Flail Chest


Article Author:
Thomas Perera


Article Editor:
Brian Daley


Editors In Chief:
Jesse Cole


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
12/24/2018 8:22:19 AM

Introduction

Flail chest is a traumatic condition of the thorax.  It may occur when 3 or more ribs are broken in at least 2 places.  It is considered a clinical diagnosis as everybody with this fracture pattern does not develop a flail chest.  A flail chest arises when these injuries cause a segment of the chest wall to move independently of the rest of the chest wall.  A flail chest can create a significant disturbance to respiratory physiology. This disturbance in respiratory function is important in patients who are older or who have chronic lung disease.  Flail chest is an important injury with significant complications.  A flail chest is usually associated with significant blunt chest wall trauma.  It often occurs in the setting of other injuries and is an extremely painful condition.  Both factors significantly contribute to the difficulty in managing this condition. Flail chest is often unilateral but can be bilateral. It may be suspected based on radiographic findings but is diagnosed clinically.  

Etiology

Because this is a traumatic disorder, risk factors for flail chest include the risk factors for major trauma. Male sex and intoxication being independent risk factors.  Motor vehicle collisions are the cause of 75% of the major trauma which result in flail chest. Falls particularly in the elderly cause another 15%.[1] Certain traumatic events like direct blows to the chest are more likely to cause 2 fractures on a given rib.  Rollover and crush injuries more commonly break ribs at only one point and thus do not, as often, cause flail chest.  In childhood metabolic bone disease and osteogenesis imperfecta predispose to this condition.  The elderly are predisposed to flail chest both because they have an age-related physiologic stiffening of the chest wall and because they may have osteoporosis.  Because they are also more likely to have pre-existing lung disease they are also at highest risk for the complications of flail chest.

Epidemiology

The American Association for the Surgery of Trauma gives trauma statistics for the US.  1% of the US population/yr will experience a significant traumatic event. Chest trauma occurs in  20% of major trauma and is responsible for 25% of traumatic deaths. Flail chest occurs in about 7% of chest trauma.[2] Flail chest patients usually require hospitalization.  Flail chest occurs in isolation in less than 40% of cases. More often it is accompanied by pulmonary contusions, hemo/pneumotharax, head injury and occasionally major vascular injury. The mortality of flail chest ranges from 10% to 20% but is often due to accompanying injury rather than the flail chest alone.[3]  Morbidity is high due to long and complicated hospital stays and recovery.

Pathophysiology

The movement of air in and out of the lungs is dependent on changes in intrathoracic pressure.  Inspiration relies on the coordinated function of respiratory muscle groups including the diaphragm, external intercostal, parasternal internal intercostal and accessory muscles.  The descent of the diaphragmatic dome increases in the vertical dimension of the chest cavity and creates negative pressure. The diaphragm alone can maintain adequate ventilation at rest. The intercostals play an increasingly important role to inspiration during exercise and in pathologic states.  Exhalation is usually passive due to the elastic recoil of the lung, but the abdominal muscles and the intercostals may participate. With a flail chest, the continuity of the chest wall is disrupted, and the physiologic action of the ribs is altered. The motion of the flail segment is paradoxical to the rest of the chest. It is paradoxical because the flail segment moves inward while the rest of the chest wall moves outward. The severity of this paradoxical motion and the physiological effect is determined by a three factors; pleural pressure, the extent of the flail, and the activation of intercostals muscles during inspiration.[4]

A flail segment of the chest wall will negatively affect respiration in three ways: ineffective ventilation, pulmonary contusion and hypoventilation with atelectasis.  There is ineffective ventilation because of increased dead space, decreased intrathoracic pressure and increased oxygen demand from injured tissue. Pulmonary contusion in adjacent lung tissue is almost universal with flail chest.  Pulmonary contusion lead to edema, hemorrhage and may eventually have some element of necrosis. Pulmonary contusions impairs gas exchange and decreases compliance. Hypoventilation and atelectasis result from the pain of the injury.  The pain causes splinting which decreases the tidal volume and predisposes to the formation of atelectasis.

History and Physical

The history may be obvious as most of the flail chests will be in the setting of major blunt force trauma.  The elderly are at increased risk. The diagnosis may be more cryptogenic in cases of abuse. nonverbal patients, cases of abuse or when a history can not be obtained.

The physical exam should be the exam performed in all patients with potential thoracic trauma.   Fully expose the patient. Obtain a full set of vitals including an accurate measure of respiratory rate and oxygen saturation. Start with the ABC’s and continue through the secondary survey.  Always listen for bilateral breath sounds then palpate for pain, deformity or crepitus. Examine the chest for bruising or bleeding, seatbelt signs. The patient usually complains of severe chest wall pain and may have tachypnea and splinting or manifest respiratory insufficiency.

Specifically, observe the chest for paradoxical wall motion.  In inspiration the flail segment will go in while the rest of the chest expands and in expiration the flail segment will be pushed out while the rest of the chest contracts.  Of note the absence of observable paradoxical motion does not exclude this disease and it may become more apparent as the intercostals become fatigued.

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. Thus, in mechanically ventilated trauma patient, the diagnosis of flail chest may be delayed and become apparent only after extubation.[1]

Evaluation

Evaluation of the trauma patient should include all of the usual exams and studies used in a major multi-trauma patient. The EFAST may find pneumo/hemothorax but does not usually help define a flail chest.  The chest x-ray may be the first study that helps specifically with flail chest. Chest x-ray is not very sensitive and may miss rib fractures identified by CT; hence the diagnosis of flail chest may be missed if one just relies on the chest x-ray.  A rib series is better but may still miss ¼ of the rib fractures.[5] The test of choice for evaluating not only the flail chest but also for associated injury is the CT scan, specifically with 3D reconstruction. Finding 3 ribs broken in 2 places on x-ray or CT is suggestive of flail chest but need to be clinically correlated.  Findings on chest CT may also help decide on treatment.

Complete trauma labs should be ordered including a blood gas.  Labs have limited direct role in the diagnosis of flail chest but may aid in monitoring the patient for signs of impending respiratory failure.

Treatment / Management

Management of a flail chest should include these areas of concern; maintaining adequate ventilation, fluid management, pain management and management of the unstable chest wall. Ventilation should be maintained with oxygen and non-invasive ventilation when possible.  Invasive mechanical ventilation used only when other methods fail and extubation should be attempted as early as possible.

The judicious use of fluid is recommended in most trauma settings and is important in flail chest because of the almost ubiquitous lung contusion.

Pain management should be addressed early and aggressively.  This may include nerve blocks or epidural anesthesia. There should also be a focus on excellent pulmonary toilet and steroids should be avoided.[6]

Internal pneumatic stabilization has been used successfully to treat complicated cases.[7]  Surgical stabilization may be considered in patients who are getting a thoracotomy for other reasons, in those who fail to wean off a ventilator and in those whose respiratory status continues to decline despite other treatments.

Complications

  • Severe pain
  • Chest wall deformity
  • Dyspnea
  • Loss of exercise endurance

Pearls and Other Issues

As stated above flail chest is associated with significant complications and one should keep a high level of suspicion for this condition.  Flail chest is a clinical diagnosis. It most often occurs when 3 or more ribs are broken in at least 2 places but this injury will not always cause flail chest.

The elderly are particularly at risk for flail chest and suffer more from the complications.  Children rarely develop flail chest because of the elasticity of their chest wall. If a child does develop this condition it is a marker for a significant amount of trauma and should warrant extra care in the evaluation.

Mechanical ventilation should be avoided when possible in favor of non-invasive positive pressure ventilation.

Enhancing Healthcare Team Outcomes

A flail chest represents a major traumatic injury.  Teamwork, good communication, and a coordinated multidisciplinary response are all part of trauma care.  When you consider the main determinants in the management of a flail chest; maintaining adequate ventilation, adequate pain control, and pulmonary toilet, they all require multiple providers working together for a successful outcome.[8][9]

Data indicate that flail chest when associated with other organ injury has a mortality rate of 5-10%. Complications that may occur include ARDs, sepsis, respiratory failure, and pneumonia. Overall, patients who do not require mechanical ventilation have better outcomes compared to patients who are intubated. Even in the absence of other organ injury, the recovery after flail chest is prolonged. Most patients take 6-12 months before they can fully recover and some continue to have chest pain for many years.[10]

 


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Flail Chest - Questions

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A patient was involved in a motor vehicle accident. He presents to the emergency department with severe pain in his right chest. The chest x-ray reveals numerous rib fractures and pulmonary contusion. What one finding on physical examination that would make one suspect flail chest?



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Which of the following is false about flail chest?



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Which statement about a flail chest is not true?



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A patient is brought to the emergency room by ambulance. She was involved in a motor vehicle accident. Close observation shows that her chest expands with expiration and contracts with inspiration. What is the most likely diagnosis?



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Which of the following patients does not need immediate intubation?



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A patient involved in a motor vehicle accident presents with a flail chest. Which of the following is not true about this condition?



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Which of the following is true of flail chest?



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Which is true about flail chest breathing pattern?



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Which of the following is a common cause of flail chest?



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After a MVA, an individual is observed with paradoxical movement of the chest wall while breathing. What is the diagnosis?



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A patient has respiratory distress following a crushing rollover incident during a motor vehicle accident. Which of the following findings is consistent with a flail chest?



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What condition is associated with paradoxical chest movements?



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A 17-year-old is thrown off his motor bike and fall on the pavement on his left chest. In the emergency department, he is found to have 4 successive rib fractures on the left. What abnormality would you see on a physical exam?



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A 30-year-old male is brought to the emergency department by emergency medical services (EMS). He was the driver of a single vehicle motorcycle collision. The patient was wearing a full-face helmet and abrasion protection. EMS personnel reports the patient is complaining of left flank pain and crepitus was noted over the fourth, fifth, and sixth ribs during the physical exam. A paradoxical motion of the chest wall can now be seen. What it the most likely diagnosis?



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Flail Chest - References

References

Bastos R,Calhoon JH,Baisden CE, Flail chest and pulmonary contusion. Seminars in thoracic and cardiovascular surgery. 2008 Spring     [PubMed]
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. The journal of trauma and acute care surgery. 2014 Feb     [PubMed]
Benjamin E,Recinos G,Aiolfi A,Inaba K,Demetriades D, Flail Chest: Less Deadly than Originally Thought. World journal of surgery. 2018 Jun 19     [PubMed]
Poirier WJ,Vacca VM Jr, Flail chest. Nursing. 2013 Dec     [PubMed]
Chardoli M,Hasan-Ghaliaee T,Akbari H,Rahimi-Movaghar V, Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2013     [PubMed]
Nishiumi N,Fujimori S,Katoh N,Iwasaki M,Inokuchi S,Inoue H, Treatment with internal pneumatic stabilization for anterior flail chest. The Tokai journal of experimental and clinical medicine. 2007 Dec 20     [PubMed]
Balci AE,Ozalp K,Duran M,Ayan E,Vuraloğlu S, [Flail chest due to blunt trauma: clinical features and factors affecting prognosis]. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma     [PubMed]
Farquhar J,Almarhabi Y,Slobogean G,Slobogean B,Garraway N,Simons RK,Hameed SM, No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study. Canadian journal of surgery. Journal canadien de chirurgie. 2016 Sep     [PubMed]
Zegg M,Kammerlander C,Schmid S,Roth T,Kammerlander-Knauer U,Gosch M,Luger TJ, Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases. Geriatric orthopaedic surgery     [PubMed]
Udekwu P,Roy S,McIntyre S,Farrell M, Flail Chest: Influence on Length of Stay and Mortality in Blunt Chest Injury. The American surgeon. 2018 Sep 1     [PubMed]

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