Flail Chest

Epidemiology

  • Occurs in 20% of cases with blunt chest wall trauma
  • Associated with (in 60% of cases)
    • Pulmonary Contusion
    • Hemothorax
    • Pneumothorax

Etiology

  • Abnormal chest wall movement during breathing due to multiple rib fractures (double fracture of > 3 contiguous ribs or combined sternal and rib fractures): disconnected piece paradoxically moves inward on inspiration
  • Rib fractures may occur due to trauma/ pathologic fracture (associated with multiple myeloma, ect.)

Physiology

  • Ipsilateral Fracture of >3 Consecutive Ribs in Two or More Places with Paradoxical Motion of the Chest Wall During Respiration

Clinical Manifestations

Pulmonary Manifestations

  • xxx

  • Chest Pain/Tightness

  • Dyspnea
  • Acute/Chronic Hypoventilation

Treatment

  • Pain Control: by intercostal nerve block/epidural block
    • Improves VT/VC/cough
  • Stabilization of Chest Wall: stabilized via internal splinting due to positive pressure ventilation (for 3-5 weeks with tracheostomy)
    • Surgical fixation of chest wall may avoid long-term mechanical ventilation
  • Mechanical Ventilation: useful only in the presence of complicating respiratory failure (higher morbidity has been seen in mechanically ventilated cases: AC was worse than SIMV with PEEP)
    • Use of CPAP is probably better than AC and SIMV (due to increased negativity of pleural pressure, chest wall distortion, oxygen cost of breathing, and with AC/ due to increased chest wall distortion with SIMV)
    • Major Determinants (and risk factors for morbidity/mortality) of Need for Mechanical Ventilation: sepsis/ arrhythmias

Surgical Stabilization

  • Indications for Surgical Stabilization
    • Advancing Age
    • Failure to Wean from Mechanical Ventilation
    • Flail Segment with Chest Wall Deformity
    • Need for Mechanical Ventilation
  • Clinical Efficacy
    • Trial of Surgical Stabilization Using Internal Pneumatic Stabilization of Flail Chest (J Trauma, 2002) [MEDLINE]
      • Surgical Stabilization Using Judet Struts has Beneficial Effects with Respect to Less Ventilatory Support, Lower Incidence of Pneumonia, Shorter Trauma ICU Stay, and Decreased Medical Cost as Compared to Internal Fixation
    • Trial of Surgical vs Conservative Treatment of Flail Chest (Interact Cardiovasc Thorac Surg, 2005) [MEDLINE]
      • Surgical Group Had Stabilization of the Chest Wall in 85% of Cases, as Compared to Stabilization in 50% of Conservative Group Patients
      • Surgical Group Had Decreased Ventilator Requirement and Less Restrictive PFT’s at 2 Months

Prognosis

  • 30-40% mortality

References

  • Surgical stabilization of internal pneumatic stabilization?  A prospective randomized study of management of severe flail chest patients.  J Trauma  2002;52:727–732; discussion 732 [MEDLINE]
  • Surgical versus conservative treatment of flail chest.  Evaluation of the pulmonary status.  Interact Cardiovasc Thorac Surg  2005;4:583–587 [MEDLINE]