Snapshot A 17-year-old boy presents to the emergency department following an altercation at school. He was beaten up by 4 other boys and was found lying on the ground by a teacher after recess. Chest radiograph demonstrates several broken ribs. Introduction Occurs when a segment of the chest wall does not have bony continuity with the rest of the thoracic cage 3 or more adjacent ribs are fractured in 2 or more places Causes paradoxical inward movement of the flail segment during inspiration Produces inadequate inspiratory or expiratory pressure Can result in damage of underlying lung pulmonary contusion Presentation Symptoms pleuritic chest pain dyspnea hyperventilation dizziness syncope Physical exam abnormal chest wall movement may not be appreciated if patient is splinting with pain crepitus over the defect Evaluation CXR diagnostic gold standard shows three or more adjectent ribs fractures in two or more places CT may show associated injuries but usually does not add to diagnosis O2 saturation / blood gas may show signs of respiratory alkalosis secondary to rapid, short breaths Differential Secondary pneumothorax, musculocutaneous injury Treatment Non-operative supplemental oxygen narcotic analgesics Operative usually does not require immediate operative intervention wound closure in cases of open fractures intubation with mechanical ventilation only to rexpand lung when necessary Prognosis, Prevention, and Complications Prognosis good to excellent depending on severity of defect Prevention no preventive measures may be taken as most often presents post-traumatically lifestyle modification to avoid at-risk scenarios Complications may result in respiratory compromise due to underlying pulmonary contusion