Table 1.

Review characteristics

Review Year Country	Review aim	Search strategy	Studies and participants	Patient, Intervention, Comparator, Outcome and Study type (PICOS)	Risk of bias	Authors’ conclusions
Swart et al 17 2017 USA	To perform a meta-analysis of high quality literature to evaluate both economic and medical benefits of early fixation of rib fractures in severe chest trauma.	PubMed, Embase, Medline and Scopus. No search start date. Last search date 1 June 2016. Search terms defined, No limitations described. Evidence of hand searching. Eligibility criteria: over 18 years of age and studies comparing operative versus non-operative treatment,	3 RCT n=123 14 Case–control 3 Case series	Population Acute flail chest 18 years or older. Intervention Operative fixation. Comparator Non-operative. Studies type All study designs.	No evidence of quality assessment.	Acute ORIF of rib fractures in patients with flail chest injuries results in reduced mortality and medical complications in conjunction with being cost effective intervention.
Schuurmans et al 18 2017 The Netherlands	Investigate how operative management improves patient care for adults with flail chest.	PubMed, Trip database, Google Scholar. No search start date. Last search date November 2015. Search terms defined, No limitations described. Evidence of reference checking. Eligibility criteria: studies comparing operative versus non-operative treatment, RCT only and English.	3 RCT n=123	Population Acute flail chest. Intervention Operative fixation. Comparator Non-operative. Studies type RCTs.	Quality assessment completed but criteria and explanation unclear.	The operative management group showed a significant lower incidence of pneumonia, whereas mortality rate did not differ between treatment groups.
Schulte et al 13 2016 UK	In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality?	OVID MEDLINE. Search start date 1946. Last search date January 2016. Search terms defined. Search strategy description minimal, no limitations described. No evidence of reference checking. No specific inclusion or exclusion criteria defined.	1 Meta-analysis by separate author. 1 RCT n=123 (2 further coded as RCT which are non-randomised studies). 3 Retrospective cohort studies.	Population Acute flail chest. Intervention Operative fixation. Comparator Non-operative. Studies type Unclear.	No evidence of quality assessment.	Surgical stabilisation of flail chest in thoracic trauma patients has beneficial effects with respect to reduced ventilatory support, shorter intensive care and hospital stay, reduced incidence of pneumonia and septicaemia, decreased risk of chest deformity and an overall reduced mortality when compared with patients who received non-operative management.
Coughlin et al 19 2016 UK	Compare the efficacy of flail chest surgical stabilisation to non-operative management.	PubMed MEDLINE, Embase, Cochrane Library, clinical trials.gov. No search start date. Last search date February 2015. Search terms defined, No limitations. Evidence of reference checking. Eligibility criteria: studies comparing operative versus non-operative treatment in flail chest and RCT only.	3 RCT n=123	Population Traumatic flail chest. Intervention Surgical stabilisation of any kind. Comparator Patients treated non-operatively by any other means. Studies type RCTs only.	Clear quality appraisal of the studies.	Surgical stabilisation for a traumatic flail chest is associated with significant clinical benefits including rate of pneumonia, length of hospital an ICU stay and duration of mechanical ventilation in this meta-analysis of three relatively small RCTs.
Unsworth et al 24 2015 Australia	To review the treatments for blunt chest trauma and their impact on patient and hospital outcomes. Specifically alludes to surgical stabilisation of flail chest.	Cochrane, Medline, EMBASE and CINAHL databases. Search limited to 1990 onwards. Last search date March 2014. Search terms defined. Limited to humans and adults. Evidence of reference checking. Eligibility criteria: original research, blunt chest trauma, intervention for blunt chest trauma including a comparator and contained measured outcomes.	3 RCT n=123 5 Retrospective case–controls n=642. 1 Retrospective cohort n=21.	Population Adult blunt chest trauma. Flail chest. Intervention Multidisciplinary intervention (models of care, management intervention, care practices, care protocols). Comparator Other intervention not specified. Studies type RCTs.	Some quality assessment completed but criteria and explanation unclear.	Across the literature there were consistent improvements in patients with flail chest and surgical fixation with fewer days of mechanical ventilation, ICU-LOS and cost savings compared with non-operative techniques. Three out of nine studies were randomised controlled trials, and the level of evidence in all studies was primarily fair or good.
de Lesquen et al 15 2015 France	In flail chest is open reduction and internal fixation needed?	Medline and Science Direct. Search start date limited to 1994 onwards. Last search date January 2014. Search Terms defined. No evidence of hand searching or reference checking. Eligibility criteria: Exclusions of both child and vascular injuries.	2 Meta-analysis. 3 RCT n=123. 1 Prospective cohort n=60. 5 Retrospective cohort n=238.	Population Blunt chest trauma. Flail chest. Intervention Open reduction and internal fixation. Comparator Unclear. Studies type Unclear.	No evidence of quality assessment.	For flail chest, early surgical stabilisation can be considered in patients who would require mechanical ventilation for >48 hours.
Cataneo et al 20 2015 Brazil	To evaluate the effectiveness and safety of surgical stabilisation compared with clinical management for people with flail chest.	Cochrane Injuries Group Specialised Register, CENTRAL, Medline, Embase, CINAHL, SCI, CPCI-S, Clinical trials.gov, ICTR. No search start date. Last search Date 12 May 2014. Search terms defined, no limitations. Evidence of reference checking. Eligibility criteria: RCTs.	3 RCTs n=123.	Population Adults or children with flail chest. Intervention Surgical stabilisation of any kind. Comparator Clinical management included any type of chest wall stabilisation without surgical intervention such as straps or bags and any type of ventilatory assistance. Studies type RCTs only.	Clear quality appraisal of the studies.	There was no evidence that surgical intervention reduced mortality in people with FC compared with non-surgical management. There was some evidence that surgical intervention could reduce the risk of developing pneumonia and thoracic deformity; need for tracheostomy; duration of mechanical ventilation, length of ICU stay and hospital stay; and chronic pain, but the trials to date have been small. There is an urgent need for larger high-quality randomised con-trolled trials.
de Jong et al 23 2014 The Netherlands	To specify indications for rib fracture fixation of non-flail chests.	Medline, Cochrane, Embase. Search start date limited to 2010. Last search date December 2013. Search terms defined, limited to year 2000 onwards. Evidence of reference checking. Eligibility criteria: Studies included at least 10 participants who were surgically treated for non-flail chest rib fractures. Reported in English, Dutch or German. Excluded were case reports, biomechanical studies, animal studies and expert opinions.	1 Case–control n=60. 2 Cohort studies n=47.	Population Traumatic non-flail chest. Intervention Surgical treatment of non-flail chest. Comparator Unclear. Studies type All studies with at least 10 surgically treated.	No evidence of quality assessment.	The evidence for surgical treatment of non-flail chest rib fractures is limited.
Slobogean et al 21 2013 Canada	Compare the critical care outcomes of surgical fixation to non-operative management in patients with flail chest injuries.	Medline, Embase, Cochrane Database of Systematic Reviews and the Cochrane Central, Register of Controlled Trials (CENTRAL). No search start date. Last search date May 2011. No limitations. No evidence of reference checking or hand searching. Eligibility criteria: Comparator studies with more than 10 cases.	2 RCTs. 1 Case–control n=60. 8 Cohort n=676.	Population Acute flail chest. Intervention Operative fixation. Comparator Conservative management. Studies Type RCTs.	No evidence of quality assessment.	Improved outcomes of multiple critical care outcomes with narrow CIs but based on small retrospective studies. Suggests prospective RCT to overcome potential biases.
Leinicke et al 22 2013 USA	Comparing operative to non-operative therapy in adult flail chest patients.	MEDLINE (1966–2012), Embase (1947–2012), Scopus (all years), Cochrane Databases and ClinicalTrials.gov Last search date February 2012. Search terms defined, limited to English and human studies. Evidence of reference checking. Eligibility criteria: Studies comparing operative versus non-operative treatment in patients with flail chest. Excluded case reports and case series.	2 RCTs. 3 Case–control n=158. 4 Cohort n=303.	Population Flail chest. Intervention Operative fixation. Comparator Non-operative. Studies type RCTs, cohort and case-control trials.	Clear quality appraisal of the studies.	As compared with non-operative therapy, operative fixation of FC is associated with reductions in DMV, LOS, mortality and complications associated with prolonged MV. These findings support the need for an adequately powered clinical study to further define the role of this intervention.
Girsowicz et al 14 2012 France	In patients over 45 years old with isolated, movable and painful rib fractures without true flail chest is surgical stabilisation superior to non-operative management in improving outcomes?	OVID Medline 1948 –2011. Last search date June 2011. Search terms defined, limited to Human and English language. Evidence of reference checking. Eligibility criteria: Excluded flail chest but inclusions not well described.	4 Retrospective cohort n=107. 1 Non-systematic review. 1 Case–control=30. 2 Case report n=2.	Population Over 45 years old with isolated, movable and painful. Rib fractures without true flail chest. Intervention surgical stabilisation. Comparator Non-operative management. Studies type Unclear.	Some comments on strengths and weaknesses but no quality or risk of bias assessment.	Surgical stabilisation in the management of isolated multiple non-flail and painful rib fractures improved outcomes (pain, respiratory function, quality of life and reduced socio-professional disability). Studies provided a low level of evidence (small studies with few numbers of patients and short-term follow-up or case reports). Large prospective controlled trials are thus necessary to confirm these encouraging results.
NICE Evidence12 2010 UK	To make recommendations about the safety and efficacy of surgical rib fracture fixation in flail chest.	MEDLINE, PREMEDLINE, EMBASE, Cochrane Library. No search start date. Last search date May 2010. Search terms defined. No limitations. No evidence of reference checking but other searches performed. Eligibility criteria: clinical studies of patients with flail chest operated with metal rib reinforcements and published in English. Excluded conference abstracts and reviews.	1 RCT. 2 Non-randomised studies. Four case series. Total 225 patients.	Population Flail chest. Intervention Insertion of metal rib reinforcements. Comparator Unclear. Studies type Clinical studies were included. Abstracts were excluded where no clinical outcomes were reported or where the paper was a review, editorial or a laboratory or animal study. Conference abstracts were also excluded.	No evidence of quality assessments.	Surgical rib fracture fixation should be consider in patients with flail chest.

DMV, duration of mechanical ventilation; FC, flail chest; ICU, Intensive care unit; LOS, length of stay; MV, mechanical ventilation; NICE, National Institute for Health and Care Excellence; ORIF, open reduction internal fixation; RCT, randomised controlled trial.