The stove-in chest: a complex flail chest injury.

The stove-in chest is a rare form of flail chest in which there is collapse of a segment of the chest wall, associated with a high immediate mortality. A 65-year-old male pedestrian was admitted with severe chest pain and dyspnoea, after being struck by a car. The initial chest radiograph demonstrated multiple right-sided rib fractures and pulmonary contusion. His gas exchange was good, and after pain relief via an epidural catheter was achieved, an intercostal drain was inserted into the right hemi-thorax. Clinically apparent deformation of the chest then occurred. A further chest radiograph confirmed the stove-in chest. The patient remained well initially, but on day 5 he deteriorated precipitously with respiratory failure, and signs of systemic sepsis. He died despite maximal ventilatory and inotropic support on the Intensive Care Unit (ICU). Post-mortem examination demonstrated congested, oedematous lungs with a right-sided empyema. The management of complex flail chest injuries requires treatment to be tailored to the individual patient. Early ventilatory support, despite good gas exchange, may have closed down the pleural space prevented the empyema. Prophylactic ventilation and possibly surgical stabilisation of the chest wall should be considered early in the course of admission, even when the conventional parameters to indicate ventilation are not met.