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3 -Flail Chest

3 -Flail Chest

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Published by: Krishna Chaitanya Govardhanam on Aug 04, 2010
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11/22/2012

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Flail chest
Definition
A
flail chest
is a life-threatening medical condition that occurs when a segmentof thechestwall bones breaks under extreme stress and becomes detached fromthe rest of the chest wall, often associated with underlying pulmonary injury andis most commonly seen in cases of significant blunt trauma. It occurs whenmultiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently that gives an appearance of 
stove inchest.
The number of ribs that must be broken varies by differing definitions: somesources say at least two adjacent ribs are broken in at least two places, somerequire three or more ribs in two or more places.The flail segment moves in the opposite direction as the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs,it goes in while the rest of the chest is moving out, and vice versa. This so-called
"paradoxical motion"
can increase the work and pain involved in breathing.Studies have found that up to half of people with flail chest die. In emergencydepartment presentations, approximately 30% of patients with extensivethoracic trauma have a flail chest. Flail chest is invariably accompanied by pulmonary contusion, a bruise of the lung tissue that can interfere with bloodoxygenation. Often, it is the contusion, not the flail segment, that is the maincause of respiratory failure in patients with both injuries.
Causes
Flail chest is a serious, life-threatening chest injury.
This typically occurs when three or more adjacent ribs are fractured intwo or more places.
Ribs fractured proximally in conjunction with disarticulation of costochondral cartilagesdistally. For the condition to occur, generallythere must be a significant force applied over a large surface of the thoraxto create the multiple anterior and posterior rib fractures.
Rollover and crushing injuries most commonly break ribs at only one point– for flail chest to occur a significant impact is required, breakingthe ribs in two or more places.
 
Presentation
Pain when taking a deep breath
Pain that gets worse when pressed on the injured area, or when bendingor twisting the body
Very tender spot in the rib area that occurs after trauma or is present withdeep breaths or hinders the breathing
An experience of pressure, fullness or a squeezing pain in thecentre of thechest that lasts for more than a few minutes
Pain that extends beyond the chest to the shoulder or arm, andincreasingepisodes of chest pain, get medical attention immediately. These symptomsmay indicate a heart attack.
The characteristic paradoxical motion of the flail segment occurs due to pressure changes associated with respiration that the rib cage normallyresists:
During normal inspiration, the diaphragm contracts and intercostalmuscles push the rib cage out. Pressure in the thorax decreases belowatmospheric pressure, and air rushes in through the trachea. However, aflail segment will not resist the decreased pressure and will appear to push in while the rest of the rib cage expands.
During normal expiration, the diaphragm and intercostal muscles relax,allowing the abdominal organs to push air upwards and out of the thorax.However, a flail segment will also be pushed out while the rest of the ribcage contracts.

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