Article Commentary: Contemporary Management of Flail Chest

Abstract

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.

Meta-Analysis on Comparison of Therapeutic Effects of Different Treatment Methods on Multiple Rib Fractures

“…In addition, hemodynamic instability like the progressive hemothorax and delayed hemothorax, is also one of the indications of surgical treatment. Therefore, the change degree of chest volume within 24-48 hours, the dislocation degree of fracture end and the influence on the respiratory function should be considered when we assess whether a patient with multiple rib fractures should be treated surgically or non-surgically [5]. The timing of surgery is not unified at present.…”

“…The thorax has relatively good stability, and it is usually considered that the rib fractures without flail chest are relatively stable and have little influence on the chest even if many ribs are broken. Some patients with severe flail chest are still treated with analgesia, chest bandage for fixation, backplate for fixation, rest in bed, bronchoscopy and aspiration of sputum, mechanical or artificial ventilation [4][5]. The treatment of rib fractures has changed with the rapid development of surgery, and especially, the studies in recent years have made positive and objective comments on the treatment effect of surgery [6][7][8][9][10][11], but applying surgical intervention in the treatment of rib fractures is still very controversial and challenging.…”

Rib Fractures, Flail Chest, and Pulmonary Contusion

“…This will prevent iatrogenic barotrauma in the uninjured lung from the higherpressure settings necessary to inflate the injured lung. If a patient with pulmonary contusion also meets criteria for flail chest ORIF, most agree that this should only be attempted after resolution of pulmonary contusion [48]. Patients with a unilateral pulmonary contusion and flail chest may not tolerate the Bgood lung down^lateral positioning necessary in the operating room to address the injured hemichest and the benefit of early extubation seen in patients with flail chest without pulmonary contusion is less likely to materialize.…”

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“…Flail chest: The flail chest is an uncommon lesion that usually occurs with a high speed vehicular accident. It is commonly characterized by three or more rib fractures in two or more sites, with or without sternal lesion [13] where the injured segment of the thoracic wall show paradoxical respiratory movement, mechanical respiratory dysfunction, and frequent respiratory failure. 75% of the cases are associated with pulmonary contusion, which produces an inflammatory response with right to left shunts, resulting in severe hypoxia, severe pulmonary restriction with the need of tracheal intubation and pulmonary ventilation.…”