Question discuss flail chest

NEET PG Anaesthesia
#1

QUESTION
DISCUSS FLAIL CHEST

ANSWER
:black_small_square: DEFINITION
It is where 3 or more ribs with segmental fractures
This is quite a bad Injury as there is at times serious physiologic compromise caused by the pain of the rib fractures, the tidal volume changes, and the underlying pulmonary and cardiac injury.

:black_small_square: EPIDEMIOLOGY
bimodal distribution

  • younger patients involved in trauma
  • older patients with osteopenia

:black_small_square: MECHANISM

  • blunt forces
  • decelerating Injuries

:black_small_square: ASSOCIATED INJURIES

  • scapula fractures
  • clavicle fractures
  • hemo/pneumothorax

:black_small_square: PROGNOSIS
varies depending on underlying pulmonary injury or other concomitant injuries

:black_small_square: 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

:black_small_square: PRESENTATION

  1. Symptoms
    pain
    respiratory difficulty
    hemopneumothorax
  2. 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
  3. 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)

:black_small_square:TREATMENT

  1. Nonoperative observation
    INDICATIONS
  • no respiratory compromise
  • no flail chest segment (>3 consecutive segmentally fractured ribs)
    METHODS
  • pain control; #EPIDURAL
  • systemic narcotics or local anesthetics
    positive pressure ventilation
  1. 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

:black_small_square:TECHNIQUES
APPROACH

  • full thoracotomy approach
  • limited exposure approach
  • open reduction and internal fixation
  • plate and screw constructs
  • intramedullary splinting

:black_small_square: POST OPERATIVE

  • early shoulder and periscapular range of motion

:black_small_square: COMPLICATIONS

  • Intercostal neuralgia
  • Periscapular muscle weakness
  • Pneumonia
  • Restrictive type pulmonary function