Stove-in Chest

Definition

Mechanism of Injury

• Caused by a direct, heavy, localized crushing force applied to the chest wall (e.g., road traffic accidents, industrial crush injuries, falls).
• The force fractures several ribs at or near the same site, usually in the mid-axillary line or anterolaterally.
• Unlike flail chest, the fractured segment in stove-in chest may remain stable (inward depression without paradoxical movement), because the fractures occur in a single line and the segment retains some structural continuity.

Pathophysiology

• The fractured rib segment is driven inward and remains depressed, causing a localized reduction in thoracic volume on that side.
• Relative immobility of the chest wall in the affected region leads to impaired coughing and deep breathing.
• This results in accumulation of bronchopulmonary secretions, atelectasis, and risk of pneumonia.
• If the depressed segment is associated with a fractured (depressed) clavicle, the condition becomes significantly more serious, as it can impair the neurovascular structures of the shoulder and neck.

Comparison with Flail Chest

Clinical Features

• History: Significant trauma with direct force to the thorax; common in road traffic accidents.
• Symptoms: Chest pain (worse on deep breathing and coughing), dyspnoea, inability to take a deep breath.
• Signs:
  • Localized depression of the chest wall
  • Tenderness, crepitus, and palpable bony irregularity over the fractured ribs
  • Reduced chest expansion on the affected side
  • Surgical emphysema if underlying lung is injured
  • Signs of associated injury to lung (haemoptysis), liver (right side), or spleen (left side)

Diagnosis

• Chest X-ray (Skialography): Multiple rib fractures with depression of chest wall; may miss hairline fractures.
• CT scan of chest: More sensitive - shows rib fractures, chest wall deformity, underlying pulmonary contusion, pneumothorax, or haemothorax.
• The compression test (gentle anterior-posterior compression of the thorax) elicits pain at the fracture site.

Complications

1. Accumulation of bronchopulmonary secretions leading to atelectasis and pneumonia
2. Haemopneumothorax
3. Surgical emphysema (indicates lung injury)
4. Progression to respiratory failure, especially in elderly or those with pre-existing lung disease
5. Aortic injury in very high-energy trauma

Management

General Measures

• Adequate analgesia (intercostal nerve blocks, epidural analgesia, or multimodal pain management) to allow effective breathing and coughing.
• Supplemental oxygen.
• Physiotherapy with incentive spirometry to prevent secretion retention and atelectasis.
• Close monitoring of oxygen saturation and respiratory rate.

Specific Measures

• Treatment of associated injuries: Haemothorax or pneumothorax requires intercostal tube drainage.
• Surgical fixation: Indicated for large depressed segments, respiratory failure despite conservative management, or when thoracotomy is needed for another reason. The ribs can be stabilized using rib plates or intramedullary devices.
• If clavicle is also depressed and fractured: This is a serious combination requiring prompt surgical attention to restore chest wall integrity.

Key Points for Examination

• Stove-in chest = localized, depressed chest wall from crushing injury with multiple rib fractures - NO paradoxical movement (distinguishes it from flail chest).
• The danger lies in secretion retention, not paradoxical breathing.
• Association with depressed fractured clavicle makes it a significantly more serious condition.
• Treatment is largely conservative (analgesia, physiotherapy) unless respiratory failure develops.