Chapter 21: The Thorax and
Abdomen
© 2010 McGraw-Hill Higher Education. All rights reserved.
© 2010 McGraw-Hill Higher Education. All rights reserved.
© 2010 McGraw-Hill Higher Education. All rights reserved.
© 2010 McGraw-Hill Higher Education. All rights reserved.
Preventing Injuries to the
Thorax and Abdomen
• Utilize appropriate protective equipment
– Imperative in collision sports
• Abdominal musculature strengthening
to protect underlying viscera
• Be sure hollow organs are empty prior
to competition
– Reduces chance of injury to them
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Assessment of the Thorax
Abdomen
• Injuries to this region can produce lifethreatening situations
• ATC’s evaluation should focus on signs
and symptoms that indicate potentially
life-threatening conditions
• Continually monitor breathing,
circulation and any indication of internal
bleeding or shock
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• History
– What happened to cause this injury?
– Was there direct contact or a direct blow?
– What position were you in?
– What type of pain, was it immediate or
gradual, location(s)?
– Difficulty breathing?
– What positions are most comfortable?
– Do you feel faint, light-headed or
nauseous?
– Chest pain?
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– Hear or feel snap, crack or pop in your
chest?
– Muscle spasms?
– Blood or pain during urination?
– Was the bladder full or empty?
– How long has it been since you last ate?
– Is there a personal or family history of any
heart, abdominal problems or other
diseases involving the abdomen and
thorax?
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• Observations
– Is the athlete breathing? Are they having
difficulty breathing? Does breathing cause
pain?
– Is the athlete holding the chest wall?
– Is there symmetry of the chest during
breathing?
– If the athlete’s wind was knocked out, is
normal breathing returning? How rapidly?
– Body position
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– Check for areas of discoloration, swelling
or deformities
• Around umbilicus = intra-abdominal bleed
• Flanks = swelling outside the abdomen
– Protrusion or swelling in any portion of
abdomen (internal bleeding)
– Does the thorax appear to be symmetrical?
– Are the abdominal muscles tight and
guarding?
– Is the athlete holding or splinting a
particular part?
– Monitor vital signs (pulse, respiration, BP)
• Rapid weak pulse or drop in BP is an indication
of a serious internal injury (involves blood loss)
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• Palpation
– Thorax
• Check for symmetry of chest wall movement
and search for areas of tenderness
• Palpate along ribs and intercostal spaces as
well as costochondral junctions – locate points
of tenderness
– Abdomen
• Patient should have arms at side, knees and
hips flexed to relax abdomen
• Feel for guarding and tenderness, rigidity
(internal bleeding)
• Be aware of possibility of referred pain
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© 2010 McGraw-Hill Higher Education. All rights reserved.
Referred Pain Patterns
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Recognition and Management
of Specific Injuries
• Rib Contusion
– Cause of Injury
• Blow to the rib cage can bruise ribs,
musculature or result in fracture
– Signs of Injury
• Painful breathing (particularly if muscles are
involved)
• Point tenderness; pain with rib compression
– Care
• RICE and NSAID’s
• Rest and decrease in activity
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• Rib Fractures
– Cause of Injury
• Caused by a direct blow or the result of a
violent muscular contraction
• Can be caused by violent coughing and
sneezing
– Signs of Injury
• History is critically important
• Pain with inspiration, point tenderness and
possible deformity with palpation
– Care
• Refer for X-rays
• Support and rest; brace
• Generally heals in 3-4 weeks
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• Costal Cartilage Injury
– Cause of Injury
• Result of a direct blow to the anterolateral
aspect of the rib cage
– Signs of Injury
• Localized pain in region of costochondral
junctions
• Pain with movement; difficulty with breathing
• Point tenderness and possible deformity
– Care
• Rest and immobilization
• Healing may take 1-2 months
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© 2010 McGraw-Hill Higher Education. All rights reserved.
• Intercostal Muscle Injuries
– Cause of Injury
• Muscles are subject to contusions and strains
• Occur most often from direct blows or sudden
torsion of the trunk
– Signs of Injury
• Pain occurs on active motions; pain with
inspiration and expiration, coughing, sneezing
and laughing
– Care
• Immediate pressure and application of cold for
approximately 20 minutes
• After hemorrhaging is controlled, immobilize the
injury to make the athlete comfortable
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• Lung Injuries
– Cause of Injury
– Pneumothorax • pleural cavity becomes filled with air, negatively
pressurizing the cavity, causing a lung to collapse
– Tension Pneumothorax
• Pleural sac on one side fills with air displacing lung
and heart, compressing the opposite lung
– Hemothorax
• Blood in pleural cavity causes tearing or puncturing
of the lungs or pleural tissue
– Traumatic Asphyxia
– Result of a violent blow or compression of rib cage
– Causes cessation of breathing and immediate medical
attention
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– Signs of Injury
• Breathing difficulty, shortness of breath, chest pain
on side of injury
• Coughed up blood, cyanosis, and potentially shock
• With collapse of lung medical attention is required
immediately
– Care
• Each of these conditions are medical emergencies
and require immediate attention
• Transport athlete to hospital immediately
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• Sudden Death Syndrome in Athletes
– Cause of Condition
• Hypertrophic cardiomyopathy - thickening of cardiac
muscle w/ no increase in chamber size
• Anomalous origin of coronary arteries
• Marfan’s syndrome- abnormality in connective tissue
results in weakening of aorta and cardiac vessels
• Series of additional cardiac causes
• Non-cardiac causes include drugs and alcohol,
intracranial bleeding, obstructive respiratory disease
– Signs of Condition
• Most do not exhibit any signs prior to death
• May exhibit chest pain, heart palpitations, syncope,
nausea, profuse sweating, shortness of breath, malaise
and/or fever
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– Care
• Immediate medical attention is necessary – life
threatening condition
– Prevention
• Counseling and screening are critical in early
identification and prevention of sudden death
• Screening questions should address the
following
–
–
–
–
–
History of heart murmurs
Chest pain during activity
Periods of fainting during exercise
Family history
Thickening of heart or history of Marfan’s syndrome
• Cardiac screening - electrocardiograms and
echocardiograms may be needed to determine
existing pathology
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• Breast Problems
– Cause of Injury
• Constant uncontrolled movement (particularly in
large breasted women)
• Stretching of Cooper’s ligament
• Runner’s and cyclist’s nipple
– Management
• Females should wear well-designed bra that has
minimum elasticity and allows for little movement
• Special plastic cup-type brassieres may be required
in sports with high levels of physical contact
• Use of an adhesive bandage can be used to prevent
runner’s nipple
• Wearing a windbreaker can prevent cyclist nipple
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Injuries to the Abdominal Wall
• Abdominal Muscle Strain
– Cause of Injury
• Result of sudden twisting or reaching of trunk,
tearing abdominal musculature
• Contusions of Abdominal Wall
– Cause of Injury
• Caused by a compressive force - generally
occurring in collision sports
• Extent of injury depends on whether force is
blunt or penetrating
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– Signs of Injury
• May cause a hematoma to develop under fascia
of surrounding muscle tissue
• Swelling may cause pain and tightness w/in the
region
– Care
•
•
•
•
Cold pack and compression
Be sure to check for signs of internal injuries
Conservative management
Exercise should be kept pain free
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• Hernia (sports hernia)
– Cause of Injury
• Protrusion of abdominal viscera through portion
of abdominal wall (congenital or acquired)
• Inguinal vs. femoral hernias
• Complications and strangulated hernias
– Signs of Injury
• Acquired hernia occur when natural weakness
is further aggravated by a direct blow or strain
– History of direct blow to groin area, pain and
prolonged discomfort, superficial protrusion with pain
increasing with coughing & reported pulling
sensation in groin area
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– Care
• Most physicians
prefer athlete to
refrain from hard
physical activity
until surgically
repaired
• Mechanical devices
are not suitable for
athletics due to
friction and irritation
they produce
• While exercise is
thought to be
beneficial with
regards to
strengthening that
is not the case
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• Blow to Solar Plexus
– Cause of Injury
• Transitory paralysis of the diaphragm due to
blow to the middle portion of the abdomen
– Signs of Injury
• Stops respiration and leads to anoxia
• Generally transitory
– Care
• Must help athlete overcome apprehension
• Use short inspirations and long expirations
• Calm athlete, prevent hyperventilation, blow
into a paper bag
• ATC should question possibility of internal
injury
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• Stitch in the Side
– Cause of Injury
• Idiopathic condition with obscure cause and
several hypotheses
– Constipation, intestinal gas, overeating, diaphragmatic
spasm, poor conditioning, lack of visceral support and
weak abdominals, distended spleen, breathing
techniques resulting in lack of oxygen, ischemia of
diaphragm or intercostal muscles
– Signs of Injury
• Cramp-like pain that develops on either the right
or left costal angle during hard physical activity
– Management
• Relaxation of the spasm
– Stretch arm on affected side as high as possible
– Flex trunk forward on the thighs
• Additional problems may warrant further study
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• Injury of the Spleen
– Cause of Injury
• Result of a direct blow
• Infectious mononucleosis (causing an enlarged
spleen)
– Signs of Injury
• Indications of a ruptured spleen involve history
of a direct blow, signs of shock, abdominal
rigidity, nausea, vomiting
• Kehr’s sign
• Ability to splint self may produce delayed
hemorrhaging - easily disrupted resulting in
internal bleeding
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– Care
• Conservative treatment involves 1 wk of
hospitalization and a gradual return to activity
• Surgery will result in three months of recovery
while removal of spleen will result in a 6 month
removal from activity
• In cases of mononucleosis athlete may resume
training in 3 weeks if spleen not enlarged and if
there is no fever
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• Kidney Contusion
– Cause of Injury
• Result of an external force (force and angle dependent)
• Susceptible to injury due to normal distention of blood
– Signs of Injury
• May display signs of shock, nausea, vomiting, rigidity of
back muscles and hematuria (blood in urine)
• Referred pain (costovertebral angle posteriorly radiating
forward around the trunk)
– Care
• Monitor status of urine (hematuria) - refer if necessary
• 24 hour hospitalization and observation with a gradual
increase in fluid intake
• Surgery may be required if hemorrhaging continues
• 2 weeks of rest and close surveillance following initial
return to activity is necessary
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• Liver Contusion
– Cause of Injury
• Blunt trauma - right side of rib cage
• More susceptible if enlarged due to illness
(hepatitis)
– Signs of Injury
• Hemorrhaging and shock may present
• May require immediate surgery
• Presents with referred pain in right scapula,
shoulder and substernal area and occasionally in
left anterior side of chest
– Care
• Referral to a physician for diagnosis and
treatment
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• Appendicitis
– Cause of Injury
• Inflammation of the vermiform appendix (chronic or
acute)
• Result of blockage, lymph swelling, or carcinoid tumor
• Early stages it presents as a gastric complaint, that
gradually develops from red swollen vessel to a
gangrenous structure that can rupture into bowels
causing peritonitis
– Signs of Injury
• Mild to severe pain in lower abdomen, associated with
nausea, vomiting and low grade fever
• Pain may localize in lower right abdomen (McBurney’s
point)
– Care
• Surgical intervention is often necessary (particularly if
it is resulting in an obstructed bowel = life threatening)
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• Injuries to the Bladder
– Cause of Injury
• Blunt force to the lower abdomen may cause
injury to urinary bladder if distended with urine
• Hematuria is often associated with contusion of
bladder during running (runner’s bladder)
– Signs of Injury
• Pain, discomfort of lower abdominal region,
abdominal rigidity, nausea, vomiting, shock,
bleeding from the urethra, increased quantity of
bloody urine
• Athlete should be instructed to monitor urine
• Inability to urinate will present in case of
ruptured bladder
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• Scrotal/Testicular Contusion
– Cause of Injury
• Result of blunt trauma and contusion to the
vulnerable and sensitive scrotum
– Signs and Symptoms
• Hemorrhaging, fluid effusion, muscle spasm,
severe pain (disabling)
• May cause nauseating, disabling and painful
condition
– Care
• Place athlete on side with knees to chest
• Apply cold pack as pain subsides
• If pain persist after 15-20 minutes referral will
be necessary
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© 2010 McGraw-Hill Higher Education. All rights reserved.
• Gynecological Injuries
– Low incidence of injury in sports
– Most common occurrence involve
contusion of external genitalia (vulva including the labia, clitoris and the vaginal
vestibule)
– Signs and Symptoms
• Hematoma results from contusion - may also
involve pubic symphysis resulting in osteitis
pubis
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