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Flail Chest


Presentation

Severe pain at the site of injury and breathing problems are the common symptoms experienced by individuals suffering from flail chest. In addition to these, the following are the signs and symptoms of flail chest:

  • Pain in the chest region
  • Dyspnea 
  • Development of bruises and grazes in the affected chest area
  • Telltale marks of seat belt
Splenectomy
  • Exploratory laparotomy followed by splenectomy was performed under general anaesthesia but the patient developed a witnessed cardiac arrest in postoperative period.[ncbi.nlm.nih.gov]
Chest Pain
  • Problem in breathing followed by severe chest pain and respiratory failure are some of the major complications faced by affected individuals.[symptoma.com]
  • A 65-year-old male pedestrian was admitted with severe chest pain and dyspnoea, after being struck by a car. The initial chest radiograph demonstrated multiple right-sided rib fractures and pulmonary contusion.[ncbi.nlm.nih.gov]
  • There were no significant differences in long-term outcomes, such as chest pain or dyspnea.[ncbi.nlm.nih.gov]
  • Two of the symptoms of flail chest are chest pain and shortness of breath.It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently.[en.wikipedia.org]
  • He is alert and responsive, but is having difficulty breathing and extreme chest pain. The emergency response providers rushed him to the hospital to be further evaluated.[study.com]
Thrombosis
  • The incidences of ventilator-associated pneumonia, tracheostomy, sepsis, prolonged ventilation, deep vein thrombosis, pulmonary embolism, wound infection, and postoperative hemorrhage were obtained based on literature review.[ncbi.nlm.nih.gov]
Loss of Initiative
  • Among the 91 rib plates, 15 splints and 605 screws in this study there was no hardware failure and no loss of initial fixation. There was one incidence of wound infection. Implants were removed in one patient after fractures had healed.[ncbi.nlm.nih.gov]

Workup

A chest x-ray is done to analyze the condition of flail chest. The x-ray would also give information about fractures in the neighboring regions. However, x-rays are not competent enough to diagnose all rib fractures. Some of the fractures may not be spotted properly. But, when conditions such as pneumothorax, pulmonary contusion or hemothorax are diagnosed through x-ray examination it indicates that rib fractures are bound to be present.

In addition to x-ray, CT scan is also necessary to be carried out. A thoracic multi-slice computed tomography scan can identify rib fractures quite well compared to plain radiograph [5]. However, such an examination gives little information regarding chest injuries and its use in diagnosing flail chest is limited.

Arterial blood gas measurement is also done to analyze the severity of the condition and also assess the need for mechanical ventilation. Such a kind of test helps in providing useful information during the management phase.

Decreased Vital Capacity
  • Historically, the free-floating flail segment was deemed responsible for an the increased work of breathing with subsequent hypoxemia and decreased vital capacity; this belief was based upon the “Pendelluft” phenomenon, which describes the movement of[jtojournal.com]

Treatment

Management of the condition and putting the patient on 100% oxygen forms the basis of treatment of flail chest. Methods to protect lungs from further damage due to injury should also be employed. It is also necessary to prevent pneumonia which is one of the grave complications of this condition. The following are the several methods employed to treat flail chest.

  • Mechanical ventilation helps decrease the mortality rates and is employed for chest cavity stabilization. However, if such a method is used for longer duration then pneumonia may set in. It is also the method of choice in conditions when the chest cavity is unstable. In some cases, continuous positive airway pressure (CPAP) by mask may lower the rate of mortality in patients and lower incidence of nosocomial pneumonia [6]. Patient in pneumatic stabilizers like CPAP has shortened duration in mechanical ventilation and have significantly lowered morbidity rates [7].
  • Surgery: Candidates for surgery are the ones who require support from mechanical ventilation even after the wounds begin to heal. Surgical stabilization procedures have been found to shorten mechanical ventilator dependence rate [8]. Thoracoscopy assisted minimally invasive surgery for flail chest stabilization has proven to be very promising in terms of minimal blood loss, lesser trauma and shortened hospital stay [9].
  • Pain medications are administered to relieve the severe pain at the site of injury. Higher doses of such medications have been found to produce side effects. However, lower doses are helpful. Studies have shown that a good pain medication coverage and adequate pulmonary toilet produces better outcome in patient compared to those in mechanical ventilation [10].

Prognosis

Prognosis of the condition largely depends on the extent of injury to the rib cage, age of patient, and volume of blood loss [3]. After discharge from the hospital, the patient is generally called for a 12 week outpatient program. In such a program, the patient is taught physiotherapy to improve mobility. After few weeks, the patient will be made to practice walking and posture correction exercises will also be taught.

Complications

If the condition of the patient is not stabilized on time, then it can give rise to various life threatening conditions. Problem in breathing followed by severe chest pain and respiratory failure are some of the major complications faced by affected individuals [4]. The sharp edges of the broken ribs can even puncture the pleural sac as well as the lungs leading to pneumothorax. In serious conditions, if prompt treatment is not initiated it can even cause death.

Etiology

Serious accidents and trauma continue to be the major causative factors. It has been estimated that about 76% of vehicle accidents contribute to flail chest. The elderly population is severely affected due to their weak bones which are frequently prone to fractures.

Children can even fall prey to flail chest either due to trauma or metabolic bone diseases such as osteogenesis imperfecta. Flail chest continues to be a leading cause of mortality and morbidity among trauma patients in both young and old [1].

Epidemiology

It has been estimated that about 1 in every 13 patients who are admitted to hospital for trauma related cases suffer flail chest. Between the periods 1998 – 2003 as high as 262 cases of flail chest has been recorded. The actual numbers can be much higher that what is reported. The diagnosis of flail chest in neonates is suggestive of child abuse in most cases [2].

Sex distribution
Age distribution

Pathophysiology

For the process of breathing to take place under normal conditions, it is required that muscle surrounding the rib cage and diaphragm move in order to expand the chest cavity. Such an activity creates vacuum which gets filled when air is inhaled. In conditions of flail chest these sequence of events do not occur as a result of which air is not drawn inside the lungs causing difficulty in breathing.

Flail chest is a condition wherein sections of broken rib cage interfere with normal movements of the chest. Therefore, it is important to immediately stabilize the condition of patients who have suffered blunt trauma. Blunt trauma not only causes flail chest but also is responsible for serious damage to the lungs.

Prevention

Flail chest cannot be prevented; however, early initiation of treatment and proper management can prevent development of complications.

Summary

Flail chest is a serious condition wherein a segment of the rib cage separates from the chest wall as a result of severe injury. Due to this, the affected area is not able to contribute to lung expansion. Such a condition can be life threatening and can pose serious health risks for the individual. If prompt treatment is not initiated it can cause lifelong disability.

Patient Information

Definition

Flail chest is a condition caused due to blunt trauma wherein a segment of the rib cage gets separated from the chest wall. It is a life threatening condition that can lead to complications if treatment is not initiated on time.

Cause

Vehicle accidents and trauma are the major cause of chest injuries that can lead to flail chest.

Symptoms

Symptoms of flail chest include difficulty in breathing, severe chest pain and dyspnea.

Diagnosis

An x- ray of the chest is helpful in diagnosing the condition of flail chest. In addition to x-rays, a test known as arterial gas measurement is done which is helpful in analyzing the need for mechanical ventilation. Such a test is also helpful during the management of the disease condition.

Treatment

The patient is put on mechanical ventilator for stabilization of the chest cavity. Surgical procedures may be required depending upon the condition of the patients. It is often a treatment of choice when patients continue to depend on mechanical ventilator even when the wounds begin to heal. Medications to relieve pain are administered to reduce the discomfort caused due to injuries.

References

Article

  1. Kilic D, Findikcioglu A, Akin S, Akay TH, Kupeli E, Aribogan A, et al. Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location. Thorac Cardiovasc Surg. Feb 2011; 59(1):45-8.
  2. Gipson CL, Tobias JD. Flail chest in a neonate resulting from nonaccidental trauma. South Med J. May 2006; 99(5):536-8.
  3. Freedland M, Wilson RF, Bender JS, Levison MA. The management of flail chest injury: factors affecting outcome. J Trauma. Dec 1990; 30(12):1460-8.
  4. Beal SL, Oreskovich MR. Long-term disability associated with flail chest injury. Am J Surg. Sep 1985; 150(3):324-6.
  5. Sangster GP, Gonzalez-Beicos A, Carbo AI,et al. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol. Oct 2007; 14(5):297-310.
  6. Gunduz M, Unlugenc H, Ozalevli M, Inanoglu K, Akman H. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J. May 2005; 22(5):325-9.
  7. Nishiumi N, Fujimori S, Katoh N, Iwasaki M, Inokuchi S, Inoue H. Treatment with internal pneumatic stabilization for anterior flail chest. Tokai J Exp Clin Med. 2007; 32(4):126-30 (ISSN: 2185-2243)
  8. Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: an underused procedure? Am Surg. Jun 2007; 73(6):591-6; discussion 596-7.
  9. Ke S, Duan H, Cai Y, Kang J, Feng Z. Thoracoscopy-assisted minimally invasive surgical stabilization of the anterolateral flail chest using Nuss bars.Ann Thorac Surg. 2014; 97(6):2179-82
  10. Trinkle JK, Richardson JD, Franz JL, et al. Management of flail chest without mechanical ventilation. Ann Thorac Surg. Apr 1975; 19(4):355-63.

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Last updated: 2019-07-11 22:26