Initial evaluation and management of chest wall trauma in adults
- Eric Legome, MD
Eric Legome, MD
- Professor of Clinical Emergency Medicine
- SUNY Downstate School of Medicine
- Chief of Emergency Medicine
- Kings Count Hospital, Brooklyn
- Jean M Hammel, MD
Jean M Hammel, MD
- Vice Chairman
- Department of Emergency Medicine
- Norwalk Hospital/Western CT Health Network
The chest wall, defined here as the bony and muscular structures covering the entire thoracic cavity, protects internal thoracic organs (heart and lungs), mediastinal structures (esophagus and trachea), and major vasculature (aorta and vena cava). Damage to the chest wall may coincide with significant injury to certain of these internal structures and thus, warrants careful evaluation.
The evaluation and initial management of chest wall injuries in adults will be reviewed here. Rib fractures, clavicle fractures, internal thoracic injuries, and general trauma management are discussed in detail separately. (See "Initial evaluation and management of rib fractures" and "Clavicle fractures" and "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Initial management of trauma in adults".)
Interpreting the literature about the epidemiology of chest wall trauma is problematic. Most studies use data from trauma registries, which primarily involve patients admitted to the hospital with significant injuries. Patients with minor injuries or an isolated rib fracture are often discharged, leading to a bias in the literature toward the more seriously injured. As a result, the epidemiology of minor chest wall injuries (eg, muscle contusion and strains) is largely unknown. Many patients with such injuries do not present to the medical system at the time of injury. Therefore, available information is largely retrospective or obtained about patients with other more serious injuries.
Nevertheless, available studies provide some insight. Several studies of chest trauma from motor vehicle collisions (MVCs) report that rib fractures are identified in nearly two-thirds of admitted patients [1-3]. Sternal fractures are found in up to 8 percent of blunt chest trauma patients and 18 percent of multiple trauma patients with thoracic injuries, and are usually the result of a direct, high-energy blow to the sternum from the steering wheel and column [4-7]. Although life-saving in many instances, over-the-shoulder seat belts contribute to these fractures and their incidence has risen with the increased use of these seat belts. The incidence is greater among passengers in older cars where occupants wear seat belts but air bags are not available.
Scapular fractures account for only 1 percent of all fractures and less than 5 percent of fractures to the shoulder complex; they occur in up to 3.7 percent of blunt trauma patients [8-12]. As scapular fractures generally require great force, over 90 percent are associated with other significant injuries, including rib fracture, pneumothorax, and pulmonary contusion [8,9]. Scapular fractures rarely cause blunt aortic injury . Although the reasons are unclear, in one large prospective study scapula fractures were associated with lower mortality compared with similarly injured patients without them [10,13].
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- ANATOMY, PHYSIOLOGY, AND MECHANISM
- DIFFERENTIAL DIAGNOSIS
- PREHOSPITAL MANAGEMENT
- PRIMARY EVALUATION AND MANAGEMENT
- Initial assessment
- History and physical examination
- Diagnostic imaging
- DIAGNOSIS, INITIAL MANAGEMENT, AND DISPOSITION OF SPECIFIC INJURIES
- Minor chest wall injuries
- Clavicle fractures
- Clinical or radiographic rib fractures
- Flail chest
- Sternal fracture
- Sternoclavicular dislocation
- Scapular fracture
- Internal injuries associated with chest wall trauma
- - Blunt aortic and other mediastinal injury
- - Pneumothorax
- - Pulmonary contusion
- SUMMARY AND RECOMMENDATIONS