Elsevier

Thoracic Surgery Clinics

Volume 17, Issue 1, February 2007, Pages 25-33
Thoracic Surgery Clinics

The Management of Flail Chest

https://doi.org/10.1016/j.thorsurg.2007.02.005Get rights and content

Flail chest is an uncommon consequence of blunt trauma. It usually occurs in the setting of a high-speed motor vehicle crash and can carry a high morbidity and mortality. The outcome of flail chest injury is a function of associated injuries. Isolated flail chest may be successfully managed with aggressive pulmonary toilet including facemask oxygen, continuous positive airway pressure, and chest physiotherapy. Surgical stabilization is associated with a faster ventilator wean, shorter ICU time, less hospital cost, and recovery of pulmonary function in a select group of patients with flail chest. There is no role for stabilization for patients who have severe pulmonary contusion. Supportive therapy and pneumatic stabilization is the recommended approach for this patient subset.

Section snippets

Pathophysiology

A common result of compressive injury to the thoracic cage is rib fracture. The fracture location is influenced by the angle of impact. Rib fractures tend to occur anteriorly at 60-degree rotation from the sternum [7]. Frontal and lateral impact, however, may result in multiple anterior and posterior rib fracture points. Severe anterior compressive forces may cause sternochondral disruption and a subsequent sternal flail. Flail chest occurs in 10% of thoracic trauma cases and has a reported

Initial evaluation

The diagnosis of flail chest is clinical and requires evaluation of the injury mechanism, physical examination, and radiographic studies including plain film chest radiograph. With regard to injury mechanism, motor vehicle crash is a major contributor to the development of flail chest. Emergency medical personnel reports of steering wheel deformity, high speed frontal or lateral crash, and the presence or absence of front and side airbags is useful during patient triage. Shoulder harness

Medical management

The initial management of flail chest focuses primarily on maintaining adequate ventilation. Intermittent positive pressure ventilation was first successfully used to manage flail chest in the mid 1950s [13]. Cullen and colleagues [14] further supported the use of intermittent mechanical ventilation in the treatment of flail chest. During the late 1960s and early 1970s, flail chest was managed with early tracheostomy and mechanical ventilation. It was believed that the hypoxia, decreased

Outcome and prognosis

The high mortality rate is primarily caused by associated injuries, such as pulmonary contusion and intra-abdominal or intracranial injury. In one series, 100% mortality was observed in patients with flail chest and concomitant head injuries [27].

The Injury Severity Score has been a useful marker for determining the effects of associated injuries on outcome in patients with flail chest. An increased Injury Severity Score has been related to an increased morbidity and mortality in patients with

Surgical management

The surgical management of flail chest has traditionally been reserved for the following indications: (1) patients with flail chest who require thoracotomy for other intrathoracic injury, (2) those who are unable to be successfully weaned from mechanical ventilatory assistance, (3) severe chest wall instability, (4) persistent pain secondary to fracture malunion, and (5) persistent or progressive loss of pulmonary function [40], [41]. Landreneau and colleagues [42] demonstrated that Luque rod

Summary

Flail chest is an uncommon consequence of blunt trauma. It usually occurs in the setting of a high-speed motor vehicle crash and can carry a high morbidity and mortality. The outcome of flail chest injury is a function of associated injuries. Isolated flail chest may be successfully managed with aggressive pulmonary toilet including facemask oxygen, CPAP, and chest physiotherapy. Adequate analgesia is of paramount importance in patient recovery and may contribute to the return of normal

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