Flail chest


A “flail chest” occurs when part of the thoracic wall is fractured in such a way to create a floating segment. For this to occur peripherally, adjacent ribs need to be broken in 2 or more places. A central flail segment occurs when the sternum is separated from the chest wall from multiple fractures around the costochondral junctions.

Flail chest leads to respiratory compromise from pain, underlying lung injury (contusion, haemothorax, pneumothorax) and the increased work of breathing created from paradoxical chest wall movements (due to pleural forces acting on the detached segment).




Clinical signs



  • Tachypnoea, hypoxia and respiratory distress
  • Paradoxical chest wall movements



  • Clinically apparent paradoxical chest wall movement
  • CXR or CT





  • Oxygen to maintain saturations >92%
  • Analgesia
    • Intravenous opiates
    • Regional anaesthesia eg: epidural, paravertebral block1,2
  • Tube thoracostomy for underlying pneumo or haemothoraces
  • Early consideration of positive pressure ventilation if signs of respiratory compromise
    • non-invasive ventilation can be option, but should not delay intubation if required
  • Surgical fixation
    • An emerging technique that can decrease the need for mechanical ventilation and improve recovery times.3,4


Disposition – inter-hospital transfer guidelines

flail chest




  1. Battle C, Hutchings HA, Driscoll T et al. A multicentre randomised feasibility Study evaluating the impact of a prognostic model for the Management of Blunt chest wall
    trauma patients: STUMBL trial. BMJ Open. 2019; 9e029187.
  2. Peek J, Smeeing DPJ, Hietbrink F et al. Comparison of analgesic interventions for
    traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg
    Surg. 2019; 45: 597-622
  3. Cataneo AJ, Cataneo DC, de Oliveira FH, et al. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev 2015; :CD009919. 
  4. Simon B, Ebert J, Bokhari F, Capella J, Emhoff T, Hayward III T, Rodriguez A, Smith L. Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery. 2012 Nov 1;73(5):S351-61.

About this guideline

First published: February 2018 (Author: Emma Batistich)
Updated April 2021 (Sue Johnson), May 2024 (Ian Civil)
Approved by: Northern Region Trauma Network, Health New Zealand | Te Whatu Ora – Northern Region, NRHL, St John
Review due: 2 years