Blunt Chest Trauma
Sef lucr. Dr. Cristina Grigorescu
Clinic of Thoracic Surgery
• Chest trauma is a significant source of
morbidity and mortality in the United States.
• Blunt injury to the chest can affect any one or
all components of the chest wall and thoracic
cavity. These components include the bony
skeleton (ribs, clavicles, scapulae, sternum),
lungs and pleurae, tracheobronchial tree,
esophagus, heart, great vessels of the chest,
and the diaphragm.
• Records describing chest trauma and its
treatment date to antiquity. An ancient
Egyptian treatise (the Edwin Smith Surgical
Papyrus [circa 3000-1600 BC]) and
Hippocrates' writings in the 5th century
contain a series of trauma case reports,
including thoracic injuries
Morbidity and mortality
• Trauma is the leading cause of death,
morbidity, hospitalization, and disability in
Americans aged 1 year to the middle of the
fifth decade of life. As such, it constitutes a
major health care problem. According to the
Centers for Disease Control and Prevention,
approximately 118,000 accidental deaths
occurred in the United States in 2005.
Frequency
• Trauma is responsible for more than 100,000
deaths annually in the United States.1
Estimates of thoracic trauma frequency
indicate that injuries occur in 12 persons per
million population per day. Approximately
33% of these injuries require hospital
admission. Overall, blunt thoracic injuries are
directly responsible for 20-25% of all deaths,
and chest trauma is a major contributor in
another 50% of deaths.
Etiology
• By far, the most important cause of significant
blunt chest trauma is motor vehicle accidents
(MVAs). MVAs account for 70-80% of such
injuries. As a result, preventive strategies to
reduce MVAs have been instituted in the form
of speed limit restriction and the use of
restraints. Pedestrians struck by vehicles, falls,
and acts of violence are other causative
mechanisms. Blast injuries can also result in
significant blunt thoracic trauma.
Pathophisiology
• The major pathophysiologies encountered in
blunt chest trauma involve derangements in the
flow of air, blood, or both in combination. Sepsis
due to leakage of alimentary tract contents, as in
esophageal perforations, also must be
considered.
• Blunt trauma commonly results in chest wall
injuries (eg, rib fractures). The pain associated
with these injuries can make breathing difficult,
and this may compromise ventilation
• Direct lung injuries, such as pulmonary contusions
(see the image below), are frequently associated
with major chest trauma and may impair ventilation
by a similar mechanism.
• Shunting and dead space ventilation produced by
these injuries can also impair oxygenation.
•
• Space-occupying lesions, such as pneumothoraces,
hemothoraces, and hemopneumothoraces, interfere
with oxygenation and ventilation by compressing
otherwise healthy lung parenchyma. A situation of
special concern is tension pneumothorax in which
pressure continues to build in the affected hemithorax
as air leaks from the pulmonary parenchyma into the
pleural space. This can push mediastinal contents
toward the opposite hemithorax. Distortion of the
superior vena cava by this mediastinal shift can result
in decreased blood return to the heart, circulatory
compromise, and shock.
• At the molecular level, animal experimentation supports a
mediator-driven inflammatory process further leading to
respiratory insult after chest trauma. Following blunt chest
trauma, several blood-borne mediators are released,
including interleukin-6, tumor necrosis factor, and
prostanoids. These mediators are thought to induce
secondary cardiopulmonary changes. Blunt trauma that
causes significant cardiac injuries (eg, chamber rupture) or
severe great vessel injuries (eg, thoracic aortic disruption)
frequently results in death before adequate treatment can
be instituted. This is due to immediate and devastating
exsanguination or loss of cardiac pump function. This
causes hypovolemic or cardiogenic shock and death.
Clinical
• The clinical presentation of patients with blunt chest
trauma varies widely and ranges from minor reports of pain
to florid shock. The presentation depends on the
mechanism of injury and the organ systems injured.
• Obtaining as detailed a clinical history as possible is
extremely important in the assessment of a patient with a
blunt thoracic trauma. The time of injury, mechanism of
injury, estimates of MVA velocity and deceleration, and
evidence of associated injury to other systems (eg, loss of
consciousness) are all salient features of an adequate
clinical history. Information should be obtained directly
from the patient whenever possible and from other
witnesses to the accident if available.
• For the purposes of this discussion, the authors
divide blunt thoracic injuries into 3 broad
categories as follows: (1) chest wall fractures,
dislocations, and barotrauma (including
diaphragmatic injuries); (2) blunt injuries of the
pleurae, lungs, and aerodigestive tracts; and (3)
blunt injuries of the heart, great arteries, veins,
and lymphatics. A concise exegesis of the clinical
features of each condition in these categories is
presented. This classification is used in
subsequent sections to outline indications for
medical and surgical therapy for each condition.
Relevant Anatomy
• The thorax is bordered superiorly by the thoracic inlet,
just cephalad to the clavicles. The major arterial blood
supply to and venous drainage from the head and neck
pass through the thoracic inlet.
• The thoracic outlets form the superolateral borders of
the thorax and transmit branches of the thoracic great
vessels that supply blood to the upper extremities. The
nerves that comprise the brachial plexus also access
the upper extremities via the thoracic outlet. The veins
that drain the arm, most importantly the axillary vein,
empty into the subclavian vein, which returns to the
chest via the thoracic outlet.
• Inferiorly, the pleural cavities are separated from the peritoneal
cavity by the hemidiaphragms. Communication routes between the
thorax and abdomen are supplied by the diaphragmatic hiatuses,
which allow egress of the aorta, esophagus, and vagal nerves into
the abdomen and ingress of the vena cava and thoracic duct into
the chest.
• The chest wall is composed of layers of muscle, bony ribs, costal
cartilages, sternum, clavicles, and scapulae. In addition, important
neurovascular bundles course along each rib, containing an
intercostal nerve, artery, and vein. The inner lining of the chest wall
is the parietal pleura. The visceral pleura invests the lungs. Between
the visceral and parietal pleurae is a potential space, which, under
normal conditions, contains a small amount of fluid that serves
mainly as a lubricant.
• The lungs occupy most of the volume of each
hemithorax. Each is divided into lobes. The right
lung has 3 lobes, and the left lung has 2 lobes.
Each lobe is further divided into segments.
• The trachea enters through the thoracic inlet and
descends to the carina at thoracic vertebral level
4, where it divides into the right and left
mainstem bronchi. Each mainstem bronchus
divides into lobar bronchi. The bronchi continue
to arborize to supply the pulmonary segments
and subsegments
• The heart is a mediastinal structure contained within the
pericardium. The right atrium receives blood from the
superior vena cava and inferior vena cava. Right atrial blood
passes through the tricuspid valve into the right ventricle.
Right ventricular contraction forces blood through the
pulmonary valve and into the pulmonary arteries. Blood
circulates through the lungs, where it acquires oxygen and
releases carbon dioxide. Oxygenated blood courses through
the pulmonary veins to the left atrium. The left heart
receives small amounts of nonoxygenated blood via the
thebesian veins, which drain the heart, and the bronchial
veins. Left atrial blood proceeds through the mitral valve
into the left ventricle.
• Left ventricular contraction propels blood
through the aortic valve into the coronary
circulation and the thoracic aorta, which exits
the chest through the diaphragmatic hiatus
into the abdomen. A ligamentous attachment
(remnant of ductus arteriosus) exists between
the descending thoracic aorta and pulmonary
artery just beyond the take-off of the left
subclavian artery.
• The esophagus exits the neck to enter the posterior
mediastinum. Through much of its course, it lies
posterior to the trachea. In the upper thorax, it lies
slightly to the right with the aortic arch and descending
thoracic aorta to its left. Inferiorly, the esophagus turns
leftward and enters the abdomen through the
esophageal diaphragmatic hiatus. The thoracic duct
arises primarily from the cisterna chyli in the abdomen.
It traverses the diaphragm and runs cephalad through
the posterior mediastinum in proximity to the spinal
column. It enters the neck and veers to the left to
empty into the left subclavian vein.
Approach Considerations
• Initial emergency workup of a patient with
multiple injuries should begin with the ABCs
of trauma, with appropriate intervention
taken for each step.
Laboratory studies
• CBC count
• A CBC count is a routine laboratory test for
most trauma patients. The CBC count helps
gauge blood loss, although the accuracy of
findings to help determine acute blood loss is
not entirely reliable. Other important
information provided includes platelet and
white blood cell counts, with or without
differential
• Arterial blood gas
• Arterial blood gas (ABG) analysis, though not as
important in the initial assessment of trauma
victims, is important in their subsequent
management. ABG determinations are an
objective measure of ventilation, oxygenation,
and acid-base status, and their results help guide
therapeutic decisions such as the need for
endotracheal intubation and subsequent
extubation.
• Serum chemistry profile
• Patients who are seriously injured and require
fluid resuscitation should have periodic
monitoring of their electrolyte status. This can
help to avoid problems such as hyponatremia
or hypernatremia. The etiology of certain acidbase abnormalities can also be identified, eg,
a chloride-responsive metabolic alkalosis or
hyperchloremic metabolic acidosis.
• Coagulation profile
• The coagulation profile, including prothrombin
time/activated partial thromboplastin time,
fibrinogen, fibrin degradation product, and Ddimer analyses, can be helpful in the
management of patients who receive massive
transfusions (eg, >10 U packed RBCs). Patients
who manifest hemorrhage that cannot be
explained by surgical causes should also have
their profile monitored.
• Serum troponin levels
• The rate of cardiac injury in patients with blunt chest
trauma varies widely depending upon the diagnostic
criteria. Troponin is a protein specific to cardiac cells. While
elevated serum troponin I levels correlate with the
presence of echocardiographic or electrocardiographic
abnormalities in patients with significant blunt cardiac
injuries, these levels have low sensitivity and predictive
values in diagnosing myocardial contusion in those without.
As such, troponin I level determination does not, by itself,
help predict the occurrence of complications that may
require admission to the hospital. Accordingly, their routine
use in this clinical situation is not well supported.
• Serum myocardial muscle creatine kinase
isoenzyme levels
• Measurement of serum myocardial muscle
creatine kinase isoenzyme (creatine kinase-MB)
levels is frequently performed in patients with
possible blunt myocardial injuries. The test is
rapid and inexpensive. This diagnostic modality
has recently been criticized because of poor
sensitivity, specificity, and positive predictive
value in relation to clinically significant blunt
myocardial injuries.
• Serum lactate levels
• Lactate is an end product of anaerobic glycolysis
and, as such, can be used as a measure of tissue
perfusion. Well-perfused tissues mainly use
aerobic glycolytic pathways. Persistently elevated
lactate levels have been associated with poorer
outcomes. Patients whose initial lactate levels are
high but are rapidly cleared to normal have been
resuscitated well and have better outcomes.
• Blood type and crossmatch
• Type and crossmatch are some of the most
important blood tests in the evaluation and
management of a seriously injured trauma
patient, especially one who is predicted to
require major operative intervention.
• Chest radiographs
• The chest radiograph (CXR) is the initial radiographic study
of choice in patients with thoracic blunt trauma. A chest
radiograph is an important adjunct in the diagnosis of many
conditions, including chest wall fractures, pneumothorax,
hemothorax, and injuries to the heart and great vessels (eg,
enlarged cardiac silhouette, widened mediastinum).
• In contrast, certain cases arise in which physicians should
not wait for a chest radiograph to confirm clinical suspicion.
The classic example is a patient presenting with decreased
breath sounds, hyperresonant hemithorax, and signs of
hemodynamic compromise (ie, tension pneumothorax).
This should be immediately decompressed before obtaining
a chest radiograph.
• Chest CT scan
• Due to lack of sensitivity of chest radiography to
identify significant injuries, computed tomography (CT)
scan of the chest is frequently performed in the trauma
bay in the hemodynamically stable patient. In one
study, 50% of patients with normal chest radiographs
were found to have multiple injuries on chest CT scan.
As a result, obtaining a chest CT scan in a supposedly
stable patient with significant mechanism of injury is
becoming routine practice.
• .
• Helical CT scanning and CT angiography (CTA)
are being used more commonly in the
diagnosis of patients with possible blunt aortic
injuries. Most authors advocate that positive
findings or findings suggestive of an aortic
injury (eg, mediastinal hematoma) be
augmented by aortography to more precisely
define the location and extent of the injury.
• Aortogram
• Aortography has been the criterion standard for diagnosing
traumatic thoracic aortic injuries. However, its limited
availability and the logistics of moving a relatively critical
patient to a remote location make it less desirable. In
addition, with the new generation spiral CT scanners, which
have 100% sensitivity and greater than 99% specificity, the
role of aortography in the evaluation of trauma patients is
declining. However, where spiral CT is equivocal,
aortography can provide a more exact delineation of the
location and extent of aortic injuries. Aortography is much
better at demonstrating injuries of the ascending aorta. In
addition, it is superior at imaging injuries of the thoracic
great vessels
• Thoracic ultrasound
• Ultrasound examinations of the pericardium,
heart, and thoracic cavities can be expeditiously
performed by surgeons and emergency
department (ED) physicians within the ED.
Pericardial effusions or tamponade can be
reliably recognized, as can hemothoraces
associated with trauma. The sensitivity,
specificity, and overall accuracy of ultrasound in
these settings are all more than 90%
• Contrast esophagogram
• Contrast esophagograms are indicated for patients with
possible esophageal injuries in whom esophagoscopy
results are negative. The esophagogram is first performed
with water-soluble contrast media. If this provides a
negative result, a barium esophagogram is completed. If
these results are also negative, esophageal injury is reliably
excluded.
• Esophagoscopy and esophagography are each
approximately 80-90% sensitive for esophageal injuries.
These studies are complementary and, when performed in
sequence, identify nearly 100% of esophageal injuries
• Focused Assessment for the Sonographic
Examination of the Trauma Patient
• The Focused Assessment for the Sonographic
Examination of the Trauma Patient (FAST) is
routinely conducted in many trauma centers.
Although mainly dealing with abdominal trauma,
the first step in the examination is to obtain an
image of the heart and pericardium to assess for
evidence of intrapericardial bleeding
• Twelve-lead electrocardiogram
• The 12-lead electrocardiogram (ECG) is a standard test
performed on all thoracic trauma victims. ECG findings can
help identify new cardiac abnormalities and help discover
underlying problems that may impact treatment decisions.
Furthermore, it is the most important discriminator to help
identify patients with clinically significant blunt cardiac
injuries.
• Patients with possible blunt cardiac injuries and normal
ECG findings require no further treatment or investigation
for this injury. The most common ECG abnormalities found
in patients with blunt cardiac injuries are tachyarrhythmias
and conduction disturbances, such as first-degree heart
block and bundle-branch blocks.
• Transesophageal echocardiography
• Transesophageal echocardiography (TEE) has been
extensively studied for use in the workup of possible blunt
rupture of the thoracic aorta. Its sensitivity, specificity, and
accuracy in the diagnosis of this injury are each
approximately 93-96%. Its advantages include the easy
portability, no requisite contrast, minimal invasiveness, and
short time required to perform. TEE can also be used
intraoperatively to help identify cardiac abnormalities and
monitor cardiac function.
• The disadvantages include operator expertise, long learning
curve, and the fact that it is relatively weak at helping
identify injuries of the descending aorta.
• Transthoracic echocardiography
• Transthoracic echocardiography (TTE) can help
identify pericardial effusions and tamponade,
valvular abnormalities, and disturbances in
cardiac wall motion. TTEs are also performed
in cases of patients with possible blunt
myocardial injuries and abnormal ECG
findings.
• Flexible or rigid esophagoscopy
• Esophagoscopy is the initial diagnostic procedure of
choice in patients with possible esophageal injuries.
Either flexible or rigid esophagoscopy is appropriate,
and the choice depends on the experience of the
clinician. Some authors prefer rigid esophagoscopy to
evaluate the cervical esophagus and flexible
esophagoscopy for possible injuries of the thoracic and
abdominal esophagus. If esophagoscopy findings are
negative, esophagography should be performed as
outlined above
• Fiberoptic or rigid bronchoscopy
• Fiberoptic or rigid bronchoscopy is performed in
patients with possible tracheobronchial injuries.
Both techniques are extremely sensitive for the
diagnosis of these injuries. Fiberoptic
bronchoscopy offers the advantage of allowing an
endotracheal tube to be loaded onto the scope
and the endotracheal intubation to be performed
under direct visualization if necessary.
Indications and Contraindications
• Indications
• Operative intervention is rarely necessary in
blunt thoracic injuries. In one report, only 8%
of cases with blunt thoracic injuries required
an operation. Most can be treated with
supportive measures and simple
interventional procedures such as tube
thoracostomy.
• The following section reviews indications for
surgical intervention in blunt traumatic
injuries according to the previously presented
classification system. Surgical indications are
further stratified into conditions requiring an
immediate operation and those in which
surgery is needed for delayed manifestations
or complications of trauma
Chest wall fractures, dislocations, and
barotrauma (including diaphragmatic injuries)
• Indications for immediate surgery include (1)
traumatic disruption with loss of chest wall
integrity and (2) blunt diaphragmatic injuries.
• Relatively immediate and long-term
indications for surgery include (1) delayed
recognition of blunt diaphragmatic injury and
(2) the development of a traumatic
diaphragmatic hernia
Blunt injuries of the pleurae, lungs, and
aerodigestive tracts
• Indications for immediate surgery include (1) a
massive air leak following chest tube insertion;
(2) a massive hemothorax or continued high rate
of blood loss via the chest tube (ie, 1500 mL of
blood upon chest tube insertion or continued loss
of 250 mL/h for 3 consecutive hours); (3)
radiographically or endoscopically confirmed
tracheal, major bronchial, or esophageal injury;
and (3) the recovery of gastrointestinal tract
contents via the chest tube.
• Relatively immediate and long-term
indications for surgery include (1) a chronic
clotted hemothorax or fibrothorax, especially
when associated with a trapped or
nonexpanding lung; (2) empyema; (3)
traumatic lung abscess; (4) delayed
recognition of tracheobronchial or esophageal
injury; (5) tracheoesophageal fistula; and (6) a
persistent thoracic duct fistula/chylothorax.
Blunt injuries of the heart, great arteries, veins,
and lymphatics
• Indications for immediate surgery include (1)
cardiac tamponade, (2) radiographic confirmation
of a great vessel injury, and (3) an embolism into
the pulmonary artery or heart.
• Relatively immediate and long-term indications
for surgery include the late recognition of a great
vessel injury (eg, development of traumatic
pseudoaneurysm).
Contraindications
• No distinct, absolute contraindications exist for surgery
in blunt thoracic trauma. Rather, guidelines have been
instituted to define which patients have clear
indications for surgery (eg, massive hemothorax,
continued high rates of blood loss via chest tube).
• A controversial area has been the use of ED
thoracotomy in patients with blunt trauma presenting
without vital signs. The results of this approach in this
particular patient population have been dismal and
have led many authors to condemn it.
Rib fractures
Rib fractures are the most common blunt thoracic injuries.
Ribs 4-10 are most frequently involved. Patients usually report
inspiratory chest pain and discomfort over the fractured rib or
ribs. Physical findings include local tenderness and crepitus
over the site of the fracture. If a pneumothorax is present,
breath sounds may be decreased and resonance to percussion
may be increased. Rib fractures may also be a marker for
other associated significant injury, both intrathoracic and
extrathoracic. In one report, 50% of patients with blunt
cardiac injury have rib fractures. Fractures of ribs 8-12 should
raise the suggestion of associated abdominal injuries. Lee and
colleagues reported a 1.4- and 1.7-fold increase in the
incidence of splenic and hepatic injury, respectively, in those
with rib fractures
• Elderly patients with 3 or more rib fractures have been
shown to have a 5-fold increased mortality rate and a
4-fold increased incidence of pneumonia. Effective pain
control is the cornerstone of medical therapy for
patients with rib fractures. For most patients, this
consists of oral or parenteral analgesic agents.
Intercostal nerve blocks may be feasible for those with
severe pain who do not have numerous rib fractures. A
local anesthetic with a relatively long duration of action
(eg, bupivacaine) can be used. Patients with multiple
rib fractures whose pain is difficult to control can be
treated with epidural analgesia.
• Adjunctive measures in the care of these patients
include early mobilization and aggressive
pulmonary toilet. Rib fractures do not require
surgery. Pain relief and the establishment of
adequate ventilation are the therapeutic goals for
this injury. Rarely, a fractured rib lacerates an
intercostal artery or other vessel, which requires
surgical control to achieve hemostasis acutely. In
the chronic phase, nonunion and persistent pain
may also require an operation.
Flail chest
• A flail chest, by definition, involves 3 or more consecutive
rib fractures in 2 or more places, which produces a freefloating, unstable segment of chest wall. Separation of the
bony ribs from their cartilaginous attachments, termed
costochondral separation, can also cause flail chest.
Patients report pain at the fracture sites, pain upon
inspiration, and, frequently, dyspnea. Physical examination
reveals paradoxical motion of the flail segment. The chest
wall moves inward with inspiration and outward with
expiration. Tenderness at the fracture sites is the rule.
Dyspnea, tachypnea, and tachycardia may be present. The
patient may overtly exhibit labored respiration due to the
increased work of breathing induced by the paradoxical
motion of the flail segment.
• A significant amount of force is required to
produce a flail segment. Therefore, associated
injuries are common and should be
aggressively sought. The clinician should
specifically be aware of the high incidence of
associated thoracic injuries such as pulmonary
contusions and closed head injuries, which, in
combination, significantly increase the
mortality associated with flail chest.
• All of the treatment modalities mentioned above for
patients with rib fractures are appropriate for those
with flail chest. Respiratory distress or insufficiency can
ensue in some patients with flail chest because of
severe pain secondary to the multiple rib fractures, the
increased work of breathing, and the associated
pulmonary contusion. This may necessitate
endotracheal intubation and positive pressure
mechanical ventilation. Intravenous fluids are
administered judiciously because fluid overloading can
precipitate respiratory failure, especially in patients
with significant pulmonary contusions.
• In an attempt to stabilize the chest wall and to avoid
endotracheal intubation and mechanical ventilation,
various operations have been devised for correcting
flail chest. These include pericostal sutures, the
application of external fixation devices, or the
placement of plates or pins for internal fixation. With
improved understanding of pulmonary mechanics and
better mechanical ventilatory support, surgical therapy
has not been proven superior to the supportive and
medical measures discussed. However, most authors
would agree that stabilization is warranted if a
thoracotomy is indicated for another reason.
First and second rib fractures
• First and second rib fractures are considered a separate
entity from other rib fractures because of the excessive
energy transfer required to injure these sturdy and
well-protected structures. First and second rib fractures
are harbingers of associated cranial, major vascular,
thoracic, and abdominal injuries. The clinician should
aggressively seek to exclude the presence of these
other injuries.
• Pain control and pulmonary toilet are the specific
treatment measures for rib fractures. First and second
rib fractures do not require surgical therapy. An
exception to this would be the need to excise a greatly
displaced bone fragment.
Clavicular fractures
• Clavicular fractures are one of the most common injuries to
the shoulder girdle area. Common mechanisms include a
direct blow to the shaft of the bone, a fall on an outstretched
hand, or a direct lateral fall against the shoulder.
Approximately 75-80% of clavicular fractures occur in the
middle third of the bone. Patients report tenderness over the
fracture site and pain with movement of the ipsilateral
shoulder or arm.
• Physical findings include anteroinferior positioning of the
ipsilateral compared to the contralateral arm. The proximal
segment of the clavicle is displaced superiorly because of the
action of the sternocleidomastoid muscle.
• Nearly all clavicular fractures can be managed
without surgery. Primary treatment consists of
immobilization with a figure-of-eight dressing,
clavicle strap, or similar dressing or sling. Oral
analgesics can be used to control pain. Surgery
is rarely indicated. Surgical intervention is
occasionally indicated for the reduction of a
badly displaced fracture.
Sternal fractures
• Most sternal fractures are caused by MVAs. The upper and
middle thirds of the bone are most commonly affected in a
transverse fashion. Patients report pain around the injured
area. Inspiratory pain or a sense of dyspnea may be present.
Physical examination reveals local tenderness and swelling.
Ecchymosis is noted in the area around the fracture. A
palpable defect or fracture-related crepitus may be present.
• Associated injuries occur in 55-70% of patients with sternal
fractures. The most common associated injuries are rib
fractures, long bone fractures, and closed head injuries. The
association of blunt cardiac injuries with sternal fractures has
been a source of great debate. Blunt cardiac injuries are
diagnosed in fewer than 20% of patients with sternal
fractures. Caution should be used before completely excluding
myocardial injury. The workup should begin with an ECG.
• Most sternal fractures require no therapy specifically
directed at correcting the injury. Patients are treated
with analgesics and are advised to minimize activities
that involve the use of pectoral and shoulder girdle
muscles. The most important aspect of the care for
these patients is to exclude blunt myocardial and other
associated injuries. Patients who are experiencing
severe pain related to the fracture and those with a
badly displaced fracture are candidates for open
reduction and internal fixation. Various techniques
have been described, including wire suturing and the
placement of plates and screws. The latter technique is
associated with better outcomes.
Chest wall defects
• The management of large, open chest wall
defects initially requires irrigation and
debridement of devitalized tissue to avoid
progression into a necrotizing wound infection.
Once the infection is under control, subsequent
treatment depends on the severity and level of
defect. Reconstructive options range from skin
grafting to well vascularized flaps to a variety of
meshes with or without methylmethacrylate. The
choice of reconstruction depends upon the depth
of the defect.
Traumatic asphyxia
• This curious clinical constellation is the result of thoracic
injury due to a strong crushing mechanism, as might occur
when an individual is pinned under a very heavy object.
Some effects of the injury are compounded if the glottis is
closed during application of the crushing force. Patients
present with cyanosis of the head and neck,
subconjunctival hemorrhage, periorbital ecchymosis, and
petechiae of the head and neck. The face frequently
appears very edematous or moonlike. Epistaxis and
hemotympanum may be present. A history of loss of
consciousness, seizures, or blindness may be elicited.
Neurologic sequelae are usually transient. Recognition of
this syndrome should prompt a search for associated
thoracic and abdominal injuries.
• The head of the patient's bed should be elevated
to approximately 30° to decrease transmission of
pressure to the head. Adequate airway and
ventilatory status must be assured, and the
patient is given supplemental oxygen. Serial
neurological examinations are performed while
the patient is monitored in an intensive care
setting. No specific surgical therapy is indicated
for traumatic asphyxia. Associated injuries to the
torso and head frequently require surgical
intervention.
Blunt diaphragmatic injuries
• Diaphragmatic injuries are relatively uncommon. Blunt
mechanisms, usually a result of high-speed MVAs,
cause approximately 33% of diaphragmatic injuries.
Most diaphragmatic injuries recognized clinically
involve the left side, although autopsy and CT scan–
based investigations suggest a roughly equal incidence
for both sides. This injury should be considered in
patients who sustain a blow to the abdomen and
present with dyspnea or respiratory distress. Because
of the very high incidence of associated injuries, eg,
major splenic or hepatic trauma, it is not unusual for
these patients to present with hypovolemic shock.
• Most diaphragmatic injuries are diagnosed incidentally at
the time of laparotomy or thoracotomy for associated intraabdominal or intrathoracic injuries. Initial chest radiographs
are normal. Findings suggestive of diaphragmatic disruption
on chest radiographs may include abnormal location of the
nasogastric tube in the chest, ipsilateral hemidiaphragm
elevation, or abdominal visceral herniation into the chest.
In a patient with multiple injuries, CT scan is not very
accurate, and MRI is not very realistic. Bedside emergency
ultrasonography is gaining popularity, and case reports in
the literature have supported its use in the evaluation of
diaphragm. Diagnostic laparoscopy and thoracoscopy have
also been reported to be successful in the identification of
diaphragmatic injury.
• A confirmed diagnosis or the suggestion of blunt diaphragmatic
injury is an indication for surgery. Blunt diaphragmatic injuries
typically produce large tears measuring 5-10 cm or longer. Most
injuries are best approached via laparotomy. An abdominal
approach facilitates exposure of the injury and allows exploration
for associated abdominal organ injuries. The exception to this rule is
a posterolateral injury of the right hemidiaphragm. This injury is
best approached through the chest because the liver obscures the
abdominal approach. Most injuries can be repaired primarily with a
continuous or interrupted braided suture (1-0 or larger). Centrally
located injuries are most easily repaired. Lateral injuries near the
chest wall may require reattachment of the diaphragm to the chest
wall by encirclement of the ribs with suture during the repair.
Synthetic mesh made of polypropylene or Dacron is occasionally
needed to repair large defects.
Pneumothorax
• Pneumothoraces in blunt thoracic trauma are most
frequently caused when a fractured rib penetrates the
lung parenchyma. This is not absolute.
Pneumothoraces can result from deceleration or
barotrauma to the lung without associated rib
fractures.
• Patients report inspiratory pain or dyspnea and pain at
the sites of the rib fractures. Physical examination
demonstrates decreased breath sounds and
hyperresonance to percussion over the affected
hemithorax. In practice, many patients with traumatic
pneumothoraces also have some element of
hemorrhage, producing a hemopneumothorax.
• Patients with pneumothoraces require pain control and
pulmonary toilet. All patients with pneumothoraces
due to trauma need a tube thoracostomy. The chest
tube is connected to a collection system (eg, Pleurevac) that is entrained to suction at a pressure of
approximately -20 cm water. The tube continues
suctioning until no air leak is detected. The tube is then
disconnected from suction and placed to water seal. If
the lung remains fully expanded, the chest tube may
be removed and another chest radiograph obtained to
ensure continued complete lung expansion.
Hemothorax
• The accumulation of blood within the pleural space can
be due to bleeding from the chest wall (eg, lacerations
of the intercostal or internal mammary vessels
attributable to fractures of chest wall elements) or to
hemorrhage from the lung parenchyma or major
thoracic vessels. Patients report pain and dyspnea.
Physical examination findings vary with the extent of
the hemothorax. Most hemothoraces are associated
with a decrease in breath sounds and dullness to
percussion over the affected area. Massive
hemothoraces due to major vascular injuries manifest
with the aforementioned physical findings and varying
degrees of hemodynamic instability
• Hemothoraces are evacuated using tube
thoracostomy. Multiple chest tubes may be
required. Pain control and aggressive pulmonary
toilet are provided. The chest tube output is
monitored closely because indications for surgery
can be based on the initial and cumulative hourly
chest tube drainage. This is because massive
initial output and continued high hourly output
are frequently associated with thoracic vascular
injuries that require surgical intervention
• Large, clotted hemothoraces may require an
operation for evacuation to allow full expansion of
the lung and to avoid the development of other
complications such as fibrothorax and empyema.
Thoracoscopic approaches have been used
successfully in the management of this problem
Open pneumothorax
• This injury is more commonly caused by penetrating
mechanisms but may rarely occur with blunt thoracic
trauma. Patients are typically in respiratory distress
due to collapse of the lung on the affected side.
Physical examination should reveal a chest wall defect
that is larger than the cross-sectional area of the
larynx. The affected hemithorax demonstrates a
significant-to-complete loss of breath sounds. The
increased intrathoracic pressure can shift the contents
of the mediastinum to the opposite side, decreasing
the return of blood to the heart, potentially leading to
hemodynamic instability.
• Treatment for an open pneumothorax consists of
placing a 3-way occlusive dressing over the wound to
preclude the continued ingress of air into the
hemithorax and to allow egress of air from the chest
cavity. A tube thoracostomy is then performed. Pain
control and pulmonary toilet measures are applied.
• After initial stabilization, most patients with open
pneumothoraces and loss of chest wall integrity
undergo operative wound debridement and closure.
Those with loss of large chest wall segments may need
reconstruction and closure with prosthetic devices
such as polytetrafluoroethylene patches. Patch
placement can serve as definitive therapy or as a
bridge to formal closure with rotational or free tissue
flaps. With low chest wall injuries, some authors
describe detaching the diaphragm, with operative
reattachment at a higher intrathoracic level. This
converts the open chest wound into an open
abdominal wound, which is easier to manage.
Tension pneumothorax
• The mechanisms that produce tension pneumothoraces are
the same as those that produce simple pneumothoraces.
However, with a tension pneumothorax, air continues to
leak from an underlying pulmonary parenchymal injury,
increasing pressure within the affected hemithorax.
Patients are typically in respiratory distress. Breath sounds
are severely diminished to absent, and the hemithorax is
hyperresonant to percussion. The trachea is deviated away
from the side of the injury. The mediastinal contents are
shifted away from the affected side. This results in
decreased venous return of blood to the heart. The patient
exhibits signs of hemodynamic instability, such as
hypotension, which can rapidly progress to complete
cardiovascular collapse.
• Immediate therapy for this life-threatening condition
includes decompression of the affected hemithorax
by needle thoracostomy. A large-bore needle (ie, 14to 16-gauge) is inserted through the second
intercostal space in the midclavicular line. A tube
thoracostomy is then performed. Pain control and
pulmonary toilet are instituted.
Pulmonary contusion
• The forces associated with blunt thoracic trauma can
be transmitted to the lung parenchyma. This results
in pulmonary contusion, as characterized by
development of pulmonary infiltrates with
hemorrhage into the lung tissue. Clinical findings in
pulmonary contusion depend on the extent of the
injury. Patients present with varying degrees of
respiratory difficulty. Physical examination
demonstrates decreased breath sounds over the
affected area. Other parenchymal injuries (eg,
lacerations) can be produced by fractured ribs and,
rarely, by deceleration mechanisms
• Pain control, pulmonary toilet, and supplemental oxygen are
the primary therapies for pulmonary contusions and other
parenchymal injuries. If the injury involves a large amount of
parenchyma, significant pulmonary shunting and dead space
ventilation may develop, necessitating endotracheal
intubation and mechanical ventilation. Laceration or avulsion
injuries that cause massive hemothoraces or prolonged high
rates of bloody chest tube output may require thoracotomy
for surgical control of bleeding vessels. If central bleeding is
identified during thoracotomy, hilar control is gained first.
Once the extent of injury is confirmed, it may become
necessary to perform a pneumonectomy, keeping in mind that
trauma pneumonectomy is generally associated with a high
mortality rate (>50%).
Blunt tracheal injuries
• While incidence of blunt tracheobronchial injuries is
rare (1-3%), most patients with these injuries die
before reaching the hospital. These injuries include
fractures, lacerations, and disruptions. Blunt trauma
most often produces fractures. These injuries are
devastating and are frequently caused by severe rapid
deceleration or compressive forces applied directly to
the trachea between the sternum and vertebrae.
Patients are in respiratory distress. They typically
cannot phonate and frequently present with stridor.
Other physical signs include an associated
pneumothorax and massive subcutaneous
emphysema.
• Blunt tracheal injuries are immediately life threatening and
require surgical repair. Bronchoscopy is required to make
the definitive diagnosis. The first therapeutic maneuver is
the establishment of an adequate airway. If airway
compromise is present or probable, a definitive airway is
established. Endotracheal intubation remains the preferred
route if feasible. This can be facilitated by arming a flexible
bronchoscope with an endotracheal tube and performing
the intubation under direct bronchoscopic guidance. The
tube must be placed distal to the site of injury. Always be
prepared to perform an emergent tracheotomy or
cricothyroidotomy to establish an airway if this fails. These
maneuvers are best performed in the controlled
environment of an operating room.
• The operative approach to repair of a blunt tracheal
injury includes debridement of the fracture site and
restoration of airway continuity with a primary endto-end anastomosis. Defects of 3 cm or larger
frequently require proximal and distal mobilization of
the trachea to reduce tension on the anastomosis.
The type of incision made for repairing the tracheal
injury is determined by the level and extent of injury
and the involvement of other thoracic organs
Blunt bronchial injuries
• Rapid deceleration is the most common mechanism
causing major blunt bronchial injuries. Many of these
patients die of inadequate ventilation or severe
associated injuries before definitive therapy can be
provided. Patients are in respiratory distress and
present with physical signs consistent with a massive
pneumothorax. Ipsilateral breath sounds are severely
diminished to absent, and the hemithorax is
hyperresonant to percussion. Subcutaneous
emphysema may be present and may be massive.
Hemodynamic instability may be present and is caused
by tension pneumothorax or massive blood loss from
associated injuries.
• Laceration, tear, or disruption of a major bronchus is
life threatening. These injuries require surgical repair.
As with tracheal injuries, establishment of a secure and
adequate airway is of primary importance. Patients
with major bronchial lacerations or avulsions have
massive air leaks. The approach to repair of these
injuries is ipsilateral thoracotomy on the affected side
after single-lung ventilation is established on the
uninjured side. Some patients cannot tolerate this and
require jet-insufflation techniques. Operative repair
consists of debridement of the injury and construction
of a primary end-to-end anastomosis.
Blunt esophageal injuries
• Because of the relatively protected location of the
esophagus in the posterior mediastinum, blunt
injuries of this organ are rare. Blunt esophageal
injuries are usually caused by a sudden increase in
esophageal luminal pressure resulting from a forceful
blow. Injury occurs predominantly in the cervical
region; rarely, intrathoracic and subdiaphragmatic
ruptures are also encountered.
• Associated injuries to other organs are common.
Physical clues to the diagnosis may include
subcutaneous emphysema, pneumomediastinum,
pneumothorax, or intra-abdominal free air. Patients
who present a significant time after the injury may
manifest signs and symptoms of systemic sepsis.
• General medical supportive measures are appropriate. Fluid
resuscitation and broad-spectrum intravenous antibiotics with
activity against gram-positive organisms and anaerobic oral flora are
administered. Surgery is required.
• Injuries identified within 24 hours of their occurrence are treated by
debridement and primary closure. Some surgeons choose to
reinforce these repairs with autologous tissue. Wide mediastinal
drainage is established with multiple chest tubes. If more than 24
hours have passed since injury, primary repair buttressed by wellvascularized autologous tissue is still the best option if technically
feasible. Examples of tissues used to reinforce esophageal repairs
include parietal pleura and intercostal muscle. Very distal
esophageal injuries can be covered with a tongue of gastric fundus.
This is called a Thal patch.
• For patients in poor general condition and those with
advanced mediastinitis or severe associated injuries,
esophageal exclusion and diversion is the most
prudent choice. A cervical esophagostomy is made,
the distal esophagus is stapled, the stomach is
decompressed via gastrostomy, and a feeding
jejunostomy tube is placed. Wide mediastinal
drainage is established with multiple chest tubes.
Blunt pericardial injuries
• Isolated blunt pericardial injuries are rare. Blunt
mechanisms produce pericardial tears that can result
in herniation of the heart and associated decrements
in cardiac output. Physical examination may elicit a
pericardial rub.
• Most blunt pericardial injuries can be closed by
simple pericardiorrhaphy. Large defects that cannot
be closed primarily without tension can usually be
left open or be patch-repaired.
Blunt cardiac injuries
• MVAs are the most common cause of blunt cardiac
injuries. Falls, crush injuries, acts of violence, and
sporting injuries are other causes. Blunt cardiac injuries
range from mild trauma associated only with transient
arrhythmias to rupture of the valve mechanisms,
interventricular septum, or myocardium (cardiac
chamber rupture). Therefore, patients can be
asymptomatic or can manifest signs and symptoms
ranging from chest pain to cardiac tamponade (eg,
muffled heart tones, jugular venous distension,
hypotension) to complete cardiovascular collapse and
shock due to rapid exsanguination.
• Many patients with blunt cardiac injuries do not require specific
therapy. Those who develop an arrhythmia are treated with the
appropriate antiarrhythmic drug. Elaboration on these drugs and
their administration is beyond the scope of this article.
• Patients with severe blunt cardiac injuries who survive to reach the
hospital require surgery. Most patients in this group have cardiac
chamber rupture due to a high-speed MVA. The right side
involvement is most common, involving the right atrium and right
ventricle. They present with signs and symptoms of cardiac
tamponade or exsanguinating hemorrhage. A few may be stable
initially, resulting in delayed diagnosis. Those with tamponade
benefit from rapid pericardiocentesis or surgical creation of a
subxiphoid window. The next step is to repair the cardiac chamber
by cardiorrhaphy. Cardiopulmonary bypass techniques can facilitate
this procedure. Unstable patients may benefit from insertion of an
intra-aortic counterpulsation balloon pump.
• Commotio cordis or sudden cardiac death in an
otherwise healthy individual generally results from
participation in a sporting event or some form of
recreational activity. It is a direct result of blow to the
heart just before the T-wave, resulting in ventricular
fibrillation. Survival is not unheard of, if resuscitation
and defibrillation are started within minutes.
Preventive strategies include chest protective gear
during sporting activities.
Blunt thoracic aortic injuries
• High-speed MVAs are the most common cause of blunt
thoracic aortic injuries and blunt injuries of the major
thoracic arteries. Falls from heights and MVAs involving
a pedestrian are other recognized causes. The
mechanisms of injury are rapid deceleration,
production of shearing forces, and direct luminal
compression against points of fixation (especially at the
ligamentum arteriosum). Many of these patients die
from vessel rupture and rapid exsanguination at the
scene of the injury or before reaching definitive care.
Blunt aortic injuries follow closely behind head injury
as a cause of death after blunt trauma
• Important historical details include the exact
mechanism of injury and estimates of the amount of
energy transferred to the patient (eg, magnitude of
deceleration). Other important details include
whether the victim was ejected from a vehicle or
thrown if struck by a vehicle, height of the fall, and
whether other fatalities occurred at the scene.
• Physical clues include signs of significant chest wall trauma
(eg, scapular fractures, first or second rib fractures, sternal
fractures, steering wheel imprint), hypotension, upper
extremity blood pressure differential, loss of upper or lower
extremity pulses, and thoracic spine fractures. Signs of cardiac
tamponade may be present. Decreased breath sounds and
dullness to percussion due to massive hemothorax can also be
found. Up to 50% of patients with these devastating, lifethreatening injuries have no overt external signs of injury.
Therefore, a high index of suspicion is warranted for earlier
intervention.
• The management of these injuries, especially those of the thoracic
aorta, is evolving. Many patients have delayed repair of contained
descending thoracic aortic ruptures. This approach is most
frequently used when severe associated injuries are present that
require urgent correction.
• Temporizing medical therapy includes the administration of shortacting beta-blocking agents (eg, labetalol, esmolol) to control the
heart rate and to decrease the mean arterial pressure to
approximately 60 mm Hg. Because repair of thoracic aortic injuries
using cardiopulmonary bypass is associated with fewer major
neurologic complications, some authors advocate stabilization of
the victim plus beta-blocker administration until transfer is feasible
to a facility where the injury can be repaired using cardiopulmonary
bypass or centrifugal pump techniques. These techniques maintain
distal aortic perfusion. Results have been excellent, and
postoperative paraplegia rates have been significantly reduced.
• Endovascular stent grafts are being developed to repair
thoracic aortic injuries. While several authors have
reported success in treating such injuries with endo stents,
the long-term durability of the stents is yet unknown.
Further experience with this technique will allow more
victims with concomitant severe injuries to become
operative candidates. Techniques for repair of the
innominate artery and subclavian vessels vary depending
on the type of injury. Many require only lateral
arteriorrhaphy. Large injuries of the innominate artery are
managed first by placement of a bypass graft from the
ascending aorta to the distal innominate artery. The injury
is then approached directly and is oversewn or patched
• Proximal pulmonary arterial injuries are relatively
easy to repair when in an anterior location. Posterior
injuries frequently require cardiopulmonary bypass.
Pulmonary hilar injuries present the possibility of
rapid exsanguination and are best treated with
pneumonectomy. Peripheral pulmonary arterial
injuries are approached easily by thoracotomy on the
affected side. They may be repaired or the
corresponding pulmonary lobe or segment may be
resected.
Blunt injuries of the thoracic duct
• Thoracic ductal injuries due to blunt mechanisms are
rare. They are sometimes found in association with
thoracic vertebral trauma. No signs or symptoms are
specific for this injury at presentation. The diagnosis
is usually delayed and is confirmed when a chest
tube is inserted for a pleural effusion and returns
chyle. This is termed a chylothorax.
• Conservative management with chest tube drainage is
successful in most cases, effecting closure of the ductal
injury without surgery. Chyle production can be decreased
by maintaining the patient on total parenteral nutrition or
by providing enteral nutrition with medium-chain
triglycerides as the fat source. If a fistula persists after an
attempt at nonoperative management, thoracotomy is
performed to identify and ligate the fistula. This is usually
advisable after 2-3 weeks of persistent drainage or if the
total lymphocyte count dwindles. Provision of a meal high
in fat content (or ice cream) the night before the operation
increases the volume of chyle and facilitates identification
of the fistula.
Complications
• Patients with blunt thoracic trauma are
subject to myriad complications during the
course of their care. This section outlines most
major complications that may occur.
• Wound
• Wound infection
• Wound dehiscence - Particularly problematic
in sternal wounds.
• Cardiac
•
•
•
•
•
•
Myocardial infarction
Arrhythmias
Pericarditis
Ventricular aneurysm formation
Septal defects
Valvular insufficiency
• Pulmonary and bronchial
Atelectasis
• Pneumonia
• Pulmonary abscess
• Empyema
• Pneumatocele, lung cyst
• Clotted hemothorax
• Fibrothorax
• Bronchial repair disruption
• Bronchopleural fistula
• Vascular
•
•
•
•
•
Graft infection
Pseudoaneurysm
Graft thrombosis
Deep venous thrombosis
Pulmonary embolism
• Neurological
• Causalgia - Injuries that involve the brachial plexus
• Paraplegia - Spinal cord at risk during repair of
ruptured thoracic aorta
• Stroke
• Esophageal
• Leakage of repair
• Mediastinitis
• Esophageal fistula
• Esophageal stricture .
• Bony skeleton
• Skeletal deformity
• Chronic pain
• Impaired pulmonary mechanics
Future and Controversies
• Future directions for improving the diagnosis and
management of blunt thoracic trauma involve
diagnostic testing, endovascular techniques, and
patient selection.
• The use of thoracoscopy for the diagnosis and
management of thoracic injuries will increase. Also,
ultrasound use for the diagnosis of conditions such
as hemothorax and cardiac tamponade will become
more widespread.
• Finally, spiral CT scanning techniques will be used
more frequently for definitive diagnosis of major
vascular lesions (eg, injuries to the thoracic aorta
and its branches).
• Endovascular techniques for the repair of great
vessel injuries will be developed further and
applied more frequently. Also, patient selection
and nonsurgical therapies for delayed operative
management of thoracic aortic rupture will be
refined.