Flail Chest
Original Editor - Jennifer Lohmus
Contributions Made By - Collin Lim
Muscles of Respiration[edit | edit source]
Refer to the Physiopedia page below for clinically relevant anatomy and how the muscles involved in breathing mechanics operate
Pathophysiology[edit | edit source]
“A break in the structural continuity of the bone” that can be caused by trauma, stress and pathological factors." (Apley, Solomon, Warwick, Nayagam & Apley, 2005)
Types:
- Complete
- Incomplete
- Physeal
Classification according to the nature of the fracture:
- Spiral
- Transverse
- Comminuted
- Compression
Associated conditions:[edit | edit source]
Pulmonary complications 48-72 hours after admission (Battle, Hutchings, James, & Evans, 2013):
- Haemothorax
- Pneumothorax
- Atelectasis
- Pneumonia
- Pleural effusion
- Subcutaneous emphysema
- ARDS (Acute Respiratory Distress Syndrome)
- Pulmonary emboli
- Aspiration
- Lobar collapse
Risk factors for developing associated conditions (Battle, Hutchings, James, & Evans, 2013):
- >65 years old
- >3 rib fractures
- Hx. of chronic lung conditions or CVD
- Pre-injury anti-coagulant use
- <90% SpO2
Clinical Presentation[edit | edit source]
A flail segment is a portion of the rib cage that breaks due to trauma and becomes unattached from the chest wall. (Pettiford, Luketich & Landreneau, 2007). Generation of negative intrapleural pressure indicates a true paradoxical flail segment (May, Hillermann & Patil, 2015).
Diagnostic Procedures[edit | edit source]
Radiologists use Chest X-Rays to look for the following:
“Three or more adjacent ribs are fractured in two or more places. Clinically this can be a segment of only one or two ribs can act as a flail segment” (Stanislavsky, 2018).
Outcome Measures[edit | edit source]
Physiotherapy Management / Interventions[edit | edit source]
Chest physiotherapy management consists of the following:
1. Ventilatory Management - supplemental oxygen therapy, continuous positive airway pressure or intubation if necessary (May, Hillermann & Patil, 2016)
- CPAP - for negative intrapleural pressure and paradoxical movement, increases TV (May, Hillermann & Patil, 2015)
- Open/closed suction if patient intubated (Berney, Haines & Denehy, 2012)
2. Pain Management and Education (May, Hillermann & Patil, 2016)
- Education on fracture healing
3. Early mobilization if possible (May, Hillermann & Patil, 2016)
- Transfers to sitting out of bed
- Mobilization 2-3x daily and SOOB 3-4x/day
4. Chest and airway clearance techniques (if inadequate) (May, Hillermann & Patil, 2016)
- ACT: nebulizer with ACBT and education
- Bubble PEP or Flutter
5. Deep breathing exercises and supported coughing technique (May, Hillermann & Patil, 2016)
- Supported Cough: Wrap around technique or rolled up towel
- DBE/TEE’s with SMIs (2-4 secs hold)
6. Positioning (Berney, Haines & Denehy, 2012)
- Positioning in side lying and high sitting
Medical Management[edit | edit source]
Medications: (May, Hillermann & Patil, 2016)
- Simple Analgesics
- Opioids
- Patient Controlled Analgesia
- Operative fixation and Regional Anaesthetic
Surgery:
Conservative (May, Hillermann & Patil, 2016)
- Regional anaesthesia
- Serratus anterior block
- Paravertebral block
- Thoracic epidural
Internal fixation (May, Hillermann & Patil, 2015)
- Decreases stay in ICU and MV duration (Leinicke et al., 2013)
- Similar to thoracotomy but incision but spares Latissimus Dorsi
- Anterior # - plates and locking screws
- Posterior # - intramedullary splints
Resources[edit | edit source]
https://www.rch.org.au/trauma-service/manual/chest-injury/
https://www.wcpt.org/wcpt2017/FS-01
References[edit | edit source]
- Battle C, Hutchings H, Evans PA. Blunt chest wall trauma: A review. Trauma. 2013;15(2):156-75.
2. Berney S, Haines K, Denehy L. Physiotherapy in Critical Care in Australia. Cardiopulmonary Physical Therapy. 2012;23(1):19-25.
3. Jena R, Agrawal A, Sandeep Y, Shrikhande N. Understanding of flail chest injuries and concepts in management. International Journal of Studentsí Research. 2016;6(1):3-5.
4. Leinicke AJ, Elmore DL, Freeman AB, Colditz AG. Operative Management of Rib Fractures in the Setting of Flail Chest: A Systematic Review and Meta-Analysis. Annals of Surgery. 2013;258(6):914-21.
5. May L, Hillermann C, Patil S. Rib fracture management. BJA Education. 2016;16(1):26-32.
6. Pettiford BL, Luketich JD, Landreneau RJ. The Management of Flail Chest. Thoracic Surgery Clinics. 2007;17(1):25-33.
7. Solomon L. Apley's concise system of orthopaedics and fractures. 3rd ed.. ed. Warwick D, Nayagam S, Apley AG, editors. London : New York: London : Hodder Arnold New York : Distributed in the United States by Oxford University Press; 2005.
8. Stanislavsky A. Radiology Reference Article. Flail chest. https://radiopaedia.org/articles/flail-chest (accessed 15 June 2018).
