Flail chest

Background

Diagrams depicting the paradoxical motion observed during respiration with a flail segment.

3D reconstruction from a CT scan showing a flail chest. Arrows mark the rib fractures.

• Due to segmental rib fractures (in 2 or more locations on same rib) of 3 or more adjacent ribs
  • Leads to free-floating segment of ribs that no longer attach to rest of thorax
• Commonly associated with respiratory failure (due to pulmonary contusion)

Clinical Features

• Paradoxical movement of affected segment
  • Inward movement of involved portion during inspiration, outward during expiration
• Often have concomitant pulmonary contusion

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Evaluation

Chest x-ray off a flail chest associated with right sided pulmonary contusion and subcutaneous emphysema.

• Possibly a clinical diagnosis
• Consider CXR or chest CT

Management

• Analgesia
• Consider positive pressure ventilation
  • Otherwise healthy patients with mild-moderate flail chest may be managed without positive pressure ventilation
• Consider intubation even if patient's breathing initially seems adequate, especially if:
  • Shock
  • Severe head injury
  • Comorbid pulmonary disease
  • Fracture of 8 or more ribs
  • Age >65
• Surgical fixation is controversial

Disposition

• Admit

See Also

• Thoracic Trauma
• Traumatic Pneumothorax
• Spontaneous Pneumothorax
• Tension Pneumothorax
• Fractures (main)