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    • Flail chest is a traumatic chest injury defined as segmental fractures of 3 or more consecutive ribs and is often associated with pulmonary injuries such as hemothorax and pneumothorax.
    • Diagnosis is made with radiographs of the chest. 
    • Treatment can be nonoperative or operative depending on the presence of respiratory compromise, the number of consecutive rib fractures, and the presence of open fractures. 
    • Incidence
      • approximately 300,000 cases per year, 7% require hospitalization for medical and/or surgical treatment
      • greater number of fractured ribs correlates with increased morbidity and mortality
      • ribs 7-10 are most commonly fractured
    • Demographics
      • bimodal distribution
        • younger patients involved in trauma
        • older patients with osteopenia
    • Mechanism
      • direct blunt vs penetrating trauma
        • fracture at the site of impaction or at the angle (i.e. posterolateral bend) of the rib (i.e. biomechanically weakest point)
      • pathologic / metastatic
    • Associated Injuries
      • fractures involving ribs 1, 2, or 3 associated with mediastinal injury (aorta or brachial plexus) and worse mortality
      • fractures involving ribs 9 through 12 are associated with intra-abdominal organ injuries (hepatic and splenic most common)
      • scapula fractures
      • hemopneumothorax and/or pulmonary contusions
      • clavicle fractures
        • risk for progressive clavicle fracture displacement with ipsilateral upper rib fractures (i.e. ribs 1-4)
    • Osteology
      • 12 pairs of ribs; numbered 1 through 12 according to the corresponding thoracic vertebra to which they are connected posteriorly
        • anterior ribs articulate with the sternum via the costal cartilage
        • ribs 11-12 are "floating ribs" without anterior sternal costal cartilage attachment 
    • Neurovascular supply
      • intercostal neurovascular bundle lies posterior-inferiorly adjacent to each rib within the costal groove
    • Symptoms
      • pain
      • bruising along chest wall
      • respiratory difficulty
    • Exam
      • paradoxical respiration
        • area of injury "sinks in" with inspiration, and expands with expiration (opposite of normal chest wall mechanics)
      • chest wall deformity can be seen
      • bony or soft-tissue crepitus is often noted
    • Radiographs
      • low sensitivity with standard AP and lateral radiographs
      • dedicated rib radiographs are more sensitive (added oblique views and higher energy radiation)
      • may see associated hemothorax
    • CT
      • improved accuracy of diagnosis with CT (vs. radiographs)
      • also shows associated thoracic or abdominal injuries
      • best modality to assess displacement, segmental injuries, and need for surgery 
    • Nonoperative
      • observation
        • indications
          • no respiratory compromise
          • no flail chest segment (>3 consecutive segmentally fractured ribs)
        • techniques
          • supplemental O2 as needed 
          • incentive spirometry
          • multimodal pain control
    • Operative
      • open reduction internal fixation
        • indications 
          • displaced rib fractures associated with intractable pain recalcitrant to conservative measures
          • flail chest segment (3 or more consecutive ribs with segmental injuries)
          • rib fractures associated with failure to wean from a ventilator
          • open rib fractures
          • symptomatic nonunion 
          • follow Chest Wall Injury Society recommendations for surgical stabilization of rib fractures (SSRF)
        • techniques
          • plate and screw constructs
          • intramedullary splinting
        • outcomes
          • surgical repair of flail chest has been shown to reduce rates of pneumonia, permanent chest deformity, and mortality
          • also shown to reduce the need for tracheostomy, duration of mechanical ventilation, shorter ICU/hospital stays, and overall cost savings 
  • Techniques
    • open reduction and internal fixation
      • technique
        • approach
          • lateral thoracotomy 
            • treats anterolateral and posterolateral fractures with lateral decubitus positioning
          • posterior paramedian approach
            • treats very posterior rib fractures near costovertebral junction
          • inframammary approach
            • treats anterior fracture and costochondral dislocations via supine positioning
      • contraindications
        • hemodynamic instability
        • spinal or pelvic fractures that must be stabilized before rib fixation 
    • Nonunion
      • persistent chest pain >3 months after injury
      • obtain nonunion workup before fixation 
    • Intercostal neuralgia
      • avoid injuring the intercostal neurovascular bundle during plating (located posteroinferior to rib)
    • Periscapular muscle weakness
    • Pneumonia
    • Restrictive type pulmonary function
    • Mortality rate as high as 33% when flail chest is present, 2.5% with surgical stabilization 
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