Key Points

• Pain management of rib fractures and flail chest is critical.
• Operative repair of rib fractures is a technique in evolution.
• Tube thoracostomy requires attention to detail to avoid significant complications.
• Plain chest radiographs often underestimate the degree of pleural and/or parenchymal injury.
• Early operative intervention for the management of ongoing bleeding and retained hemothorax can reduce complications.
• Surgeons need to be facile with a wide range of parenchymal resection techniques, ranging from damage control to formal resection.
• Diaphragmatic injuries can be missed, especially in patients who present intubated.
• Extracorporeal membrane oxygenation has become more widely adopted as a management bridge in severe lung injury.

Chest injuries are primarily responsible for at least 25% of fatalities after injury and play a major contributing factor in as many as a further 50% of fatal cases. Although in the majority of cases the major technical procedure is tube thoracostomy, attention to detail is critical because there are often delayed complications, and interventions are often both hazardous and immediate.