A full description of varieties of chest trauma in the clinical setting.

1. Chest Wall
Trauma
Dr. Walid Abukhudair

2. • Identify the clinical presentation of rib fractures.
• Plan the management of chest wall trauma.
Student Learning Outcomes
• Identify divisions and compartments of the thoracic cavity.
• Recognize the surgical anatomy of the thoracic wall.
• Explain the mechanisms of chest wall trauma.

3. Thorax
Major contents
• Thoracic vertebrae
• Ribs
• True ribs (1-7)
• False ribs (8-10)
• Floating ribs (11-
12)

4. Thorax
Major contents
• Esophagus
• Trachea and bronchi
• Heart
• Lungs
• Pleura

5. Thorax
Major contents
• Sternum
• Manubrium
• Body
• Xiphoid process
• Costal cartilages

6. Thorax
Major contents
• Clavicle
• Scapula
• Humerus

7. Thorax
Major contents
• Liver
• Spleen
• Diaphragm

8. Thorax
Major contents
• Deltoid
• Pectoralis major
• Rectus abdominis
• Exterior oblique
• Sternocleidomastoid

9. Thorax
Surface anatomy
TIV/V trasnverse plane
• Costal cartilage of rib II
articulates with the sternum.
• Separates the superior and
inferior mediastinum.
• Ascending aorta ends and
arch of aorta begins.
• Arch of aorta ends and
thoracic aorta begins.
• Trachea bifurcates.
II
III
IV
V
VI
VII
VIII
IX
X
Jugular notch
Sternal angle

10. Auscultaion position
for pulmonary valve
Auscultaion position
for mitral valve
Auscultaion position
for aortic valve
Auscultaion position
for tricuspid valve
Thorax
Surface anatomy

11. Thorax
Cross-section of the chest at TVII

12. Thorax
Surface anatomy
Superior lobe
Middle lobe
Inferior lobe
Superior lobe
Inferior lobe
Parietal pluera
Costophragmatic recess
I
II
X
IX
VIII
VII
VI
V
IV
III

13. Thorax
Surface anatomy
Auscultation for
apex of right lung
Auscultation for
superior lobe of
right lung
Auscultation for
middle lobe of
right lung
Auscultation for
inferior lobe of
right lung
I
II
X
IX
VIII
VII
VI
V
IV
III

14. Thorax
Surface anatomy

15. Chest wall trauma
Overview
Penetrating trauma Blunt trauma
• Lifethreatening due to
vital cardiopulmonary
structures.
• Chest injuries result
equally from blunt and
penetrating trauma.
• Overall mortality of 9.9%.
• Lifethreatening due to
vital cardiopulmonary
structures.
• Chest injuries result
equally from blunt and
penetrating trauma.
• Overall mortality of 9.9%.
Penetrating trauma Blunt trauma
Penetrating mechanisms
result in direct laceration
of pulmonary and
mediastinal structures
Gunshot wounds can also
cause significant lung
contusion to tissue
adjacted to track of missle
Falls and motor vehicle
accidents cause the
majority of blunt chest
injuries.
Rib fractures are the
most common injury.

16. Chest wall trauma
Penetrating trauma
Pneumothorax
Hemothorax
CXR, 6h CXR
(Echo, CT)
Chest tube
Cardiac tear
Pericardial effusion
Echocardiogram
OR
(Cardiac window)
Aortic rupture
Aortic tears
CT angiogram
OR
Tracheal injury
Esophageal injury
Bronchoscopy
Esophagoscopy

17. Chest wall trauma
Blunt trauma
Rib fracture
Fail chest
Pulmonary contusion
Pneumothorax
Cardiac contusion Aortic transection
Rule out complications
CXR, 6h CXR, CT
CXR
CT
ECG
Echo
CT angiogram
Treat complications
Supportive
Supportive
Chest tube (PTX)
Monitor vitals
Supportive
OR
Rib fracture
Fail chest
Rule out complications
CXR, 6h CXR, CT
Treat complications
Supportive

18. Thorax
Imaging
Pneumothorax

19. Thorax
Imaging
Bronchial injury

20. Thorax
Imaging
Pneumothorax

21. Thorax
Imaging
Pericardial
effusion

22. Thorax
Imaging
Aortic transection

23. Thorax
Imaging
Hemothorax

24. Thorax
Imaging
Massive pericardial effusion

25. Rib fracture

26. Rib fracture
Etiology
• Most common injury after blunt trauma, also
occurs in penetrating trauma.
• Ribs 1 - 3 are the hardest to break and signify
a significant degree of trauma if fractured.
• In the elderly, falls are a common etiology of
rib fractures and are associated with higher
mortality and morbidity.
• Children tend to have more elastic ribs than
adults do, so they are less likely to sustain rib
fractures.
• Should warrant an investigation of
possible child abuse.

27. Pain on
inspiration
Rib fracture
Clinical presentation
History of blunt
or penetrating
chest trauma
Chest wall bruising
and bony tenderness
to palpitation
or crepitus.
Pain on
inspiration
Chest wall bruising
and bony tenderness
to palpitation
or crepitus.

28. Rib fracture
Diagnosis
• Rib fractures can be diagnosed clinically based upon history and physical
exam without imaging.
• Dedicated rib x-ray series are typically not necessarily due to the benign
clinical course of isolated rib fractures.
• If there is suspicion for multiple rib fractures or significant trauma with
underlying organ damage, imaging can be the next step.
• Point-of-care ultrasonography can reliably detect rib fractures along with
complications of rib fractures such as pneumothorax.
• Chest computed tomography (CT) scan is the gold standard of detecting rib
fractures, although the fractures detected may not be clinically significant.
• The utility of chest CT during evaluation has more importance in the general
assessment of trauma for other injuries.

29. Rib fracture

30. Rib fracture
Management
Treatment targets pathophysiology of
rib fracture largely due to pain:
(1) Hypoventilation due to pain
(2) Impaired gas exchange in damaged
lung underlying the fractures, and
(3) Altered breathing mechanics.

31. Rib fracture
Management
1. Analgesia
• NSAIDs
• Opiates
• Local nerve block or epidural
catheter
2. Simple, uncomplicated
fractures
• Appropriate analgesia, rest,
and ice
3. Complicated rib fracture
• Manage complications
• Supportive treatment
4. Indications for surgery
• Significant chest
wall deformity
• Severe flail chest
• Nonunion
• Refractory rib
fracture pain causing
respiratory failure

32. Rib fracture
Complications
Pneumothorax
The sharp fractured end of the rib can
puncture the lung, causing air leakage
which is potentially life threatening.
Hemothorax
The most common causes
are intercostal vessel injury associated
with rib fractures, bleeding from injured
lung tissue, or more rarely from sub-
lobar, lobar, or great vessel injury.
Atelectasis/pneumonia
Especially in the elderly individuals,
caused by splinting and hypoventilation
Pulmonary contusion
Can be the result of fractured ribs that injure
the lung or occur alongside rib fractures as a direct
result of a high energy blow to the rib cage.
Abdominal organ injury
The lower ribs, also known as floating ribs, are not
attached to the sternum. Due to the proximity to
the kidneys and spleen, fractured ribs can
penetrate visceral organs. Patients with fractures of
the lower ribs should be examined for abdominal
organ injuries!
Respiratory failure
Develops acutely or chronically when the respiratory
system is unable to adequately oxygenate the body
and/or eliminate carbon dioxide.

33. Flail chest
Pathophyisiology
Multiple (≥ 3) rib fractures in 2
or more places
Resulting in a floating section
of ribs and soft tissue within
the chest wall
Paradoxical movement: the
floating segment moves inward
during inspiration and outward
during expiration
https://www.youtube.com/watch?v=YbTx9aVJBOw

34. Flail chest
Pathophyisiology

35. Rib series x-ray

36. Flail chest

37. Flail chest
Diagnosis and managament
Chest wall deformity
Paradoxical chest
movement
Confirmed by CXR
Intubation with positive
pressure ventilation in
severe flail chest
(bridge to surgery)
Confirmed by CXR
Supportive treatment
Intubation with positive
pressure ventilation in
severe flail chest
(bridge to surgery)
Chest stabilization

38. A 17-year-old comes to you with an acute nondisplaced left 6th anterior rib
fracture on x-ray. Blood pressure is 130/80, heart rate 80, respiratory rate 16,
and the patient has an oxygen saturation of 99% on room air. What is the
next step in management?
a. Transfer to ED for further management
b. Refer for an outpatient CT scan
c. Discharge with pain control
d. Ask the patient to return to the urgent care clinic in 2 days for re-
evaluation.
Question 1 of 2

39. A 32-year-old male patient was involved in a motor vehicle collision. He
presents to the emergency department with severe pain in his right chest. The
chest x-ray reveals numerous rib fractures and pulmonary contusion. What
one finding on physical examination would be most concerning for flail chest?
a. Difficulty breathing
b. Increased stridor
c. Paradoxical breathing
d. Severe point tenderness over the fractured ribs
Question 2 of 2

40. Summary
• Depending on the extent of injury, the outcomes of chest trauma vary.
• For isolated rib fractures, the prognosis is good, but if the aorta has been disrupted
or there is lung or cardiac contusion, the recovery is often prolonged.
• The highest morbidity following chest trauma is seen in very young and very old
patients.
• Early identification of potential patient decompensation should receive attention as
a team, and possible interventions such as intubation, chest tubes, thoracotomies
should be a team discussion to achieve optimal patient care and clinical results.
• When you consider the main determinants in the management of a flail chest;
maintaining adequate ventilation, adequate pain control, and pulmonary toilet, they
all require multiple providers working together for a successful outcome.
• Depending on the extent of injury, the outcomes of chest trauma vary.
• For isolated rib fractures, the prognosis is good, but if the aorta has been disrupted
or there is lung or cardiac contusion, the recovery is often prolonged.
• The highest morbidity following chest trauma is seen in very young and very old
patients.
• Early identification of potential patient decompensation should receive attention as
a team, and possible interventions such as intubation, chest tubes, thoracotomies
should be a team discussion to achieve optimal patient care and clinical results.
• When you consider the main determinants in the management of a flail chest;
maintaining adequate ventilation, adequate pain control, and pulmonary toilet, they
all require multiple providers working together for a successful outcome.

41. References
1. Drake, R., Vogl, W., Mitchell, A., Tibbitts, R.,
Richardson, P., & Horn, A. Gray's basic anatomy.
2. Jain, A., & Waseem, M. (2022). Chest Trauma.
Retrieved 27 March 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK482194/
3. Kuo, K., & Kim, A. (2022). Rib Fracture. Retrieved 27
March 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK541020/
4. Perera, T., & King, K. (2022). Flail Chest. Retrieved 27
March 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK534090/
5. Townsend, C., Beauchamp, R., Evers, B., Mattox, K.,
& Christopher, F. Sabiston textbook of surgery.

42. 1. https://www.ncbi.nlm.nih.gov/books/NBK541020/
2. https://www.ncbi.nlm.nih.gov/books/NBK534090/
3. https://www.ncbi.nlm.nih.gov/books/NBK482194/
Studying resources