Trauma: Chest Wall Trauma

Chest Wall Injury

AAST Chest Wall Injury Scale

Rib Fracture

Respiratory Splinting

  • Definition: Reduced Inspiratory Effort Due to Severe Pleuritic Chest Pain Upon Inspiration
  • Results In:
    • Hypoventilation
    • Atelectasis
    • Pneumonia
    • Retained Secretions
    • Respiratory Failure
  • Can Quantify with Incentive Spirometry (IS)
    • Goal: > 15 cc/kg Ideal Body Weight

Elderly

  • Most Common Injury in Elderly After Blunt Chest Trauma
  • Each Additional Rib Fracture Increases:
    • Risk of Death by 19%
    • Risk of PNA by 27%
    • *Risk May Be Overestimated by Older Studies without Modern Imaging

Descriptions

  • Types:
    • Simple: Single Fracture Line Across the Rib with No Fragmentation or Comminution
    • Wedge: A Second Fracture Line that Does Not Span the Entire Rib Width
    • Complex: ≥ 2 Fracture Lines with ≥ 1 Fragment Spanning the Entire Rib Width
  • Displacement:
    • Nondisplaced: ≥ 90% of the Fracture Cortical Surfaces are in Contact
    • Offset: Some Cortical Contact But < 90% of the Fracture Cortical Surfaces are in Contact
    • Displaced: No Cortical Contact Between Fracture Surfaces
  • Location:
    • Anterior: Anterior to the Anterior Axillary Line
    • Lateral: Between the Anterior & Posterior Axillary Lines
    • Posterior: Posterior to the Posterior Axillary Line

Diagnosis

  • May Be Seen on CXR but Often Underestimates or Misses
    • CXR Sensitivity Only 33-40%
  • CT is the Gold Standard – Also Able to Provide 3D Reconstructions for Surgical Planning

Flail Chest

  • Definitions:
    • Flail Segment: ≥ 3 Adjacent Ribs Fractured in ≥ 2 Places
      • *Some Texts Say ≥ 2 Adjacent Ribs Fractured in ≥ 2 Places
    • Flail Chest: Flail Segment with the Clinical Paradoxical Chest Wall Movement
  • Paradoxic Breathing – Segment Pulled Inward with Inhalation & Outward with Exhalation
    • Disrupts Normal Respiratory Mechanics
    • Collapse Causes Air Movement from the Injured Lung to the Uninjured Lung – Results in a Possible Mediastinal Shift to the Injured Side
  • Risk for Underlying Pulmonary Contusion
    • Initial CXR Underestimates & Worsens with Time and IVF Resuscitation

Treatment

  • Primary Tx: Aggressive Pain Control & Pulmonary Therapy
    • Consider Epidural Analgesia as the Primary Pain Control Modality for Severe Blunt Thoracic Trauma with Multiple Rib Fractures
  • In Elderly Patients: Consider Admission to ICU (High Mortality Risk)
  • Rib Plating (ORIF) Indications:
    • Flail Segment if No Underlying Contusion
    • Nonunion
    • Significant Deformity
    • Refractory Pain
    • Unable to Wean Off Ventilator
    • During Thoracotomy for Other Indication – “On the Way Out”
  • Typical Ribs Plated:
    • Ribs #1-3: Not Plated
      • Have Little Movement & Are Difficult to Access
    • Ribs #4-9: The Only Ribs Plated
      • Where the Majority of Chest Wall Movement Occurs
    • Ribs #10-12: Not Plated
      • Add Little to Chest Wall Stability

Pain Control Options

  • Multimodal Approach:
    • Ice Packs/Heat Packs
    • Acetaminophen
    • Ibuprofen
    • Gabapentin
    • Muscle Relaxants (Flexeril)
    • Lidocaine Patches
    • Ketamine
  • PO Narcotics
  • IV Narcotics/PCA
  • Nerve Block
  • Erector Spinae Block
  • Epidural Analgesia

Flail Chest 1

Rib Plating 2

Sternal Fracture

General

  • Significant Force Required to Fracture, Often Multiple Injuries Present
  • No Increased Concern for Underlying Cardiac Contusion
    • *Previously Believed to Be

Most Common Associated Injuries

  • Rib Fracture (57.8%) – Most Common
  • Lung Contusion (33.7%)
  • Pneumothorax (22.0%)
  • Vertebral Fracture (21.6%)
  • Lumbar Vertebrae Fracture (16.9%)
  • Concussion (3.9%)
  • Blunt Cardiac Injury (3.6%)

Diagnosis

  • Dx: CT
  • CXR Only 50% Sensitive

Treatment

  • Tx: Supportive
  • ORIF Indications: Chronic Pain or Unstable

Sternum Fracture 3

Scapula Fracture

General

  • Significant Force Required to Fracture, Often Multiple Injuries Present
  • Dx: CXR/CT

Treatment

  • Tx: Supportive (Sling for 2 Weeks)
  • ORIF Indications:
    • Open Fracture
    • Glenoid Instability
    • Loss of Rotator Cuff Function
    • Unstable Neck Fractures
    • Significant Displacement

Scapula Fracture 4

Clavicle Fracture

General

  • Often Occur in Isolation (Opposed to Sternum/Scapula Fractures)
  • Mostly from Falling on An Outstretched Arm or Direct Blow

Allman Classification

  • Group I: Middle Third (69-80%) – Most Common Site
  • Group II: Distal Third (10-28%)
  • Group III: Proximal Third (2-9%)

Treatment

  • Tx: Conservative
    • Sling with ROM Exercises vs Figure-of-Eight Bandage
  • Surgery (ORIF or Intramedullary Fixation) Indications:
    • Open Fractures
    • Displaced with Skin Tenting
    • Associated Neurovascular Injury
    • Floating Shoulder (Scapula Neck & Clavicle Fracture)
    • Nonunion with Refractory Pain

Clavicle Fracture

Extrapleural Hematoma

General

  • Hematoma of the Extrapleural Space
  • Often Confused with HTX

Types

  • Nonconvex: Smaller, Likely Due to Venous Injury
  • Biconvex: Larger, Likely Due to Arterial Injury
    • More Likely to Require Surgical Intervention

Diagnosis

  • Sx: Bleeding, Chest Pain & Shortness of Breath
    • Most ASx
  • Dx: CT
    • “Extrapleural Fat Sign” – Inward Displacement of Extrapleural Fat

Treatment

  • Small/Stable: Conservative Management
  • Large/Cardiorespiratory Sx: VATS
    • If Fails: Thoracotomy

Extrapleural Hematoma

References

  1. Granhed HP, Pazooki D. A feasibility study of 60 consecutive patients operated for unstable thoracic cage. J Trauma Manag Outcomes. 2014 Dec 30;8(1):20. (License: CC BY-2.0)
  2. Evman S, Kolbas I, Dogruyol T, Tezel C. A Case of Traumatic Flail Chest Requiring Stabilization with Surgical Reconstruction. Thorac Cardiovasc Surg Rep. 2015 Dec;4(1):8-10. (License: CC BY-NC-SA-4.0)
  3. Lahham S, Patane J, Lane N. Ultrasound of Sternal Fracture. West J Emerg Med. 2015 Dec;16(7):1057-8. (License: CC BY-4.0)
  4. Memişoğlu S, Yılmaz B, Aktaş E, Kömür B. Isolated scapula fracture: Ice hockey player without trauma. Ann Med Surg (Lond). 2015 Jul 29;4(3):235-7. (License: CC BY-NC-ND-4.0)