Flail chest with subsequent internal fixation of rib fractures

Case contributed by Dr Henry Knipe

Presentation

High-speed motor vehicle collision. Intubated.

Patient Data

Age: 45 years
Gender: Female

Fractured midshaft of left clavicle. Multiple rib fractures on the left 2-9 with underlying pulmonary opacity consistent with pulmonary contusion. The tip of the ETT is at the level of thoracic inlet.

There are fractures through the lateral curvatures of ribs 2, 3, 4, 5, 6, 7, 8, 9 on the left. There is moderate displacement of rib fractures 9, 8, 7, 6 and 4. Fractures of the anterior curvatures of ribs 2, 3, 4 and 5 are present which are undisplaced; a left-sided flail segment is therefore present involving the ribs 2 to 5. 

A moderately displaced left clavicular fracture is present.

Widespread extensive emphysematous changes are present throughout both lungs. There is confluent density seen within the posterior aspect of the left lower lobe adjacent to a rib fracture consistent with pulmonary haemorrhage and probable pulmonary laceration here.

Tiny bilateral pneumothoraces. There is a tiny left haemothorax.

Internal fixation of left-sided rib fractures. Internal fixation of left clavicle fracture. Left lower lobe collapse and left pleural effusion. 

No filling defect demonstrated within the pulmonary arteries. Almost complete left lower lobe collapse. Large left pleural fluid collection. Minor dependent atelectasis in the right lung. Background changes of emphysema. No pneumothorax. Heart and mediastinum are unremarkable. Imaged upper abdomen is unremarkable. Bilateral breast prostheses noted. Left clavicular intramedullary nail is partially imaged with a small volume of adjacent surgical emphysema. Left-sided rib fixation is noted as well as multiple rib fractures.

Case Discussion

There are varying (and somewhat controversial) indications for internal fixation of rib fractures but commonly include 1

  • flail segment with respiratory function that does not improve with positive pressure ventilation
  • chest wall deformity
  • pain
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Case information

rID: 28604
Case created: 2nd Apr 2014
Last edited: 10th Oct 2017
Systems: Chest, Forensic, Trauma
Tag: trauma
Inclusion in quiz mode: Included

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