Flail chest is a serious chest wall injury defined by fractures in at least 3 ribs in two locations, creating a detached rib segment that moves in paradoxically during breathing. This disrupts respiration and causes pain. Diagnosis is by clinical exam and chest x-ray showing fractures. Management focuses on pain control, splinting the chest, treating associated injuries like pneumothorax, and mechanical ventilation if needed. Physiotherapy during recovery aims to rebuild strength. Mortality rates are 10-25% depending on severity of injuries. Surgical fixation can be considered but is usually not necessary.

1. CHEST TRAUMA: FLAIL CHEST
MIRITI M.D
MASTERS OF CLINICAL MEDICINE: ACCIDENTS AND EMERGENCY
MCM/2017/73494
FACILITATOR: DR NYAGA

2. CONTENTS
• Relevant Anatomy of the Chest
• Definition of Flail Chest
• Epidemiology
• Pathophysiology of Flail chest
• Clinical Features
• Diagnostic modalities
• Management of Flail Chest
• Complications
• Prognosis

3. Anatomy of the Chest
• The thorax is the superior part of the trunk between the neck
and abdomen. The thoracic cavity, surrounded by the thoracic
wall, contains the heart, lungs, thymus, distal part of the
trachea, and most of the esophagus
• The thoracic wall consists of skin, fascia, nerves, vessels,
muscles, cartilages, and bones. The functions of the thoracic
wall include protecting the thoracic and abdominal internal
organs; resisting the negative internal pressures generated by
the elastic recoil of the lungs and Inspiratory movements;
providing attachment for and supporting the weight of the
upper limbs; and providing attachment for many of the
muscles of the upper limbs, neck, abdomen, and back and the
muscles of respiration.
• The mammary glands of the breasts are in the subcutaneous
tissue overlying the pectoral muscles covering the
anterolateral thoracic wall.

4. Skeleton of Thoracic Wall
• The thoracic skeleton forms the osteocartilaginous
thoracic cage
• The thoracic skeleton includes 12 pairs of ribs and
costal cartilages, 12 thoracic vertebrae and
intervertebral (IV) discs, and the sternum.
• Costal cartilages form the anterior continuation of
the ribs, providing a flexible attachment at their
articulation with the sternum
• The ribs and their cartilages are separated by
intercostal spaces, which are occupied by
intercostal muscles, vessels, and nerves.

7. Superior Thoracic Aperture
• The thoracic cavity communicates with the neck and
upper limb through the superior thoracic aperture, the
anatomical thoracic inlet. Structures entering and
leaving the thoracic cavity through this aperture include
the trachea, esophagus, vessels, and nerves. Because of
the obliquity of the first pair of ribs, the superior
thoracic aperture slopes anteroinferiorly. The superior
thoracic aperture is bounded:
 Posteriorly by the T1 vertebra.
 Laterally by the first pair of ribs and their
costal cartilages.
 Anteriorly by the superior border of the
manubrium.

8. Inferior Thoracic aperture
• The thoracic cavity communicates with the abdomen through
the inferior thoracic aperture, the anatomical thoracic outlet
• In closing the inferior thoracic aperture, the diaphragm
separates the thoracic and abdominal cavities almost
completely. The inferior thoracic aperture is more spacious
than the superior thoracic aperture.
• Structures passing to or from the thorax to the abdomen pass
through openings in the diaphragm (e.g., the inferior vena
cava and esophagus) or posterior to it (e.g., aorta).
• The inferior thoracic aperture is bounded:
 Posteriorly by the T12 vertebra.
 Posterolaterally by the eleventh and twelfth pairs
of ribs.
 Anterolaterally by the joined costal cartilages of
ribs 7-10, forming the costal margin.
 Anteriorly, by the xiphisternal joint.

9. RIBS AND COSTAL CARTILAGES
• The ribs are curved, flat bones that form most of the thoracic
cage They are remarkably light in weight yet highly resilient.
• Each rib has a spongy interior containing bone marrow which
forms blood cells (hematopoietic tissue).
• There are three types of ribs:
 True (vertebrocostal) ribs (first through seventh ribs) attach
directly to the sternum through their own costal cartilages.
 False (vertebrochondral) ribs (eighth through tenth ribs) have
cartilages that are joined to the cartilage of the rib just
superior to them; thus, their connection with the sternum is
indirect.
 Floating (free) ribs (eleventh and twelfth ribs; sometimes the
tenth rib) have rudimentary cartilages that do not connect
even indirectly with the sternum; instead, they end in the
posterior abdominal musculature.

10. Typical ribs (third through ninth) have a:
Head that is wedge-shaped and two facets that are
separated by the crest of the head. One facet is for
articulation with the numerically corresponding vertebra, and
one facet is for the vertebra superior to it.
Neck that connects the head with the body (shaft) at the
level of the tubercle.
Tubercle at the junction of the neck and body. The tubercle
has a smooth articular part for articulating with the
corresponding transverse process of the vertebra and a rough
nonarticular part for the attachment of the costotransverse
ligament.
Body (shaft) that is thin, flat, and curved, most markedly at
the angle where the rib turns anterolaterally. The concave
internal surface has a costal groove that protects the
intercostal nerve and vessels

11. Atypical ribs (first, second, and tenth through twelfth) are
dissimilar
The first rib is the broadest (i.e., its body is widest and is
nearly horizontal), shortest, and most sharply curved of
the seven true ribs; it has two grooves crossing its
superior surface for the subclavian vessels; the grooves
are separated by a scalene tubercle and ridge.
The second rib is thinner, less curved, and much longer
than the first rib; it has two facets on its head for
articulation with the bodies of the T1 and T2 vertebrae.
The tenth through twelfth ribs, like the first rib, have
only one facet on their heads.
The eleventh and twelfth ribs are short and have no
necks or tubercles.

12. Thoracic Vertebrae
• Thoracic vertebrae are typical vertebrae in that they are
independent and have bodies, vertebral arches, and
seven processes for muscular and articular
connections.
• Characteristic features of thoracic vertebrae include:
 Bilateral costal facets (demifacets) on their bodies for
articulation with the heads of ribs; atypical thoracic
vertebrae have one whole costal facet in place of the
demifacets.
 Costal facets on their transverse processes for
articulation with the tubercles of ribs, except for the
inferior two or three thoracic vertebrae.
 Long inferiorly slanting spinous processes.

13. STERNUM
The sternum is the flat, vertically elongated bone that
forms the middle of the anterior part of the thoracic
cage. The sternum consists of three parts:
manubrium, body, and xiphoid process.
The manubrium, the superior part of the sternum,
is a roughly trapezoidal bone that lies at the level of
the bodies of the T3 and T4 vertebrae. Its thick
superior border is indented by the jugular notch
(suprasternal notch). On each side of this notch, a
clavicular notch articulates with the sternal (medial)
end of the clavicle. Just inferior to this notch, the
costal cartilage of the first rib fuses with the lateral
border of the manubrium.

14. The manubrium and body of the sternum lie in slightly different
planes, forming a projecting sternal angle (of Louis). This readily
palpable clinical landmark is located opposite the second pair of
costal cartilages at the level of the IV disc between the T4 and T5
vertebrae.
The body of the sternum (T5-T9 vertebral level) is longer,
narrower, and thinner than the manubrium. Its width varies
because of the scalloping of its lateral borders by the costal
notches for articulation with the costal cartilages.
The xiphoid process (T10 vertebral level) is the smallest and
most variable part of the sternum. It is relatively thin and
elongated but varies considerably in form. The process is
cartilaginous in young people but more or less ossified in adults
older than 40 years. In elderly people, the xiphoid process may
fuse with the sternal body. It is a midline marker for the superior
level of the liver, the central tendon of the diaphragm, and the
inferior border of the heart.

15. Joints of Thoracic Wall
Although movements of the joints of the thoracic wall are frequent (e.g.,
during respiration), the range of movement at the individual joints is
small. Any disturbance that reduces the mobility of these joints
interferes with respiration.
Joints of the thoracic wall occur between the:
Vertebrae (intervertebral joints).
Ribs and vertebrae (costovertebral joints: joints of the heads of ribs
and the costotransverse joints).
Sternum and costal cartilages (sternocostal joints).
Sternum and clavicle (sternoclavicular joints).
Ribs and costal cartilages (costochondral joints).
Costal cartilages (interchondral joints).
Parts of the sternum (manubriosternal and xiphisternal joints) in
young people; usually the manubriosternal joint and sometimes the
xiphisternal joint are fused in elderly people.
The intervertebral joints between the bodies of adjacent vertebrae are
joined together by longitudinal ligaments and intervertebral discs

16. Deadly Dozen
Immediately Life
threatening
• Airway obstruction
• Tension Pneumothorax
• Pericardial Temponade
• Open Pneumothorax
• Massive hemothorax
• Flail chest
Potentially life Threatening
• Aortic injuries
• Tracheobronchial
injuries
• Myocardial contusion
• Rupture of diaphragm
• Esophageal injury
• Pulmonary contusion

17. Flail Chest
• A flail chest occurs when a segment of
the rib cage breaks under extreme stress
and becomes detached from the rest of
the chest wall.
• This is usually defined as at least two
fractures per rib (producing a free
segment), in at least three ribs.

18. Flail Chest

19. •Flail chest is an injury that involves 3 or
more consecutive rib fractures in two or
more locations, producing a comminuted
fracture with a free-floating, unstable bony
segment that is detached from the
remainder of the chest wall.
•Associated injuries are common and should
be aggressively sought.
•Pulmonary contusion is the most common
local disturbance in association with flail
segment. Mortality is significant.

20. Epidemiology
• 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.
• 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 non trauma center
facilities is currently unknown.
• Flail chest in a neonate has been reported as a
potential marker of child abuse.
• In Kenya, the incidence could be higher but no
epidemiological studies done yet.

21. • Most Common – Vehicle Accidents (76%)
• Second most common – Falls, especially
in elderly population (weak, frail bones)
(14%)
• Third most common – blunt trauma in
children, especially those with genetic
conditions, eg. Osteogenesis Imperfecta.
Flail Chest - causes

22. • During normal
inspiration, the
diaphragm contracts
and intercostal
muscles pull the rib
cage out. Pressure in
the thorax decreases
below atmospheric
pressure, and air
rushes in through the
trachea.
Flail Chest – What is happening..?

23. • The flail segment
will be pulled in with
the decrease in
pressure while the
rest of the rib cage
expands.
Flail Chest – What is happening..?

24. • During normal
expiration, the
diaphragm and
intercostal muscles
relax increasing
internal pressure,
allowing the
abdominal organs to
push air upwards and
out of the thorax.
Flail Chest – What is happening..?

25. • However, a flail
segment will also be
pushed out while the
rest of the rib cage
contracts.
Flail Chest – What is happening..?

26.  Two Types
Flail Chest – Types

27. • Since the flail segment moves in an
opposite direction to rest of the chest wall
Flail Chest – What is happening..?
Paradoxical Breathing

28. Pain
Flail Chest – Implications
Pneumothorax,
Hemothorax
Mediastinal
Flutter
Pulmonary
Contusion
Respiratory
Failure

29. Flail Chest – Diagnosis
• Clinical examination for bruises,
paradoxical movement of flail segment.
• Chest X – Ray
• CT
• ABGs

30. S/S of Flail Chest
• Painful Breathing.
• Paradoxical Chest Movements.
• Rapid, Shallow respiration, Dyspnea,
Tachypnea, Tachycardia.
• Bruising/Swelling.
• Crepitus (Grinding of bone ends on palpation).
• Hypoventilation signs

31. Management of Flail Chest
• ABC’s with c-spine control as indicated
• High Flow oxygen
• Adequate analgesia (Including opiates)
• Intra-plural local analgesia
• Observe the patient for development of
Pneumothorax and even worse Tension
Pneumothorax
• If Tension Develops Needle Decompress
affected side
• Surgery -> internal operative fixation.
• Rapid Transport! Remember a True Emergency

32. BulkyDressingfor splint of FlailChest
• UseTrauma bandage
and Triangular
Bandagesto splint
ribs.
• Canalso place abagof
D5Won area and tape
down. (The only good
useof D5WI canfind)

33. •The severity of flail injuries and associated
contusions frequently require endotracheal
intubation and positive pressure
mechanical ventilation- IPPV. Double lumen
tracheal tube with each tube connected to a
different ventilator
•Optimal ventilatory management is crucial
•Judicial IV fluids to avoid fluid overload.
•Chest Tube Insertion so as to treat hemothorax
and treat pneumothorax

34. Flail Chest – Management
Rib Fracture Fixation
Usually not required
Preferred choice before intubation &
ventilation.

35. Flail Chest – Management
Physiotherapy
•To aid better drainage
of
•secretions
•To rebuild musculature
•To reposition chest
wall
•Coughing exercises
•Resistance exercises
•Trunk exercises

36. Flail Chest – Management
Rehabilitation
12 week outpatient program for at least 3
days a week
patient should be seen for 30–45 minutes a
day after a 5-10 minute warm up session.
After discharge, patient should be given an
exercise regimen to be performed at home.

37. Flail chest Prognosis
• Mortality Rate of flail chest ranges from 10-
25%.
• Ventilation has little effect on outcome

38. References
• Andreas Granetzny et al Surgical versus conservative
treatment of flail chest. Evaluation of the pulmonary
status Interactive CardioVascular and Thoracic Surgery,
Volume 4, Issue 6, 1 December 2005, Pages 583–587.
• Cataneo AJM, Cataneo DC, de Oliveira FHS, Arruda KA,
El Dib R, de Olivei ra Carvalho PE. Surgical versus
nonsurgical interventions for flail chest. Cochrane
Database of Systematic Reviews 2015, Issue 7. Art. No.:
CD009919.
• Athanassiadi, Kalliopi, Michalis Gerzounis, Nikolaos
Theakos. Management of 150 flail chest injuries:
analysis of risk factors affecting outcome. European
Journal of Cardio- thoracic surgery 26. (2004).