eMedicine Specialties > Trauma > Thoracic Trauma

Flail Chest: Workup

Author: H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
Contributor Information and Disclosures

Updated: May 4, 2009

Workup

Laboratory Studies

  • Laboratory studies are helpful in the management of flail chest and its associated physiologic abnormalities, but no single test confirms the diagnosis of the condition. Chest x-rays occasionally demonstrate the fractured ribs, but may not show all fracture sites, and underlying pulmonary contusion may be initially masked by hypovolemia.
    Multiple left rib fractures, pulmonary contusion,...

    Multiple left rib fractures, pulmonary contusion, and hemothorax in an elderly man after a motor vehicle accident.

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    Multiple left rib fractures, pulmonary contusion,...

    Multiple left rib fractures, pulmonary contusion, and hemothorax in an elderly man after a motor vehicle accident.


    {{mediacaption:1677003_0}}Arterial blood gas (ABG) measurements show the severity of the hypoventilation created by both the pulmonary contusion and the pain of the rib fractures, and are helpful at baseline to assess the need for mechanical ventilation and to follow the patient during management.

Imaging Studies

  • Portable anteroposterior (AP) or more formal posteroanterior (PA) chest radiography is the simplest and easiest radiologic test to perform to delineate the number of fractured ribs. Plain films can miss rib fractures and pneumothoraces however. The flail chest diagnosis is a clinical observation that is supported by the radiologic identification of the fracture pattern.
  • Saggital and coronal reformats of a thoracic MSCT scan also identifies rib fractures quite well.6 Because many of these patients sustain concomitant internal thoracic injury, thoracic CT scanning images may be available for reasons other than rib fracture identification (ie, evaluation of an abnormal mediastinal contour). Three-dimensional (3-D) reconstruction of helical CT images is also possible though not widely available.
    Axial computed tomography image of the chest in a...

    Axial computed tomography image of the chest in a patient with left posterior rib fractures. The left pneumothorax (white arrows) is associated with a displaced posterior left rib fracture (black arrow). Secondary effects on the left lung include a pulmonary contusion and volume loss.

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    Axial computed tomography image of the chest in a...

    Axial computed tomography image of the chest in a patient with left posterior rib fractures. The left pneumothorax (white arrows) is associated with a displaced posterior left rib fracture (black arrow). Secondary effects on the left lung include a pulmonary contusion and volume loss.

More on Flail Chest

Overview: Flail Chest
Workup: Flail Chest
Treatment: Flail Chest
Follow-up: Flail Chest
Multimedia: Flail Chest
References
Further Reading
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References

  1. Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma. Nov 1990;30(11):1356-65. [Medline].

  2. Landercasper J, Cogbill TH, Lindesmith LA. Long-term disability after flail chest injury. J Trauma. May 1984;24(5):410-4. [Medline].

  3. Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg. Dec 1995;110(6):1676-80. [Medline].

  4. Borman JB, Aharonson-Daniel L, Savitsky B, Peleg K. Unilateral flail chest is seldom a lethal injury. Emerg Med J. Dec 2006;23(12):903-5. [Medline]. [Full Text].

  5. Gipson CL, Tobias JD. Flail chest in a neonate resulting from nonaccidental trauma. South Med J. May 2006;99(5):536-8. [Medline].

  6. Sangster GP, Gonzalez-Beicos A, Carbo AI,et al. Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings. Emerg Radiol. Oct 2007;14(5):297-310. [Medline].

  7. Trinkle JK, Richardson JD, Franz JL, et al. Management of flail chest without mechanical ventilation. Ann Thorac Surg. Apr 1975;19(4):355-63. [Medline].

  8. Gunduz M, Unlugenc H, Ozalevli M, Inanoglu K, Akman H. A comparative study of continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation (IPPV) in patients with flail chest. Emerg Med J. May 2005;22(5):325-9. [Medline]. [Full Text].

  9. Tanaka H, Tajimi K, Endoh Y, Kobayashi K. Pneumatic stabilization for flail chest injury: an 11-year study. Surg Today. 2001;31(1):12-7. [Medline].

  10. Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: an underused procedure?. Am Surg. Jun 2007;73(6):591-6; discussion 596-7. [Medline].

  11. Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin. Feb 2007;17(1):25-33. [Medline].

  12. Beal SL, Oreskovich MR. Long-term disability associated with flail chest injury. Am J Surg. Sep 1985;150(3):324-6. [Medline].

  13. Kishikawa M, Minami T, Shimazu T, et al. Laterality of air volume in the lungs long after blunt chest trauma. J Trauma. Jun 1993;34(6):908-12; discussion 912-3. [Medline].

  14. Freedland M, Wilson RF, Bender JS, Levison MA. The management of flail chest injury: factors affecting outcome. J Trauma. Dec 1990;30(12):1460-8. [Medline].

  15. Albaugh G, Kann B, Puc MM, et al. Age-adjusted outcomes in traumatic flail chest injuries in the elderly. Am Surg. Oct 2000;66(10):978-81. [Medline].

  16. Athanassiadi K, Gerazounis M, Theakos N. Management of 150 flail chest injuries: analysis of risk factors affecting outcome. Eur J Cardiothorac Surg. Aug 2004;26(2):373-6. [Medline]. [Full Text].

  17. Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg. Spring 2008;20(1):39-45. [Medline].

  18. Bibas BJ, Bibas RA. Operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate. Eur J Cardiothorac Surg. Jun 2006;29(6):1064-6. [Medline]. [Full Text].

  19. Cavanaugh JM. The biomechanics of thoracic trauma. In: Nahum AM, Melvin JW, eds. Accidental Injury: Biomechanics and Prevention. New York, NY: Springer-Verlag; 1993.

  20. Ciraulo DL, Elliott D, Mitchell KA, Rodriguez A. Flail chest as a marker for significant injuries. J Am Coll Surg. May 1994;178(5):466-70. [Medline].

  21. Keel M, Meier C. Chest injuries - what is new?. Curr Opin Crit Care. Dec 2007;13(6):674-9. [Medline].

  22. Landercasper J, Cogbill TH, Strutt PJ. Delayed diagnosis of flail chest. Crit Care Med. Jun 1990;18(6):611-3. [Medline].

  23. Mayberry JC, Ham LB, Schipper PH, Ellis TJ, Mullins RJ. Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. J Trauma. Mar 2009;66(3):875-9. [Medline].

  24. Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg. Jan 2009;33(1):14-22. [Medline].

  25. Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg. Oct 1982;196(4):481-7. [Medline]. [Full Text].

  26. Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion. J Am Coll Surg. Aug 1998;187(2):130-8. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials
 National Guidelines Clearinghouse

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Keywords

flail chest, chest trauma, rib fractures, sternum fractures, thoracic trauma, thoracic injuries, blunt chest trauma, blunt force chest trauma, stove-in chest motor vehicle accident, sternal absence, total sternectomy

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Contributor Information and Disclosures

Author

H Scott Bjerke, MD, FACS, Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine, Medical Director of Trauma Services, Methodist Hospital, Clarian Health Partners, Inc
H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Lewis J Kaplan, MD, FACS, FCCM, FCCP, Director, SICU and Surgical Critical Care Fellowship, Associate Professor, Department of Surgery, Section of Trauma, Surgical Critical Care, and Surgical Emergencies, Yale University School of Medicine
Lewis J Kaplan, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association for Surgical Education, Connecticut State Medical Society, Eastern Association for the Surgery of Trauma, International Trauma Anesthesia and Critical Care Society, Society for the Advancement of Blood Management, Society of Critical Care Medicine, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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