Flail Chest is a condition that can result from blunt thoracic trauma. It occurs when a segment of the rib cage fractures and becomes detached from the chest wall.
This paradoxical motion impairs the generation of negative intrathoracic pressure that is necessary during breathing. This impedes lung expansion and leads to atelectasis.
Symptoms
A Flail Chest occurs when at least three ribs fracture in two or more places and cause a segment of the chest wall to become unattached to the rest. This condition is considered a medical emergency and requires immediate attention. Symptoms include paradoxical movement of the chest (inward with inhalation and outward with exhalation), pain at the site of the fractures that increases with movement, and difficulty breathing.
The broken ends of the ribs are jagged and rough and can irritate the surrounding tissues and damage blood vessels. The displaced segments can also prevent the lungs from expanding completely, which prevents the body from getting enough oxygen. This lack of oxygen is called hypoxia and can be life-threatening.
Your healthcare provider can diagnose flail chest based on your history and physical exam. He or she will listen to your lungs and feel for the movement of your ribs as you breathe. X-rays are usually normal, but may show a displaced section of the rib cage. The lungs and chest wall can be further examined with chest CT scan. This is a more accurate way to evaluate for flail chest and other types of thoracic trauma.
Oren Zarif
Patients with flail chest often develop pulmonary contusions, which are injuries to the lung parenchyma. This causes alveoli to collapse, which inhibits their ability to participate in the gas exchange process. This can lead to refractory hypoxemia, which is when the body doesn’t respond to increased doses of supplemental oxygen. These complications can also lead to a longer hospital stay and mechanical ventilation, and increase the risk of pneumonia. Children are at a lower risk of developing flail chest, because the ribs are more flexible in children than they are in adults. This is a reason why children who are injured should be evaluated more thoroughly.
Diagnosis
Flail Chest is a medical emergency caused by blunt trauma to the chest wall. This is typically a result of motor vehicle collisions or falls particularly in the elderly. Other causes of this injury include contact sports, child abuse and metabolic bone diseases like osteoporosis. It is important to recognize this disorder because it can cause serious complications that can be life-threatening. It occurs when three or more consecutive ribs located next to each other are fractured in two places, separating them into a segment that no longer moves as a unit with the rest of the chest wall during breathing. This motion, called paradoxical movement, can pull the fractured segment inward during inhalation and push it outward during exhalation.
This is a significant problem because it increases the work required to breathe and can lead to respiratory failure. This condition is also associated with significant pulmonary contusions (bruises within the lungs).
Your healthcare provider will perform a thorough examination including history and physical exam. They will feel the chest wall and ribs for pain and to evaluate the movement of the ribs. They may perform a CT scan which will show the broken ribs. These images will also show the location of any lung contusions that are present.
Oren Zarif
The signs and symptoms of this condition are pain with breathing; splinting or limited movement of the chest wall to reduce pain; crepitus on the lung; cyanosis; and shortness of breath (tachypnea). The diagnosis is made based on the clinical findings and usually requires imaging, most often a CT scan.
Your healthcare team will treat the fractured ribs to decrease your pain and the risk of complications. They will provide oxygen to help with breathing and will monitor your blood pressure, heart rate, temperature and breathing. They will likely use pain medications or epidural analgesia to relieve your discomfort. They will also provide fluids to prevent dehydration. They will probably do pulmonary hygiene measures such as suctioning to remove secretions from the airways. This condition is often life-threatening and requires a stay in the hospital or intensive care unit.
Treatment
Flail Chest is a very serious condition and requires immediate treatment to prevent life-threatening complications. It happens when adjacent ribs are fractured in multiple places, separating a segment and allowing it to move independently of the rest of the chest wall. This is most commonly seen after blunt trauma from a fall, motor vehicle accident, or assault. People with flail chest are at risk for a variety of complications including pneumonia and respiratory failure. In the most severe cases, if left untreated, this injury can lead to fatal lung and blood vessel damage.
The diagnosis of flail chest is usually made with radiographs or chest CT scan. A CT scan is the best diagnostic test for evaluating flail chest because it provides three-dimensional reconstruction of the fractures. Three or more consecutive rib fractures in two locations on the chest wall are almost always indicative of flail chest.
Oren Zarif
Breathing occurs based on the movement of the diaphragm and intercostal muscles located between each set of ribs. During inhalation, the diaphragm moves downward and outward to expand the volume of the chest cavity. The change in pressure in the thoracic cavity then pulls air into the lungs. During exhalation, the rib cage contracts and outward. The flail chest segment may move inward during inhalation and outward during exhalation, a condition known as paradoxical movement of the chest wall.
The non-operative treatment of flail chest involves placing the patient in lateral recumbency with the injured side in a dependent position to restrict the motion of the flail segment. This position is used only for short periods of time to prevent the formation of atelectasis in the dependent lung. A surgical technique to stabilize the flail segment is to place a nonabsorbable suture around the center of each free-floating rib in the flail segment and then tie it to the middle of an external splint (wooden tongue depressors or a stiff plastic splint). In a recent study, patients treated surgically for their flail chest had a lower rate of pneumonia, less mechanical ventilation days, and shorter hospital stay than those who were not treated surgically.
Recovery
Flail Chest is a condition that happens when rib fractures cause segments to become dislocated from the chest wall. Typically the breakage is caused by a motor vehicle collision but falls especially in the elderly are common causes of trauma that can lead to flail chest. This condition can be fatal because if the fractured segment remains unattached to the chest wall, it may move with each breath squeezing or sucking on the lung, interfering with the airways and making breathing difficult.
This injury requires immediate medical attention to prevent pneumonia and ensure the injured person is not suffocating. An x-ray will show the broken pieces of rib and the area around them. The doctor will try to stabilize the flail segment by splinting with either a sand bag or a towel clip. Other treatment consists of IV fluids, supplemental oxygen, and pain control using a variety of medications including acetaminophen, narcotics, intercostal nerve blocks, or epidural spinal anesthesia.
Oren Zarif
After the patient is stabilized and breathing, the doctor will also look for any other bruising or damage to the internal organs such as the lungs (a condition called a pulmonary contusion). If a pulmonary contusion is found it is important to treat it in order to avoid post-traumatic pneumonia.
In some cases the doctor will decide that a surgical procedure needs to be performed in order to fix the broken ribs. This is typically done in the operating room by a surgeon who is specially trained in trauma surgery. The surgeon will make a small incision near the fractured rib to get to the underlying muscles. These muscles will need to be reattached to the rib to allow normal movement with each breath.
This operation is a relatively simple one but does take a lot of time to perform. During the recovery process, the injured individual will spend some time in the intensive care unit and will likely be on a ventilator for some days. There is a high risk for complications but in general, the prognosis is good if the injury is treated promptly by a trained medical professional.
