Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXVIII: Wounds and Injuries of the Chest
United States Department of Defense
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The clinical syndrome associated with multiple rib fractures and a flail chest is the quintessential expression of blunt trauma and does not differ in its manifestations or treatment in combat casualties and civilian trauma victims. The severity of the injury is dependent upon the number and locations of the fractured ribs (which in turn determine the extent to which the chest wall is unstable), the presence of an underlying lung injury, whether a hemo/pneumothorax is present, and the magnitude of associated injuries to other thoracic viscera, such as an aortic disruption or a ruptured diaphragm. The unstable portion of the chest wall moves paradoxically with respiration, being drawn inward during inspiration and blown outward during expiration. The former results in decreased pulmonary ventilation, while the latter results in a weak cough and consequent retention of tracheobronchial secretions. Pulmonary contusion is frequently associated with flail chest and this, rather than the mechanical instability of the chest wall, may dominate the clinical picture.
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