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.  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.INTRODUCTION  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.

.INCIDENCE • 6% of the total global Vehicular accidents.

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

heart. including the lungs. flail chest is observed with lower frequency than injury to the underlying structures.PATHOPHYSIOLOGY • In an adult. who have a more compliant chest wall. and mediastinal structures. 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.

. which occasionally results in a delayed diagnosis of the condition. • This clinical finding disappears after intubation with positive pressure ventilation.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.

and they may have minimal to incapacitating respiratory insufficiency. rather than the chest wall abnormality.• The strict definition of 3 ribs broken in 2 or more places can be confirmed only by x-ray. • Patients may demonstrate only the paradoxical chest wall motion. • The degree of respiratory insufficiency is typically related to the underlying lung injury. . although these individuals usually show some tachypnea with a notable decrease in resting tidal volume due to fracture pain. 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.

and underlying pulmonary contusion may be initially masked by hypovolemia. but may not show all fracture sites. .INVESTIGATION • Chest x-rays occasionally demonstrate the fractured ribs.

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• 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 .

. • 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.• 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.

evaluation of an abnormal mediastinal contour). • Because many of these patients sustain concomitant internal thoracic injury.• Saggital and coronal reformats of a thoracic MSCT scan also identifies rib fractures quite well. . thoracic CT scanning images may be available for reasons other than rib fracture identification (ie.

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.• Three-dimensional (3-D) reconstruction of helical CT images is also possible though not widely available. .

and indwelling epidural catheters form the mainstay of current treatment. • Patient-controlled analgesia (PCA) machines. oral pain medications. .MEDICAL THERAPY • 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.

• Flail chest from multiple myeloma.• In general. operative fixation is most commonly performed in patients requiring a thoracotomy for other reasons or in cases of gross chest wall deformity. or total sternectomy more frequently responds well to surgical fixation. sternal absence. .

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

• Judet struts.INTRAOPERATIVE MANAGEMENT • fractured rib must be stabilized for operative intervention to be most effective. and even prosthetic mesh secured with methylmethacrylate techniques . Kirschner (K-) wires.

.POSTOPERATIVE MANAGEMENT • Routine post-thoracotomy 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. .

• persistent chest wall pain.COMPLICATIONS • long-term disability in patients sustaining flail chest. deformity. • altered pulmonary function . and dyspnea on exertion.

.OUTCOME AND PROGNOSIS • Overall. patients with flail chest have a 510% reported mortality if they reach the hospital alive.

. including safer automobiles and newer airbag design may affect the incidence and outcome of these multifactorial injuries. • Prevention.NEW TRENDS • Improvements in noninvasive ventilation techniques like CPAP.