Flail Chest

First aid

1. Call 911 or your local emergency number.
2. Keep the person still, especially if a neck or back injury is possible.
3. If they are conscious, let them adopt the position in which they breathe most easily. Lying on the injured side can help some people by splinting the segment, if spinal injury is not a concern.
4. Do not tightly strap or bandage the chest, which restricts breathing.
5. Monitor breathing and be ready to start CPR if they stop breathing.

How flail chest affects breathing

Normally, the rib cage expands as the diaphragm and rib muscles create negative pressure, drawing air in. A flail segment is no longer connected to the rest of the rib cage, so it is sucked inward during inhalation and pushed outward during exhalation. This reduces the efficiency of breathing.

The bigger problem is usually the pulmonary contusion, bruising of the lung beneath the broken ribs. Bleeding and swelling in the lung reduce oxygen transfer and can worsen over the first 24 to 72 hours. Severe pain also stops people taking deep breaths and coughing, leading to collapsed lung areas and pneumonia.

Causes

• motor vehicle crashes, the most common cause
• falls from height
• crush injuries
• assaults and sports collisions
• falls from standing height in older adults with osteoporosis
• rarely, vigorous CPR

Symptoms and signs

• severe chest pain, worse with breathing and coughing
• shortness of breath and fast, shallow breathing
• paradoxical movement of part of the chest wall
• bruising, tenderness and crackling (crepitus) over the ribs
• low oxygen levels, blue lips
• signs of associated injuries: pneumothorax, hemothorax, shoulder blade or collarbone fractures, and abdominal injuries

Paradoxical movement may not be visible at first, because muscle spasm can splint the segment or the person may be on a ventilator.

Diagnosis

• Examination: looking and feeling for paradoxical movement
• Chest X-ray: shows rib fractures, collapsed lung or blood in the chest; it can miss some fractures
• CT scan: the best test to count fractures, assess lung contusion and find other injuries
• Blood gases and oxygen monitoring

Treatment

Pain control

Effective pain relief is critical so the person can breathe deeply and cough. Options include:

• regional anesthesia: epidural or paravertebral catheters, or chest wall nerve blocks such as serratus anterior or erector spinae blocks
• IV and oral pain medicines, often combined
• patient-controlled analgesia

Breathing support

• oxygen
• breathing exercises and incentive spirometry to keep lungs expanded
• physical therapy and assisted coughing
• non-invasive ventilation (CPAP or BiPAP) in some patients
• mechanical ventilation for respiratory failure

Surgical stabilization of rib fractures (SSRF)

Plates and screws fix the broken ribs, restoring a stable chest wall. In selected patients, especially those with flail chest who need a ventilator, studies show surgery can reduce ventilator days, pneumonia, ICU stay and long-term deformity. Surgery is usually done within the first few days.

Treating associated injuries

Chest drains for pneumothorax or hemothorax, careful fluid management to avoid worsening lung contusion, and treatment of other injuries.

Complications

• respiratory failure
• pneumonia
• acute respiratory distress syndrome (ARDS)
• persistent chest wall pain and deformity
• reduced lung function
• higher risk of death in older adults

Outlook

The outlook depends on age, the severity of lung injury and other injuries. Older adults have much higher complication and death rates. Many survivors return to normal activity over months, but some have long-term chest pain, breathlessness or reduced exercise capacity.

Frequently asked questions

What is flail chest?

Flail chest is a serious chest injury where three or more adjacent ribs are each broken in at least two places. The loose segment of chest wall moves in the opposite direction to the rest during breathing, which makes breathing less effective.

What causes flail chest?

Flail chest is usually caused by high-energy blunt trauma, such as car crashes, falls from height or crush injuries. In frail older adults, a simple fall can cause multiple rib fractures and flail chest.

What is paradoxical breathing in flail chest?

Paradoxical breathing means the loose segment of the chest moves inward when you breathe in and outward when you breathe out, the opposite of normal. It happens because the segment is no longer attached to the rest of the rib cage.

How is flail chest treated?

Treatment includes oxygen, strong pain relief (often nerve blocks or epidurals), breathing exercises, and breathing support with a ventilator if needed. Surgery to fix the ribs with plates is increasingly used in selected patients to stabilize the chest wall.

How long does it take to recover from flail chest?

Rib fractures generally heal in 6 to 12 weeks, but full recovery from flail chest often takes several months. Some people have ongoing chest wall pain or breathlessness. Recovery is slower in older adults and those with severe lung injury.