Abstract

The authors present a 21-day-old infant who sustained a flail chest as a result of nonaccidental trauma. Initial treatment included endotracheal intubation and mechanical ventilation for hypoxemic respiratory failure followed by the administration of continuous positive airway pressure by nasal cannula. Further evaluation resulted in the identification of nonaccidental as the mechanism of injury. The pathophysiology of flail chest, its etiology, and treatment options are reviewed. In the absence of a documented history of significant thoracic injury or the presence of metabolic bone disease, nonaccidental trauma is the most likely diagnosis in infants and children with a flail chest.

Key Points

* Flail chest occurs most commonly as the result of traumatic injury, has been estimated to affect 1 in 13 patients with fractured ribs, and even with modern therapy can be a source of morbidity and mortality.

* Due to the substantial force necessary to produce flail chest injuries, pediatric patients with such injuries are at high risk for having associated injuries to underlying structures such as the pulmonary parenchyma.

* Respiratory compromise associated with a flail chest may occur either from the alteration in pulmonary dynamics related to the flail segment or associated trauma to the underlying pulmonary parenchyma.

* Given the rarity of such injuries in the pediatric patient, in the absence of an appropriate explanation such as a significant traumatic event, non-accidental trauma (child abuse) should be suspected in an infant with a flail chest.