all information about flail chest has been tried to incorporate along with pictoral depiction.

1. FLAIL CHEST
Dr Pooja Pandey
JR-1 MS General Surgery
Mayo institute of Medical Sciences,Barabanki

2. Content
 Introduction
 Causes
 Types of Flail Chest
 Pathophysiology of Flail chest
 Clinical Features
 Diagnostic modalities
 Management of Flail Chest
 Complications
 Prognosis

3. INTRODUCTION
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.

4.  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.

5.  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.
CAUSES

6.  Blunt Trauma- Blunt force to
chest. E.g. automobile crashes
and falls.
 Penetrating Trauma- Projectile
that enters chest causing small
or large hole. E.g. gun shot and
stabbing.
 Compression Injury- Chest is
caught between two objects
and chest is compressed.

7. TYPES OF FLAIL CHEST
 ANTERIOR – Near costochondral region
 POSTERIOR – safer
 LATERAL - in ribs shafts
 FLAIL STERNUM

10. CLINICAL FEATURES
 Shortness of Breath
 Paradoxical Movement
 Bruising/Swelling
 Crepitus (Grinding of bone ends on
palpation)
 Tachycardia
 Hypotension

12.  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.
 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.
The flail segment will be pulled
in with the decrease in pressure
while the rest of the rib cage expands.
a flail segment will also be
pushed out while the rest
of the rib cage contracts.

13. ASSESMENT
 Frequent and prompt Respiratory assessment
 Adequate oxygenation
 Analgesia to improve ventilation.
 Clearing secretion
 Stabilize the thoracic cage
 Deep breathing exercises
 Intubation and mechanical ventilation may be required to prevent further
hypoxia

14. Diagnosis
 Clinical examination for bruises,
paradoxical movement of flail
segment.
 Chest X – Ray
 Computed Tomography

15. Principle of 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

16. Splint and Bandage
 Use Trauma bandage and Triangular
Bandages to splint ribs.
 Can also place a bag of D5Won area
and tape down. (The only good use of
D5WI can find)

17. Analgesia
-Mainstay
 Opioid Analgesics (risk of respiratory
depression)
 NSAIDs
 Thoracic or high lumbar Epidurals
with or without Opioid additives.
 Posterior rib blocks (lasts up to 24
hours)
 Instillation of L.A. into pleural space
through ICD (controversial)

19. Intubation & Ventilation
(Rarely indicated)
 Indicated for hypoxia due to pulmonary contusions.
 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.

20. Management Chest Tube Insertion
 To treat hemothorax
 To treat pneumothorax

22. Management Rib Fracture
Fixation
 Usually not required
 Preferred choice before intubation &
ventilation.

23. Physiotherapy
 To aid better drainage of secretions
 To rebuild musculature
 To reposition chest wall
 Coughing exercises
 Resistance exercises
 Trunk exercises

24. 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.

25. COMPLICATIONS
 Pneumonia
 ARDS
 Lung abscess
 Emphysema
 Hypoventilation
 Atelectasis
 Mediastinal flutter (mediastinal
structures tend to swing back n forth)

26. Prognosis
 Mortality Rate of flail chest ranges from 10- 25%
 Ventilation has little effect on outcome

27. 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.