Flail chest is a life-threatening medical condition that occurs when a segment of the

rib cage The rib cage, as an enclosure that comprises the ribs, vertebral column and sternum in the thorax of most vertebrates, protects vital organs such as the heart, lungs and great vessels. The sternum, together known as the thoracic cage, is a semi- ...

breaks due to

trauma Trauma most often refers to: *Major trauma, in physical medicine, severe physical injury caused by an external source *Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic inju ...

and becomes detached from the rest of the

chest wall The thoracic wall or chest wall is the boundary of the thoracic cavity. Structure The bone, bony human skeleton, skeletal part of the thoracic wall is the rib cage, and the rest is made up of muscle, skin, and fasciae. The chest wall has 10 lay ...

. Two of the

symptoms Signs and symptoms are the observed or detectable signs, and experienced symptoms of an disease, illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormali ...

of flail chest are

chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...

and

shortness of breath Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing disc ...

. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. The number of ribs that must be broken varies by differing definitions: some sources say at least two adjacent ribs are broken in at least two places, some require three or more ribs in two or more places. The flail segment moves in the opposite direction to the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This so-called "paradoxical breathing" is painful and increases the work involved in breathing. Flail chest is usually accompanied by a

pulmonary contusion A pulmonary contusion, also known as lung contusion, is a bruise of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, pot ...

, a bruise of the lung tissue that can interfere with blood oxygenation. Often, it is the contusion, not the flail segment, that is the main cause of respiratory problems in people with both injuries. Surgery to fix the fractures appears to result in better outcomes.

Signs and symptoms

Two of the

of flail chest are

and

.Athanassiadi, Kalliopi, Michalis Gerzounis, Nikolaos Theakos. Management of 150 flail chest injuries: analysis of risk factors affecting outcome. European Journal of Cardio-thoracic surgery 26. (2004). Pg 373–376. The characteristic paradoxical motion of the flail segment occurs due to pressure changes associated with respiration that the rib cage normally resists: * During normal inspiration, the diaphragm contracts and intercostal muscles pull the rib cage out. Pressure in the thorax decreases below atmospheric pressure, and air rushes in through the trachea. The flail segment will be pulled in with the decrease in pressure while the rest of the rib cage expands. * During normal expiration, the diaphragm and intercostal muscles relax increasing internal pressure, allowing the abdominal organs to push air upwards and out of the thorax. However, a flail segment will also be pushed out while the rest of the rib cage contracts. Paradoxical motion is a late sign of flail segment; therefore, an absence of paradoxical motion does not mean the patient does not have a flail segment. The constant motion of the ribs in the flail segment at the site of the fracture is extremely painful, and, untreated, the sharp broken edges of the ribs are likely to eventually puncture the pleural sac and lung, possibly causing a

pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...

. The concern about "mediastinal flutter" (the shift of the

mediastinum The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...

with paradoxical diaphragm movement) does not appear to be merited. Pulmonary contusions are commonly associated with flail chest and that can lead to

respiratory failure Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...

. This is due to the paradoxical motions of the chest wall from the fragments interrupting normal breathing and chest movement. Typical paradoxical motion is associated with stiff lungs, which requires extra work for normal breathing, and increased lung resistance, which makes air flow difficult. The respiratory failure from the flail chest requires

mechanical ventilation Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...

and a longer stay in an intensive care unit. It is the damage to the lungs from the flail segment that is life-threatening.

Causes

The most common causes of flail chest injuries are vehicle collisions, which account for 76% of flail chest injuries. Another main cause of flail chest injuries is falling. This mainly occurs in the

elderly Old age refers to ages nearing or surpassing the life expectancy of human beings, and is thus the end of the human life cycle. Terms and euphemisms for people at this age include old people, the elderly (worldwide usage), OAPs (British usage ...

, who are more impacted by the falls as a result of their weak and frail

bone A bone is a Stiffness, rigid Organ (biology), organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red blood cell, red and white blood cells, store minerals, provid ...

s, unlike their younger counterparts who can fall without being impacted as severely. Falls account for 14% of flail chest injuries. Flail chest typically occurs when three or more adjacent ribs are fractured in two or more places, allowing that segment of the thoracic wall to displace and move independently of the rest of the chest wall. Flail chest can also occur when ribs are fractured proximally in conjunction with disarticulation of

costal cartilage The costal cartilages are bars of hyaline cartilage that serve to prolong the ribs forward and contribute to the elasticity of the walls of the thorax. Costal cartilage is only found at the anterior ends of the ribs, providing medial extension. ...

s distally. For the condition to occur, generally there must be a significant force applied over a large surface of the thorax to create the multiple anterior and posterior rib fractures. Rollover and crushing injuries most commonly break ribs at only one point, whereas for flail chest to occur a significant impact is required, breaking the ribs in two or more places. This can be caused by forceful accidents such as the aforementioned vehicle collisions or significant falls. In the elderly, it can be caused by

deterioration Deterioration may refer to: * Worsening of health * Physical wear See also * Decadence (disambiguation) * Degeneracy (disambiguation) * ''Deteriorata'', a parody of ''Desiderata'' * Decay * Decline Decline may refer to: *Decadence, involves a ...

of bone, although rare. In children, the majority of flail chest injuries result from common blunt force traumas or metabolic bone diseases, including a group of genetic disorders known as

osteogenesis imperfecta Osteogenesis imperfecta (; OI), colloquially known as brittle bone disease, is a group of genetic disorders that all result in bones that break easily. The range of symptoms—on the skeleton as well as on the body's other organs—may be mi ...

Diagnosis

Diagnosis is by physical examination performed by a physician. The diagnosis may be assisted or confirmed by use of medical imaging with either plain X ray or CT scan.

Treatment

Treatment of the flail chest initially follows the principles of advanced trauma life support. Further treatment includes: *Good pain management includes early regional anesthesia (e.g. intercostal blocks or erector spinae plane blocks) and avoiding opioid pain medication as much as possible. This allows much better

ventilation Ventilation may refer to: * Ventilation (physiology), the movement of air between the environment and the lungs via inhalation and exhalation ** Mechanical ventilation, in medicine, using artificial methods to assist breathing *** Ventilator, a ma ...

, with improved

tidal volume Tidal volume (symbol VT or TV) is the volume of air moved into or out of the lungs during a normal breath. In a healthy, young human adult, tidal volume is approximately 500 ml per inspiration or 7 ml/kg of body mass. Mechanical vent ...

, and increased blood

oxygenation Oxygenation may refer to: * Oxygenation (environmental), a measurement of dissolved oxygen concentration in soil or water * Oxygen saturation (medicine), the process by which concentrations of oxygen increase within a tissue * Water oxygenation, t ...

. *Positive pressure ventilation, meticulously adjusting the ventilator settings to avoid

pulmonary barotrauma Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or contact with, the body and the surrounding gas or liquid. The initial damage is usually due to over-stretching the tissues in tensio ...

. *

Chest tube A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substanc ...

s as required. *Adjustment of position to make the person most comfortable and provide relief of pain. *Aggressive

pulmonary toilet Pulmonary hygiene, formerly referred to as pulmonary toilet, is a set of methods used to clear mucus and secretions from the airways. The word ''pulmonary'' refers to the lungs. The word ''toilet'', related to the French ''toilette'', refers to ...

A person may be

intubated Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Patients are generally anesthetized beforehand. Examples include tracheal intubation, and the balloon tamponade with a Sengstaken-Blakemo ...

with a double lumen tracheal tube. In a double lumen endotracheal tube, each lumen may be connected to a different ventilator. Usually one side of the chest is affected more than the other, so each lung may require drastically different pressures and flows to adequately ventilate. Surgical fixation can help in significantly reducing the duration of ventilatory support and in conserving the pulmonary function. Surgical intervention has also been shown to reduce the need for tracheostomy, reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event.

Physiotherapy

In order to begin a rehabilitation program for a flail chest it is important to treat the person's pain so they are able to perform the proper exercises. Due to the underlying conditions that the flail segment has caused onto the respiratory system,

chest physiotherapy Chest physiotherapy (CPT) are treatments generally performed by physical therapists and respiratory therapists, whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient. Other terms include respirato ...

is important to reduce further complications. Proper positioning of the body is key, including postural alignment for proper drainage of mucous secretions.Ciesla, Nancy D. "Chest Physical Therapy for Patients in the Intensive Care Unit". Journal of the American Physical Therapy Association (1996) 76:609–625. The therapy will consist of a variety of postural positioning and changes in order to increase normal breathing. Along with postural repositioning, a variety of breathing exercises are also very important in order to allow the chest wall to reposition itself back to normal conditions. Breathing exercises will also include coughing procedures. Furthermore,

range of motion Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...

exercises are given to reduce the

atrophy Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations (which can destroy the gene to build up the organ), poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply t ...

of the musculature. With progression, resistance exercises are added to the regimen to the shoulder and arm of the side containing the injury. Moreover, trunk exercises will be introduced while sitting and will progress to during standing.Kumar, Senthil. "Post Operative Physiotherapy Management for Flail Chest". https://www.scribd.com/doc/59432747/Post-operative-physiotherapy-management-for-flail-chest-or-Multiple-ribs-fracture-or-Cardio-pulmonary-rehabilitation-or-physiotherapy-or-physical-ther Hip flexion exercises can be done to expand the thorax. This is done by lying supine on a flat surface, flexing the knees and hips and bringing them in toward the chest. The knees should come in toward the chest while the person inhales, and exhale when the knees are lowered. This exercise can be done in 3 sets of 6–8 repetitions with a pause in between sets. The person should always make sure to maintain controlled breaths. Eventually, the person will be progressed to walking and posture correction while walking. Before the person is discharged from the hospital, the person should be able to perform mobility exercises to the core and should have attained good posture. File:Flail 2.jpg, Mobilization of the chest and pectoral muscle stretch. During inspiration, the person will clasp hands behind the head and will horizontally abduct the arms. File:Flail 1.jpg, During exhalation, the person will bend forward bringing the elbows together.

Prognosis

The death rate of people with flail chest depends on the severity of their condition, ranging from 10 to 25%. A systematic review comparing the safety and effectiveness of surgical fixation versus non-surgical methods for the treatment of flail chest, reported that there was no statistically significant difference in the reported deaths between patients treated surgically and those treated non-surgically i.e. with conservative management methods. The results of the systematic review suggested that surgical intervention reduces the need for tracheostomy, reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event.

Epidemiology

Approximately 1 out of 13 people admitted to the

hospital A hospital is a health care institution providing patient treatment with specialized health science and auxiliary healthcare staff and medical equipment. The best-known type of hospital is the general hospital, which typically has an emerge ...

with

fractured ribs Fractured may refer to: * Fracture, the separation of a material into pieces under the action of stress * Bone fracture, a partial or complete break in the continuity of the bone Books * ''Fractured'', a 2008 novel by Karin Slaughter * ''Fractu ...

are found to have flail chest.Richardson, J. David M.D, Lee Adams M.D, Lewis M. Flint, M.D. Selective Management of Flail Chest and Pulmonary Contusion. Department of Surgery, University of Louisville, School of Medicine, Louisville, Kentucky.

References

External links

Rib Fractures & Flail Chest
at Trauma.org – info, images, and video of paradoxical flail-segment motion {{DEFAULTSORT:Flail Chest Chest trauma