Flail chest

Background

• Due to segmental 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)

Evaluation

• Paradoxical inward movement of involved portion during inspiration

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragm injury
  • Hemothorax
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac contusion
  • Cardiac trauma
  • Cardiac tamponade
  • Commotio cordis
    • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Flail chest
  • Rib fracture
  • Scapula fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Traumatic asphyxia

Management

• Otherwise healthy patients with mild-moderate flail chest may be managed without positive pressure ventilation
• Analgesia
• 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

See Also

• Thoracic Trauma
• Traumatic Pneumothorax
• Spontaneous Pneumothorax
• Tension Pneumothorax

Authors

Ross Donaldson, Jordan Swartz, Claire, Neil Young, Daniel Ostermayer