eMedicine Specialties > Trauma > Thoracic Trauma

Flail Chest: Treatment

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

Treatment

Medical Therapy

Internal pneumatic stabilization for flail chest was popularized in the 1950s, but this treatment has subsequently been shown to be unnecessary in most patients without respiratory compromise. In a mid-1970s report, Trinkle et al provided compelling evidence that many patients fared better with adequate pain control and pulmonary toilet (including medical management of their pulmonary injury) than those placed on mechanical ventilation.7 This remains the standard today. Mechanical ventilation is reserved for patients with persistent respiratory insufficiency or failure after adequate pain control or when complications related to excessive narcotic use occur. Patient-controlled analgesia (PCA) machines, oral pain medications, and indwelling epidural catheters form the mainstay of current treatment.

Two recent clinical reports, one from Turkey (prospective)8 and one from Japan (retrospective),9 showed that continuous positive airway pressure (CPAP) by mask may decrease mortality and nosocomial pneumonia in the ICU, but CPAP by mask does not appear to change the length of ICU stay.

Surgical Therapy

Surgical stabilization of the chest was rarely considered necessary in the past, but increasing numbers of reports of positive outcomes in more severe cases are now available in the world literature. Both external (lower efficacy) and internal stabilization have been advocated, usually in reports from outside the United States. As previously noted in traumatic causes, however, severity of respiratory failure is less a result of either the paradoxical motion of the chest wall (tidal volume abnormalities) or chest wall instability. Accordingly, surgical stabilization is still not routinely performed, although many reports show a benefit in decreasing mechanical ventilator days, long-term outcome, and overall lower cost of hospitalization in  select patients with severe flail chest.10 11

In general, operative fixation is most commonly performed in patients requiring a thoracotomy for other reasons or in cases of gross chest wall deformity. Flail chest from multiple myeloma, sternal absence, or total sternectomy more frequently responds well to surgical fixation. Underlying pulmonary injury with respiratory insufficiency resulting from changes in tidal volume and minute ventilation in these patients is rare.

Preoperative Details

Assessment of the severity of underlying pulmonary contusion versus chest wall instability should direct the need for surgical fixation. Preoperatively, a double-lumen endotracheal tube should be considered in patients with flail chest undergoing fixation.

Intraoperative Details

The current literature suggests that both ends of a fractured rib must be stabilized for operative intervention to be most effective. Judet struts, Kirschner (K-) wires, and even prosthetic mesh secured with methylmethacrylate techniques have been described in the literature, but no large randomized prospective trial has been completed to compare the techniques at this time.  Because of the increasing interest in surgical stabilization, there are multiple commercially available fixation devices within the last few years.

Postoperative Details

Routine postthoracotomy care with ICU or surgical step-down level observation and close monitoring of respiratory parameters is crucial.

Follow-up

Follow-up chest x-rays and pulmonary function tests determine the resolution of underlying pulmonary pathology and any possible long-term disability as a result of the initial condition.

Complications

Reports in the medical literature note a high level of long-term disability in patients sustaining flail chest. Beal and Oreskovich reported a 22% disability rate with over 63% having long-term problems, including persistent chest wall pain, deformity, and dyspnea on exertion.12 Kishikawa et al, however, noted resolution of altered pulmonary function within 6 months, even with chest wall deformity still present.13

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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