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Flail Chest
General Considerations
- Segment of thoracic cage is separated from remainder of chest wall by significant blunt chest trauma
- Relatively uncommon, but potentially life-threatening
- Definition varies from two fractures per rib for two contiguous ribs to two fractures per rib for three contiguous ribs
- Sternum may also be involved with ribs on both sides of chest
- Severity of underlying lung and cardiac injury are clinically more important than fractures themselves
Clinical Findings
- Chest wall bruising
- Pain on inspiration
- Crepitus
- Flail segment moves paradoxically with respiration
- Moves inward on inspiration and outward on expiration
Imaging Findings
- Chest radiographs are invariably performed first
- Two or more fractures in two or three or more contiguous ribs
- Chest x-rays tend to underestimate the number of fractures
- Chest CT is also invariably performed, and may show
- Rib fractures
- Pulmonary contusion (almost always)
- Airspace disease representing hemorrhage into the alveoli usually subjacent to the point of impact
- Pulmonary laceration
- Lacerations in the lung may be blood-containing, air-containing, or both
- Frequently masked by the surrounding pulmonary contusion
- Pneumothorax (very common)
- Since the severity of the injury means a supine radiograph will be performed, pneumothoraces may only be seen on chest CT
- Hemothorax (common)
- Pneumomediastinum
- Subcutaneous emphysema
- Mediastinal hemorrhage
- Aortic injuries
Treatment
- Analgesia, including intercostal nerve blocks
- Ventilation and oxygenation
- Patients who do not need mechanical ventilation do better than those who do
Complications
- Almost always accompanied by pulmonary contusion
- May have long-term disability
Prognosis
- Up to 10% mortality if patients reach hospital alive
Flail Chest. Radiograph demonstrates multiple rib fractures (black arrows) with
some ribs fractured in two or more places. There is also a pulmonary contusion (red arrow) and subcutaneous emphysema (white arrow)
For this same photo without the arrows, click here
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eMedicine: Flail Chest. Bjerke, H
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