Flail Chest Workup: Laboratory Studies, Imaging Studies

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Flail Chest

Workup

Laboratory Studies

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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. See the image below.

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

See the list below:

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.^[7]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. See the image below.

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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Treatment & Management

Kilic D, Findikcioglu A, Akin S, Akay TH, Kupeli E, Aribogan A, et al. Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location. Thorac Cardiovasc Surg. 2011 Feb. 59(1):45-8. [Medline].
Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J Trauma. 1990 Nov. 30(11):1356-65. [Medline].
Landercasper J, Cogbill TH, Lindesmith LA. Long-term disability after flail chest injury. J Trauma. 1984 May. 24(5):410-4. [Medline].
Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J Thorac Cardiovasc Surg. 1995 Dec. 110(6):1676-80. [Medline].
Borman JB, Aharonson-Daniel L, Savitsky B, Peleg K. Unilateral flail chest is seldom a lethal injury. Emerg Med J. 2006 Dec. 23(12):903-5. [Medline]. [Full Text].
Gipson CL, Tobias JD. Flail chest in a neonate resulting from nonaccidental trauma. South Med J. 2006 May. 99(5):536-8. [Medline].
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. 2007 Oct. 14(5):297-310. [Medline].
Trinkle JK, Richardson JD, Franz JL, et al. Management of flail chest without mechanical ventilation. Ann Thorac Surg. 1975 Apr. 19(4):355-63. [Medline].
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. 2005 May. 22(5):325-9. [Medline]. [Full Text].
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].
Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: an underused procedure?. Am Surg. 2007 Jun. 73(6):591-6; discussion 596-7. [Medline].
Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin. 2007 Feb. 17(1):25-33. [Medline].
Althausen PL, Shannon S, Watts C, Thomas K, Bain MA, Coll D, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011 Nov. 25(11):641-7. [Medline].
Fitzpatrick DC, Denard PJ, Phelan D, Long WB, Madey SM, Bottlang M. Operative stabilization of flail chest injuries: review of literature and fixation options. Eur J Trauma Emerg Surg. 2010 Oct. 36(5):427-433. [Medline]. [Full Text].
Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011 Jan 5. 93(1):97-110. [Medline].
Cataneo AJ, Cataneo DC, de Oliveira FH, Arruda KA, El Dib R, de Oliveira Carvalho PE. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev. 2015 Jul 29. CD009919. [Medline].
Doben AR, Eriksson EA, Denlinger CE, Leon SM, Couillard DJ, Fakhry SM, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care. 2014 Feb. 29(1):139-43. [Medline].
Slobogean GP, MacPherson CA, Sun T, Pelletier ME, Hameed SM. Surgical fixation vs nonoperative management of flail chest: a meta-analysis. J Am Coll Surg. 2013 Feb. 216(2):302-11.e1. [Medline].
Beal SL, Oreskovich MR. Long-term disability associated with flail chest injury. Am J Surg. 1985 Sep. 150(3):324-6. [Medline].
Kishikawa M, Minami T, Shimazu T, et al. Laterality of air volume in the lungs long after blunt chest trauma. J Trauma. 1993 Jun. 34(6):908-12; discussion 912-3. [Medline].
Freedland M, Wilson RF, Bender JS, Levison MA. The management of flail chest injury: factors affecting outcome. J Trauma. 1990 Dec. 30(12):1460-8. [Medline].
Albaugh G, Kann B, Puc MM, et al. Age-adjusted outcomes in traumatic flail chest injuries in the elderly. Am Surg. 2000 Oct. 66(10):978-81. [Medline].
Athanassiadi K, Gerazounis M, Theakos N. Management of 150 flail chest injuries: analysis of risk factors affecting outcome. Eur J Cardiothorac Surg. 2004 Aug. 26(2):373-6. [Medline]. [Full Text].
Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014 Feb. 76(2):462-8. [Medline].
Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg. 2008 Spring. 20(1):39-45. [Medline].
Bibas BJ, Bibas RA. Operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate. Eur J Cardiothorac Surg. 2006 Jun. 29(6):1064-6. [Medline]. [Full Text].
Cavanaugh JM. The biomechanics of thoracic trauma. Nahum AM, Melvin JW, eds. Accidental Injury: Biomechanics and Prevention. New York, NY: Springer-Verlag; 1993.
Ciraulo DL, Elliott D, Mitchell KA, Rodriguez A. Flail chest as a marker for significant injuries. J Am Coll Surg. 1994 May. 178(5):466-70. [Medline].
Keel M, Meier C. Chest injuries - what is new?. Curr Opin Crit Care. 2007 Dec. 13(6):674-9. [Medline].
Landercasper J, Cogbill TH, Strutt PJ. Delayed diagnosis of flail chest. Crit Care Med. 1990 Jun. 18(6):611-3. [Medline].
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. 2009 Mar. 66(3):875-9. [Medline].
Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indications, technical issues, and future directions. World J Surg. 2009 Jan. 33(1):14-22. [Medline].
Richardson JD, Adams L, Flint LM. Selective management of flail chest and pulmonary contusion. Ann Surg. 1982 Oct. 196(4):481-7. [Medline]. [Full Text].
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. 1998 Aug. 187(2):130-8. [Medline].
Farquhar J, Almahrabi Y, Slobogean G, Slobogean B, Garraway N, Simons RK, et al. No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study. Can J Surg. 2016 Aug 1. 59 (4):515. [Medline].

Media Gallery

Image depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result.
Multiple left rib fractures, pulmonary contusion, and hemothorax in an elderly man after a motor vehicle accident.
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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Author

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

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, Midwest Surgical Association, Royal Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc, Mediwound.

Chief Editor

John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, AGAF 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, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Lewis J Kaplan, MD, FACS, FCCM, FCCP Associate Professor of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania; Section Chief, Surgical Critical Care, Philadelphia Veterans Affairs Medical Center

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, Surgical Infection Society

Disclosure: Nothing to disclose.

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