Flail chest, scoliosis and kyphosis

1Flail chest

Definition

A segment of chest wall that has lost its bony connection to the rest of the rib cage, usually defined as 3 or more neighbouring ribs, each broken in 2 or more places. The loose segment moves in the opposite direction to the rest of the chest.

Causes and key features

• Major blunt trauma: road accidents, falls from height (W17 electrician), crush injuries; in older people, lesser falls.
• Paradoxical movement: the flail segment is sucked in during inspiration and pushed out during expiration.
• Severe pain, shallow breathing, poor cough, low oxygen.
• The underlying lung contusion is the main cause of low oxygen; haemothorax or pneumothorax may coexist.
• X-ray/CT: multiple rib fractures, contusion (patchy opacity), air or fluid in the pleura.

Medical point that matters for physio

• Pain control is the key treatment: epidural, paravertebral or other nerve blocks, regular analgesia.
• Oxygen; non-invasive ventilation in selected patients; intubation and ventilation for respiratory failure (positive pressure splints the segment from inside).
• Surgical rib fixation in selected patients; chest drain for pneumothorax or haemothorax.

ICF summary

Impairments: pain, reduced lung volumes, ineffective cough, low oxygen, reduced shoulder movement. Activity: bed mobility, walking, self-care. Participation: work (often manual) for weeks.

PT management by problem

• Pain: treat after analgesia takes effect; supported positions; splint the chest with a hand or pillow during cough.
• Reduced lung volumes: sit upright; deep breathing with a 3-second hold, 5–10 breaths every hour while awake; thoracic expansion avoiding pressure on the fractures.
• Secretions: ACBT with gentle huffs and supported cough; suction if needed.
• On a ventilator: positioning, suction, careful handling of the chest, early mobilisation when stable.
• Mobility: early sitting out and walking; shoulder range on the injured side.

Precautions

• No percussion, vibration or shaking over fractured ribs.
• Undrained pneumothorax: no positive-pressure techniques.
• Watch for worsening hypoxia (contusion often worsens over the first day or two), haemoptysis and spinal or head injuries.

Exam points

• Definition (3 ribs, 2 places), paradoxical movement, lung contusion, pain control first, no percussion over fractures.

2Scoliosis

Definition and types

A sideways curvature of the spine with rotation of the vertebrae, defined as a Cobb angle of 10° or more on an X-ray.

• Idiopathic: infantile, juvenile, adolescent (commonest; mostly girls).
• Congenital: vertebral malformations.
• Neuromuscular: cerebral palsy, muscular dystrophy, spinal muscular atrophy, spinal cord injury.
• Degenerative (adult) and secondary (for example after thoracoplasty or empyema).

Key features

• Uneven shoulders and waist, prominent shoulder blade; rib hump on forward bending (Adam's test); scoliometer measures the trunk rotation.
• Breathing: large thoracic curves, especially early-onset and neuromuscular curves, stiffen the chest wall and reduce lung growth and volumes (restrictive pattern), sometimes leading to breathing failure, especially at night.

Medical point that matters for physio

Management depends on curve size, growth remaining and progression (SOSORT 2016): observation, physiotherapeutic scoliosis-specific exercises, bracing for moderate curves in growing children, and surgery (spinal fusion) for large or progressive curves.

PT management by problem

• Curve and posture: scoliosis-specific exercises (for example Schroth or SEAS methods): self-correction, stabilisation and breathing into the concave side.
• Restricted breathing: thoracic expansion exercises directed to the concave side, rib mobility, inspiratory muscle training; aerobic fitness.
• Neuromuscular scoliosis: seating and positioning, airway clearance and assisted cough, night ventilation as prescribed.
• After fusion surgery: breathing exercises, early mobilisation, log-roll and spinal precautions as advised.

Precautions

• Follow brace-wearing schedules; avoid forceful spinal mobilisation in progressive or post-surgical curves.

Exam points

• Cobb angle 10° or more; rib hump; restrictive pattern in large thoracic curves; breathing into the concave side.

3Kyphosis

Definition and types

Excessive forward curvature of the thoracic spine (normal thoracic kyphosis is about 20–40°).

• Postural: flexible, corrects on extension.
• Scheuermann's: rigid kyphosis in adolescence with wedging of 5° or more in 3 neighbouring vertebrae.
• Osteoporotic: from vertebral wedge fractures in older adults.
• Ankylosing spondylitis: rigid kyphosis with fused costovertebral joints, so chest expansion is very reduced.
• Tuberculosis of the spine (Pott's disease): sharp angular kyphosis (gibbus); congenital kyphosis.

Key features

Rounded back, forward head, back pain; reduced chest expansion and vital capacity in severe or rigid kyphosis; breathlessness on exertion; falls risk in osteoporosis.

PT management by problem

• Posture: spinal extension and back-extensor strengthening, chest stretching, scapular retraction, posture awareness.
• Breathing: thoracic expansion (lateral costal) and diaphragmatic breathing; in ankylosing spondylitis, daily chest expansion and spinal mobility exercises.
• Osteoporosis: weight-bearing and balance exercise, falls prevention; avoid loaded spinal flexion.
• Bracing for growing patients with Scheuermann's as advised.

Precautions

• No forceful flexion or heavy loading in osteoporotic spines; careful manual techniques on a rigid, fragile thorax.

Exam points

• Types of kyphosis; reduced chest expansion; extension and breathing exercises.

4Exam corner

• W17 Q3(a), 5 + 5 + 5 marks30-year-old electrician with electrical burns and a fall, 3 fractured ribs on the right, unconscious and ventilated (see the burns page). Impairments, activity and participation; short-term management.

Technique cards for this topic: breathing exercises, ICU physiotherapy.