Chest trauma, rib fractures and flail chest

Plain radiography significantly under-detects rib fractures, and the adequacy of initial imaging is frequently in issue. Whether CT was indicated, and whether the injury pattern identified should have prompted further imaging or a period of observation.

Undertreated rib fracture pain leads to splinting, retained secretions, atelectasis and pneumonia. In the elderly the sequence is a recognised cause of death. Whether the analgesic strategy — including regional techniques — was appropriate to the injury and to the patient is a live issue in a growing number of claims.

Surgical stabilisation of rib fractures has moved from rarity to established option for flail chest and for selected severely displaced fracture patterns. Whether fixation was considered, whether the patient was discussed with a unit that performs it, and whether the failure to consider it was reasonable at the relevant date, are questions I am asked increasingly often. The answer depends heavily on when the events occurred, and I set out the state of practice at the material time rather than at today’s date.

Respiratory failure following chest wall injury is usually preceded by observable deterioration. Whether it was observed, escalated and acted on.

Chronic chest wall pain after rib fracture is common, under-recognised and frequently the largest component of quantum. Non-union, malunion, intercostal neuralgia, costochondral injury and post-traumatic slipping rib syndrome all produce persistent pain that is real, treatable in some cases, and often dismissed at earlier stages of the claim.