Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks under extreme stress and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. The number of ribs that must be broken varies by differing definitions: some sources say at least two adjacent ribs are broken in at least two places, some require three or more ribs in two or more places. The flail segment moves in the opposite direction to the rest of the chest wall: because of the ambient pressure in comparison to the pressure inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This so-called "paradoxical breathing" is painful and increases the work involved in breathing.
Flail chest is usually accompanied by a pulmonary contusion, a bruise of the lung tissue that can interfere with blood oxygenation. Often, it is the contusion, not the flail segment, that is the main cause of respiratory problems in people with both injuries. Two of the symptoms of flail chest are chest pain and shortness of breath. 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" does not appear to be merited. 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. The respiratory failure from the flail chest requires mechanical ventilation and a longer stay in an intensive care unit. It is the damage to the lungs from the flail segments that are life-threatening. The most common reason for flail chest injuries are vehicle collisions, which account for 76% of flail chest injuries. Another main cause of flail chest injuries results from falling which is mainly elderly related. The elderly 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. This 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– for flail chest to occur a significant impact is required, breaking the ribs in two or more places. 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. Mobilization of the chest and pectoral muscle stretch. During inspiration, the person will clasp hands behind the head and will horizontally abduct the arms.
Surgical fixation can help in significantly reducing the duration of ventilatory support and in conserving the pulmonary function. 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.
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