Flail chest

Definition
A flail chest is a life-threatening medical condition that occurs when a segment
of the chest wall bones breaks under extreme stress and becomes detached from
the rest of the chest wall, often associated with underlying pulmonary injury and
is most commonly seen in cases of significant blunt trauma. It occurs when
multiple adjacent ribs are broken in multiple places, separating a segment, so a
part of the chest wall moves independently that gives an appearance of stove in
chest.

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 as 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 motion" can increase the work and pain involved in
breathing.

Studies have found that up to half of people with flail chest die. In emergency
department presentations, approximately 30% of patients with extensive
thoracic trauma have a flail chest. Flail chest is invariably accompanied by
pulmonary contusion, 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 failure in patients with both injuries.

Causes
• Flail chest is a serious, life-threatening chest injury.
• This typically occurs when three or more adjacent ribs are fractured in
two or more places.
• Ribs fractured proximally in conjunction with disarticulation of
costochondral cartilages 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– for flail chest to occur a significant impact is required, breaking
the ribs in two or more places.
Presentation
 Pain when taking a deep breath

 Pain that gets worse when pressed on the injured area, or when bending
or twisting the body
 Very tender spot in the rib area that occurs after trauma or is
present with
deep breaths or hinders the breathing
 An experience of pressure, fullness or a squeezing pain in the
centre of the
chest that lasts for more than a few minutes
 Pain that extends beyond the chest to the shoulder or arm, and
increasing
episodes of chest pain, get medical attention immediately. These symptoms
may indicate a heart attack.
• 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 push the rib cage out. Pressure in the thorax decreases below
atmospheric pressure, and air rushes in through the trachea. However, a
flail segment will not resist the decreased pressure and will appear to
push in while the rest of the rib cage expands.

• During normal expiration, the diaphragm and intercostal muscles relax,

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.
The constant motion of the ribs in the flail segment at the site of the fracture is
incredibly painful, and, untreated, the sharp broken edges of the ribs are likely
to eventually puncture the pleural sac and lung, possibly causing a
pneumothorax.

Treatment
Treatment of the flail chest initially follows the principles of Advanced Trauma
Life Support. Further treatment includes:

 Good analgesia including intercostal blocks, avoiding narcotic analgesics

as much as possible. This allows much better ventilation, with improved
tidal volume, and increased blood oxygenation.

 Positive pressure ventilation, meticulously adjusting the ventilator

settings to avoid barotrauma.

 Chest tubes as required.

 Adjustment of position to make the patient most comfortable and provide

relief of pain.

Surgical fixation is usually not required.

A patient may be intubated with a double lumen tube. In a double lumen

endotracheal tube, each lumen is 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.