Chest trauma can cause serious injury and is a common cause of disability and mortality after head and spinal cord injuries. Mechanisms of injury include blunt trauma, crush injuries, penetrating wounds, burns, and inhalation of foreign objects. Specific injuries include rib fractures, lung injuries, pneumothoraces, hemothoraces, aortic ruptures, and diaphragm injuries. Diagnosis involves history, physical exam noting diminished breath sounds and tracheal deviation, chest X-ray to detect fractures and lung abnormalities, and CT scan which aids in precise diagnosis of injuries.

1. 9/4/2014
CHEST TRAUMA
Sharmin Susiwala

2. •Chest trauma (or thoracic
trauma) is a serious injury of
the chest.
•Thoracic trauma is a common
cause of significant disability and
mortality, the leading cause of
death from physical trauma after
head and spinal cord injury.

3. Mechanisms of injury
 Blunt injuries
 Crush injuries
 Penetrating injuries
 Inhalation burns
 Aspiration of foreign bodies
2 major forces within chest which lead to injury:
• Compression
• Distraction
Compression results in destruction of vascular components,
haemorrhage, oedema and impairment of function.
Distraction injuries usually result in shearing forces which
destroy integrity of intrathoracic viscera.

4. Classification
• Specific types of chest trauma include:
• Injuries to the chest wall:
– Chest wall contusions or hematomas.
– Rib fractures
– Flail chest
– Sternal fractures
– Fractures of the shoulder girdle
• Pulmonary injury (injury to the lung) and injuries involving
the pleural space:
– Pulmonary contusion
– Pulmonary laceration
– Pneumothorax
– Hemothorax
– Hemopneumothorax

5. • Injury to the airways:
– Tracheobronchial tear
• Cardiac injury:
– Pericardial tamponade
– Myocardial contusion
– Traumatic arrest
• Blood vessel injuries:
– Traumatic aortic rupture
– Thoracic aorta injury
– Aortic dissection
• And injuries to other structures within the torso:
– Esophageal injury (Boerhaave syndrome)
– Diaphragm injury

6. Clinical features
• Initial history and examination are often abbreviated
• Examination
o Air hunger; use of accessory muscles; tracheal deviation; cyanosis or
distended neck veins; (evidence of tension pneumothorax, or
tamponade);
o Tracheal deviation (evidence of tension pneumothorax)
o Major defects in the chest (sucking chest wounds);
o Unilaterally diminished breath sounds or hyperresonance to
percussion (evidence of closed pneumothorax or tension
pneumothorax);
o Decreased heart sounds (pericardial tamponade);
o Location of foreign bodies;
o Location of entry and exit wounds.

7. Investigations
• CXR:
- CXR most useful screening investigation
- Look for subcutaneous air, foreign bodies, bony fractures, widening of mediastinum, pneumothorax,
pneumomediastinum, pleural fluid, pulmonary parenchymal abnormalities(infiltrates, atelectasis etc)
Pneumothorax:
 "deep" costophrenic sulcus
 "double-diaphragm" contour +/- depression of hemidiaphragm
 hyperlucency in lower thorax and upper abdomen
 sharp demarcation of cardiac apex
 visceral pleura at base of lung may be outlined
Pneumomediastinum:
 parietal pleura visible along left mediastinal border. NB pleura descends below mid-hemidiaphragm
 sharply defined edge to descending aorta which can often be followed into upper abdomen
 "continuous diaphragm" sign under cardiac shadow
 subcutaneous, retroperitoneal or intraperitoneal emphysema

8. Pneumopericardium:
 air around heart that does not rise above level of pericardial reflection at root of great vessels
 air shifts with position of patient (unlike pneumomediastinum)
Pleural effusion:
 uniform increase in density over hemithorax
 pleural cap
Pulmonary contusion:
 homogenous infiltrates that tend to be peripheral and non-segmental
 may be associated with adjacent rib fractures
 air bronchograms are rare due to blood in small airways
Ruptured hemidiaphragm:- more commonly left sided
 non-specific signs include: apparent elevation of hemidiaphragm, obliteration or distortion of contour of
hemidiaphragm, contralateral displacement of mediastinum, pleural effusion
 presence of gas containing viscera in thorax, particularly with a focal constriction across gas-containing
bowel is pathognomonic
 haemopneumothorax may be misdiagnosed when dilated stomach gives horizontal air-fluid interface on
erect CXR
 in absence of right rib #s a small right haemothorax with a "high R diaphragm" suggestive of ruptured
diaphragm
 findings may be absent in 25-50% initially

9. Chest wall injuries:
 may give clues to associated injuries
 fractures of first 3 ribs in particular indicates significant trauma
 thoracic outlet fractures associated with brachial plexus or vascular injuries
 subclavian vascular injury should be suspected in patients with fractures of first 3 ribs,
clavicle and scapula, particularly when associated with significant fracture displacement,
extrapleural haematoma, brachial plexus neuropathy or radiological evidence of mediastinal
haemorrhage
 fractures of sternum are rare and require both lateral and oblique views of thorax for
diagnosis. The presence of a fractured sternum and an abnormal mediastinal contour should
prompt a search for injury to great vessels
Haemopericardium:
 Rapid accumulation of blood in pericardial space often causes cardiac tamponade wthout
altering appearance of cardiac silhouette
• CT Scan:
 Valuable tool
 Aids in diagnosis and precise location of numerous lesions.
 Contrast is useful particularly when looking for mediastinal haemorrhage
and periaortic haematomas.

10. • Echocardiography:
 Cardiac wall motion abnormalities and valve function and presence of pericardial
fluid or blood.
• ECG:
 Most common abnormality in thoracic trauma are S-T and T wave changes and
findings indicative of bundle branch block
• Angiography:
 Remains the gold standard for defining thoracic vascular injuries
• Bronchoscopy:
 Indications include evaluation of airway injury, haemoptysis, segmental or
lobar collapse, and removal of aspirated foreign bodies.