Define flail chest and outline its main management approach.

• A. A segment of the chest wall moves paradoxically due to multiple rib fractures
• B. A single rib fracture with chest wall stability
• C. A contusion of the lung without rib fracture
• D. A fractured sternum with stable chest wall

Answer: (A)

Flail chest occurs when a segment of the chest wall becomes detached from the rest of the thoracic cage because multiple adjacent ribs are fractured in more than one place, causing that segment to move paradoxically with respiration. This paradoxical movement impairs effective ventilation and increases the risk of pulmonary contusion, atelectasis, and hypoxemia.

The main management aims to stabilize the chest wall and optimize breathing. Start with securing the airway and providing supplemental oxygen as needed, while monitoring for respiratory failure. Aggressive analgesia is essential to allow deep breaths and effective coughing; regional techniques such as intercostal nerve blocks or epidural analgesia can be very helpful. Implement pulmonary hygiene with incentive spirometry, chest physiotherapy, and careful suctioning to prevent atelectasis.

If the patient is in respiratory distress or has significant pulmonary contusion, definitive management often requires endotracheal intubation with mechanical ventilation using positive pressure/PEEP to stabilize the flail segment from within and improve oxygenation and ventilation. Surgical fixation of the flail segment may be considered in select cases where chest wall instability persists despite optimal nonoperative care.