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Flail Chest Mechanism

Flail Chest Definition

Flail chest is an injury associated with the rib cage. It is known as rib fractures in at least four consecutive costals ipsilaterally. ^[1] The fractures must be in at least two places to create fragments. These segments then move independently of the rib cage.

Causes

A flail chest occurs by blunt force trauma to the thoracic cavity in any direction causing costal fractures in at least two segments, instead of a single fracture that is commonly seen. This can be caused by a significant fall, car accident or other forceful accidents. In the elderly, it can be caused by deterioration of bone, although rare. In children, the majority of flail chest injuries can be a result of the common blunt force traumas or metabolic bone diseases, one known as osteogenesis imperfecta. ^[2] $This picture demonstrates the placement of fractures in a chest that would be considered a flail chest versus a normal chest fracture in one segment of a rib.$

Paradoxical Movement

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. Paradoxical motion is when the chest wall projects out during expiration and depresses in during inspiration. ^[3] This movement can be fatal because since the chest cannot expand correctly when inhaling it cannot take in the proper amount of air needed for the body. Typical paradoxical motion is associated with stiff lungs, which requires extra work for normal breathing, and increased lung resistance, which makes air flow difficult. ^[4] The respiratory failure from the flail chest requires mechanical ventilation and a longer stay in an intensive care unit. ^[5] It is the damage to the lungs from the flail segments that are life-threatening.

File:Paradoxical movement.png

This shows the paradoxical movement of the lungs due to the flail chest segements.

^ Zegg M, Kammerlander C, Schmid S, Roth T, Kammerlander-Knauer U, Gosch M, and Luger T. Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures. Geriatric Orthopaedic Surgery & Rehabilition 3(4): 164-166, 2012.
^ Gipson CL and Tobias JD. Flail Chest in a Neonate Resulting from Nonaccidental Trauma. Southern Medical Journal 99(5): 536-538, 2006.
^ Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, and Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest – outcomes of patients with or without pulmonary contusion. Journal of the American College of Surgeons 187(2): 130-138, 1998.
^ Bemelman M, Poeze M, Blokhuis TJ, and Leenen LP. Historic overview of treatment techniques for rib facturs and flail chest. Eur J Trauma Emerg Surg. 36(5): 407-415, 2010.
^ Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M, & Fitzgerald M. Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest. Journal of the American College of Surgeons 216(5): 924-932, 2013.

[1] Zegg M, Kammerlander C, Schmid S, Roth T, Kammerlander-Knauer U, Gosch M, and Luger T. Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures. Geriatric Orthopaedic Surgery & Rehabilition 3(4): 164-166, 2012.

[2] Gipson CL and Tobias JD. Flail Chest in a Neonate Resulting from Nonaccidental Trauma. Southern Medical Journal 99(5): 536-538, 2006.

[3] Voggenreiter G, Neudeck F, Aufmkolk M, Obertacke U, and Schmit-Neuerburg KP. Operative chest wall stabilization in flail chest – outcomes of patients with or without pulmonary contusion. Journal of the American College of Surgeons 187(2): 130-138, 1998.

[4] Bemelman M, Poeze M, Blokhuis TJ, and Leenen LP. Historic overview of treatment techniques for rib facturs and flail chest. Eur J Trauma Emerg Surg. 36(5): 407-415, 2010.

[5] Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, Lee G, Bailey M, & Fitzgerald M. Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest. Journal of the American College of Surgeons 216(5): 924-932, 2013.