Flail Chest

Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, tachypnea, hypoxia, and paradoxical chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall movement. Management includes oxygen supplementation, pain control, ventilation if respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure presents, and possible surgery. Severe traumatic intrathoracic injuries, such as pulmonary contusions, pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax, and cardiac injuries, are often seen in conjunction with flail chest.

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Overview

Definition

Flail chest is defined as 3 or more contiguous ribs that are fractured in 2 or more different locations, resulting in a freely moving segment of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall that is discontinuous from the rest of the thoracic cage.

Epidemtiology

  • Seen in 7% of all chest trauma
  • 60% of cases are associated with other injury (most commonly hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax, pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax, or head trauma Head trauma Head trauma occurs when external forces are directed to the skull and brain structures, resulting in damage to the skull, brain, and intracranial structures. Head injuries can be classified as open (penetrating) or closed (blunt), and primary (from the initial trauma) or secondary (indirect brain injury), and range from mild to severe and life-threatening. Head Trauma)
  • Risk factors:
    • Male gender
    • Intoxication

Etiology

  • Motor vehicle accidents (approximately 75%)
  • Falls, particularly in the elderly (approximately 15%)
  • Blunt trauma

Pathophysiology

  • Significant traumatic force is applied to the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall, creating multiple rib fractures.
  • Disruption of structural components of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall (e.g., bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage, muscle) leads to free-floating segment of chest.
  • During respiratory cycle, segments move paradoxically:
    • During inspiration, segment moves inward (instead of outward) due to negative intrathoracic pressure → leading to ineffective ventilation → hypoxia
    • During expiration, segment moves outward (instead of inward) due to positive intrathoracic pressure.
  • Mechanical limitation of chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall motion affects the size of changes in thoracic volume and patient-generated tidal volume → respiratory insufficiency
Flail chest

Flail chest
Multiple rib fractures and disruption of structural components of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall (i.e., bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage, muscle) leading to a free-floating segment of the chest. The separated segment moves opposite to the rest of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall during the breath cycle (paradoxical movement), creating ineffective ventilation.

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Diagnosis

Flail chest is a clinical diagnosis (confirmed by imaging) made by identifying the paradoxical movement of a chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall segment when the patient is spontaneously breathing. 

Symptoms

  • Severe chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain
  • Shortness of breath

Signs

  • Paradoxical chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall movement (disappears after intubation with positive pressure ventilation)
  • Respiratory distress
  • Tachypnea
  • Hypoxemia
  • ↓ breath sounds during auscultation
  • Chest wall deformity and/or ecchymosis

Imaging

  • Chest X-ray (less sensitive, but usually sufficient to confirm clinical suspicion) 
  • CT scan (most sensitive)
  • Findings include:
    • Multiple adjacent rib fractures
    • Fractures 1 + location

Management and Complications

Management

  • Oxygen supplementation
  • Adequate pain control:
    • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain impairs respiratory effort → hypoventilation, atelectasis Atelectasis Atelectasis is the partial or complete collapse of a part of the lung. Atelectasis is almost always a secondary phenomenon from conditions causing bronchial obstruction, external compression, surfactant deficiency, or scarring. Atelectasis, pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia, and respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure
    • Epidural infusion: preferred method for extensive rib fractures
    • Intercostal nerve blocks also used
  • Intubation with mechanical positive pressure ventilation if respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure presents (improves ventilation and ↓ paradoxical movement)
  • Chest physiotherapy
  • Monitor with serial chest X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays, arterial blood gasses, pulse oximetry, and capnography (to detect early signs of respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure).
  • Treat associated conditions.
  • Surgical fixation of ribs (not often used)

Complications

Pneumothorax:

  • Collapsed lung
  • Signs and symptoms:
    • ↓ breath sounds on ipsilateral chest
    • Hyperresonance on percussion
  • Management:
    • Supplemental oxygen
    • Possible chest tube (large pneumothoraces)

Tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax:

  • Pneumothorax that is under pressure
  • Signs and symptoms:
    • Tracheal deviation → mediastinal shift away from tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
    • Distended neck veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
  • Management: emergent needle decompression → chest tube placement

Hemothorax:

  • Blood in chest cavity leading to lung compression
  • Signs and symptoms:
    • ↓ breath sounds
    • Dullness on percussion
    • Tracheal deviation, mediastinal shift
    • ↓ tactile vocal fremitus
    • ↓ jugular venous pressure
  • Management: 
    • Chest tube
    • Thoracotomy (if > 1.5 L blood drained directly or continuous high output)

Pulmonary contusion:

  • Bruised lung
  • Signs and symptoms:
    • Onset < 24 hours after blunt thoracic trauma
    • Tachypnea, tachycardia, hypoxemia
    • Imaging shows patchy alveolar infiltrates not restricted by anatomical borders (non-lobar pacification).
  • Management:
    • Oxygen
    • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain control, chest physiotherapy, mechanical ventilation in severe cases

Acute respiratory distress syndrome Acute Respiratory Distress Syndrome Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome ( ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome):

  • Diffuse inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of lung parenchyma due to different etiologies
    • Sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock
    • Acute pancreatitis Acute pancreatitis Acute pancreatitis is an inflammatory disease of the pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain radiating to the back. Acute Pancreatitis
    • Massive transfusion
    • Trauma
  • Signs and symptoms:
    • New worsening respiratory condition, usually after 24 hours of insult 
    • Imaging shows bilateral, patchy alveolar infiltrates ( pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema).
    • Hypoxemia with PaO2/FiO2 ratio < 300 mm Hg
  • Management: mechanical ventilation

Pneumonia:

  • Infection of lung parenchyma often due to hypoventilation, usually polymicrobial
  • Signs and symptoms:
    • Hypoxia
    • Tachypnea
    • Fever
  • Management: broad-spectrum antibiotics

Blunt cardiac contusion:

  • Injury to cardiac muscle due to trauma often associated with sternal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Signs and symptoms:
    • New electrocardiogram Electrocardiogram An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) ( ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG)) findings (arrhythmias)
    • ↑ cardiac enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes (troponin) 
  • Management: Treat complications (arrhythmias).

Differential Diagnosis

  • Pulmonary contusion: parenchymal lung injury and accumulation of blood within the lung tissue after chest trauma. Patients present with tachypnea, tachycardia, and hypoxemia. Imaging shows patchy alveolar infiltrates not restricted by anatomical borders. Management involves oxygen administration, pain control, chest physiotherapy, and mechanical ventilation in severe cases.
  • Pneumothorax: abnormal collection of air in pleural space due to laceration of lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs. Types of pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax include simple (spontaneous) and tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax. Exam findings include decreased breath sounds, hyperresonance on percussion, and tracheal deviation away from tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax. Treatment includes needle decompression and chest tube placement.
  • Hemothorax: collection of blood in pleural cavity. Usually occurs following lung laceration or damage to intercostal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries. Patients present with shortness of breath and chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain. Exam findings include tachycardia, tracheal deviation, and dullness on percussion. Management is with chest tube insertion and thoracotomy if > 1.5 L of blood directly evacuated or collecting of > 1 L of blood over 4 hours.
  • ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome: severe inflammatory reaction of the lung that is characterized by pulmonary infiltrates due to alveolar fluid accumulation, not in cardiogenic etiology. Patients present in respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure. Chest X-ray shows diffuse bilateral lung infiltrates. Management depends mainly on treating underlying etiology and maintaining adequate oxygenation, which usually requires mechanical ventilation.

References

  1. Legome, E. (2020). Initial evaluation and management of blunt thoracic trauma in adults. UpToDate. Retrieved December 12, 2020, from https://www.uptodate.com/contents/initial-evaluation-and-management-of-blunt-thoracic-trauma-in-adults?search=Flail%20chest&source=search_result&selectedTitle=1~30&usage_type=default&display_rank=1
  2. Sarani, B. (2020). Inpatient management of traumatic rib fractures. UpToDate. Retrieved December 12, 2020, from https://www.uptodate.com/contents/inpatient-management-of-traumatic-rib-fractures?search=Flail%20chest&source=search_result&selectedTitle=2~30&usage_type=default&display_rank=2 
  3. Liman ST, Kuzucu A, Tastepe AI, et al. (2003). Chest injury due to blunt trauma. Eur J Cardiothorac Surg, 2003(23), 374.
  4. Kilic D, Findikcioglu A, Akin S, et al. (2011). Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location. Thorac Cardiovasc Surg. 59(1), 45–8.
  5. Sangster GP, Gonzalez-Beicos A, Carbo AI, et al. (2007) Blunt traumatic injuries of the lung parenchyma, pleura Pleura The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol. 14(5), 297–310. 
  6. Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. (2014). Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 276(2), 462–8.

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