|
|
| Line 4: |
Line 4: |
| {{CMG}} | | {{CMG}} |
|
| |
|
| ==Overview== | | ==[[Flail chest overview|Overview]]== |
| A ''flail chest'' is a life-threatening medical condition that occurs when a segment of the [[chest]] wall 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,<ref name="mancare">{{cite book|last=Emergency Nurses Association|title=Sheehy's Manual of Emergency Care|coauthors=Lorene Newberry (ed), Laura M. Criddle (ed) |publisher=Elsevier Mosby|location=St Loius, Missouri|date=2005|edition=6th|pages=655–657}}</ref> some require three or more ribs in two or more places.<ref name="Keel07">
| |
| {{
| |
| cite journal |author=Keel M, Meier C |title=Chest injuries - what is new? |journal=Current Opinion in Critical Care |volume=13 |issue=6 |pages=674–9 |year=2007 |month=December |pmid=17975389 |doi=10.1097/MCC.0b013e3282f1fe71 }}</ref> The flail segment moves in the opposite direction as 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 motion" can increase the work and pain involved in breathing. Studies have found that up to half of people with flail chest die. Flail chest is invariably accompanied by [[pulmonary contusion]], a bruise of the lung tissue that can interfere with blood oxygenation.<ref name="Yamamoto05">{{cite journal |author=Yamamoto L, Schroeder C, Morley D, Beliveau C |title=Thoracic trauma: The deadly dozen |journal=Critical Care Nursing Quarterly |volume=28 |issue=1 |pages=22-40 |year=2005 |pmid=15732422 |doi= |url=}}</ref> Often, it is the contusion, not the flail segment, that is the main cause of respiratory failure in patients with both injuries.<ref name="Dohert05">{{cite book |author= Hemmila MR, Wahl WL |chapter= Management of the injured patient |editor=Doherty GM |title=Current Surgical Diagnosis and Treatment |publisher=McGraw-Hill Medical |location= |year=2005 |pages= 214 |isbn=0-07-142315-X |oclc= |doi= |accessdate=2008-07-04 |url= http://books.google.com/books?id=c3I-PFkMN2YC&pg=PA863&dq=%22level+of+consciousness%22&lr=&client=firefox-a&sig=ACfU3U084SW9323Y0i399lPQxCu2AeJlBw}}</ref>
| |
|
| |
|
| ==Causes== | | ==[[Flail chest historical perspective|Historical Perspective]]== |
|
| |
|
| It is a serious, life-threatening chest injury often associated with underlying pulmonary injury and is most commonly seen in cases of significant blunt trauma.
| | ==[[Flail chest pathophysiology|Pathophysiology]]== |
|
| |
|
| This typically occurs when three or more 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 costochondral 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.<ref name="flailbje">
| | ==[[Flail chest causes|Causes]]== |
| {{cite web
| |
| | last =Bjerke
| |
| | first =H Scott
| |
| | authorlink =
| |
| | title = Flail Chest
| |
| | publisher = eMedicine
| |
| | date = June 16, 2006
| |
| | url = http://www.emedicine.com/med/topic2813.htm
| |
| | accessdate = 2007-08-04 }}
| |
| </ref>
| |
|
| |
|
| ==Presentation== | | ==[[Flail chest differential diagnosis|Differentiating Flail chest from other Diseases]]== |
|
| |
|
| The characteristic paradoxical motion of the flail segment occurs due to pressure changes associated with respiration that the rib cage normally resists:
| | ==[[Flail chest epidemiology and demographics|Epidemiology and Demographics]]== |
|
| |
|
| * During normal inspiration, the diaphragm contracts and intercostal muscles push the rib cage out. Pressure in the thorax decreases below atmospheric pressure, and air rushes in through the trachea. However, a flail segment will not resist the decreased pressure and will appear to push in while the rest of the rib cage expands.
| | ==[[Flail chest natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * During normal expiration, the diaphragm and intercostal muscles relax, 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.
| |
|
| |
|
| The constant motion of the ribs in the flail segment at the site of the fracture is exquisitely painful, and, untreated, the sharp broken edges of the ribs are likely to eventually puncture the pleural sac and lung, which may be fatal.
| | ==Diagnosis== |
|
| |
|
| ==Diagnostic Findings==
| | [[Flail chest history and symptoms|History and Symptoms]] | [[Flail chest physical examination|Physical Examination]] | [[Flail chest laboratory findings|Laboratory Findings]] | [[Flail chest chest x ray|Chest X Ray]] | [[Flail chest CT|CT]] | [[Flail chest other imaging findings|Other Imaging Findings]] |
| | |
| <gallery>
| |
| Image:Rib fracture 101.jpg|CT: Rib fracture
| |
| Image:Rib fracture 102.jpg|CT: Rib fracture
| |
| Image:Rib-fractures-bone-scan-001.jpg|Bone scan demonstrates multiple rib fractures
| |
| </gallery>
| |
|
| |
|
| ==Treatment== | | ==Treatment== |
|
| |
|
| Treatment of the flail chest initially follows the principles of [[Advanced Trauma Life Support]]. Further treatment includes:
| | [[Flail chest medical therapy|Medical Therapy]] | [[Flail chest surgery|Surgery]] | [[Flail chest cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Flail chest future or investigational therapies|Future or Investigational Therapies]] |
| * Good analgesia including intercostal blocks, avoiding narcotic analgesics as much as possible. This allows much better [[ventilation]], with improved [[tidal volume]], and increased blood [[oxygenation]].
| |
| * Positive ventilation, meticulosly adjusting the ventilator settings to avoid [[barotrauma]].
| |
| * [[Chest tube]]s as required.
| |
| * Adjustment of position to make the patient most comfortable and provide relief of pain.
| |
| | |
| Surgical fixation is usually not required.
| |
| | |
| ==Videos: Flail Chest==
| |
| | |
| {{#ev:youtube|e0VNBDbr67U}}
| |
| | |
| | |
| {{#ev:youtube|OzBmQi5rgTE}}
| |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
|
| |
|
| | ==Case Studies== |
| | [[Flail chest case study one|Case #1]] |
|
| |
|
| {{Fractures}} | | {{Fractures}} |
| {{chest trauma}} | | {{chest trauma}} |
|
| |
|
| |
|
| [[Category:Chest trauma]] | | [[Category:Chest trauma]] |