Cochrane Database Syst Rev. J Trauma Acute Care Surg. Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. [Full Text]. Balci AE, Ozalp K, Duran M, Ayan E, Vuraloğlu S. [Flail chest due to blunt trauma: clinical features and factors affecting prognosis]. [Full Text]. The test of choice for evaluating not only the flail chest but also for associated injury is the CT scan, specifically with 3D reconstruction. Kishikawa et al 15), however, noted resolution of altered pulmonary function within 6 months, even with chest wall deformity still present. Ann Thorac Surg. 2004 Apr;10(2):102-9. The management of flail chest. Long-term disability associated with flail chest injury. Underlying pulmonary injury with respiratory insufficiency resulting from changes in tidal volume and minute ventilation in these patients is rare. Flail chest is a clinical anatomic diagnosis noted in blunt trauma patients with paradoxical or reverse motion of a chest wall segment while spontaneously breathing. However, this treatment was subsequently proven to increase morbidity and mortality in patients who did not need intubation for other reasons. John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine In childhood metabolic bone disease and osteogenesis imperfecta predispose to this condition. 2013 Feb. 216(2):302-11.e1. The chest x-ray may be the first study that helps specifically with flail chest. H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Midwest Surgical Association, Royal Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical SocietyDisclosure: Nothing to disclose. Call us at (386) 255-4596 to schedule an appointment. [Medline]. Mayberry JC, Ham LB, Schipper PH, Ellis TJ, Mullins RJ. Age-adjusted outcomes in traumatic flail chest injuries in the elderly. 59 (4):515. Mechanically, flail chest generally requires a significant force diffused over a large area (ie, the thorax) to create multiple anterior and posterior rib fractures. Dehghan et al 32) conducted a retrospective analysis of data from the National Trauma Data Bank of injury patterns, management, and clinical outcomes for 3,467 patients in whom flail chest was identified from 2007 to 2009. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvNDMzNzc5LW92ZXJ2aWV3. Because they are also more likely to have pre-existing lung disease they are also at highest risk for the complications of flail chest. 2008 Spring;20(1):39-45. Int Orthop 2009;33:1425–33. Findings on chest CT may also help decide on treatment. Flail Chest Diagnosis. Flail chest. Certain traumatic events like direct blows to the chest are more likely to cause 2 fractures on a given rib. Both external (lower efficacy) and internal stabilization have been advocated, usually in reports from outside the United States. Footnote: Image depicting multiple fractures of the left upper chest wall. [Medline]. 824654-overview Flail Chest cannot be prevented since accidents are typically unavoidable. 2001. Cataneo AJ, Cataneo DC, de Oliveira FH, Arruda KA, El Dib R, de Oliveira Carvalho PE. Flail chest is considered a clinical diagnosis as everybody with this fracture pattern does not develop a flail chest. Diagnosis is by medical imaging with either plain X ray or CT scan. Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, Surgical Infection SocietyDisclosure: Nothing to disclose. Older patients are more likely to suffer from complications, such as pneumonia, deformity, chronic chest pain, or respiratory failure. This alters the mechanics of breathing so that the floating segment of chest wall and soft tissue moves paradoxically in the opposite direction from the rest of the rib cage. 34(6):908-12; discussion 912-3. The first rib is often fractured posteriorly (black arrows). J Trauma. The arch design of the ribs allows for some flexing, more so in children than adults, which can absorb small amounts of blunt kinetic energy. [Medline]. 1993 Jun. Morbidity is high due to long and complicated hospital stays and recovery. Borman JB, Aharonson-Daniel L, Savitsky B, Peleg K. Unilateral flail chest is seldom a lethal injury. J Bone Joint Surg Am. The intercostals play an increasingly important role to inspiration during exercise and in pathologic states. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what is the benefit? The most common way of diagnosing flail chest in a patient who’s suffered from trauma is a visual examination of the chest and a close evaluation of the patient’s breathing patterns. World J Surg. If the structural components (ie, the ribs) are weakened for any reason (eg, osteoporosis), then much lower force may be required. J Trauma. Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Fakhry SM, et al. 20(1):39-45. The strict definition of 3 ribs broken in 2 or more places can be confirmed only by x-ray, but the inherent structural stability of the chest wall due to the ribs and intercostal muscles usually does not show abnormal or paradoxical motion without 3 or more ribs involved. The authors concluded that alternative methods of treatment, including more consistent use of epidural catheters for pain and surgical fixation, should be investigated 33). In an adult, a transfer of significant kinetic energy in blunt trauma to the rib cage or a crushing rollover injury is the most frequent cause of flail chest. This clinical finding disappears after intubation with positive pressure ventilation, which occasionally results in a … 2014 Feb. 76(2):462-8. Flail chest is an indicator of significant kinetic force to the chest wall and rib cage, but it may also may occur with lesser trauma in persons with underlying pathology, including osteoporosis, total sternectomy, and multiple myeloma, as well as individuals with congenital absence of the sternum. [Medline]. More than 99% of patients were treated nonoperatively, and a small proportion (8%) received aggressive pain management with epidural catheters. [Medline]. Further studies are needed to confirm these results 24). 99(5):536-8. In children, who have a more compliant chest wall, flail chest is observed with lower frequency than injury to the underlying structures, including the lungs, heart, and mediastinal structures. Am Surg. [Full Text]. More advanced radiologic work-up with multislice computed tomography (MSCT) scanners is increasing the frequency of diagnosis of this problem. Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Selective management of flail chest and pulmonary contusion. Veysi VT, Nikolaou VS, Paliobeis C, et al. [Medline]. 22(5):325-9. Pain management should be addressed early and aggressively. The first rib is often fractured posteriorly (black arrows). 1984 May. As previously noted, some reports suggest a high rate of disability after flail chest; however, most patients do well and return to normal function after 6-12 months. Operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate. Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion. 19(4):355-63. Acta Chir Orthop Traumatol Cech 2015;82:303–7. Thorac Cardiovasc Surg. 2005 May. Nishiumi N, Fujimori S, Katoh N, Iwasaki M, Inokuchi S, Inoue H. Treatment with internal pneumatic stabilization for anterior flail chest. J Trauma. CD009919. google_ad_client: "ca-pub-9759235379140764", Surg Today. If a person has experienced severe trauma and has any of the symptoms below, it may be an indication of Flail Chest: As explained above, the most common cause of flail chest is severe trauma. You might need to have more than one X-ray taken in orde… [Full Text]. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. A flail segment of the chest wall will negatively affect respiration in three ways: ineffective ventilation, pulmonary contusion and hypoventilation with atelectasis. Because of the pressure changes with positive pressure ventilation, patients on bipap or those who are mechanically intubated do not exhibit paradoxical chest wall motion. [Medline]. [Medline]. If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result. Landercasper J, Cogbill TH, Strutt PJ. [Medline]. 2006 Dec. 23(12):903-5. Thorac Surg Clin. A computed tomography (CT) scan is the preferred test for identifying flail chest, as an X-raymay not identify all rib fractures.
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