emedicine.medscape.com

Flail Chest 
Updated: Dec 16, 2021
Author: H Scott Bjerke, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF 

Overview

Background
Severe blunt injury to the chest continues to be one of the leading causes of morbidity and mortality in both young and old
trauma victims.[1] Flail chest is one of the worst subset of these injuries and is likely the most common serious injury to the
thorax seen by clinicians.

See the image below.

Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If
multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black
lines) may result.

Multiple care patterns and treatment modalities have emerged, many based on anecdotal clinical observation and evidence.
Within the last 20 years, more rigorous scientific methods have been applied to the problem of flail chest, in both the clinical
setting and laboratory. More advanced radiologic work-up with multislice computed tomography (MSCT) scanners is
increasing the frequency of diagnosis of this problem. This article reviews the most salient data of the recent literature and
discusses some of the diagnostic and treatment options that are now available in the treatment of flail chest.

History of the Procedure

Flail chest has been observed and reported for many years in the medical and emergency medical science literature. The
relatively infrequent occurrence in any one geographic location made large-scale treatment trials difficult, if not impossible.
The 1958 Emergency War Surgery NATO Handbook mentions flail chest twice, once as a potential cause of failed
resuscitation and once to note field treatment. This field treatment consisted of "firm strapping" of the affected area to
prevent the flail-like motion. By 1988, the Emergency War Surgery NATO Handbook (second US revision) mentions flail
chest only once, without noting treatment recommendations and broaches the concept that the underlying lung injury—not
the flail segment itself—is the major determinant of morbidity.

Older surgical textbooks contain photographs depicting the use of towel clips placed around rib segments and placed on
traction to stabilize the rib cage. With the advent of intensive care units (ICUs), older textbooks often advocated orotracheal
intubation with positive pressure ventilation to pneumatically stent the ribcage. However, this treatment was subsequently
proven to increase morbidity and mortality in patients who did not need intubation for other reasons. Although many patients
with flail chest require intubation, advances in the knowledge of physiology and chest wall mechanics, as well as the
potential morbidity of prolonged mechanical ventilation, have reestablished that it is the severity of the underlying lung injury
and not the flail segment that causes a problem.

Problem
Flail chest is traditionally described as the paradoxical movement of a segment of chest wall caused by fractures of 3 or
more ribs anteriorly and posteriorly within each rib. Variations include posterior flail segments, anterior flail segments, and
flail including the sternum with ribs on both sides of the thoracic cage fractured.

Flail chest is foremost a clinical finding and observation that is often accompanied by physiologic derangements, which are
sometimes globally lumped into the diagnosis. The lumping of signs and symptoms has resulted in confusion regarding both
the treatment strategies and the overall importance of the clinical finding.

Mechanically, flail chest generally requires a significant force diffused over a large area (ie, the thorax) to create multiple
anterior and posterior rib fractures. If the structural components (ie, the ribs) are weakened for any reason (eg,
osteoporosis), then much lower force may be required. The actual motion of the flail segment is usually limited by the
surrounding structural components, the intercostals, and the surrounding musculature. This mechanical limitation of motion
affects the actual size of the changes in thoracic volume and patient-generated tidal volume. Underlying pulmonary or
cardiac disease determines the physiologic perturbations to respiration caused by the flail segment.

Even more important is the amount of injury to the underlying structures, specifically the lungs and heart. Respiratory
insufficiency in flail chest is much more likely to be a result of the underlying severity of pulmonary contusion and ventilation
perfusion mismatch than the actual structural defect to the chest wall. Thus, the adept surgeon usually looks past the
structural deformity and determines the physiologic compromise caused by the pain of the rib fractures, the tidal volume
changes, and the underlying pulmonary and cardiac injury.

See the image below.

Multiple left rib fractures, pulmonary contusion, and hemothorax in an elderly man after a motor vehicle accident.
Epidemiology
Frequency

The exact incidence of flail chest is not precisely known. The Major Trauma Outcome Study of more than 80,000 patients
documented about 75 patients with flail chest injuries.[2] From 1971 to 1982, Landercasper et al documented 62 consecutive
patients.[3] From 1981 to 1987, the Detroit Receiving Hospital noted 57 patients with flail chest. In 1995, Ahmed and
Mohyuddin documented 64 cases over a 10-year period.[4] Borman evaluated data from the Israel National Trauma Registry
noting 262 fail chest diagnoses of 11,966 chest injuries (118,211 total patients) examined between 1998 and 2003.[5]

The true incidence of flail chest may be even higher than those noted above, based on newer diagnostic modalities and
procedures including MSCT scanning of the chest. Based on these articles, an average American College of Surgeons
(ACS)-verified level 1 or level 2 trauma center will see about 1-2 cases per month. The incidence of flail chest at nontrauma
center facilities is currently unknown. Flail chest in a neonate has been reported as a potential marker of child abuse.[6]

Etiology
Flail chest requires significant blunt force trauma to the torso to fracture the ribs in multiple areas. Such trauma may be
caused by motor vehicle accidents, falls, and assaults in younger, healthy patients. Flail chest is an indicator of significant
kinetic force to the chest wall and rib cage, but it may also may occur with lesser trauma in persons with underlying
pathology, including osteoporosis, total sternectomy, and multiple myeloma, as well as individuals with congenital absence of
the sternum.

Pathophysiology
In an adult, a transfer of significant kinetic energy in blunt trauma to the rib cage or a crushing rollover injury is the most
frequent cause of flail chest. In children, who have a more compliant chest wall, flail chest is observed with lower frequency
than injury to the underlying structures, including the lungs, heart, and mediastinal structures.

Presentation
Flail chest is a clinical anatomic diagnosis noted in blunt trauma patients with paradoxical or reverse motion of a chest wall
segment while spontaneously breathing. This clinical finding disappears after intubation with positive pressure ventilation,
which occasionally results in a delayed diagnosis of the condition.

The strict definition of 3 ribs broken in 2 or more places can be confirmed only by x-ray, but the inherent structural stability of
the chest wall due to the ribs and intercostal muscles usually does not show abnormal or paradoxical motion without 3 or
more ribs involved. Patients may demonstrate only the paradoxical chest wall motion, and they may have minimal to
incapacitating respiratory insufficiency, although these individuals usually show some tachypnea with a notable decrease in
resting tidal volume due to fracture pain. The degree of respiratory insufficiency is typically related to the underlying lung
injury, rather than the chest wall abnormality.

Relevant Anatomy
The chest wall is inherently stable, with 12 ribs attaching posteriorly to the spinal column and anteriorly to the sternum.
Intercostal muscles with fascial attachments, coupled with other muscle groups, including the trapezius and the serratus
groups, add further strength to the bony cage around the thoracic organs. The arch design of the ribs allows for some
flexing, more so in children than adults, which can absorb small amounts of blunt kinetic energy. Crush or rollover injuries,
especially with heavy objects or significant deceleration injury commonly breaks a rib in 1 position, but only a significant
impact breaks a rib in 2 or more positions.

See the image below.

Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If
multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black
lines) may result.

Outcome and Prognosis

Overall, patients with flail chest have a 5-10% reported mortality if they reach the hospital alive. Patients who do not need
mechanical ventilation do better statistically, and overall mortality seems to increase with increasing injury severity scores
(ISS), age, and number of total rib fractures.

Few long-term follow-up studies regarding flail chest are available. In the absence of concomitant lethal injuries, Freedland
et al reported adverse outcomes to be more likely with more severe associated injuries noted by ISS scoring, excessive
blood loss and transfusion requirements, bilateral flail chest, and patient age older than 50 years.[7]  A report by Albaugh
and associates in New Jersey noted flail chest mortality increased 132% with each decade of life,[8]  but another report by
Athanassiadi and associates found no correlation with age.[9]  Both studies noted increasing mortality with increasing ISS.
As previously noted, some reports suggest a high rate of disability after flail chest; however, most patients do well and return
to normal function after 6-12 months.

Dehghan et al conducted a retrospective analysis of data from the National Trauma Data Bank of injury patterns,
management, and clinical outcomes for 3,467 patients in whom flail chest was identified from 2007 to 2009. The mean age
of the patients was 52 years; 77.5% were male. Treatment practices included use of epidural catheters (8%); surgical fixation
of the chest wall (0.7%); and mechanical ventilation (59%). Complications included pneumonia (21%); adult respiratory
distress syndrome (14%); sepsis (7%); and death (16%). More than 99% of patients were treated nonoperatively, and a
small proportion (8%) received aggressive pain management with epidural catheters. The authors concluded that alternative
methods of treatment, including more consistent use of epidural catheters for pain and surgical fixation, should be
investigated.[10]

A study by Daskal et al included 407 patients with blunt trauma who had at least three rib fractures and were hospitalized at
a level 2 trauma center. Both pneumothorax and hemothorax were more common among the 79 patients in the study with
flail chest.[11]

Complications

Reports in the medical literature note a high level of long-term disability in patients sustaining flail chest. Beal and
Oreskovich reported a 22% disability rate with over 63% having long-term problems, including persistent chest wall pain,
deformity, and dyspnea on exertion.[12]  Kishikawa et al, however, noted resolution of altered pulmonary function within 6
months, even with chest wall deformity still present.[13]

 
Workup

Laboratory Studies
Laboratory studies are helpful in the management of flail chest and its associated physiologic abnormalities, but no single
test confirms the diagnosis of the condition. Chest x-rays occasionally demonstrate the fractured ribs, but may not show all
fracture sites, and underlying pulmonary contusion may be initially masked by hypovolemia. See the image below.

Multiple left rib fractures, pulmonary contusion, and hemothorax in an elderly man after a motor vehicle accident.

Arterial blood gas (ABG) measurements show the severity of the hypoventilation created by both the pulmonary contusion
and the pain of the rib fractures, and are helpful at baseline to assess the need for mechanical ventilation and to follow the
patient during management.

Imaging Studies
Portable anteroposterior (AP) or more formal posteroanterior (PA) chest radiography is the simplest and easiest radiologic
test to perform to delineate the number of fractured ribs. Plain films can miss rib fractures and pneumothoraces however.
The flail chest diagnosis is a clinical observation that is supported by the radiologic identification of the fracture pattern.

Saggital and coronal reformats of a thoracic MSCT scan also identifies rib fractures quite well.[14] Because many of these
patients sustain concomitant internal thoracic injury, thoracic CT scanning images may be available for reasons other than
rib fracture identification (ie, evaluation of an abnormal mediastinal contour). Three-dimensional (3-D) reconstruction of
helical CT images is also possible though not widely available. See the image below.
Axial computed tomography image of the chest in a patient with left posterior rib fractures. The left pneumothorax (white
arrows) is associated with a displaced posterior left rib fracture (black arrow). Secondary effects on the left lung include a
pulmonary contusion and volume loss.

Treatment

Medical Therapy
Internal pneumatic stabilization for flail chest was popularized in the 1950s, but this treatment has subsequently been shown
to be unnecessary in most patients without respiratory compromise. In a mid-1970s report, Trinkle et al provided compelling
evidence that many patients fared better with adequate pain control and pulmonary toilet (including medical management of
their pulmonary injury) than those placed on mechanical ventilation.[15] This remains the standard today. Mechanical
ventilation is reserved for patients with persistent respiratory insufficiency or failure after adequate pain control or when
complications related to excessive narcotic use occur. Patient-controlled analgesia (PCA) machines, oral pain medications,
and indwelling epidural catheters form the mainstay of current treatment.

Two recent clinical reports, one from Turkey (prospective)[16] and one from Japan (retrospective),[17] showed that
continuous positive airway pressure (CPAP) by mask may decrease mortality and nosocomial pneumonia in the ICU, but
CPAP by mask does not appear to change the length of ICU stay.

Surgical Therapy
Surgical stabilization of the chest was rarely considered necessary in the past, but increasing numbers of reports of positive
outcomes in more severe cases are now available in the world literature. Both external (lower efficacy) and internal
stabilization have been advocated, usually in reports from outside the United States. As previously noted in traumatic
causes, however, severity of respiratory failure is less a result of either the paradoxical motion of the chest wall (tidal volume
abnormalities) or chest wall instability. Accordingly, surgical stabilization is still not routinely performed, although many
reports show a benefit in decreasing mechanical ventilator days, long-term outcome, and overall lower cost of hospitalization
in select patients with severe flail chest.[18, 19, 20, 21, 22]

In general, operative fixation is most commonly performed in patients requiring a thoracotomy for other reasons or in cases
of gross chest wall deformity. Flail chest from multiple myeloma, sternal absence, or total sternectomy more frequently
responds well to surgical fixation. Underlying pulmonary injury with respiratory insufficiency resulting from changes in tidal
volume and minute ventilation in these patients is rare.

A Cochrane Review evaluated the effectiveness and safety of surgical stabilization compared with clinical management for
people with flail chest. The study found some evidence from three small studies that showed surgical treatment was
preferable to nonsurgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical
ventilation, and length of ICU stay. Further studies are needed to confirm these results.[23]

In a retrospective study involving 21 patients with flail chest who were admitted to a level I trauma center between
September 2009 and June 2010, Doben et al examined the effectiveness of surgical rib fixation for patients in whom
standard therapy had failed. Standard therapy consisted of pain control, aggressive pulmonary hygiene, positive pressure
therapy with an acapella device, and frequent chest therapy (chest wall percussion, deep breathing, and coughing
exercises). The surgical rib fixation surgeries were performed via a standard anterolateral or posterolateral muscle-sparing
thoracotomy incision; ribs were reduced and internally fixated through use of osteosyntheses plates and intramedullary nails.
Surgical rib fixation resulted in a significant decrease in ventilator days (4.5 vs 16.0), and the authors concluded that the
technique may represent a means to decrease morbidity in patients with flail chest whose pulmonary status is declining.[24]

In a retrospective meta-analysis that included 11 studies with a total of 753 patients with flail chest, Slobogean et al
compared the results of surgical fixation with those of nonoperative treatment. Surgical fixation resulted in better outcomes
for all pooled analyses, including substantial decreases in ventilator days (mean, 8 days; 95% CI, 5 - 10 days) and the odds
of developing pneumonia (odds ratio [OR] 0.2; 95% CI, 0.11 - 0.32). Additional benefits included decreased ICU days (mean,
5 days, 95% CI, 2 - 8 days), mortality (OR, 0.31; 95% CI 0.20 - 0.48), septicemia (OR, 0.36; 95% CI, 0.19 - 0.71),
tracheostomy (OR, 0.06; 95% CI, 0.02 - 0.20), and chest deformity (OR 0.11; 95% CI, 0.02 - 0.60). The authors concluded
that surgical fixation offers substantial clinical benefits over nonopoerative treatment.[25]

Preoperative Details
Assessment of the severity of underlying pulmonary contusion versus chest wall instability should direct the need for surgical
fixation. Preoperatively, a double-lumen endotracheal tube should be considered in patients with flail chest undergoing
fixation.

Intraoperative Details
The current literature suggests that both ends of a fractured rib must be stabilized for operative intervention to be most
effective. Judet struts, Kirschner (K-) wires, and even prosthetic mesh secured with methylmethacrylate techniques have
been described in the literature, but no large randomized prospective trial has been completed to compare the techniques at
this time. Because of the increasing interest in surgical stabilization, there are multiple commercially available fixation
devices within the last few years.

Postoperative Details
Routine postthoracotomy care with ICU or surgical step-down level observation and close monitoring of respiratory
parameters is crucial.

Follow-up
Follow-up chest x-rays and pulmonary function tests determine the resolution of underlying pulmonary pathology and any
possible long-term disability as a result of the initial condition.

Future and Controversies

Further improvements in emergency medical systems and the education of prehospital personnel may increase the
observed frequency of flail chest in the future. Improvements in noninvasive ventilation techniques like CPAP and pain
control may also improve currently observed outcomes. Prevention, including safer automobiles and newer airbag design
may affect the incidence and outcome of these multifactorial injuries.

Contributor Information and Disclosures

Author

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School
of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery,
Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine,
American Association for the Surgery of Trauma, American College of Surgeons, Midwest Surgical Association, Royal
Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association
of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of
Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical
School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American
Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine,
Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical
Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of
the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological
Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery,
International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Lewis J Kaplan, MD, FACS, FCCM, FCCP Professor of Surgery, Division of Trauma, Surgical Critical Care, and Emergency
Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania; Section Chief, Surgical
Critical Care, Philadelphia Veterans Affairs Medical Center

Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the
Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education,
Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and
Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, Surgical
Infection Society

Disclosure: Nothing to disclose.

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