Characteristics

• Occurs when there is loss of continuity of a segment of chest wall with the rest of the thoracic cage.

• Usually traumatic with two or more ribs fractured in two or more places.

• Results in disruption of normal chest wall movements, and indeed paradoxical movement may be seen.

• Always consider underlying lung injury (pulmonary contusion).

• The combination of pain, decreased or paradoxical chest wall movements and underlying lung contusion are likely to contribute to the patient's hypoxia.

Clinical features

• Dyspnoea.

• Tachycardia.

• Cyanosis.

• Tachypnoea.

• Hypotension.

• Chest wall bruising ± palpable abnormal movement or rib crepitus.

• The degree of hypoxia often depends on the severity of the underlying pulmonary contusion.

Radiological features

• Multiple rib fractures.

• Costochondral separation may not be evident.

• Air-space shadowing may be seen with pulmonary contusion (often absent on initial films).

Management

• Initial management includes securing the airway and maximising oxygenation.

• In the absence of systemic hypotension judicious fluid replacement is required as the injured lung is susceptible to both under-resuscitation and fluid overload.

• Definitive treatment includes judicious fluid therapy, oxygenation and adequate analgesia to optimise ventilation/lung re-expansion.