SUMMARY 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. EPIDEMIOLOGY 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 Demographics bimodal distribution younger patients involved in trauma older patients with osteopenia Location ribs 7-10 are most commonly fractured ETIOLOGY Pathophysiology mechanism of injury direct blunt vs penetrating trauma login to view 1 more bullet pathologic / metastatic Associated Injuries medical mediastinal injury login to view 1 more bullet intra-abdominal organ injuries login to view 1 more bullet hemopneumothorax and/or pulmonary contusions orthopaedic scapula fractures clavicle fractures login to view 1 more bullet ANATOMY 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 Nervous System and Nerves intercostal neurovascular bundle lies posterior-inferiorly adjacent to each rib within the costal groove PRESENTATION Symptoms pain bruising along chest wall respiratory difficulty Exam inspection paradoxical respiration login to view 1 more bullet chest wall deformity can be seen palpation bony or soft-tissue crepitus is often noted IMAGING Radiographs recommended views dedicated rib radiographs are more sensitive (added oblique views and higher energy radiation) findings may see associated hemothorax sensitivity and specificity low sensitivity with standard AP and lateral radiographs CT indications best modality to assess displacement, segmental injuries, and need for surgery findings also shows associated thoracic or abdominal injuries sensitivity and specificity improved accuracy of diagnosis with CT (vs. radiographs) TREATMENT Nonoperative observation indications login to view 2 more bullets techniques login to view 3 more bullets Operative open reduction internal fixation (ORIF) indications login to view 6 more bullets contraindications login to view 2 more bullets techniques login to view 2 more bullets outcomes login to view 2 more bullets Techniques Open reduction internal fixation (ORIF) technique approach login to view 6 more bullets COMPLICATIONS 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 PROGNOSIS Mortality rate as high as 33% when flail chest is present 2.5% with surgical stabilization