Citation, DOI & article data
Flail chest or flail thoracic segment occurs when three (3) or more contiguous ribs are fractured in two (2) or more places. Clinically, a segment of only one or two ribs can act as a flail segment, hence there is some controversy between the clinical and radiological definitions.
Clinically, this is observed in a non-ventilated patient as a paradoxical movement of the flail segment. It can often be clinically occult 4,5. Its significance lies in the fact that it can lead to severe ventilation difficulties, especially in the peri-intubated patient.
A flail chest is predominantly regarded as a marker for chest trauma severity and is almost always associated with other thoracic injuries, which are also major contributors to respiratory insufficiency, such as 1,2,5:
If there are bilateral rib or costal cartilage fractures and the sternum can move independently from the rest of the chest wall, the term flail sternum is used.
Rarely the flail segment of the chest wall may collapse in (medially), termed a stove-in chest which is associated with even higher morbidity and mortality 7.
Flail chest is most commonly associated with high-impact thoracic blunt trauma and results from severe anteroposterior compression found in motor vehicle collisions, blast or crush injuries 5.
A chest x-ray is less sensitive than CT for the diagnosis of flail segments 4:
- defined as ≥3 adjacent ribs with segmental fractures and/or >5 adjacent rib fractures
- traumatic 1st rib fracture: a marker of severe chest trauma, as the rib is protected by the clavicle and scapula
- costal hook sign: elephant trunk-shaped ribs owing to rotation of segmental fractures
Treatment and prognosis
Flail chest is usually managed supportively, with adequate analgesia and chest physiotherapy to assist with volume expansion, and secretion management to prevent secondary complications of atelectasis and pneumonia 6. 'Internal splinting' with positive pressure ventilation can help and select cases can be treated surgically by internal fixation 3.
- 1. Kaewlai R, Avery LL, Asrani AV et-al. Multidetector CT of blunt thoracic trauma. Radiographics. 2008;28 (6): 1555-70. doi:10.1148/rg.286085510 - Pubmed citation
- 2. Borman JB, Aharonson-daniel L, Savitsky B et-al. Unilateral flail chest is seldom a lethal injury. Emerg Med J. 2006;23 (12): 903-5. doi:10.1136/emj.2006.037945 - Free text at pubmed - Pubmed citation
- 3. Igai H, Kamiyoshihara M, Nagashima T et-al. Rib fixation for severe chest deformity due to multiple rib fractures. Ann Thorac Cardiovasc Surg. 2013;18 (5): 458-61. Pubmed citation
- 4. Emergency Radiology Cases (Cases in Radiology). Oxford University Press, USA. ISBN:0199941173. Read it at Google Books - Find it at Amazon
- 5. Parker M, Rosado-de-Christenson M. Teaching Atlas of Chest Imaging. TNY. ISBN:B005OCNCTK. Read it at Google Books - Find it at Amazon
- 6. Todd SR, McNally MM, Holcomb JB et-al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am. J. Surg. 2006;192 (6): 806-11. doi:10.1016/j.amjsurg.2006.08.048 - Pubmed citation
- 7. Bloomer R, Willett K, Pallister I. The stove-in chest: a complex flail chest injury. (2004) Injury. 35 (5): 490-3. doi:10.1016/S0020-1383(03)00291-2 - Pubmed