A flail chest occurs when a segment of the rib cage breaks and becomes detached from the rest of the chest wall, usually caused by two or more rib fractures in two or more places. Most commonly caused by vehicle accidents. During breathing, the detached flail segment moves in opposite direction to the rib cage, causing pain and paradoxical breathing. Management involves analgesia, intubation if needed, chest tube insertion, and physiotherapy. Outcomes range from full recovery to mortality rates of 10-25%.

1. Flail ChestFlail Chest
Speaker: Dr S. N. Bhagirath
Moderator: Dr Ravi Narayanan

2.  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 two ribs.
 some definitions require three or more
ribs in two or more places
Flail ChestFlail Chest

3.  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 - causesFlail Chest - causes

4.  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..?Flail Chest – What is happening..?

5.  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..?Flail Chest – What is happening..?

6.  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..?Flail Chest – What is happening..?

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

8.  Two Types
Flail Chest – TypesFlail Chest – Types

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

10. Pai
n
Flail Chest – ImplicationsFlail Chest – Implications
Pneumothorax,
Hemothorax
Mediastinal
Flutter
Pulmonar
y
Contusion
Respirator
y
Failure

11. Flail Chest – DiagnosisFlail Chest – Diagnosis
 Clinical examination for bruises, paradoxical
movement of flail segment.
 Chest X – Ray
 Computed
Tomography

12. Flail Chest – ManagementFlail Chest – Management
 Analgesia.
 Intubation and Ventilation.
 Chest Tube Insertion
 Rib Fracture Fixation

13. Flail Chest – ManagementFlail Chest – Management
Analgesia.
Mainstay
Opioid Analgesics (risk of respiratory depression)
NSAIDs
Thoracic or high lumbar Epidurals with or
without Opioid additives.
Posterior rib blocks (lasts upto 24 hours)
Instillation of L.A. into pleural space through
ICD (controversial)

14. Flail Chest – ManagementFlail Chest – Management
Intubation & Ventilation.
Rarely indicated
Indicated for hypoxia due to pulm.
contusions.
Double lumen tracheal tube.
each lumen connected to a different
ventilator.
each lung may require drastically different
pressures and flows to adequately ventilate.

15. Flail Chest – ManagementFlail Chest – Management
Chest Tube Insertion
To treat hemothorax
To treat pneumothorax

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

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

18. Flail Chest – ManagementFlail 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.

19. Flail Chest – OutcomeFlail Chest – Outcome
 Mortality Rate of flail chest ranges from 10-
25%.
 Ventilation has little effect on outcome

20. Flail Chest – VideoFlail Chest – Video

21. Flail Chest – ReferencesFlail Chest – References
 Millers Anesthesia
 Morgan’s Clinical Anesthesia
 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).
 Wikipedia
 www.trauma.org
 Blunt thoracic trauma: flail chest, pulmonary contusion, and
blast injury Sandra Wanek, MD, John C. Mayberry, MD,
FACS
 Ziegler DW, Agarwal NN. The morbidity and mortality of rib
fractures. J Trauma 1994;37(6):975 – 9.