Consider the following statements regarding flail chest: 1. Three or more ribs are fractured at two or more places. 2. The chest wall shows paradoxical motion. 3. An X-ray chest AP view is the gold standard for diagnosis. 4. Treatment involves oxygen support, analgesia and physiotherapy. Which of the statements given above are correct?
1, 2 and 4
The correct combination is 1, 2 and 4. Flail chest is fracture of three or more contiguous ribs at two or more sites, freeing a segment of chest wall. The flail segment moves paradoxically, drawn in during inspiration and out during expiration. However, hypoxia is caused mainly by the underlying pulmonary contusion rather than the paradoxical movement. Management is supportive: oxygen, aggressive analgesia (intercostal, paravertebral or epidural block), chest physiotherapy and pulmonary toilet, with ventilation or operative rib fixation reserved for respiratory failure.
Statement 3 is wrong. Flail chest is a clinical, bedside diagnosis made by inspecting and palpating paradoxical movement; a plain AP chest film is insensitive and misses non-displaced, anterior and costochondral fractures. CT chest is far more accurate for the fracture pattern and associated contusion, haemothorax and pneumothorax. Options 1,2,3; 1,3,4; and 2,3,4 all include this false statement.
Key point: Diagnose flail chest clinically by paradoxical movement and treat the pulmonary contusion; never strap the chest.
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Select the correct answer using the code given below:
