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Copyright (c) 2025 Elham Ahmad Mohammed Bokar, Abdulaziz Fahad Alamrani, Mariam Saud Alanazi, Hanan Saud Alanazi, Ahmad Talal Matar Almarshadi, Rawan Ayidh Alqahtani, Shahad Abdullah Alanazi, Mohammed Omar Mohammed Sultan, Nada Jaber Jaboor, Shouq Ali Mohammed Assiri, Huda Awad Alanazi, Wadyah Ahmed Mohammed Yahya, Fatma abdulaziz al eid
This work is licensed under a Creative Commons Attribution 4.0 International License.
Flail Chest: Clinical Management, Nursing Interventions, and Radiological Assessment
Corresponding Author(s) : Elham Ahmad Mohammed Bokar
Saudi Journal of Medicine and Public Health,
Vol. 2 No. 2 (2025)
Abstract
Background: Flail chest is a severe thoracic injury defined by fractures of multiple ribs in at least two locations, resulting in paradoxical chest wall motion and impaired ventilation. It most commonly arises from high-energy blunt trauma and is frequently associated with pulmonary contusions and multisystem injuries.
Aim: This article aims to provide an integrated overview of the etiology, epidemiology, pathophysiology, clinical assessment, radiologic evaluation, and management strategies for flail chest to guide effective multidisciplinary care.
Methods: A comprehensive narrative review approach was used, synthesizing current trauma guidelines and contemporary evidence on diagnosis, imaging, respiratory support, analgesia, and surgical stabilization of rib fractures (SSRF).
Results: Findings indicate that flail chest significantly compromises respiratory mechanics, increases the risk of hypoxemia and pneumonia, and often necessitates hospitalization or mechanical ventilation. CT imaging provides the most accurate diagnosis. Optimal outcomes rely on multimodal analgesia, respiratory support, pulmonary hygiene, and selective early SSRF, which reduces ventilation duration, pneumonia rates, and hospital stay.
Conclusion: Early recognition and individualized, multidisciplinary management substantially improve outcomes. Surgical stabilization is particularly beneficial in severe cases with persistent instability or ventilatory dependence.
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- Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg. 2008 Spring;20(1):39-45.
- Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014 Feb;76(2):462-8.
- Benjamin E, Recinos G, Aiolfi A, Inaba K, Demetriades D. Flail Chest: Less Deadly than Originally Thought. World J Surg. 2018 Dec;42(12):3927-3931.
- Poirier WJ, Vacca VM. Flail chest. Nursing. 2013 Dec;43(12):10-1.
- Rogers FB, Larson NJ, Rhone A, Amaya D, Olson-Bullis BA, Blondeau BX. Comprehensive Review of Current Pain Management in Rib Fractures With Practical Guidelines for Clinicians. J Intensive Care Med. 2023 Apr;38(4):327-339.
- Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol. 2013;16(6):351-4.
- Balci AE, Ozalp K, Duran M, Ayan E, Vuraloğlu S. [Flail chest due to blunt trauma: clinical features and factors affecting prognosis]. Ulus Travma Acil Cerrahi Derg. 2004 Apr;10(2):102-9.
- Nishiumi N, Fujimori S, Katoh N, Iwasaki M, Inokuchi S, Inoue H. Treatment with internal pneumatic stabilization for anterior flail chest. Tokai J Exp Clin Med. 2007 Dec 20;32(4):126-30.
- Gabram SG, Schwartz RJ, Jacobs LM, Lawrence D, Murphy MA, Morrow JS, Hopkins JS, Knauft RF. Clinical management of blunt trauma patients with unilateral rib fractures: a randomized trial. World J Surg. 1995 May-Jun;19(3):388-93.
- Sermonesi G, Bertelli R, Pieracci FM, Balogh ZJ, Coimbra R, Galante JM, Hecker A, Weber D, Bauman ZM, Kartiko S, Patel B, Whitbeck SS, White TW, Harrell KN, Perrina D, Rampini A, Tian B, Amico F, Beka SG, Bonavina L, Ceresoli M, Cobianchi L, Coccolini F, Cui Y, Dal Mas F, De Simone B, Di Carlo I, Di Saverio S, Dogjani A, Fette A, Fraga GP, Gomes CA, Khan JS, Kirkpatrick AW, Kruger VF, Leppäniemi A, Litvin A, Mingoli A, Navarro DC, Passera E, Pisano M, Podda M, Russo E, Sakakushev B, Santonastaso D, Sartelli M, Shelat VG, Tan E, Wani I, Abu-Zidan FM, Biffl WL, Civil I, Latifi R, Marzi I, Picetti E, Pikoulis M, Agnoletti V, Bravi F, Vallicelli C, Ansaloni L, Moore EE, Catena F. Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper. World J Emerg Surg. 2024 Oct 18;19(1):33.
- Sawyer E, Wullschleger M, Muller N, Muller M. Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-analysis. J Surg Res. 2022 Aug;276:221-234.
- Pieracci FM, Leasia K, Hernandez MC, Kim B, Cantrell E, Bauman Z, Gardner S, Majercik S, White T, Dieffenbaugher S, Eriksson E, Barns M, Benjamin Christie D, Lasso ET, Schubl S, Sauaia A, Doben AR. Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes? J Trauma Acute Care Surg. 2021 Jun 01;90(6):1014-1021.
- Tran Z, Cho NY, De Polo N, Mukherjee K, Benharash P, Burruss S. Association of Early Rib Plating on Clinical and Financial Outcomes: A National Analysis. Am Surg. 2024 Apr;90(4):754-761.
- Wang Z, Jia Y, Li M. The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial. J Cardiothorac Surg. 2023 Apr 10;18(1):118.
- Otaka S, Aso S, Matsui H, Fushimi K, Yasunaga H. Effectiveness of surgical fixation for rib fractures in relation to its timing: a retrospective Japanese nationwide study. Eur J Trauma Emerg Surg. 2022 Apr;48(2):1501-1508.
- Menard A, Testart J, Philippe JM, Grise P. Treatment of flail chest with Judet's struts. J Thorac Cardiovasc Surg. 1983 Aug;86(2):300-5.
- Farquhar J, Almarhabi Y, Slobogean G, Slobogean B, Garraway N, Simons RK, Hameed SM. No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study. Can J Surg. 2016 Sep;59(5):299-303.
- Zegg M, Kammerlander C, Schmid S, Roth T, Kammerlander-Knauer U, Gosch M, Luger TJ. Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases. Geriatr Orthop Surg Rehabil. 2012 Dec;3(4):164-6.
- Udekwu P, Roy S, McIntyre S, Farrell M. Flail Chest: Influence on Length of Stay and Mortality in Blunt Chest Injury. Am Surg. 2018 Sep 01;84(9):1406-1409.
References
Bastos R, Calhoon JH, Baisden CE. Flail chest and pulmonary contusion. Semin Thorac Cardiovasc Surg. 2008 Spring;20(1):39-45.
Dehghan N, de Mestral C, McKee MD, Schemitsch EH, Nathens A. Flail chest injuries: a review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014 Feb;76(2):462-8.
Benjamin E, Recinos G, Aiolfi A, Inaba K, Demetriades D. Flail Chest: Less Deadly than Originally Thought. World J Surg. 2018 Dec;42(12):3927-3931.
Poirier WJ, Vacca VM. Flail chest. Nursing. 2013 Dec;43(12):10-1.
Rogers FB, Larson NJ, Rhone A, Amaya D, Olson-Bullis BA, Blondeau BX. Comprehensive Review of Current Pain Management in Rib Fractures With Practical Guidelines for Clinicians. J Intensive Care Med. 2023 Apr;38(4):327-339.
Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol. 2013;16(6):351-4.
Balci AE, Ozalp K, Duran M, Ayan E, Vuraloğlu S. [Flail chest due to blunt trauma: clinical features and factors affecting prognosis]. Ulus Travma Acil Cerrahi Derg. 2004 Apr;10(2):102-9.
Nishiumi N, Fujimori S, Katoh N, Iwasaki M, Inokuchi S, Inoue H. Treatment with internal pneumatic stabilization for anterior flail chest. Tokai J Exp Clin Med. 2007 Dec 20;32(4):126-30.
Gabram SG, Schwartz RJ, Jacobs LM, Lawrence D, Murphy MA, Morrow JS, Hopkins JS, Knauft RF. Clinical management of blunt trauma patients with unilateral rib fractures: a randomized trial. World J Surg. 1995 May-Jun;19(3):388-93.
Sermonesi G, Bertelli R, Pieracci FM, Balogh ZJ, Coimbra R, Galante JM, Hecker A, Weber D, Bauman ZM, Kartiko S, Patel B, Whitbeck SS, White TW, Harrell KN, Perrina D, Rampini A, Tian B, Amico F, Beka SG, Bonavina L, Ceresoli M, Cobianchi L, Coccolini F, Cui Y, Dal Mas F, De Simone B, Di Carlo I, Di Saverio S, Dogjani A, Fette A, Fraga GP, Gomes CA, Khan JS, Kirkpatrick AW, Kruger VF, Leppäniemi A, Litvin A, Mingoli A, Navarro DC, Passera E, Pisano M, Podda M, Russo E, Sakakushev B, Santonastaso D, Sartelli M, Shelat VG, Tan E, Wani I, Abu-Zidan FM, Biffl WL, Civil I, Latifi R, Marzi I, Picetti E, Pikoulis M, Agnoletti V, Bravi F, Vallicelli C, Ansaloni L, Moore EE, Catena F. Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper. World J Emerg Surg. 2024 Oct 18;19(1):33.
Sawyer E, Wullschleger M, Muller N, Muller M. Surgical Rib Fixation of Multiple Rib Fractures and Flail Chest: A Systematic Review and Meta-analysis. J Surg Res. 2022 Aug;276:221-234.
Pieracci FM, Leasia K, Hernandez MC, Kim B, Cantrell E, Bauman Z, Gardner S, Majercik S, White T, Dieffenbaugher S, Eriksson E, Barns M, Benjamin Christie D, Lasso ET, Schubl S, Sauaia A, Doben AR. Surgical stabilization of rib fractures in octogenarians and beyond-what are the outcomes? J Trauma Acute Care Surg. 2021 Jun 01;90(6):1014-1021.
Tran Z, Cho NY, De Polo N, Mukherjee K, Benharash P, Burruss S. Association of Early Rib Plating on Clinical and Financial Outcomes: A National Analysis. Am Surg. 2024 Apr;90(4):754-761.
Wang Z, Jia Y, Li M. The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial. J Cardiothorac Surg. 2023 Apr 10;18(1):118.
Otaka S, Aso S, Matsui H, Fushimi K, Yasunaga H. Effectiveness of surgical fixation for rib fractures in relation to its timing: a retrospective Japanese nationwide study. Eur J Trauma Emerg Surg. 2022 Apr;48(2):1501-1508.
Menard A, Testart J, Philippe JM, Grise P. Treatment of flail chest with Judet's struts. J Thorac Cardiovasc Surg. 1983 Aug;86(2):300-5.
Farquhar J, Almarhabi Y, Slobogean G, Slobogean B, Garraway N, Simons RK, Hameed SM. No benefit to surgical fixation of flail chest injuries compared with modern comprehensive management: results of a retrospective cohort study. Can J Surg. 2016 Sep;59(5):299-303.
Zegg M, Kammerlander C, Schmid S, Roth T, Kammerlander-Knauer U, Gosch M, Luger TJ. Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases. Geriatr Orthop Surg Rehabil. 2012 Dec;3(4):164-6.
Udekwu P, Roy S, McIntyre S, Farrell M. Flail Chest: Influence on Length of Stay and Mortality in Blunt Chest Injury. Am Surg. 2018 Sep 01;84(9):1406-1409.