What is Flail Chest?
Flail chest is a severe injury to the chest area. It happens when three or more ribs are broken in at least two places. However, not everyone with this type of fracture ends up having flail chest. The condition is so named because, due to the broken ribs, a section of the chest wall moves separately from the rest of the chest.
This irregular movement can cause some significant breathing problems, which can be particularly concerning for older individuals or those who already have chronic lung disease. Flail chest is a serious injury and can lead to significant complications. It usually results from a hard blow to the chest. It is often accompanied by other injuries and can be very painful. These factors make flail chest quite challenging to manage.
Usually, a flail chest affects only one side of the chest, but it can affect both sides. Although X-ray images can suggest a flail chest injury, the final diagnosis depends on clinical examination by a doctor.
What Causes Flail Chest?
Flail chest is a condition that happens due to serious injury. Certain factors make some people more likely to get flail chest. These typically include being a male and being intoxicated. Motor vehicle accidents cause about 75% of the major injuries leading to flail chest, while falls – which are more common in older individuals – account for another 15%.
Certain types of injuries, like a direct blow to the chest, are more likely to cause the specific type of rib fractures that lead to flail chest. In contrast, injuries caused by rollovers or crashes usually fracture ribs in a different way, and are less likely to result in flail chest.
In children, bone diseases like metabolic bone disease or brittle bone disease (osteogenesis imperfecta) can make them more prone to getting flail chest. Older individuals are also more at risk for flail chest, partly due to age-related stiffening of the chest wall, and partly because they may have weak bones (osteoporosis). If they already have lung disease, they’re also the most likely to experience complications from flail chest.
Risk Factors and Frequency for Flail Chest
According to statistics from the American Association for the Surgery of Trauma, about 1% of the US population each year will experience a significant traumatic event. Chest trauma is fairly common, happening in 20% of major trauma cases and causing 25% of traumatic deaths. A specific type of chest trauma, called a flail chest, is seen in about 7% of chest trauma patients who usually need to go to the hospital.
- A flail chest happens on its own in less than 40% of cases.
- Most of the time, it comes with other injuries such as lung contusions, hemo/pneumothorax, head injury, and sometimes major vascular injury.
- Flail chest has a death rate of 10% to 20%, often due to other injuries rather than the flail chest itself.
- It also has a high illness rate due to long and complicated hospital stays and recovery.
Signs and Symptoms of Flail Chest
Flail chest usually occurs after severe blunt force trauma. Elderly people are more at risk of this condition. It might be harder to diagnose in situations of abuse, patients who can’t talk, or if a medical history cannot be obtained.
When patients might have suffered a chest injury, healthcare professionals conduct a thorough physical examination. This involves fully undressing the patient to examine the chest, checking vital signs (like breathing rate and oxygen levels), and listening to the patient’s breathing. Areas of pain, unusual shapes, or unusual sounds under the skin are investigated, along with signs of bruising, bleeding, or ‘seatbelt marks’. The patient usually experiences intense chest pain and might breathe rapidly, appear to splint their chest, or show signs of breathing difficulties.
A particular sign of flail chest is when the chest wall appears to move inward as the person breathes in, and outward as they breathe out – the opposite of the normal chest movement (this is known as paradoxical motion). However, absence of this sign doesn’t rule out the possibility of flail chest; it might just be that their muscles are tired.
Note that this irregular chest movement isn’t visible in patients receiving breathing support through positive pressure ventilation, such as BiPAP or mechanical intubation. The diagnosis of flail chest might be missed in these intubated patients, only becoming noticeable after the breathing support is removed.
Testing for Flail Chest
When a trauma patient comes in, an immediate evaluation means performing several medical exams and tests. One typical scan is called eFAST, but this might not be too helpful for finding something called a flail chest. The chest x-ray can be more telling in this case as it may show signs of a flail chest. This condition occurs when a segment of the rib cage breaks and separates from the rest of the chest wall.
However, chest x-rays might not catch everything. They could potentially miss rib fractures that a CT (computed tomography) scan could identify. Therefore, solely relying on a chest x-ray might risk missing a diagnosis of flail chest. A rib series scan, which is a set of x-rays of the ribs, can be more useful, but it still might not catch all rib fractures.
The most reliable test is a CT scan, especially when the results are shown in a 3D image. This type of imaging is best for finding a flail chest or related injuries. If three ribs appear broken in two places on an x-ray or CT scan, this could suggest a flail chest, but doctors will also consider the patient’s symptoms.
Complete blood tests should also be ordered, including measuring the gases in your blood. While these tests may not directly tell whether a patient has a flail chest, they can help doctors monitor the patient for signs of worsening lung function, which could be a serious complication from a flail chest.
Treatment Options for Flail Chest
Managing a flail chest, a severe injury where a section of the ribcage breaks off and moves separately from the rest of the chest wall, involves tackling a few important areas: ensuring enough oxygen, managing body fluids, controlling pain, and stabilizing the chest wall.
It’s crucial to provide enough oxygen to the patient, ideally through non-invasive methods where oxygen is delivered through a mask or nasal tube. However, if these methods don’t provide enough oxygen, a machine that pushes air into the lungs might be used. It’s beneficial to remove the breathing tube and stop using the machine as early as possible when conditions allow.
Managing body fluids is key in most trauma situations, including flail chest, largely due to the common association with lung contusion, or bruising of the lung tissue.
Early and effective pain control is another priority. This might be achieved through nerve blocks or epidural anesthesia, which numbs the area around the injury site. Additionally, excellent lung care should be a focus in the treatment strategy, while corticosteroids, anti-inflammatory drugs that can suppress the immune system should generally be avoided.
In some complicated cases, internal pneumatic stabilization, a process that fills the chest cavity with air to help support the broken ribs, has been used successfully. Surgical stabilization can be considered for patients who require a thoracotomy (surgery to access the organs in the chest) for other reasons, patients struggling to breathe without a ventilator, or patients whose breathing continues to worsen despite other treatments. This surgical procedure often uses metallic wires to steady the ends of the broken rib. Various other fixation devices are also available, for instance, medical mesh.
What else can Flail Chest be?
When a doctor is trying to diagnose a flail chest, which is a serious condition where a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall, there are other conditions they need to consider. They might present with similar symptoms, so the doctor needs to rule these out:
- Acute aortic dissection
- Amebiasis
- Considerations in pediatric trauma
- Domestic violence
- Elder abuse
- Esophagitis
- Clavicle fracture
- Mechanical back pain
- Pneumothorax
- Pulmonary embolism
- Sternal fracture
- Upper genitourinary trauma
Considering these possibilities and conducting the right tests is crucial for the doctor to make an accurate diagnosis.
What to expect with Flail Chest
Generally, patients who don’t require a machine to assist their breathing tend to have better health prospects than those who do. However, negative side effects are quite common and often result in a high rate of disability. In some cases, patients may experience pain that lasts for months or even years.
Possible Complications When Diagnosed with Flail Chest
Having a flail chest may result in a number of complications such as:
- Intense pain
- Changes in the shape of the chest wall
- Shortness of breath, also known as dyspnea
- Lower stamina for performing physical activities
Preventing Flail Chest
It’s important for patients to know that getting medical help right away is extremely important. Doing so can greatly lower the risk of harm to the heart, lungs, and nearby tissues. This immediate action is not just about feeling better, but it can also be potentially life-saving.
