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
- Section Editor
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
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].
- Gaillard M, Hervé C, Mandin L, Raynaud P. Mortality prognostic factors in chest injury. J Trauma 1990; 30:93.
- Newman RJ, Jones IS. A prospective study of 413 consecutive car occupants with chest injuries. J Trauma 1984; 24:129.
- Shorr RM, Crittenden M, Indeck M, et al. Blunt thoracic trauma. Analysis of 515 patients. Ann Surg 1987; 206:200.
- Arajärvi E, Santavirta S. Chest injuries sustained in severe traffic accidents by seatbelt wearers. J Trauma 1989; 29:37.
- Knobloch K, Wagner S, Haasper C, et al. Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims. Ann Thorac Surg 2006; 82:444.
- Budd JS. Effect of seat belt legislation on the incidence of sternal fractures seen in the accident department. Br Med J (Clin Res Ed) 1985; 291:785.
- Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: a retrospective analysis of 272 cases. J Trauma 1993; 35:46.
- McGinnis M, Denton JR. Fractures of the scapula: a retrospective study of 40 fractured scapulae. J Trauma 1989; 29:1488.
- McLennan JG, Ungersma J. Pneumothorax complicating fracture of the scapula. J Bone Joint Surg Am 1982; 64:598.
- Brown CV, Velmahos G, Wang D, et al. Association of scapular fractures and blunt thoracic aortic injury: fact or fiction? Am Surg 2005; 71:54.
- Stephens NG, Morgan AS, Corvo P, Bernstein BA. Significance of scapular fracture in the blunt-trauma patient. Ann Emerg Med 1995; 26:439.
- Baldwin KD, Ohman-Strickland P, Mehta S, Hume E. Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database. J Trauma 2008; 65:430.
- Weening B, Walton C, Cole PA, et al. Lower mortality in patients with scapular fractures. J Trauma 2005; 59:1477.
- Peek GJ, Firmin RK. Isolated sternal fracture: an audit of 10 years' experience. Injury 1995; 26:385.
- Wojcik JB, Morgan AS. Sternal fractures--the natural history. Ann Emerg Med 1988; 17:912.
- Odell DD, Peleg K, Givon A, et al. Sternal fracture: isolated lesion versus polytrauma from associated extrasternal injuries--analysis of 1,867 cases. J Trauma Acute Care Surg 2013; 75:448.
- Oyetunji TA, Jackson HT, Obirieze AC, et al. Associated injuries in traumatic sternal fractures: a review of the National Trauma Data Bank. Am Surg 2013; 79:702.
- Kohn MA, Hammel JM, Bretz SW, Stangby A. Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med 2004; 11:1.
- Fabian TC, Richardson JD, Croce MA, et al. Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma. J Trauma 1997; 42:374.
- Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin injuries require radiographic evaluation for intraabdominal injury? Ann Emerg Med 2005; 46:232.
- Kea B, Gamarallage R, Vairamuthu H, et al. What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma? Am J Emerg Med 2013; 31:1268.
- Chauny JM, Émond M, Plourde M, et al. Patients with rib fractures do not develop delayed pneumonia: a prospective, multicenter cohort study of minor thoracic injury. Ann Emerg Med 2012; 60:726.
- Daoust R, Emond M, Bergeron E, et al. Risk factors of significant pain syndrome 90 days after minor thoracic injury: trajectory analysis. Acad Emerg Med 2013; 20:1139.
- 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