J Forensic Sci, 2017

doi: 10.1111/1556-4029.13411
PAPER Available online at: onlinelibrary.wiley.com

PATHOLOGY/BIOLOGY

Melissa Thompson,1,2 M.B., B.S.; Neil E.I. Langlois,2,3 M.D.; and Roger W. Byard,2,3 M.D.

Flail Chest Following Failed Cardiopulmonary

Resuscitation

ABSTRACT: Following the death of a woman with blunt force chest trauma, the question was asked how common was the finding at
autopsy of a flail chest in decedents after failed cardiopulmonary resuscitation. It was suggested in court that this was an uncommon occur-
rence. To address this issue, autopsy cases in adults (>18 years) with rib fractures attributable to cardiopulmonary resuscitation were taken from
the files of Forensic Science SA over a 7-year period from 2008 to 2014. Flail chest injuries were defined as those arising from fractures at
two sites in at least three consecutive ribs. From 236 cases with rib fractures attributed to resuscitation, a total of 43 flail chest injuries were
found in 35 cases (14.8%). The majority occurred in the 60-79-year-old age group. These data suggest that flail chest injuries are a more com-
mon sequelae of cardiopulmonary resuscitation than has been previously appreciated in autopsy cases, particularly in the elderly.

KEYWORDS: forensic science, flail chest, rib fracture, cardiopulmonary resuscitation, chest compression, blunt trauma

Cardiopulmonary resuscitation is a potentially lifesaving pro-

Methods
cedure (1). However, it is not without risk of injury to the
recipient. Effective chest compression is an essential compo- Postmortem records at Forensic Science South Australia were
nent of successful resuscitation, but it is necessarily forceful reviewed for rib fractures and cardiopulmonary resuscitation in
and is responsible for the most frequently reported complica- adults (aged 18 years and over) occurring over a 7-year period
tion of chest wall injury. (2–4). Rib fractures attributable to between 2008 and 2014. Cases without a preceding history of
cardiopulmonary resuscitation are common and have been the trauma and where all recent injuries could reasonably be attribu-
focus of many studies. They occur with a reported incidence ted to resuscitation attempts were included. Details of those
of between 13 and 97% in the adult population (2) with a undertaking cardiopulmonary resuscitation (bystander or profes-
pooled analysis suggesting a mean incidence of around 31% sional) and the methods employed were not considered in this
(4). Children’s ribs are more flexible than those of adults and analysis. Also no specific correlation over time was undertaken
so the incidence in children is significantly lower, reported given that guidelines, although changed, were not consistently
between 0 and 2% (2). implemented with out-of-hospital attempted resuscitations.
Flail chest implies multiple chest wall fractures that in Information was collected on the decedent’s age, sex, cause of
surviving patients may lead to mechanical and physiological death, and rib injuries. Cases where the number or location of
dysfunction and confer an increased risk of morbidity and fractures was not specified or was unclear were excluded from
mortality (5). This injury pattern occurs with severe trauma, analysis.
but has only been infrequently reported as a consequence Flail chest is generally defined by an anatomical finding of
of cardiopulmonary resuscitation in the English-language consecutive ribs broken in at least two places. For the purpose
literature (4). of this study, flail chest has been defined as the presence of at
Following the death of a 52-year-old woman from blunt least two separate fractures occurring in at least three consecu-
force injuries to the head, neck, and chest, with multiple tive ribs.
bilateral rib fractures (flail chest) (6), the question was asked
how common is the finding of a flail chest in decedents after TABLE 1––Number of cases with flail segments from 236 cases of failed
attempted cardiopulmonary resuscitation. Given the paucity of cardiopulmonary resuscitation at autopsy.
information in the literature, the following study was
Left Side Right Side
undertaken. Only Only Bilateral Total
Age 18–39 years 0 (0%) 0 (0%) 0 (0%) 0 (0%)
n = 17
Age 40–59 years 3 (3.3%) 3 (3.3%) 4 (4.4%) 10 (11%)
1
SA Pathology, Adelaide, SA 5000, Australia. n = 91
2
Forensic Science SA, 21 Divett Place, Adelaide, SA 5000, Australia. Age 60–79 years 8 (8.3%) 10 (10.3%) 4 (4.1%) 22 (22.7%)
3
School of Medicine, The University of Adelaide, Frome Rd, Adelaide, n = 97
SA 5005, Australia. Age 80+ years 2 (6.5%) 1 (3.2%) 0 (0%) 3 (9.7%)
n = 31
Received 4 Oct. 2016; and in revised form 29 Nov. 2016; accepted 30
Total 13 (5.5%) 14 (5.9%) 8 (3.4%) 35 (14.8%)
Nov. 2016.

© 2017 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES
TABLE 2––Incidence of consecutive ribs with fractures at more than one site (by age group and sex).
Female
Number of
consecutive Age 18–39 Age 40–59 Age 60–79 Age 80+
fractured ribs Years Years Years Years
Three 0 2 3 1
Four 0 1 2 0
Five 0 0 0 0
Six 0 0 0 0
Results
Two hundred and 36 cases were identified with rib fractures
attributable to cardiopulmonary resuscitation. The majority of
decedents with these injuries (79.7%) were aged between 40 and
79 years, with ages ranging from 25 to 95 years in women and
from 26 to 89 years in men. A total of 43 flail chest injuries
were identified in 35 individuals representing 14.8% of cases.
Flail segments occurred with the greatest frequency in both men
and women in the 60–79 years age group. Thirteen of the flail
segments were on the left and 14 were on the right with a fur-
ther 8 present on the left and right sides (Table 1). Flail seg-
ments were more common in males (M:F = 3.4:1). The highest
number of consecutive ribs that were fractured at more one than
one site was six (Table 2). In 34 of the 35 cases, the flail seg-
ment included the fourth rib. Seven of the cases were noted to
have osteoporosis.
Discussion
Flail chest is variably defined in the literature. A conservative
definition is of “two or more ribs broken in at least two places”
(7). Flail chest injuries have additionally been characterized as
involving three or more consecutive rib fractures, in two or more
locations (8–10), although some authors require four of more
consecutive rib fractures in at least two places (11,12). The clini-
cal definition relates to paradoxical movement of a segment of
chest (8) and thus may include fractures of the sternum (12).
Chest compression undertaken as part of cardiopulmonary
resuscitation necessitates repetitive, forceful pressure against the
thorax (1). A host of injuries may be seen secondary to car-
diopulmonary resuscitation, of which rib fractures are the most
common (3). That the often sustained and strong forces used
during cardiopulmonary resuscitation result in injury, not dissim-
ilar to that of traumatic blunt force trauma, is not surprising
(13). A postmortem study revealed that the injuries incurred may
be significant enough to constitute a cause of death if a sponta-
neous return of circulation had been achieved (14). Flail chest
injuries may impair the efficacy of resuscitation (2,15) and are
associated with increased mortality (10).
This study was performed following the death of a 52-year-
old woman due to blunt force trauma (6). Postmortem examina-
tion revealed rib fractures with flail segments. Resuscitation had
been performed and the question arose as to how likely the flail
segments might have been due to resuscitation. Data from the
English-language literature on the occurrence of flail segments
were limited, with rates of between 0.5% (16) and 3% (17) in
autopsy studies, and a rate of 5.6% in survivors of resuscitation
(18).
It was sometimes not possible to determine from the post-
mortem reports which cases had resuscitation performed.
Male
Age 18–39 Age 40–59 Age 60–79 Age 80+
Years Years Years Years Total
0 6 12 1 25
0 1 5 0 9
0 2 4 1 7
0 2 0 0 2
However, if rib fractures were identified at postmortem examina-
tion, the reporting pathologist usually had recorded whether
these were attributable to resuscitation. The method of resuscita-
tion was not recorded, but during the period of this study auto-
mated resuscitation devices (19) had not been deployed in the
State, and thus, it can be assumed that all cases involved manual
chest compression.
The findings of the present study indicate that flail chest inju-
ries may be a more common sequelae of cardiopulmonary resus-
citation in autopsy populations than has been previously
appreciated, occurring in 14.8% of cases. This means that a flail
segment in an assault victim does not necessarily indicate that it
was caused by the primary blunt chest trauma, but instead may
have occurred at the time of attempted resuscitation.
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