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Blunt Chest Trauma
Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: John Geibel, MD, DSc, MSc, MA more...

Updated: Oct 03, 2014

Overview

Overview

Chest trauma is a significant source of morbidity and mortality in the United States. This article
focuses on chest trauma caused by blunt mechanisms. Penetrating thoracic injuries are
addressed in Penetrating Chest Trauma.
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, and sternum), the lungs
and pleurae, the tracheobronchial tree, the esophagus, the heart, the great vessels of the chest,
and the diaphragm. In the subsequent sections, each particular injury and injury pattern resulting
from blunt mechanisms is discussed. The pathophysiology of these injuries is elucidated, and
diagnostic and treatment measures are outlined.

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, 126,438 deaths occurred from
unintentional injury in 2011.[1]

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 1 million population per
day. Approximately 33% of these injuries necessitate 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.

Pathophysiology
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.

Left pulmonary contusion following a motor vehicle accident involving a pedestrian.

Space-occupying lesions (eg, pneumothorax, hemothorax, and hemopneumothorax) interfere with

oxygenation and ventilation by compressing otherwise healthy lung parenchyma. A 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. After 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.
Sternal fractures are rarely of any consequence, except when they result in blunt cardiac injuries.

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 who has sustained 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, blunt thoracic injuries may be divided into the following three
broad categories:

Chest wall fractures, dislocations, and barotrauma (including diaphragmatic injuries)

Blunt injuries of the pleurae, lungs, and aerodigestive tracts
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 make up the
brachial plexus also access the upper extremities via the thoracic outlet. The veins that drain the
arm (of which the most important is 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 three lobes, and the left lung has two 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 the 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 (a remnant of the ductus arteriosus) exists between the descending
thoracic aorta and pulmonary artery just beyond the takeoff 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.

Workup

Initial emergency workup of a patient with multiple injuries should begin with the ABCs (airway,
breathing, and circulation), with appropriate intervention taken for each step.

Laboratory studies
A complete blood count (CBC) is a routine laboratory test for most trauma patients. The CBC
helps gauge blood loss, though 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 (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.
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 acid-base abnormalities can also be identified, eg, a
chloride-responsive metabolic alkalosis or hyperchloremic metabolic acidosis.
The coagulation profile, including prothrombin time (PT)/activated partial thromboplastin time
(aPTT), fibrinogen, fibrin degradation product, and D-dimer analyses, can be helpful in the
management of patients who receive massive transfusions (eg, >10 units of packed red blood
cells [RBCs]). Patients who manifest hemorrhage that cannot be explained by surgical causes
should also have their profile monitored.
Whereas 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.
Accordingly, troponin I level determination does not, by itself, help predict the occurrence of
complications that may require admission to the hospital. Accordingly, its routine use in this
clinical situation is not well supported.[2, 3]
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 been criticized because of poor sensitivity, specificity,
and positive predictive value in relation to clinically significant blunt myocardial injuries.
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.
Type and crossmatch are among 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 radiography

The chest x-ray (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 scenario warrants immediate decompression before a chest radiograph is
obtained.[4]
A 2012 study by Paydar et al indicated that routine chest radiography in stable blunt trauma
patients may be of low clinical value. The authors propose that careful physical examination and
history taking can accurately identify those patients at low risk for chest injury, thus making
routine radiographs unnecessary.[5]

Computed tomography
Because of the lack of sensitivity of chest radiography in identifying significant injuries, computed
tomography (CT) 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. As a result, obtaining a chest CT scan in a supposedly stable patient
with significant mechanism of injury is becoming routine practice.
Helical CT 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.[6, 7, 8]
Abdominal CT alone or combined with cervical spinal CT detected almost all occult small
pneumothoraces in one study of patients with blunt trauma, whereas cervical spinal CT alone
detected only one third of cases.[9]

Aortography
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, the introduction of spiral CT scanners, which have
100% sensitivity and greater than 99% specificity, has caused the role of aortography in the
evaluation of trauma patients to decline.
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.[10, 11]
Thoracic ultrasonography
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 ultrasonography in these settings are all greater
than 90%.

Contrast esophagography
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 sonographic examination of 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.

Electrocardiography

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.
However, according to a 2012 practice management guideline from the Eastern Association for
the Surgery of Trauma, ECG alone should not be considered sufficient for ruling out blunt cardiac
injury. The guideline recommends obtaining an admission ECG and troponin I from all patients in
whom blunt cardiac injury is suspected and states that such injury can be ruled out only if both the
ECG and the troponin I level are normal.[12]

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%.
The advantages of TEE 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.[13, 14, 15] 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 (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.

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.

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 such injuries 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 necessitating 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 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/hr 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 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.

Treatment & Management

Chest wall fractures, dislocations, and barotrauma (including diaphragmatic injuries)

Rib fractures
Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are the ones 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 three or more rib fractures have been shown to have a fivefold increase in
mortality and a fourfold increase in the 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, resulting in the need for surgical control to achieve hemostasis
acutely. In the chronic phase, nonunion and persistent pain may also necessitate an operation.
Flail chest
A flail chest, by definition, involves three or more consecutive rib fractures in two or more places,
which produce a free-floating, 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 treatments mentioned above for rib fractures are suitable for 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; fluid overloading can
precipitate respiratory failure, especially in those with significant pulmonary contusions.
To stabilize the chest wall and avoid endotracheal intubation and mechanical ventilation, various
operations have been devised for correcting flail chest (eg, pericostal sutures, application of
external fixation devices, and placement of plates or pins for internal fixation). With improved
understanding of pulmonary mechanics and better mechanical ventilatory support, surgical
therapy has not proved superior to supportive and medical measures. Most authors, however,
would agree that stabilization is warranted if 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 among 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, and 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 arm as compared with the
contralateral arm. The proximal segment of the clavicle is displaced superiorly because of the
action of the sternocleidomastoid.
Nearly all clavicular fractures can be managed without surgery. Primary treatment consists of
immobilization with a figure-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.
Sternoclavicular joint dislocations
Strong lateral compressive forces against the shoulder can cause sternoclavicular joint
dislocation. Anterior dislocation is more common than posterior dislocation. Patients report pain
with arm motion or when a compressive force is applied against the affected shoulder. The
ipsilateral arm and shoulder may be anteroinferiorly displaced. With anterior dislocations, the
medial end of the clavicle can become more prominent. With posterior dislocations, a depression
may be discernible adjacent to the sternum. Associated injuries to the trachea, subclavian vessels,
or brachial plexus can occur with posterior dislocations.
Closed or open reduction is generally advised. Treatment strategies depend on whether the
patient has an anterior or posterior dislocation.
For anterior dislocations, local anesthesia and sedative medications are administered, and lateral
traction is applied to the affected arm that is placed in abduction and extension. This maneuver,
combined with direct pressure over the medial clavicle, can occasionally reduce an anterior
dislocation. For posterior dislocations, a penetrating towel clip can be used to grasp the medial
clavicle to provide the necessary purchase for anterior manual traction to reduce the joint. Proper
levels of pain control, up to and including general anesthesia, are provided. If closed reduction
fails, open reduction is performed.
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
exercised before myocardial injury is completely excluded. The workup should begin with
electrocardiography (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.
Scapular fractures
Scapular fractures are uncommon. Their main clinical importance is the high-energy forces
required to produce them and the attendant high incidence of associated injuries. The rate of
associated injuries is 75-100%, most commonly involving the head, chest, or abdomen.
Patients with scapular fractures report pain around the scapula. Tenderness, swelling,
ecchymosis, and fracture-related crepitus can all be present. The fracture is most frequently
located in the body or neck of the scapula. More than 30% of scapular fractures are missed during
the initial patient evaluation. The discovery of a scapular fracture should prompt a concerted effort
to exclude major vascular injuries and injuries of the thorax, abdomen, and neurovascular bundle
of the ipsilateral arm.
Shoulder immobilization is the standard initial treatment. This can be accomplished by placing the
arm in a sling or shoulder harness. Range-of-motion exercises are started as soon as possible to
help prevent loss of shoulder mobility. Surgery is infrequently indicated. Involvement of the
glenoid, acromion, or coracoid may require open reduction and internal fixation with the goal of
maintaining proper shoulder mobility.
Scapulothoracic dissociation
Sometimes called flail shoulder, this rare injury occurs when very strong traction forces pull the
scapula and other elements of the shoulder girdle away from the thorax. The muscular, vascular,
and nervous components of the shoulder and arm are severely compromised. Physical findings
include significant hematoma formation and edema in the shoulder area. Neurologic deficits
include loss of sensation and motor function distal to the shoulder. Pulses in the arm are typically
decreased or lost due to axillary artery thrombosis.
No specific medical therapy has been developed for this devastating injury. Surgery is rarely
indicated early in the course of this injury. If the affected limb retains sufficient neurovascular
integrity and function, operative fixation may be indicated to restore shoulder stability. Many
scapulothoracic dissociations result in a flail limb that is insensate or is associated with severe
pain due to proximal brachial plexus injury. An above-the-elbow amputation may be the best
approach for these patients.
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
The curious clinical constellation known as traumatic asphyxia is the result of thoracic injury due
to a strong crushing mechanism, such 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 neurologic 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, though autopsy and computed tomography (CT)-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 intra-abdominal 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 is not very accurate, and magnetic resonance imaging (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.[16, 17]

Blunt injuries of pleurae, lungs, and aerodigestive tracts

Pneumothorax
Pneumothoraces in blunt thoracic trauma are most frequently caused when a fractured rib
penetrates the lung parenchyma. However, this is not an absolute rule. 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, Pleur-evac) that is entrained to suction at a pressure of approximately 20
cm H 2 O. Suction continues 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 tube may be removed and
another chest radiograph obtained to ensure continued complete lung expansion.
A prospective, observational, multicenter study sought to determine which factors predicted failed
observation in blunt trauma patients.[18] Using data from 569 blunt trauma patients, the study
identified 588 with an occult pneumothorax (OPTX); one group underwent immediate tube
thoracostomy and the second group was observed.
Patients in whom observation failed spent more days on ventilators and had longer hospital and
intensive care unit lengths of stay; 15% developed complications.[18] No patient in this group
developed a tension pneumothorax or experienced adverse events by delaying tube thoracostomy.
The investigators concluded that whereas most blunt trauma patients with OPTX can be carefully
monitored without tube thoracostomy, OPTX progression and respiratory distress were significant
predictors of failed observation.
Hemothorax
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 by means of tube thoracostomy. Multiple chest tubes may be
required. Pain control and aggressive pulmonary toilet are provided. Tube output is monitored
closely. Indications for surgery can be based on the initial and cumulative hourly chest tube
drainage, in that massive initial output and continued high hourly output are frequently associated
with thoracic vascular injuries that require surgical intervention. Guidelines are provided elsewhere
(see Indications).
Large, clotted hemothoraces may necessitate 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.[19]
Open pneumothorax
Open pneumothorax 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 three-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 (eg, 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.
Traumatic pulmonary herniation through the ribs, though uncommon, may occur following chest
trauma. Unless incarceration or infarction is evident, immediate repair is not indicated.
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 (ie, 14- to 16-gauge) needle 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 and other parenchymal injuries
The forces associated with blunt thoracic trauma can be transmitted to the lung parenchyma. This
results in pulmonary contusion, 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%).[20]
In 2012, the Eastern Association for the Surgery of Trauma released an updated practice
management guideline on the management of pulmonary contusion and flail chest.[21]
Blunt tracheal injuries
Although the incidence of blunt tracheobronchial injuries is low (1-3%), most patients with such
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 emergency 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 end-to-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 has passed since injury, primary repair buttressed by well-vascularized
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 injuries of heart, great arteries, veins, and lymphatics

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.[22, 23, 24]
Blunt injuries of thoracic aorta and major thoracic arteries
High-speed MVAs are the most common cause of blunt injuries to the thoracic aortic injuries and
the major thoracic arteries. Falls from heights and MVAs involving a pedestrian are other
recognized causes. Injury mechanisms include rapid deceleration, production of shearing forces,
and direct luminal compression against points of fixation (especially at the ligamentum
arteriosum). Many of these patients die of vessel rupture and rapid exsanguination at the scene 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.
As many as 50% of patients with these devastating, life-threatening 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 undergo 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 short-acting beta-blockers (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.[25]
Endovascular stent grafts are being developed to repair thoracic aortic injuries. Although several
authors have reported success in treating such injuries with endovascular 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.[26, 27, 28]
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 superior vena cava and major thoracic veins
Injuries limited to the major veins of the thorax are rare. These patients usually present with
associated injuries to other major thoracic vascular structures. The clinical history, including
mechanisms of injury, and physical examination are similar to those described for blunt injuries of
the thoracic aorta and major thoracic arteries.
Major thoracic venous injuries are amenable to lateral venorrhaphy. If repair proves to be difficult
or impossible, injured subclavian or azygous veins can be ligated. Injuries of the thoracic inferior
or superior vena cava may require shunt placement or cardiopulmonary bypass to facilitate repair.
Blunt injuries of 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.

General surgical approach

Preoperative
Patients with immediately life-threatening injuries that necessitate surgery cannot afford a
protracted workup. At minimum, the ABCs must be established. Frequently, resuscitation efforts in
these patients must continue in transit to and in the operating room.
Those with indications for surgery but who are not in extremis should also have their ABCs
established. On the basis of the mechanism of injury, clinical history, and physical findings, a
search is conducted to exclude associated injuries. Diagnostic procedures are completed if time
and the patient's condition permit (eg, cervical spine radiography, head CT, chest and abdominal
CT, FAST examination). Blood is drawn and sent for typing, crossmatching, and other tests (eg,
complete blood count and arterial blood gas analysis).
Intraoperative
An adequate, secured airway is necessary, as is intravenous access. Monitoring devices such as a
Foley urinary catheter, central venous pressure monitor, or pulmonary artery catheter should be
considered based on the severity of injury, preoperative functional status, and anticipated length of
the operation. Some injuries may require the use of single-lung ventilation techniques. This should
be discussed with the anesthesiologist as early as possible.
Cardiopulmonary bypass or a centrifugal pump is used when necessary. Patient positioning and
choice of incision are very important. Median sternotomy is used to access the heart,
intrapericardial portion of the pulmonary vessels, ascending aorta and aortic arch, venae cavae,
and the innominate artery. Branches of the innominate artery are exposed by extending the
median sternotomy into the neck.
A posterolateral left thoracotomy in the fourth intercostal space is used to approach the
descending thoracic aorta. The right subclavian artery is exposed via a median sternotomy that is
extended into the neck. Proximal control for the left subclavian artery is achieved through an
anterolateral left thoracotomy in the third intercostal space. Distal control for this vessel is
obtained through a supraclavicular incision.
The distal esophagus can be approached via a left posterolateral thoracotomy; more proximal
injuries require a right thoracotomy. The thoracic duct is approached through a right thoracotomy.
Injuries to the lung or more peripheral pulmonary vessels are accessed through a posterolateral
thoracotomy. Injuries to the proximal two thirds of the trachea are best approached through a
collar incision and extension via a T-incision through the manubrium, which allows exposure to the
middle and distal trachea. Injuries of the distal trachea, carina, or right main stem bronchus are
best approached through right fourth intercostals posterolateral thoracotomy. Injuries of the left
mainstem bronchus are best approached through a left posterolateral thoracotomy.
Postoperative
Patients are extubated as soon as feasible in the postoperative period. Monitoring devices are
kept in place while needed but are removed as soon as possible.
Intravenous fluids are provided until the patient has had a return of gastrointestinal function, at
which time the patient can be fed. Patients with severe associated injuries, especially those in a
coma, may require prolonged enteral tube feedings.
Pain control is important in these patients because it facilitates breathing and helps to prevent
pulmonary complications such as atelectasis and pneumonia. Chest physiotherapy and nebulizer
treatments are used as necessary, and the use of an incentive spirometer is encouraged.
Chest tubes are placed for suction until fluid drainage has fallen sufficiently and the lung is
completely expanded without evidence of air leak. Tubes may then be placed to water seal and
may be removed if a chest radiograph demonstrates continued lung expansion.
Follow-up
After discharge, patients are monitored to ensure that adequate wound healing has occurred and
to assess for the development of complications. Patients with vascular injuries and grafts may be
monitored to ensure that complications such as pseudoaneurysms do not develop.
For patient education resources, see the Skin Conditions and Beauty Center, as well as Bruises and
Bronchoscopy.

Complications

Patients with blunt thoracic trauma are subject to myriad complications during the course of their
care.
Wound complications include the following:

Wound infection
Wound dehiscence (particularly problematic in sternal wounds)

Cardiac complications include the following:

Myocardial infarction
Arrhythmias
Pericarditis
Ventricular aneurysm formation
Septal defects
Valvular insufficiency

Pulmonary and bronchial complications include the following:

Atelectasis
Pneumonia
Pulmonary abscess
Empyema
Pneumatocele, lung cyst
Clotted hemothorax
Fibrothorax
Bronchial repair disruption
Bronchopleural fistula

Vascular complications include the following:

Graft infection
Pseudoaneurysm
Graft thrombosis
Deep venous thrombosis
Pulmonary embolism

Neurologic complications include the following:

Causalgia (injuries that involve the brachial plexus)

 Paraplegia (the spinal cord is at risk during repair of a ruptured thoracic aorta)
Stroke

Esophageal complications include the following:

Leakage of repair
Mediastinitis
Esophageal fistula
Esophageal stricture, late (click here to complete a Medscape CME activity on treating
esophageal strictures)

Complications involving the bony skeleton include the following:

Skeletal deformity
Chronic pain
Impaired pulmonary mechanics

Outcome and Prognosis

For the great majority of patients with blunt chest trauma, outcome and prognosis are excellent.
Most (>80%) require either no invasive therapy or, at most, a tube thoracostomy to effect
resolution of their injuries. The most important determinant of outcome is the presence or
absence of significant associated injuries of the central nervous system, abdomen, and pelvis.
Some injuries, such as cardiac chamber rupture, thoracic aortic rupture, injuries of the
intrathoracic inferior and superior vena cava, and delayed recognition of esophageal rupture, are
associated with high morbidity and mortality.

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, the use of ultrasonography 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.

RELATED REFERENCE TOPICS

Flail Chest

Pediatric Thoracic Trauma

 Rib Fracture

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