JQ, Qiu PL, Yu RG, et al. Better short-term efficacy of treating severe flail chest with internal fixation surgery compared with conservative treatments. Eur J Med Res. 2015; 20:55.
23. Zhang J, Li W, Liu Z. Clinical application of a novel rib fracture score system in patients with multiple rib fractures. Front Surg. 2026; 12:1653221.
24. Zhang Y, Tang X, Xie H, Wang RL. Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion. Am J Emerg Med. 2015; 33(7):937-940.
25. Zhang Z, Wang R, Zhao W, Wang X. Risk factors affecting the efficacy of open reduction and internal fixation in rib fractures. Curr Probl Surg. 2025; 68:101790.

Government Agency, Medical Society, and Other Authoritative Publications:

1. 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.
2. U.S. Food and Drug Administration 510(k) Premarket Notification Database. Synthes MatrixRIB Fixation System. No. K081623. Rockville, MD: FDA. September 8, 2008. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf8/K081623.pdf. Accessed on March 19, 2026.
3. U.S. Food and Drug Administration 510(k) Premarket Notification Database. Sig Medical Corporation AdvantageRib System. No. K183317. Rockville, MD: FDA. February 14, 2019. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf18/K183317.pdf. Accessed on March 19, 2026.
4. U.S. Food and Drug Administration 510(k) Premarket Notification Database. ACUTE Innovations, LLC Modular RibLOC Fixation System. No. 113318. Rockville, MD: FDA. January 12, 2012. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf11/K113318.pdf. Accessed on March 19, 2026.

AdvantageRib
MatrixRIB Fixation System
RibFix Advantage^™
RibFix Blu^® Thoracic Fixation System
RibLoc System^®
Rib fracture

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

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