Flail Chest / Chest Wall Trauma (Orthopaedic Relevance)

Flail chest is three or more contiguous ribs each fractured in two or more places, creating a free segment that moves paradoxically (in on inspiration, out on expiration) - a high-energy injury. The morbidity, though, is driven mainly by the underlying pulmonary contusion and by pain-related hypoventilation (atelectasis, retained secretions, pneumonia, respiratory failure), NOT by the paradox alone. Management follows ATLS and centres on multimodal analgesia - including regional techniques (thoracic epidural, paravertebral, intercostal/erector-spinae blocks) - aggressive pulmonary toilet/physiotherapy, oxygen, and ventilatory support as needed. Surgical stabilisation of rib fractures (SSRF) is increasingly used and improves outcomes - lower mortality and pulmonary complications, more ventilator-free days - especially when performed early in flail chest. Look for associated skeletal (scapula, clavicle, sternum, spine) and intrathoracic/abdominal injuries.

• Analgesia and pulmonary care first/always: multimodal analgesia with regional techniques to enable deep breathing and coughing, aggressive pulmonary toilet/physiotherapy, oxygen, and escalation to non-invasive or invasive ventilation for respiratory failure.
• SSRF (rib plating) for flail chest and selected multiple displaced rib fractures: improves mortality and pulmonary outcomes; benefit greatest in flail chest and in ventilated patients / those with three or more fractures.
• Operate early: early SSRF (within ~3 days / ~82 hours) is associated with lower ARDS and ventilator-associated pneumonia and shorter stays than delayed fixation.
• The orthopaedic role: perform/assist rib fixation, recognise and manage associated skeletal injuries (scapula, clavicle, sternum, spine) and intrathoracic/abdominal injuries, and integrate chest-wall stabilisation into the polytrauma plan and the timing of other procedures."