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

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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, MSc, DSc, 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; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, 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 Professor of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the 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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