Flail chest

Definition
A flail chest is a life-threatening medical condition that occurs when a segment of the chest wall bones breaks under extreme stress and becomes detached from the rest of the chest wall, often associated with underlying pulmonary injury and is most commonly seen in cases of significant blunt trauma. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently that gives an appearance of stove in chest. The number of ribs that must be broken varies by differing definitions: some sources say at least two adjacent ribs are broken in at least two places, some require three or more ribs in two or more places. The flail segment moves in the opposite direction as the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This socalled "paradoxical motion" can increase the work and pain involved in breathing. Studies have found that up to half of people with flail chest die. In emergency department presentations, approximately 30% of patients with extensive thoracic trauma have a flail chest. Flail chest is invariably accompanied by pulmonary contusion, a bruise of the lung tissue that can interfere with blood oxygenation. Often, it is the contusion, not the flail segment, that is the main cause of respiratory failure in patients with both injuries.

Causes
Flail chest is a serious, life-threatening chest injury. This typically occurs when three or more adjacent ribs are fractured in two or more places. Ribs fractured proximally in conjunction with disarticulation of costochondral cartilages distally. For the condition to occur, generally there must be a significant force applied over a large surface of the thorax to create the multiple anterior and posterior rib fractures. Rollover and crushing injuries most commonly break ribs at only one point for flail chest to occur a significant impact is required, breaking the ribs in two or more places.

Presentation

Pain when taking a deep breath Pain that gets worse when pressed on the injured area, or when bending or twisting the body Very tender spot in the rib area that occurs after trauma or is present with deep breaths or hinders the breathing An experience of pressure, fullness or a squeezing pain in the centre of the chest that lasts for more than a few minutes Pain that extends beyond the chest to the shoulder or arm, and increasing episodes of chest pain, get medical attention immediately. These symptoms may indicate a heart attack.

The characteristic paradoxical motion of the flail segment occurs due to pressure changes associated with respiration that the rib cage normally resists:

During normal inspiration, the diaphragm contracts and intercostal muscles push the rib cage out. Pressure in the thorax decreases below atmospheric pressure, and air rushes in through the trachea. However, a flail segment will not resist the decreased pressure and will appear to push in while the rest of the rib cage expands.

During normal expiration, the diaphragm and intercostal muscles relax, allowing the abdominal organs to push air upwards and out of the thorax. However, a flail segment will also be pushed out while the rest of the rib cage contracts.

The constant motion of the ribs in the flail segment at the site of the fracture is incredibly painful, and, untreated, the sharp broken edges of the ribs are likely

to eventually puncture the pleural sac and lung, possibly causing a pneumothorax.

Treatment
Treatment of the flail chest initially follows the principles of Advanced Trauma Life Support. Further treatment includes: Good analgesia including intercostal blocks, avoiding narcotic analgesics as much as possible. This allows much better ventilation, with improved tidal volume, and increased blood oxygenation. Positive pressure ventilation, meticulously adjusting the ventilator settings to avoid barotrauma. Chest tubes as required. Adjustment of position to make the patient most comfortable and provide relief of pain. Surgical fixation is usually not required. A patient may be intubated with a double lumen tube. In a double lumen endotracheal tube, each lumen is connected to a different ventilator. Usually one side of the chest is affected more than the other, so each lung may require drastically different pressures and flows to adequately ventilate.