History

Fact Explanation
History of blunt trauma to chest A flail chest occurs when a segment of the chest wall loses its bony continuity with the thoracic cage. [1] A flail segment, occurs when three or more consecutive ribs are fractured in at least two places.[2]This flail segment paradoxically moves inward during inspiration and outward during expiration.[5]. There is also an associated pulmonary contusion [1], resulting from blunt trauma. Commonest causes for this presentation are road traffic accidents, falls and assaults. [3] In the elderly even low energy impact such as accidental falls can cause flail segments due to the fragility of bones. Yet, in contrast only 1% of serious impacts in children result in a flail segment due to pliability of the thoracic cage. [4]
Difficulty in breathing The typical paradoxical movement of the flail segment causes decreased lung compliancy and increased lung resistance which when associated with a lung contusion results in an increased breathing effort.[6] In addition there is shunting of air back and forth between the two lungs, which adds to the difficulty in breathing.
Chest pain Rib fractures and the underlying lung contusion results in localized chest wall pain which increases with deep inspiration, coughing and movement.[5]
Hemoptysis This is usually due to the underlying lung contusion.[5]
References
  1. WILLIAMS,Norman S,Christopher JK BULSTRODE and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder Arnold, 2008
  2. BOTTLANG,Michael, William B, LONG Daniel PHELAN,Drew FIELDER and Steven M. MADEY.Surgical stabilization of flail chest injuries with MatrixRIB implants: A prospective observational study. Injury[online] Elsevier. February 2013, vol. 44(2), 232-238 [viewed 6th April 2014]. Available from: DOI: 10.1016/j.injury.2012.08.011
  3. ATHANASSIADI , Kalliopi , Nick THEAKOS, Nikolitsa KALANTZI, and Michalis GERAZOUNIS. Prognostic factors in flail-chest patients. European Journal of Cardio-thoracic Surgery[online]. Elsevier. April 2010. vol. 38. 466—471 [ viewed 7th April 2014] Available from: doi:10.1016/j.ejcts.2010.02.034
  4. ATHANASSIADI, Kalliopi, Michalis GERAZOUNIS and Nikolaos THEAKOS. Management of 150 flail chest injuries: analysis of risk factors affecting outcome. European Journal of Cardio-thoracic Surgery[online]. Elsevier. May 2004. vol 26. 373–376,[ viewed 7th April 2014] Available from: doi:10.1016/j.ejcts.2004.04.011
  5. SCHAIDER, Jeffrey,Stephen R. HAYDEN,Richard WOLFE,Roger M. BARKIN, and Peter ROSEN. Rosen & Barkin's 5-Minute Emergency Medicine Consult. 3rd ed. Philadelphia. Lippincott Williams & Wilkins. 2007
  6. BEMELMAN ,M, M.,POEZE,T. J. BLOKHUIS and L. P. H. LEENEN. Historic overview of treatment techniques for rib fractures and flail chest. European Journal of Trauma and Emergency Surgery[online]. Springerlink. September 2010. vol. 36. 407–415[viewed 5th April 2014]. Available from : DOI 10.1007/s00068-010-0046-5

Examination

Fact Explanation
Paradoxical respitaiton Once a segment of the rib cage becomes sufficiently disconnected from the rest of the thorax, there is independent movement. Consequently, during inspiration the contraction of the diaphragm and other respiratory muscles move the flail segment inwards and conversely during expiration the flail segment moves outwards, giving rise to the term ‘paradoxical respiration’.[1] Practically, the ‘floating segment' is seen less frequently than expected. Patient may even develop this sign later during the hospital stay.[3] The real significance of the detection of paradoxical movement lies in the fact that the severity of trauma necessary to produce a flail segment has implications with respect to damage of underlying intra thoracic structures.[4] Paradoxical motion also disrupts the mechanics of ventilation which leads to a decrease in total lung capacity (TLC) and functional residual capacity (FRC)[4]
Impaired chest wall movements Mechanically impaired chest wall movement due to rib fractures, underlying lung contusion and associated pain on movement.[2]
Splinting respirations Voluntary splinting as a result of pain.[5]
Tachycardia This is due to hypoxia which is a serious consequence of flail chest. This can be caused by a number of factors including ventilation/ perfusion mismatch secondary to contusion, hematoma or alveolar collapse, and inadequate tissue oxygen delivery.[4]
Cyanosis This is due to hypoxia which is a serious consequence of flail chest and can be caused by a number of factors including ventilation/ perfusion mismatch secondary to contusion, hematoma or alveolar collapse, and inadequate tissue oxygen delivery.[4]
Flushed skin, full pulse, tachypnea, dyspnea, extrasystoles, muscle twitches, hand flaps These signs are due to hypercarbia which is consequence of inadequate ventilation and decreased levels of consciousness leading to carbon dioxide retention.[4]
Hypotension This can manifest as a consequence of hypoxia due to respiratory insufficiency[1] or as a sign of shock due to cardiovascular compromise associated with major injuries.[2]
Bony crepitations This is due to fractured ribs that form an independently moving segment of the thoracic wall.[1]
Bony step offs,ecchymosis, edema and associated erythema and tenderness over the chest wall. These signs over the flail chest segment are common at presentation, this is due to chest wall contusion and multiple rib fractures[5]
References
  1. ATHANASSIADI, Kalliopi.,Nick THEAKOS, Nikolitsa KALANTZI, Michalis GERAZOUNIS. Prognostic factors in flail-chest patients. European Journal of Cardio-thoracic Surgery[online]. Elsevier. April 2010. vol. 38. 466—471 [ viewed 7th April 2014] Available from: doi:10.1016/j.ejcts.2010.02.034
  2. WILLIAMS,Norman S.,Christopher J. K. BULSTRODE, and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder arnold, 2008
  3. PAYDAR, Shahram. ,Seyed Mohsen MOUSAVIA,Ali Taheri AKERDIA. Flail chest: are common definition and management protocols still useful?. European Journal of Cardio-Thoracic Surgery[online] Advance Access publication. January 2012, vol 42. 192[viewed 7th April 2014]. Available from: doi:10.1093/ejcts/ezr297
  4. RANASINGHE, Aaron M, Jonathan AJ HYDE,Timothy R GRAHAM. Management of flail chest. Trauma[online] Arnold. October 2001,vol. 3(4). 235–247[viewed 8th April 2014] Available from: doi: 10.1177/146040860100300406
  5. SCHAIDER, Jeffrey, Stephen R. HAYDEN, Richard WOLFE, Roger M. BARKIN, Peter ROSEN. Rosen & Barkin's 5-Minute Emergency Medicine Consult. 3rd ed. Philadelphia. Lippincott Williams & Wilkins. 2007

Differential Diagnoses

Fact Explanation
Chest wall contusion Present with chest pain, erythema, dyspnea, edema over the injured chest wall mimicking flail chest. However there is no paradoxical respiration, bony crepitations, or bony step offs.[1]
Intercostal muscle strain Present with sharp pain while breathing, sore or achy chest, and pain in the ribcage. Intercostal muscle strains are usually acquired from playing sports that involve twisting or turning of the torso. In addition there is no paradoxical respiration, bone step offs or bony crepitations like in flail chest.[1]
Sternal fracture and dislocation Injury is sustained as a result of a road traffic accident,[2] this is not uncommon and may coexists with flail chest. There will be pain , erythema, edema and bony step off over the sternum. However there will no paradoxical movements at the region of sternal fracture.[3]
References
  1. SCHAIDER, Jeffrey,Stephen R. HAYDEN,Richard WOLFE,Roger M. BARKIN, and Peter ROSEN. Rosen & Barkin's 5-Minute Emergency Medicine Consult. 3rd ed. Philadelphia. Lippincott Williams & Wilkins. 2007
  2. SADABA J.R., D OSWAL, and CM MUNSCH. Management of isolated sternal fractures:determining the risk of blunt cardiac injury. Annals of the Royal College of Surgeons of England.[online] Royal college of surgeons. May 2000, vol. 82(3), 162–166[viewed 7th April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503430/
  3. RICHTER ,Torsten and Maximilian RAGALLER.Ventilation in chest trauma. Journal of Emergencies, Trauma and Shock[online] Medknow Publications. April 2011. vol. 4(2). 251-259[ Viewed 6th April 2014] Availble from: doi: 10.4103/0974-2700.82215

Investigations - for Diagnosis

Fact Explanation
Plain chest radiograph The diagnosis is made clinically and is only aided by radiography. [3] This is the single most important investigation for patients sustaining thoracic trauma. An erect film is best and allows for optimal assessment of lung expansion and assessment of free air or blood within the thoracic cavity. The plain chest radiograph is an excellent diagnostic tool, allowing for the diagnosis of rib fractures (either single or multiple), pulmonary contusion, hemothorax, pneumothorax, sternal fracture, widened mediastinum and many other associated injuries.[1] Flail chest diagnosis by chest X-ray sometimes encounters difficulties, especially when a fracture line is located in the anteromedial part of the chest wall at the costochondral junction. In such cases, a chest CT scan may help the diagnosis[2]
Computed tomography (CT) Provides much more sensitive information than a plain radiograph. For excluding rib fractures, a CT is more sensitive than a chest radiograph.[1] Using a CT scan also could help in the diagnosis of lung contusion and in excluding the rupture of the great vessels [2].The use of CT is mainly limited by the fact that the patient has to be transferred to the scanner. This is often not possible in a hemodynamically unstable trauma patient.[1]
Magnetic resonance imaging (MRI) Can aid in diagnosis of flail chest and underlying injuries like lung, hemothorax, alveolar collapse, damage to greater vessels, but usage is limited by cost and availability. In addition the fact that there are long periods of patient isolation, as well as the availability of local radiological expertise.[1]
References
  1. RANASINGHE, Aaron M., Jonathan AJ HYDE.Timothy R GRAHAM. Management of flail chest. Trauma[online] Arnold. October 2001,vol. 3(4). 235–247[viewed 8th April 2014] Available from: doi: 10.1177/146040860100300406
  2. PAYDAR,Shahram, Seyed Mohsen MOUSAVI, and Ali Taheri AKERDI. Flail chest: are common definition and management protocols still useful?. European Journal of Cardio-Thoracic Surgery[online] Advance Access publication. January 2012, vol 42. 192[viewed 7th April 2014]. Available from: doi:10.1093/ejcts/ezr297
  3. WILLIAMS,Norman S.,Christopher J. K. BULSTRODE, and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder arnold, 2008

Investigations - Fitness for Management

Fact Explanation
Full blood count As a routine test in a patient [2] who has sustained major trauma to assess the hemoglobin status and the platelet count.[1]
Electrolytes As a routine investigation[2] to assess complications associated with major injuries like hyperkalemia.[1]
Cross matching Will be required in chest trauma patient as blood transfusion may be required. [1]
Arterial blood gases Arterial blood gases should be assessed in order to detect hypoxaemia, hypercarbia and any abnormality in the acid–base balance.[2]
Electrocardiograph monitoring Electrocardiograph monitoring should be carried out for cardiac arrhythmias or ischaemia.[2]
References
  1. WILLIAMS,Norman S.,Christopher J. K. BULSTRODE, and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder arnold, 2008
  2. RANASINGHE, Aaron M., Jonathan AJ HYDE.Timothy R GRAHAM. Management of flail chest. Trauma[online] Arnold. October 2001,vol. 3(4). 235–247[viewed 8th April 2014] Available from: doi: 10.1177/146040860100300406

Management - General Measures

Fact Explanation
Analgesia It is of paramount importance to administer appropriate and adequate analgesia. Opioid analgesics like morphine(IM 7.5 mg) can be used(caution should be observed as it may cause centrally mediated respiratory depression). Alternatively intercostal nerve block can be performed by infiltrating 0.25–0.5% Bupivicaine. Epidural analgesia is also an excellent way of achieving pain relief.Administration of analgesia allows for improved chest wall excursion and alveolar ventilation, helping to correct the frequently encountered hypoxia.[1]
High flow oxygen Supplemental high flow oxygen should be administered in all patients with flail chest.[1] It increases alveolar ventilation and corrects hypoxia.[2]
Fluid Resuscitation Is required in patients with trauma to prevent shock.Trauma patients with flail chest and/or pulmonary contusion should not be excessively fluid restricted but rather be resuscitated as necessary with isotonic crystalloid or colloid solution to maintain adequate tissue perfusion. Once adequately resuscitated, unnecessary fluid administration should be avoided.[3]
Intercoastal tube insertion Chest tube insertion is considered only in those with pneumothorax or haemothorax. [4] If a chest tube is in situ, intrapleural local analgesia( 20 to 30 mL of 0.5% bupivacaine) can be used.[2]
Nasotrachical aspiration Nasotracheal aspiration and fibreoptic bronchoscopy along with aggressive physiotherapy and humidification of inspired air is performed to clear secretions and to avoid atelectasis that leads to infection.[5]
Fixed Bandage The function of a fixed bandage (adhesive plaster strapping) is to reduce pain and possibly to render assistance in coughing. This method of fixation however, has a disadvantage, as it reduces ventilation of the half of the thorax in question and in so doing promotes the formation of atelectasis and respiratory insufficiency. [6]
Tracheotomy Early tracheostomy (after the third day of hospitalization) is usually performed in order to facilitate the drainage of bronchial secretions.The frequency of bronchial toilet depended on the cooperation of a patient to cough, is assisted by the physiotherapists and is used 2—4 times per day.[5]
Physiotherapy The use of optimal analgesia and aggressive chest physiotherapy should be employed to minimize the likelihood of respiratory failure.[3]
References
  1. RANASINGHE, Aaron M., Jonathan AJ HYDE.Timothy R GRAHAM. Management of flail chest. Trauma[online] Arnold. October 2001,vol. 3(4). 235–247[viewed 8th April 2014] Available from: doi: 10.1177/146040860100300406
  2. WILLIAMS,Norman S.,Christopher J. K. BULSTRODE, and P. Ronan O'CONNELL. Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder arnold, 2008
  3. SIMON B. et al. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery[online] Lippincott Williams & Wilkins. August 2012, vol. 73,( 5). 351-361[Viewed 7th April 2014]. Available from: DOI: 10.1097/TA.0b013e31827019fd
  4. PAYDAR,Shahram, Seyed Mohsen MOUSAVI, and Ali Taheri AKERDI. Flail chest: are common definition and management protocols still useful?. European Journal of Cardio-Thoracic Surgery[online] Advance Access publication. January 2012, vol 42. 192[viewed 7th April 2014]. Available from: doi:10.1093/ejcts/ezr297
  5. ATHANASSIADI, Kalliopi,Nick THEAKOS, Nikolitsa KALANTZI and Michalis GERAZOUNIS. Prognostic factors in flail-chest patients. European Journal of Cardio-thoracic Surgery[online]. Elsevier. April 2010. vol. 38. 466—471 [ viewed 7th April 2014] Available from: doi:10.1016/j.ejcts.2010.02.034
  6. GRANETZNYA, Andreas, Mohamad Abd EL-AALB, ElRady EMAMB, Alaa SHALABYC and Ahmad BOSEILAA. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interactive CardioVascular and Thoracic Surgery[online]. European Association for Cardio-Thoracic Surgery. September 2005. vol. 4. 583–587[Viewed 8th April 2014]. Available from: doi:10.1510/icvts.2005.111807

Management - Specific Treatments

Fact Explanation
Mechanical Ventilation This is the traditional treatment of ‘internally splinting’ the chest until fibrous union of the broken ribs occurs. However this method is reserved for patients developing respiratory failure despite adequate analgesia and oxygen.[1] Modes of ventilatory support include positive end-expiratory pressure (PEEP), and continuous positive airway pressure (CPAP). [2] Indications for ventilation in patients with flail chest are shock, several associated injuries, severe head injuries and respiratory insufficiency usually attributed to an underlying pulmonary disease, such as chronic obstructive pulmonary disease. Obligatory mechanical ventilation is not necessary[3] as this technique requires prolonged time on the ventilator, resulting in secondary chest infections and some times death.[4]
Surgical Fixation Particularly useful in a selected group with isolated or severe chest injury and pulmonary contusion.[1] Method of surgical fixation include: plate fixation (U-plate,anatomical rib plate, etc) and intra medullary stabilization with Kirschner wires, Rehbein plate, rib splint.[4] Recent NICE guidelines recommend surgical stabilization of a flail chest as it can shorten the duration of ventilator support and reduce the morbidity and mortality associated with prolonged mechanical ventilation.[5] Positives of surgical fixation are decreased pain, improved mechanics compared with preoperative performance, rapid separation from mechanical ventilation and excellent return-to-work outcomes.[2] Disadvantages of operative stabilization is that it requires general anesthesia which is inherently risky for trauma patients. The surgical technique involved in stabilization can be difficult, time consuming, and the additional dissection is required in addition implanted foreign bodies can contribute to chronic osseous and soft tissue infections[6]
References
  1. BAILEY, Hamilton., McNeill LOVE, Bailey and Love's Short Practice of Surgery. 25th ed. London: Hodder arnold, 2008
  2. SIMON B. et al. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery[online] Lippincott Williams & Wilkins. August 2012, vol. 73,( 5). 351-361[Viewed 7th April 2014]. Available from: DOI: 10.1097/TA.0b013e31827019fd
  3. ATHANASSIADI, Kalliopi.,Nick THEAKOS, Nikolitsa KALANTZI, Michalis GERAZOUNIS. Prognostic factors in flail-chest patients. European Journal of Cardio-thoracic Surgery[online]. Elsevier. April 2010. vol. 38. 466—471 [ viewed 7th April 2014] Available from: doi:10.1016/j.ejcts.2010.02.034
  4. FITZPATRICK, D. C.,P. J. DENARD,D. PHELAN, W. B. LONG ,S. M. MADEY ,M. BOTTLANG, Operative stabilization of flail chest injuries: review of literature and fixation options. European Journal of Trauma and Emergency Surgery[online]. Springerlink. June 2010. vol. 36.427–433[viewed 5th April 2014]. Available from :DOI 10.1007/s00068-010-0027-8
  5. BOTTLANG M, et al. Surgical stabilization of flail chest injuries with MatrixRIB implants: A prospective observational study. Injury[online] Elsevier. February 2013, vol. 44(2), 232-238 [viewed 6th April 2014]. Available from: DOI: 10.1016/j.injury.2012.08.011
  6. GRANETZNYA, Andreas., Mohamad Abd EL-AALB, ElRady EMAMB, Alaa SHALABYC, Ahmad BOSEILAA. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interactive CardioVascular and Thoracic Surgery[online]. European Association for Cardio-Thoracic Surgery. September 2005. vol. 4. 583–587[Viewed 8th April 2014]. Available from: doi:10.1510/icvts.2005.111807