Flail Chest

Flail Chest—Everything You Need to Know

In flail chest, three or more ribs are involved in segmental fractures. A segment of the rib cage breaks and then becomes separated or detached from the chest well. It usually requires a significant amount of violent force in order for the ribs to break in this way. Due to the nature of this injury, flail chest could be a life threatening condition.


The fractured segment will sink into the chest with inspiration and expand out of the chest wall with expiration opposite to the normal chest wall mechanics. The segmented rib fractures work independently. If the segmented section moves right, then the rest of the ribs move left, and vice versa. The flail chest moves in the opposite direction of the chest wall. The fractured segment goes in while the rest of the chest goes out—this is called paradoxical breathing.

There may be a pulmonary contusion associated with the flail chest fracture segment, and this contusion could be more significant than the flail segment. There may also be a noticeable chest wall deformity with the presence of air in the subcutaneous tissue (crepitus). Trauma to the chest usually causes scapular fractures or a clavicle fracture.

Symptoms of Flail Chest:

  • Patient will have chest pain and shortness of breath
  • Paradoxical movement of the flail segment
    • The constant movement of the ribs is very painful
    • The broken rib may puncture the lung and cause pneumothorax



On an x-ray, it is difficult to see if the fractures are displaced or nondisplaced. A CT scan is probably the best method for visualizing these fractures.

The prognosis varies and it depends on the severity of the condition, however, the death rate ranges between 10-25% usually depending on the pulmonary injury. About 8% of patients who are admitted to the hospital with fractured ribs will have a flail chest.


If there is no respiratory compromise and no flail chest segment, observation of the patient will be done. It is important to follow advanced trauma life support (ATLS) principles.

  • Airway
  • Breathing
  • Circulation

The patient’s pain will need to be managed—usually with intercostal nerve blocks. It is essential to avoid the suppression of breathing and if necessary, give the patient positive pressure ventilation (a chest tube if needed).


Surgery may help in reducing the duration of the ventilator support and aid in the pulmonary function. The patient will need aggressive pulmonary toilet and physiotherapy.

An open reduction and internal fixation should be done when there is severe pain and displaced ribs, when there is a flail chest segment (three or more consecutive fractured ribs with segmental injury), the rib fractures are associated with failure to wean the patient off of ventilation, and/or when there are open rib fractures.  Usually a plate and screw system is used in addition to early range of motion of the shoulders.


Heat Illness in Athletes

As summer approaches, athletes, coaches and other individuals will need to be aware of heat-related illnesses. Heat illnesses include a spectrum of conditions ranging from heat syncope, heat cramps and heat exhaustion to the more severe heat stroke.


Heat Syncope (fainting) is a form of orthostatic hypotension that is related to dehydration. It occurs due to inadequate cardiac output and hypotension. It also occurs with standing quickly after sitting or lying down for prolonged durations in the heat. Symptoms include fainting, dizziness and light-headedness. Treatment includes oral rehydration (water, juice or sports drinks) and placing the patient flat on the ground in a cool area with slight elevation of the legs to push the blood back to the vital organs such as the brain.

Heat Cramps are painful muscle cramps that occur due to decreased sodium heat2.pngconcentration in the blood. The patient’s core temperature is usually not elevated. Sodium may decrease when salts are lost in sweat or with excessive water intake that does not include electrolytes leading to a situation called dilutional hyponatremia. Symptoms include painful muscle cramps occurring commonly in the abdominal muscles, arms, legs and thighs. Treatment includes rest, cooling and IV fluids or oral rehydration with fluids rich in electrolytes (sports drinks and juices) to replenish the sodium stores. Prevention could be achieved by consumption of fluids high in electrolytes before strenuous activities.

heat3Heat Exhaustion is the most common heat illness. The body temperature becomes elevated but is less than 40°C. The core body temperature is best measured rectally. The signs and symptoms of heat exhaustion include profuse sweating, core body temperature lower than 40°C, weakness and fatigue, cramping, headaches, nausea and vomiting,  fainting, hypotension, increased heart rate, and fast shallow breathing. Treatment includes rest, IV fluids or oral rehydration and rapid cooling by whole-body immersion in an ice bath.

Heat Stroke is the most severe form of heat illness. It is a medical emergency that needs immediate attention. The patient should be transported to the hospital as soon as possible. Heat strokes occur due to failure of the body’s normal thermoregulatory mechanism. If treatment is not started promptly, end-organ failure and ultimately death may occur. Heat strokes have a high mortality rate and require quick reduction of the patient’s temperature. The three characteristic features of this condition are a lack of sweating, core body temperature above 40°C (best measured rectally) and an altered mental status. Additional signs and symptoms include hot, dry skin, disorientation, confusion and hallucinations, headache and slurred speech. This is a serious medical emergency that requires rapid core body temperature reduction. The patient should have close monitoring of airway, breathing and circulation. The physician should implement basic life support and ACLS protocols. Rapid cooling by whole-body immersion in an ice bath will be utilized as well as IV fluids.


Little Leaguer’s Shoulder

With the world series currently being played, many young athletes will have dreams of becoming a professional baseball player. Dr. Nabil Ebraheim, an orthopaedic Surgeon from The University of Toledo Medical Center, has a few thoughts on the subject. Dr. Nabil Ebraheim has over 30 years of orthopaedic experience and has seen and treated many different injuries over the years.

The “little leaguer’s shoulder” is a stress fracture of the growth plate of the proximal humerus. It usually occurs due to a throwing motion and is considered to be a fracture of the physeal growth plate (Salter-Harris Type I).

The overuse, repeated high loads of torque and rapidly growing child causes microtrauma to the physis. This injury is seen mostly in adolescence, pitchers and tennis players. This overuse injury is associated with pitching and is influenced by the quantity, intensity and age of the player.

Symptoms: Shoulder pain that worsens with throwing as well as tenderness over the physis of the proximal humerus. Rule out an injury to the subdeltoid bursa. The pain will usually improve with rest.

X-rays will show a widened physis compared to the other side. There will be fragmentation and sclerosis of the lateral aspect of the proximal humerus in the physeal area.

Treatment of little leaguer’s shoulder includes cessation of throwing for about 2-3 months, progressive throwing program, rotator cuff strengthening once full painless range of motion is achieved.

omplications that may arise with little leaguer’s shoulder. These complications include both premature growth arrest and a physeal fracture.

To prevent little leaguer’s shoulder from happening to a young athlete, Dr. Nabil Ebraheim suggests that these athletes avoid overusing their arm.

Whiplash Injury

Dr. Nabil Ebraheim has treated many different injuries during his 30 years at The University of Toledo Medical Center. Dr. Nabil Ebraheim sees many patients that have been involved in motor vehicle accidents. Many of these patients present with whiplash.

Sudden acceleration and deceleration force causes unrestrained, rapid forward and backward movement of the head and neck. With a whiplash injury, there is injury to the soft tissues in the neck including ligaments, tendons, muscles, and discs. Whiplash is typically not a life threatening injury, but can lead to a prolonged period of partial disability. Whiplash is most frequently caused by motor vehicle accidents; but may occur due to sports activities. Women are more likely to experience whiplash because a woman’s neck is usually nor as strong as the neck of a man.

Most patients experience neck pain, tenderness and stiffness. Injuries to the muscles and ligaments result in muscle spasms. Most whiplash symptoms develop within 24 hours of the injury and may include the following: dizziness, fatigue, blurred vision, neck pain, difficulty concentrating, memory loss, problems sleeping, and irritability. When examining the patient, inspect the patient’s posture and neck. Palpate for areas of tenderness such as the cervical spinous processes, paraspinal muscles, and anterior soft tissues. The patient should demonstrate the range of cervical motion within pain tolerance. There should be a complete neurologic examination, and x-rays and MRIs may be needed.

Managing the pain should begin with immobilization of the neck with a soft cervical collar for 2 – 3 weeks. Wearing the soft cervical collar, especially at night, may help with the muscle spasms. Ice therapy and physical therapy can be helpful. Pain medication, muscle relaxants and neck massages can also help to manage the pain. If psychological symptoms develop, treatment of the condition is recommended.

If the pain and disability exceeds three months, then the condition tends to linger. The majority of patients will have mild pain that will disappear in a few days. About 50 % of patients will have remaining symptoms of some sort, especially residual neck pain and headaches.