summary Flail Chest is a traumatic chest injury defined as segmental fractures of 3 or more 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. Epidemiology Bimodal distribution younger patients involved in trauma older patients with osteopenia Etiology Mechanism blunt forces deceleration injuries Associated Injuries scapula fractures clavicle fractures hemo/pneumothorax Prognosis Varies depending on underlying pulmonary injury or other concomitant injuries Anatomy Osteology 12 ribs per side the first seven pairs are connected with the sternum the next three are each articulated with the lower border of the cartilage of the preceding rib the last two have pointed extremities can have an accessory clavicular rib anterior ribs articulate with the sternum via the costal cartilage Blood Supply derived from intercostal vessels Presentation Symptoms pain respiratory difficulty hemopneumothorax 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 Imaging Radiographs may be hard to distinguish non- or minimally-displaced rib fractures may see associated hemothorax CT improved accuracy of diagnosis with CT (vs. radiographs) Treatment Nonoperative observation indications no respiratory compromise no flail chest segment (>3 consecutive segmentally fractured ribs) techniques pain control systemic narcotics or local anesthetics positive pressure ventilation Operative open reduction internal fixation indications displaced rib fractures associated with intractable pain flail chest segment (3 or more consecutive ribs with segmental injuries) rib fractures associated with failure to wean from a ventilator open rib fractures technique approach full thoracotomy approach limited exposure approach open reduction and internal fixation plate and screw constructs intramedullary splinting postop early shoulder and periscapular range of motion Complications Intercostal neuralgia Periscapular muscle weakness Pneumonia Restrictive type pulmonary function