Snapshot A 17-year-old boy presents to the emergency department following a motor vehicle accident 2 hours ago. He is clinically stable but reports trouble breathing and significant pain in his chest. Per the passenger, he hit the steering wheel pretty hard despite the dispatch of airbags. A physical examination demonstrates severe bruising and ecchymosis of the chest area. As the patient inhales, you observe a portion of the chest moving inward. A chest radiograph demonstrates several broken ribs. Introduction Clinical definition occurs when > 2 ribs are broken in > 2 places creating 1 floating segment, usually secondary to significant blunt trauma affected chest wall moves paradoxically to the rest of the chest wall Epidemiology Occurs in 5-13% of patients with chest wall injury Risk factors motor vehicle collisions (MVCs) is the most common cause ETIOLOGY Pathogenesis occurs following chest trauma Associated conditions significant morbidity from pulmonary contusion cardiac contusion aortic dissection sternal fracture intra-abdominal injury (e.g., spleen and liver) Presentation Symptoms pleuritic chest pain dyspnea hyperventilation dizziness syncope Physical exam paradoxical chest wall movement inward during inhale and outward during exhale may not be appreciated if the patient is splinting with pain crepitus over the defect studies Cardiac and respiratory monitoring (e.g., pulse oximetry and capnography) imaging Chest radiograph best initial test allows for evaluation of other conditions of blunt chest trauma (e.g., aortic dissection) Ultrasound (e.g, FAST exam) part of the initial trauma evaluation allows for rule out of pneumothorax or hemothorax limited by the operator Chest computed tomography (CT) more sensitive test compared to chest radiograph allows for detailed evaluation of intrathoracic structures (e.g., pulmonary contusions and lacerations) Differential Secondary pneumothorax distinguishing factor will usually be present on either chest radiograph or chest CT Musculocutaneous injury distinguishing factor paradoxical movement of the chest wall is usually not present DIAGNOSIS Diagnostic approach following initial resuscitation and primary survey, patients are often diagnosed clinically with positive physical examination findings and later confirmed via chest radiograph Treatment Management approach initial management consists of stabilization (e.g., oxygen) with close monitoring for early signs of respiratory compromise most patients will heal their rib fractures with conservative measures First-line conservative management oxygen and monitoring intubation and ventilator support indicated if signs of impending respiratory failure analgesic for pain management opioids intercostal nerve block for severe pain respiratory toilet and pulmonary care (e.g., incentive spirometry) fluid management to limit pulmonary edema Second-line surgical management rib fracture fixation indicated in patients with flail chest with respiratory failure requiring mechanical ventilation other indications include significant chest wall deformity, failure to wean from mechanical ventilation, significantly displaced ribs Complications Pneumonia most common complication prevention via adequate pain control and aggressive pulmonary support Respiratory failure secondary to increased work of breathing and poor pulmonary hygiene Retained hemothorax Empyema Chronic pain secondary to fracture nonunion