Flail Chest

Flail Chest Symptoms:

The most common symptom of flail chest is pain in the right upper quadrant of the chest. Pain may be localized or generalized.

The pain may be intense at rest, but it usually disappears when active activities are performed. Other symptoms include shortness of breath, tightness in the chest, fatigue, nausea and vomiting. The patient may have other symptoms such as cough, fever and chills without any specific cause (see image below).

Image 1: Flail Chest Symptoms

Inflamed Lymph Nodes:

The inflamed lymph nodes are located in the left upper quadrant of the chest. They may become swollen and tender after a few days.

If they become infected, then there will be fever, chills, headache and backache. Sometimes these symptoms disappear within two weeks. In some cases, the swelling subsides spontaneously without medical intervention.

Lymph Node Discharge:

When the lymph nodes become inflamed, they produce large amounts of fluid. This discharge from the lymph nodes is called lymph node discharge.

It may be white or brownish color and it consists mainly of blood cells. When the fluid level becomes high enough, it causes a red bump on your skin. These bumps are called lymphadenopathy. The most common site for swelling is under the arm.

Lung Abscess:

It is possible to have an abscess in one of your lungs after a chest trauma. The abscess is like a cavity filled with pus and it is usually surrounded by a 5-mm thick wall of inflamed tissue.

It may be painful or painless. It is usually bigger than 5 centimeters. The main symptoms include fever, chills, cough and shortness of breath. Most abscesses go away spontaneously within two months.

What are the Causes of Flail Chest?

Flail chest is caused by a blunt trauma to your chest. The impact may cause the bones in your ribcage to break or dislocate. It can also cause the cartilage that protects your lungs from the ribcage to buckle and tear. This results in the forceful movement of your chest wall during breathing. Some of the causes of flail chest are listed below :

Motor vehicle accident

Fall from a great height

Diffuse trauma to the chest

Blunt force to the chest

Gunshot wound or stabbing

What are the Complications of Flail Chest?

Complications may include:

Pneumonia. The repeated trauma to the left side of your chest can cause pneumonia.

The pneumonia can be complicated by pleurisy.

Blood clots. The clots may block the blood flow through your lungs.

Lung abscess. The repeated trauma to the left side of your chest can cause an abscess to form, which is a collection of pus in your lung.

Tension pneumothorax. Air enters the pleural space between your lungs and chest wall, but is unable to escape.

The pressure builds up in your pleural space.

Inflammation of the diaphragm. The repeated trauma to the bottom of your lungs causes the diaphragm to become inflamed.

What are the Types of Flail Chest?

The type of flail chest that you have is determined by the location of the broken ribs and whether the costal cartilage is also injured.

Paradoxical flail chest. This is the most common type of flail chest.

It involves the breaking of 3 or more ribs on the left side along with injury to the costal cartilage. The broken ribs are pulled away from the sternum and some of them pierce the costal cartilage (see image below).

Clinical evidence suggests that the majority of patients with paradoxical flail chest experience temporary loss of pulmonary function.

Synchronous flail chest. This is a rare type of flail chest in which the ribs on the left side are broken, but the cartilage is not injured.

Asynchronous flail chest. This is a rare type of flail chest in which only 1 or 2 ribs are broken and there is no injury to the cartilage.

What are the Risk Factors of Flail Chest?

Some of the factors that increase your risk of developing flail chest are:

Motor vehicle accidents. This is the most common cause of flail chest.

Drowning and near drowning. The impact of waves on swimmers can cause rib fractures.

Swallowing water and aspirating water into the lungs causes trauma to the chest.

Gunshot wounds and stabbing. The penetrating trauma causes several ribs to break.

What are the Symptoms of Flail Chest?

The main symptom of flail chest is difficulty in breathing. The forceful movement of the ribcage may cause fractured ribs to puncture or collapse the lungs. As a result, a flail chest offers less resistance to breathing.

Paradoxical flail chest is associated with tachypnea, or rapid breathing. It leads to shortness of breath and fast breathing.

Synchronous flail chest is not associated with tachypnea.

Asynchronous flail chest is not associated with tachypnea.

Other symptoms of a flail chest may include:

Pain in the injured area.

Coughing of blood (hemoptysis). This is caused by the puncture of the lungs and occurs more commonly in people who have been stabbed or shot.

Fever. This is caused by the infection in the lungs and can be a complication of any type of chest injury.

It becomes more common in patients with asynchronous flail chest.

Difficulty swallowing (dysphagia). This can be a complication of any type of chest injury.

It becomes more common in patients with asynchronous flail chest and those who have been shot or stabbed.

Difficulty breathing. More common in people with flail chest.

Bluish discoloration of the skin (cyanosis). More common in people with flail chest and may be accompanied by grayish-brown skin color (mucosal melanosis).

How is Flail Chest Diagnosed?

Your doctor will ask you questions about your symptoms and medical history. A physical exam will be done to help assess your breathing and check for other complications. A chest X-ray will be done to help assess the extent of your injury and look for other potential problems. A blood test will be done to check your blood oxygen levels and assess the health of your blood. An ECG may be done to check the rhythm of your heart.

What is the Treatment for Flail Chest?

The goal of treatment for a flail chest is to control pain and alleviate symptoms such as shortness of breath. You may also require treatment for other injuries such as a head injury.

Treatment may include:

Pain medication such as acetaminophen (Tylenol) or ibuprofen (Advil) to alleviate pain.

Breathing treatments. These involve the use of a machine that provides breathing support.

Oxygen therapy if necessary.

A tracheostomy to create an alternate airway if your breathing is severely compromised or you are unable to breathe through your mouth.

Surgery to repair any open fractures of the ribs and re-align the bones if there is severe displacement.

What is the Prognosis of a Flail Chest?

The prognosis for flail chest is good with proper treatment. Most patients are discharged from the hospital after their condition has stabilized. People who have had a flail chest are at an increased risk of developing complications in the future. Recurrent pneumonia is common and can be fatal. It is recommended that you seek medical attention immediately if you notice shortness of breath, difficulty breathing, or an accumulation of fluid in the lungs.

Survival of patients decreases if the attending physician is not able to correctly diagnose or treat the condition. Death usually occurs due to complications such as respiratory failure, hypoxia, and pneumonia.

Another risk of flail chest is that it can result in a loss of body confidence and impact your ability to participate in physical activities. You may feel anxious about engaging in certain physical activities for fear of having a similar injury again.

People with a history of chest trauma have also reported experiencing panic attacks in response to feelings of shortness of breath or pain in the chest. These reactions are common among people who have experienced flail chest and may require treatment by a mental health professional.

The psychological impact of a flail chest can be just as serious as the physical injury. It is possible to recover completely with treatment.

Sources & references used in this article:

Variables affecting outcome in blunt chest trauma: flail chest vs. pulmonary contusion by GC Clark, WP Schecter, DD Trunkey – Journal of Trauma and …, 1988 – journals.lww.com

Management of flail chest without mechanical ventilation by JK Trinkle, JD Richardson, JL Franz, FL Grover… – The Annals of Thoracic …, 1975 – Elsevier

Selective management of flail chest and pulmonary contusion. by JD Richardson, L Adams, LM Flint – Annals of surgery, 1982 – ncbi.nlm.nih.gov

Flail chest as a marker for significant injuries. by DL Ciraulo, D Elliott, KA Mitchell… – Journal of the American …, 1994 – ncbi.nlm.nih.gov

Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status by A Granetzny, M Abd El-Aal, ER Emam… – … and thoracic surgery, 2005 – academic.oup.com

The management of flail chest by BL Pettiford, JD Luketich, RJ Landreneau – Thoracic surgery clinics, 2007 – Elsevier

Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation by Z Ahmed, Z Mohyuddin – The Journal of thoracic and cardiovascular surgery, 1995 – Elsevier

Operative chest wall stabilization in flail chest—outcomes of patients with or without pulmonary contusion by G Voggenreiter, F Neudeck, M Aufmkolk… – Journal of the American …, 1998 – Elsevier

Flail chest and pulmonary contusion by R Bastos, JH Calhoon, CE Baisden – Seminars in thoracic and …, 2008 – Elsevier