Flail chest: are common definition and management protocols still useful? †

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Flail chest: are common definition and management protocols
still useful?
†
Shahram Paydara,b, Seyed Mohsen Mousavia,b,*and Ali Taheri Akerdia,b
a
Trauma Research Center, Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
b
Medical Research Club, Shiraz University of Medical Sciences, Shiraz, Iran
* Corresponding author. 12 Shaghayegh Alley, Square 59, Jouybar-Gharbi Street, Narmak, Tehran, Iran. Tel: +98-2177905779; fax: +98-2177924960;
e-mail: mohsenmousavi6788@gmail.com (S.M. Mousavi).
Received 20 October 2011; received in revised form 20 October 2011; accepted 8 December 2011
Keywords: Flail chest •Thoracic injury •Rib fracture •Management
We eagerly read and appreciate your weighty journal’s hint on
the subject flail chest in the April 2010 issue [1]. We wish to re-
spectfully comment on this subject, since we strongly suppose
that some of our observations and experience of flail chest in
our centre, with a heavy workload to contend with, [2]maybe
of great interest and useful in this field.
Flail chest is a problem whose definition, diagnosis and man-
agement has changed over the years [3]. We suppose that the
classic definition of flail chest has been sufficiently mentioned in
previous studies and textbooks, and is known to the audience
[1,3]. Diagnosis is presumed to be based on observing the float-
ing segment on the patient’s chest wall. Also, detecting specific
types of rib fracture in a plain chest radiograph would confirm
the diagnosis [1]. Also, as a result of our observations, we suggest
that another diagnostic sign could be the tenderness in two sep-
arate but parallel lines on the patient’s chest wall, which may or
may not develop to the paradoxical movement sign later.
But practically, based on our observations, the ‘floating
segment’in the chest wall is seen much less frequently than
expected. Even if present, the patient may develop this sign later
in the hospital course. This delay in, or even the absence of, this
sign seems to depend on the sites of fracture and isolated
segment as well as power of muscle bulk over the region to
support those fractured ribs.
Secondly, flail chest diagnosis by chest X-ray sometimes
encounters difficulties, especially when one of the fracture
lines is located in the anteromedial part of the chest wall in
the costochondral junction. In these cases, a chest CT scan
may help the diagnosis [4,5]. Using a CT scan also could help
in the diagnosis of lung contusion and in excluding the
rupture of the great vessels [1]. Also, in these cases, we can
depend more on the physical examination.
Moreover, as routine in Advanced Trauma Life Support (ATLS)
protocols, diagnosis and management of flail chest is always dis-
cussed in the primary survey [6]. But based on the clinical prac-
tice, and also by a review of papers and references, it is implied
that even if flail chest is diagnosed in primary survey either by
physical examination or, later on, with the plain chest radio-
graph, no quick intervention will be done for its management
and patient would rather be completely sedated, or be given
analgesics, and admitted to the intensive care unit (ICU) or
somewhere else for precise monitoring or perhaps be put on
mandatory mechanical ventilation, as suggested by our observa-
tions. These patients, if merely having non-integrity of the chest
wall and no other acute conditions, such as pneumothorax or
haemothorax, often will not need any emergency intervention
or even mechanical ventilation for hours. Also, chest tube inser-
tion is considered only in those with pneumothorax or
haemothorax. All in all, we believe that the management of flail
chest should be considered in the secondary survey and the phy-
sician’s attention would better be diverted merely towards those
conditions threatening the patient’s life in the primary survey.
Finally, confining the definition of flail chest only to those cases
with multiple rib fractures in two points may be non-
comprehensive, since we have observed repetitiously that multiple
broken ribs are present in one point but along a straight line,
causing the patient to have non-integrity of the chest wall as well
as respiratory failure. We would like to suggest using the phrase
‘non-integrated chest wall’instead of flail chest for all cases in which
insufficiency of the chest wall function leads to respiratory failure.
REFERENCES
[1] Athanassiadi K, Theakos N, Kalantzi N, Gerazounis M. Prognostic factors
in flail-chest patients. Eur J Cardiothorac Surg 2010;38:466–71.
[2] Paydar S, Ghoddusi Johari H, Salahi R, Rezaianzadeh A, Bolandparvaz S,
Abbasi HR. Surgical emergency room workload charecteristics: single
center experience during one year. IRCMJ 2010;12:469–71.
[3] Wilson B. Where we have been, where we are now, and where we are
going: preliminary results with operative fixation of flail chest. J Trauma
Nurs 2011;18:18–23.
[4] Borrelly J, Aazami MH. New insights into the pathophysiology of flail
segment: the implications of anterior serratus muscle in parietal failure.
Eur J Cardiothorac Surg 2005;28:742–9.
[5] Nirula R, Diaz JJ Jr, Trunkey DD, Mayberry JC. Rib fracture repair: indica-
tions, technical issues, and future directions. World J Surg 2009;33:14–22.
[6] American College of Surgeons, Committee on Trauma. Advanced Trauma
Life Support. Chicago, IL: American College of Surgeons, 2008.
†
The corresponding author of the original article [1] was invited to reply but
did not respond.
© The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
LETTERS TO THE
EDITOR
European Journal of Cardio-Thoracic Surgery 0 (2012) 1 LETTER TO THE EDITOR
doi:10.1093/ejcts/ezr297
European Journal of Cardio-Thoracic Surgery Advance Access published January 26, 2012