Flail Chest

Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

• Flail chest could be a life threatening condition.
• A segment of the rib cage breaks and becomes separated or detached from the chest wall.
• It usually requires significant violent force in order to break the ribs in this way.
• The fractured segment will sink into the chest with inspiration and expand out of the chest wall with expiration opposite to the normal chest wall mechanism.
• The segmented rib fractures works independently.
• If the segmented section moves right, then the rest of the ribs move left, and vice versa.
• The flail chest moves in the opposite direction to the rest of the chest wall. This is called paradoxical breathing.
• There may be a pulmonary contusion associated with the flail chest fracture segment.
• There also may be a noticeable chest wall deformity with presence of air in the subcutaneous tissue (crepitus).
• The trauma usually causes scapular fractures or clavicle fracture.
• Symptoms: – Chest pain and shortness of breath. – Paradoxical movement of the flail segment. – The constant movement of the ribs is really painful. – The broken rib may puncture the lung and cause pneumothorax.
• X-ray: it is difficult to see if the fractures are displaced or nondisplaced.
• CT scan is probably better for visualizing these fractures.
• The prognosis varies and it depends on the severity of the condition, however the death rate ranges between 10%-25% usually depending on the pulmonary injury.
• About 8% of patients who are admitted to the hospital with fractured ribs will have a flail chest.

Treatment:

• Observation: – If there is no respiratory compromise. – No flail chest segment.

• Follow advanced life trauma support (ATLS) principles: – Airway – Breathing – Circulation •
• Give the patient pain control, usually with intercostal block
• Avoid suppression of breathing
• Give the patient positive pressure ventilation, chest tube if needed.
• Surgery: – May help in reducing the duration of ventilator support and aid in the pulmonary function. – Patient will need aggressive pulmonary toilet and physiotherapy. –
• You do open reduction and internal fixation when there is severe pain and displaced ribs; When there is flail chest segment; three or more consecutive fractured ribs with segmental injury; When the rib fractures are associated with failure to wean the patient off of ventilation.