Portable chest X-ray
A 29-year-old man sustains multiple left-sided rib fractures during a motor vehicle accident 5 days prior to his visit. You see the patient in surgical consultation for severe pain with deep inhalation and palpable motion of anterior segments of the left hemi thorax. Portable chest X-ray shows approximately 9 rib fractures on the left, of which ribs 4, 5, and 6 are noted to be a flail segment. He also has decreased pulmonary function tests.
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Rib fractures are a commonly seen injury that presents in an emergency room setting. Most rib fractures are treated conservatively with observation, but more severe injuries may be considered for surgical fixation. A flail chest, defined radiographically as 3 or more consecutive ribs with fractures in 2 or more places, is such an injury in which surgical fixation is considered. Flail chest patients have a high risk of respiratory failure and mortality. Clinically, a flail chest can be seen as paradoxical movement of the flail segment during respirations. In the past, treatment has commonly been pain management and positive pressure ventilation. However, rib fractures are now being increasingly fixed surgically with a 10-fold increase in surgical procedures during the last decade.
The benefits of rib fixation over mechanical ventilation include a decrease in chest infections and chest wall deformity with an increase in pulmonary function tests. Open reduction and internal fixation also result in decreased ICU days, a trend toward a lower rate of pneumonia, and an increase in forced vital capacity. Indications for surgical fixation of a flail chest include persistent pain and decreased pulmonary function tests. Surgical fixation can be done non-urgently, and the average time to fixation in many cases is about 6 days post-injury. The most common technique for surgical fixation includes plates with cortical locking screws.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Tanaka H, Yukioka T, Yamaguti Y. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52:727-732.
- de Moya M, Nirula R, Biffl W. Rib fixation: Who, what, when? Trauma Surg Acute Care Open. 2017;2:1-4.