Flail Chest
Zhi Hu, Biao Wang
N Engl J Med 2024;391: e22
A 59-year-old man with a history of chronic obstructive pulmonary disease was brought to the emergency department after a motor vehicle collision. The steering wheel of the patient’s car had struck his chest after the airbag had not deployed. His heart rate was 99 beats per minute, blood pressure 123/84 mm Hg, respiratory rate 30 breaths per minute, and oxygen saturation 90% while he was receiving supplemental oxygen (fraction of inspired oxygen, 0.45). The physical examination was notable for ecchymoses on the chest and abdomen (Panel A). There was also inward collapse of the anterior and right chest wall during inspiration and outward expansion during expiration (see video). A diagnosis of flail chest — paradoxical movement of a segment of chest wall due to multiple rib fractures in multiple places — was made. Flail chest is associated with a high risk of pulmonary contusion and acute respiratory failure. Computed tomography of the chest showed fractures of multiple ribs on both sides, as well as several fractures in the sternal body and manubrium (Panel B, arrows). Endotracheal intubation was performed, followed by open reduction and internal fixation of the rib and sternal fractures. The patient’s trachea was extubated on postoperative day 2, and he was discharged home on postoperative day 8. At the 1-month follow-up, the flail chest had fully resolved.
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