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ib cage out pressure in the thorax decreases below atmospheric pressure and air rushes in through the trachea the flail segment will be pulled in with the decrease in pressure while the rest of the rib cage expands during normal expiration the diaphragm and intercostal muscles relax increasing internal pressure allowing the abdominal organs to push air upwards and out of the thorax however a flail segment will also be pushed out while the rest of the rib cage contracts paradoxical motion is a late sign of flail segment therefore an absence of paradoxical motion does not mean the patient does not have a flail segment the constant motion of the ribs in the flail segment at the site of the fracture is extremely painful and untreated the sharp broken edges of the ribs are likely to eventually puncture the pleural sac and lung possibly causing a pneumothorax the concern about mediastinal flutter the shift of the mediastinum with paradoxical diaphragm movement does not appear to be merited 8 pulmonary contusions are commonly associated with flail chest and that can lead to respiratory failure this is due to the paradoxical motions of the chest wall from the fragments interrupting normal breathing and chest movement typical paradoxical motion is associated with stiff lungs which requires extra work for normal breathing and increased lung resistance which makes air flow difficult 9 the respiratory failure from the flail chest requires mechanical ventilation and a longer stay in an intensive care unit 10 it is the damage to the lungs from the flail segment that is life threatening causes edit diagrams depicting the paradoxical motion observed during respiration with a flail segment the most common causes of flail chest injuries are vehicle collisions which account for 76 of flail chest injuries 11 another main cause of flail chest injuries is falling this mainly occurs in the elderly who are more impacted by the falls as a result of their weak and frail bones unlike their younger counterparts who can fall without being impacted as severely falls account for 14 of flail chest injuries 1 flail chest typically occurs when three or more adjacent ribs are fractured in two or more places allowing that segment of the thoracic wall to displace and move independently of the rest of the chest wall flail chest can also occur when ribs are fractured proximally in conjunction with disarticulation of costal cartilages distally for the condition to occur generally there must be a significant force applied over a large surface of the thorax to create the multiple anterior and posterior rib fractures rollover and crushing injuries most commonly break ribs at only one point whereas for flail chest to occur a significant impact is required breaking the ribs in two or more places 12 this can be caused by forceful accidents such as the aforementioned vehicle collisions or significant falls in the elderly it can be caused by deterioration of bone although rare in children the majority of flail chest injuries result from common blunt force traumas or metabolic bone diseases including a group of genetic disorders known as osteogenesis imperfecta 13 diagnosis edit a chest radiograph of a flail chest associated with right sided pulmonary contusion and subcutaneous emphysema diagnosis is by physical examination performed by a physician the diagnosis may be assisted or confirmed by use of medical imaging with either plain x ray or ct scan paradoxial movements of flail segments crepitus and tenderness near fractured ribs treatment edit treatment of the flail chest initially follows the principles of advanced trauma life support further treatment includes good pain management includes early regional anesthesia e g intercostal blocks or erector spinae plane blocks 14 and avoiding opioid pain medication as much as possible this allows much better ventilation with improved tidal volume and increased blood oxygenation positive pressure ventilation meticulously adjusting the ventilator settings to avoid pulmonary barotrauma chest tubes as required adjustment of position to make the person most comfortable and provide relief of pain aggressive pulmonary toilet a person may be intubated with a double lumen tracheal tube in a double lumen endotracheal tube each lumen may be connected to a different ventilator usually one side of the chest is affected more than the other so each lung may require drastically different pressures and flows to adequately ventilate surgical fixation can help in significantly reducing the duration of ventilatory support and in conserving the pulmonary function 15 surgical intervention has also been shown to reduce the need for tracheostomy reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event 16 physiotherapy edit in order to begin a rehabilitation program for a flail chest it is important to treat the person s pain so they are able to perform the proper exercises due to the underlying conditions that the flail segment has caused onto the respiratory system chest physiotherapy is important to reduce further complications proper positioning of the body is key including postural alignment for proper drainage of mucous secretions 17 the therapy will consist of a variety of postural positioning and changes in order to increase normal breathing along with postural repositioning a variety of breathing exercises are also very important in order to allow the chest wall to reposition itself back to normal conditions breathing exercises will also include coughing procedures 17 furthermore range of motion exercises are given to reduce the atrophy of the musculature 18 with progression resistance exercises are added to the regimen to the shoulder and arm of the side containing the injury moreover trunk exercises will be introduced while sitting and will progress to during standing 19 hip flexion exercises can be done to expand the thorax this is done by lying supine on a flat surface flexing the knees and hips and bringing them in toward the chest the knees should come in toward the chest while the person inhales and exhale when the knees are lowered 19 this exercise can be done in 3 sets of 6 8 repetitions with a pause in between sets the person should always make sure to maintain controlled breaths 19 eventually the person will be progressed to walking and posture correction while walking 19 before the person is discharged from the hospital the person should be able to perform mobility exercises to the core and should have attained good posture mobilization of the chest and pectoral muscle stretch during inspiration the person will clasp hands behind the head and will horizontally abduct the arms during exhalation the person will bend forward bringing the elbows together prognosis edit the death rate of people with flail chest depends on the severity of their condition ranging from 10 to 25 1 a systematic review comparing the safety and effectiveness of surgical fixation versus non surgical methods for the treatment of flail chest reported that there was no statistically significant difference in the reported deaths between patients treated surgically and those treated non surgically i e with conservative management methods the results of the systematic review suggested that surgical intervention reduces the need for tracheostomy reduces the time spent in the intensive care unit following a traumatic flail chest injury and could reduce the risk of acquiring pneumonia after such an event 20 epidemiology edit approximately 1 out of 13 people admitted to the hospital with fractured ribs are found to have flail chest 21 references edit 1 2 3 4 athanassiadi kalliopi michalis gerzounis nikolaos theakos management of 150 flail chest injuries analysis of risk factors affecting outcome european journal of cardio thoracic surgery 26 2004 pg 373 376 emergency nurses association 2005 lorene newberry laura m criddle eds sheehy s manual of emergency care 6th ed st louis missouri elsevier mosby pp 655 657 keel m meier c december 2007 chest injuries what is new current opinion in critical care 13 6 674 9 doi 10 1097 mcc 0b013e3282f1fe71 pmid 17975389 s2cid 19317500 overview paradoxical breathing oxford reference retrieved 7 sep 2013 yamamoto l schroeder c morley d beliveau c 2005 thoracic trauma the deadly dozen critical care nursing quarterly 28 1 22 40 doi 10 1097 00002727 200501000 00004 pmid 15732422 hemmila mr wahl wl 2005 management of the injured patient in doherty gm ed current surgical diagnosis and treatment mcgraw hill medical p 214 isbn 0 07 142315 x retrieved 2008 07 04 coughlin ta ng jw rollins ke forward dp ollivere bj august 2016 management of rib fractures in traumatic flail chest a meta analysis of randomised controlled trials the bone joint journal 98 b 8 1119 25 doi 10 1302 0301 620x 98b8 37282 pmid 27482027 molnar tf 2007 video assisted thoracoscopic surgery getting started j minim access surg 3 4 173 7 doi 10 4103 0972 9941 38912 pmc 2749201 pmid 19789679 bemelman m poeze m blokhuis tj leenen lp 2010 historic overview of treatment techniques for rib facturs and flail chest eur j trauma emerg surg 36 5 407 415 doi 10 1007 s00068 010 0046 5 pmc 3150827 pmid 21841952 marasco sf davies ar cooper j varma d bennett v nevill r lee g bailey m fitzgerald m 2013 prospective randomized controlled trial of operative rib fixation in traumatic flail chest journal of the american college of surgeons 216 5 924 932 doi 10 1016 j jamcollsurg 2012 12 024 pmid 23415550 borman jb l aharonson daniel b savitsky et al unilateral flail chest is seldom a lethal injury emerg med j 23 2006 p 903 905 bjerke h scott 2006 06 16 flail chest emedicine retrieved 2007 08 01 gipson cl tobias jd 2006 flail chest in a neonate resulting from nonaccidental trauma southern medical journal 99 5 536 538 doi 10 1097 01 smj 0000216471 54786 e5 pmid 16711322 mladenovic jordanna erskine ryan n riley brooke mitchell andrew abi fares catherine basson willem anstey chris white leigh 2022 11 01 the association between erector spinae plane block timing and reduced rib fracture related respiratory complications a cohort study journal of clinical anesthesia 82 110940 doi 10 1016 j jclinane 2022 110940 hdl 10072 421776 issn 0952 8180 pmid 35917775 s2cid 251206240 granetzny a abd el aal m emam e shalaby a boseila a 2005 surgical versus conservative treatment of flail chest evaluation of the pulmonary status interact cardiovasc thorac surg 4 6 583 7 doi 10 1510 icvts 2005 111807 pmid 17670487 apampa ayobobola a ali ayesha kadir bryar ahmed zubair 2021 02 06 safety and effectiveness of surgical fixation versus non surgical methods for the treatment of flail chest in adult populations a systematic review and meta analysis european journal of trauma and emergency surgery 48 2 1025 1034 doi 10 1007 s00068 021 01606 2 issn 1863 9941 pmc 7866961 pmid 33547910 1 2 ciesla nancy d chest physical therapy for patients in the intensive care unit journal of the american physical therapy association 1996 76 609 625 kigin colleen m chest physical therapy for the postoperative or traumatic injury patient journal of the american physical therapy association 1981 61 1724 1736 1 2 3 4 post operative physiotherapy management for flail chest or multiple ribs fracture or cardio pulmonary rehabilitation or physiotherapy or physical therapy or flail chest or bpt or mpt or pt or project report or case study or medical field or mgr medical university or senthil kumar bpt pdf thorax lung scribd retrieved 2023 10 12 apampa ayobobola a ali ayesha kadir bryar ahmed zubair 2022 04 01 safety and effectiveness of surgical fixation versus non surgical methods for the treatment of flail chest in adult populations a systematic review and meta analysis european journal of trauma and emergency surgery 48 2 1025 1034 doi 10 1007 s00068 021 01606 2 issn 1863 9941 pmc 7866961 richardson j david m d lee adams m d lewis m flint m d selective management of flail chest and pulmonary contusion department of surgery university of louisville school of medicine louisville kentucky external links edit rib fractures flail chest at trauma org info images and video of paradoxical flail segment motion classification d icd 10 s22 5 icd 9 cm 807 4 mesh d005409 diseasesdb 32227 snomed ct 78011002 external resources emedicine med 2813 v t e fractures and cartilage damage general avulsion fracture chalkstick fracture greenstick fracture open fracture pathologic fracture spiral fracture head basilar skull fracture blowout fracture mandibular fracture nasal fracture le fort fracture of skull zygomaticomaxillary complex fracture zygoma fracture spinal fracture cervical fracture burst fracture chance fracture clay shoveler fracture craniocervical instability flexion teardrop fracture hangman s fracture holdsworth fracture jefferson fracture vertebral compression fracture ribs rib fracture sternal fracture shoulder fracture clavicle scapular arm fracture humerus fracture proximal supracondylar holstein lewis fracture forearm fracture ulna fracture monteggia fracture hume fracture radius fracture distal radius galeazzi colles chauffeur s smith s barton s essex lopresti fracture hand fracture scaphoid rolando bennett s boxer s busch s broken finger pelvic fracture duverney fracture pipkin fracture leg tibia fracture bumper fracture segond fracture gosselin fracture toddler s fracture pilon fracture plafond fracture tillaux fracture fibular fracture maisonneuve fracture le fort fracture of ankle bosworth fracture combined tibia and fibula fracture trimalleolar fracture bimalleolar fracture pott s fracture crus fracture patella fracture femoral fracture hip fracture foot fracture lisfranc jones cuneiform march calcaneal broken toe v t e trauma principles polytrauma major trauma traumatology triage resuscitation trauma triad of death assessment clinical prediction rules abbreviated injury scale injury severity score naca score revised trauma score investigations diagnostic peritoneal lavage focused assessment with sonography for trauma management principles advanced trauma life support damage control surgery early appropriate care trauma center trauma surgery trauma team procedures resuscitative thoracotomy pathophysiology injury msk bone fracture degloving joint dislocation soft tissue injury respiratory diaphragmatic rupture flail chest hemothorax pneumothorax pulmonary contusion cardio cardiac tamponade internal bleeding thoracic aorta injury gi blunt kidney trauma splenic injury neuro intracranial hemorrhage penetrating head injury traumatic brain injury mechanism blast injury blunt trauma burn crush injury electrocution gunshot wound penetrating trauma stab wound region abdominal trauma chest injury facial trauma head injury spinal cord injury demographic geriatric trauma pediatric trauma complications acute respiratory distress syndrome chronic tra...