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How to cite:
Alvian Mohamad Yapanto. (2021). Flail Chest: A Literature Review.
Journal Eduvest. Vol (2): 660-672
E-ISSN:
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Eduvest(–(Journal(of(Universal(Studies(
Volume(2(Number(4,(April,(2022(
p-(ISSN(2775-3735-(e-ISSN(2775-3727!
FLAIL CHEST: A LITERATURE REVIEW
ARTICLE!INFO!!!!!!!!ABSTRACT!
Received:
March, 26
th
2022
Revised:
April, 16
th
2022
Approved:
April, 17
th
2022
!
!
!
This study aims to make a review about flail chest
management so this can be a simple and useful reference for
surgeons to make a decision regarding flail chest management
decisions. The research method used in this research is the
descriptive qualitative method. The type of data used in this
study is qualitative data, which is categorized into two types,
namely primary data and secondary data. The data were
obtained through library research techniques (library studies)
which refers to sources available both online and offline such
as scientific journals, books and news sourced from trusted
sources. From the results of research and discussion concluded
that early surgical stabilization of rib fracture has better
outcome in the cases of ribs fracture which are severe enough.
KEYWORDS!
Flail chest , rib fracture , thoracic trauma , chest wall fixation
!
This! work! is! licensed! under! a! Creative! Commons!
Attribution-ShareAlike!4.0!International!
INTRODUCTION
Injury of the thorax is the third most common injury in trauma cases after head and
extremity injury. Thoracic trauma occurs in A broad spectrum of severity, ranging from
single isolated rib fracture to a flail chest (Peek et al., 2020). Fractures of the rib occur up
to 10% of all trauma admission (Dehghan et al., 2018). Rib fractures are present in
approximately 25% of patients with blunt chest trauma. Most the patients with rib fractures
can heal without major complication. However, flail chest, one of the traumatic condition
of thorax, is defined as fracture of 3 or more consecutive ribs in which are broken in at least
2 places is one of the more severe instances of these these injuries with a major cause of
mechanically unstable chest wall (Liu et al., 2019). Meanwhile Flail chest is a clinical
diagnosis as clinicians observe paradoxical movement of the chest wall (Dantis et al.,
2021). In combination with lung contusion caused by trauma, flail chest can cause serious
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Alvian!Mohamad!Yapanto!
Flail Chest: A Literature Review 661
disturbance of respiratory function. Up to 30% patients with flail chest and lung contusion
reported acute respiratory insufficiency (Apostolakis et al., 2021).
Traditionally, management of flail chests is supportive care consisting of pain
control and ventilatory support as needed. However, supportive care in the management of
flail chest requires prolonged intubation or even tracheostomy, with the accompanying
medical complications and additional resource utilization associated with intensive care
and prolonged mechanical ventilation. In addition, these supportive care interventions are
associated with high levels of long-term morbidity (Swart et al., 2017). Recently, surgical
approach for flail chest by fixing the ribs is more frequently applied. Metal plates,
intramedullary devices and encircling wires are implanted to increase chest wall stability
thus correcting chest wall deformity and supporting healing process (Wijffels et al., 2020).
The researcher would to make a review about flail chest management so this can be a simple
and useful reference for surgeon to make a decision for flail chest management decision.
RESEARCH METHOD
The research method used in this research is descriptive qualitative method. The type
of data used in this study is qualitative data, which is categorized into two types, namely
primary data and secondary data. The data were obtained through library research
techniques which refers to sources available both online and offline such as scientific
journals, books, and news sourced from trusted sources. These sources are collected based
on discussion and linked from one information to another. Data collection techniques used
in this study were observation, interviews and research. This data is analyzed and then
conclusions were drawn.
RESULT AND DISCUSSION
Anatomy of the ribs
The rib cage is formed by the sternum, costal cartilage, rib, and body of vertebrae.
Rib cage is useful for protecting organs resided in thoracic cavity, assisting respiration and
providing support for upper extremity. There are twelve pairs of ribs articulated posteriorly
with two thoracic vertebrae by the costovertebral joint with exception to first rib. First rib
articulates with the first thoracic vertebra only. According to their attachment to the
sternum, there are true, false, and floating ribs. The true ribs, first seven ribs, are the ribs
that directly articulate with the sternum with their costal cartilages (Figure 1). The false
ribs, indirectly articulate with the sternum, has their costal cartilages connected with the
seventh costal cartilage by the costochondral joint. However, the floating ribs which are
the two most distal ribs are the ribs that do not articulate with the sternum at all. The true
ribs articulate with the sternum by the sternocostal joints. The first rib is an exception to
that rule which is called synarthrosis (Safarini & Bordoni, 2019).
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Figure 1 Anatomy of the thoracic wall (11)
Figure 2 Anatomy of muscle related to respiration(11)
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Flail Chest: A Literature Review 663
By the help of innervation of phrenic nerve, contraction of diaphragm may lead to
normal resting inspiration. Diaphragm is a dome-shaped muscle that separates the thoracic
cavity containing the heart and lungs from the abdominal cavity (figure 2) Expansion of
thoracic cavity may result from diaphragm contraction by increasing volume of thoracic
cavity which causes decrease of intrathoracic pressure. Not only diaphragm, contraction of
external and internal intercostal muscle will raise rib cage upward and outward which leads
to thoracic volume expansion (figure 2). This causes free air will flow into the lung due to
pressure difference (Feher, 2017).
Rib Fracture
Incidence of rib fracture caused by trauma ranged from 7-40%. The most common
cause of rib fracture is motor vehicle accident. There may be difference chest trauma
consequences between adult and children due to children’s rib flexibility (Sirmali et al.,
2003). Rib fracture happens as the consequences of blunt trauma which has significant
enough force directed at the rib causes a break (Kuo & Kim, 2019). Complications of rib
fracture are hemothorax, pneumothorax and lung contusions. The most common symptoms
following ribs fracture are significant pain which hinders respiratory effort and leads to
complication like pneumonia, pleural effusion and acute respiratory distress. The clinical
outcome may related heavily to fracture location, number and pattern (Maduka et al., 2019).
Figure 3 Rib fracture on Plain chest X ray.(16)
Ribs 1 through 3 are the hardest to break and signify a significant degree of trauma
if fractured. Ribs 4 through 10 are typically the most vulnerable while ribs 11 through 12
are more mobile and therefore more difficult to break. In the elderly, falls are a common
etiology of rib fractures and are associated with higher mortality and morbidity than
younger patients (Kuo & Kim, 2019). The number of displaced rib fractures could be a strong
predictor for developing pulmonary complications. When fewer than three rib fractures is
found without rib displacement and initial lung or other organ injuries, outpatient
management can be done safely (Chien et al., 2017). Treatment for most patients with rib
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fractures is supportive care, consisting of aggressive pain control and pulmonary
rehabilitation.(18) Based on (Fokin et al., 2020), there are indications for surgical
stabilization for ribs fracture:
• Flail chest
• Multiple rib fractures with bicortical displacement.
• Fractured ribs acting as penetrating objects.
• Displaced rib fractures combined with sternal fractures and/or ipsilateral
displaced midshaft clavicle fractures.
• Uncontrolled pain with failure of nonoperative treatment.
• Chest-wall deformity, especially with reduction of thoracic volume.
• Acute respiratory distress syndrome in patients with thoracic-cage
instability.
• Displaced rib fractures found during thoracotomy for other reasons.
• Chronic pain in cases of symptomatic rib nonunion.
Flail Chest
Figure 4 Paradoxical movement of flail chest
Flail chest, a highly morbid condition with reported mortality ranging from 10 to
20%, is defined as fractures in two or more places in three or more consecutive ribs. This
injury pattern is caused by high-energy mechanism trauma (Benjamin et al., 2018) This
life-threatening condition is seen when there is a loss of bone continuity of the flail segment
from the rigid thoracic wall around it, due to comminuted costal fractures (at least two
adjacent bifocal rib fractures) or dislocations as a result of trauma (Apampa et al., 2021)
As the result of 3 or more segmented fracture, segment of the chest wall may move
independently of the rest of the chest wall create paradoxical movement which can be
observed clinically as we may call it a flail chest.(3,5) A flail chest can create a significant
disturbance to respiratory physiology whose function is important in patients who are older
or who have chronic lung disease.(3) Multiple rib fractures may allow a sizable segment of
the anterior and/or lateral thoracic wall to move freely (figure 4). The loose segment of the
wall moves paradoxically (inward on inspiration and outward on expiration). Flail chest is
an extremely painful injury and impairs ventilation, thereby affecting oxygenation of the
blood (Moore & Dalley, 2018)
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Flail Chest: A Literature Review 665
Diagnosis and Management of Flail Chest
The first step in trauma assessment includes obtaining initial information of the
patient, preparation of the team and equipment prior to patient’s arrival. Upon arrival of
the patient, primary survey which assesses airway, breathing, circulation, disability and
exposure (ABCDE) should be done immediately and abnormality which is found in
primary survey may be managed properly as soon as possible (Kostiuk & Burns, 2020) Once
the patient has been stabilized, secondary assessment is performed (Kostiuk & Burns, 2020)
For flail chest, Observation of abnormal respiratory motion and palpation of crepitus from
rib or cartilage fractures can aid the diagnosis. A chest x-ray may suggest multiple rib
fractures but may not show costochondral separation. Chest x-ray may be useful for
assessing internal thoracic organ damage.(20) Chest trauma scoring system (Table 1) is
developed to predict longer hospital stay (score >4) or increased risk for mortality,
admission to ICU and intubation/mechanical ventilation (score >7) (Yeh & Lee, 2016) The
traditional management of flail chest is conservative which uses ICU facilitated analgesia
if needed (table 1) with rescue mechanical ventilation for chest wall integrity (internal
splinting). However, surgical management with rib plate fixation begins to become another
management option (Naidoo et al., 2017)
Figure 5 Flail chest on plain chest X-ray (Herring, 2007)
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Table 1 Chest Wall Trauma Scoring System (Yeh & Lee, 2016)
Age (years)
< 45
1 point
45-65
2 points
>65
3 points
Number of Rib fractures
<3
1 point
3-5
2 points
>5
3 points
Pulmonary Contusion
None
0 point
Mild
1 point
Severe
2 points
Bilateral
3 points
Bilateral Rib Fracture
No
0 point
Yes
2 points
Total Score
Flail chest is often associated with an underlying pulmonary contusion and should
be supported with pain relief, stabilization of the chest wall, or even mechanical ventilation
(Townsend et al., 2016). Ensuring adequate oxygenation, administering fluids judiciously,
and providing analgesia to improve ventilation are important principles management in
flail chest. Initial treatment of flail chest and pulmonary contusion includes administration
of humidified oxygen, adequate ventilation, and cautious fluid resuscitation. In the absence
of systemic hypotension, the administration of crystalloid intravenous solutions should be
carefully controlled to prevent volume overload, which can further compromise the
patient’s respiratory status. Patients with significant hypoxia (i.e., PaO2 < 60 mm Hg [8.6
kPa] or SaO2 < 90%) on room air may require intubation and ventilation within the first
hour after injury.(20) Choice of analgesic agent are intravenous narcotics or local anesthetic
administration which avoids the potential respiratory depression common with systemic
narcotics. Options for administering local anesthetics include intermittent intercostal nerve
block and transcutaneous intrapleural, extrapleural, or epidural anesthesia. However,
prevention of hypoxia is needed to be achieved for trauma patients, and a short period of
intubation and ventilation may be necessary until clinicians have diagnosed the entire injury
pattern. Careful assessment of the patient’s respiratory rate, arterial oxygen saturation, and
work of breathing will indicate appropriate timing for intubation and ventilation.
There are no clear guidelines which delineates indications for osteosynthesis in order
to restore chest wall stability. It is justified for flail chest which causes severe deformity,
and exceptionally for intractable pain (Townsend et al., 2016) In meta-analysis study, rib
fixation for patient with flail chest had found to decrease mortality, shorten days on
mechanical ventilation, hospital and intensive cate length of stay, decrease incidence of
pneumonia and need for tracheostomy (Kasotakis et al., 2017) Surgical stabilization of rib
fractures has shown success in managing flail chest (Yahn et al., 2021)
Key steps for surgical stabilization of rib fractures include CT imaging (Figure 6) to
choose the exact ribs for fixation, selection of optimal incision based on the fracture
location, and selection of appropriate technique relevant to the type of fracture (Fokin et
al., 2020).
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Flail Chest: A Literature Review 667
Figure 6 Flail chest on 3D CT scan reconstruction(29)
Surgical Fixation Approach
Figure 7 Key equipment in rib plating system(29)
Before doing operation, we should understand instruments used in ribs stabilization.
Chest instrument set, rib fixation system, shaped ribs plate, power screw driver, screw and
plate, rib reduction clamps, rib plate clamps, plate cutter and right-angle screwdriver should
be prepared before procedure.(29) The patient then is positioned depends on ribs targeted
for procedure. There are supine, lateral decubitus and prone position which are widely used
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regarding this operation.(29) (For brief illustration of the ribs fixation, see figure 8 – figure
11).
Figure 8 Incision similar to anterolateral thoracotomy is being used in supine
positioning (Left); The pectoralis major muscle is mobilized posteriorly off the anterior
chest wall to expose the underlying ribs (Right).(29)
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Flail Chest: A Literature Review 671
Figure 9 After mobilization of the pectoralis major muscle, the serratus anterior
fibers must be cleared from the underlying ribs to be plated (Left); Anterolateral approach.
Fractures of the fifth and sixth ribs (circle) are seen following mobilization of the pectoralis
major muscle (Right).(29)
Figure 10 Reduction clamps are utilized to mobilize the ribs and achieve fracture
alignment. Anterior fracture view (Left); Plates are cut to the appropriate size to fit the
wound using heavy shears (Right)
Figure 11 Plates are to be bent to fit the curvature of the rib being plated (Left); Plate
clamps secure plates to rib and maintain fracture reduction (Right). (29)
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Figure 12 A power screw driver is used to place self-drilling locking unicortical
screws (Left); Each screw is hand tightened to ensure locking into place (Right). (29)
Figure 13 Completed rib fixation of anterior sixth and seventh rib fractures. (29)
There are implant-related complications found after ribs fixation around 10%,
wound infection 2.2% and fracture-related infection around 1.2% of the patient.(1) Silvana
et al., 2022 found that rib fixation procedure when was done in non-flail, non-ventilator
dependent ribs fracture had no improvement in pain and even had no different quality of
life in 3 or 6 months compared to non-operative management (Marasco et al., 2022). This
shows rib fixation procedure should only be done when indicated or when ribs fracture was
severe enough (like flail chest). The timing of the rib fixation is also important. This was
proven by Prins et al., 2021 who found optimal time to perform surgical stabilization of rib
fractures was less than 48-72 hours in which period was associated with improved in-
hospital outcomes (Prins et al., 2021).
CONCLUSION
From the results of research and discussion concluded that early surgical stabilization
of rib fracture has better outcome in the cases of ribs fracture which are severe enough.
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