Chest wall injury is a frequent consequence of thoracic trauma and may comprise lesions of the skeleton, the respiratory and cardiovascular system. Presentation, treatment and prognosis largely depend on the severity of the injury.
Clinical presentation varies largely and depends on the extent of CWI and possible damage to intrathoracic organs. It has to be noted that the absence of visible CWI does not rule out life-threatening internal injuries!
Frequent and severe CWI-related pathologies and their symptomatology shall be described exemplarily at this point.
- Localized pain is the most characteristic symptom for rib contusion. Respiratory movements may exacerbate pain and cause dyspnea. Rib fractures cause similar complaints, but bone fragments may damage additional intrathoracic structures, e.g., pleura, lung and vessels, and provoke pneumothorax or hemothorax, respectively.
- Lung contusion is related to minor traumatic damage to lung parenchyma, but subsequently, inflammation, pulmonary edema, pneumonia and adult respiratory distress syndrome may be develop.
- Pneumothorax is generally associated with dyspnea and stabbing chest pain that may aggravate during inspiration. Patients tend to become anxious and physical examination may reveal tachycardia and hypotension.
- Tension pneumothorax causes more severe symptoms than an uncomplicated pneumothorax. Patients show increasingly severe dyspnea, tachycardia, hypotension but augmented jugular venous pressure, cyanosis and eventually shock.
- Despite its severity, aortic dissection does not necessarily manifest immediately . Typical symptoms include sharp, stabbing and radiating chest pain that may mimic myocardial infarction. Tachycardia and hypotension may be noted. In contrast, aortic rupture leads to hemothorax, respiratory failure, hypovolemic shock and death within minutes.
- Esophageal rupture is a rare, but serious complication of CWI. Common symptoms are unspecific and include fever, pain, dyspnea and crepitus .
Many CWI patients additionally present symptoms caused by traumatic injury of other areas of the body, e.g., of head, neck or abdomen.
Entire Body System
Moreover, partial damage to certain organs may not cause symptoms at the time of initial presentation, but an overlooked esophageal lesion may rupture later and lead to fatal sepsis. [symptoma.com]
[…] greatly expanded coverage of emergency ultrasound and emergency gynecological disorders, along with sweeping updates throughout, to place the latest knowledge at your fingertips, as well as state-of-the-art coverage of emergency ultrasound, management of sepsis [books.google.com]
Contraindication can be costal cartilage repair, active or latent infection, sepsis, osteoporosis, insufficient quantity or quality of bone/soft tissue, and material sensitivity. [acuteinnovations.com]
Commonest causes of death: respiratory sepsis, severe head injury, exsanguination. [aic.cuhk.edu.hk]
[…] trauma Recognition Chest or epigastric pain, dysphagia, hematemesis Neck and/or chest wound Surgical emphysema Pleural effusion, especially on left side (CXR or bedside ultrasound) Drainage of gastrointestinal contents from an intercostal catheter Shock (sepsis [lifeinthefastlane.com]
Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. J Trauma. 1991;31(4):443–9; discussion 449–51. [link.springer.com]
Mackersie RC 1991 Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. [east.org]
Localized pain is the most characteristic symptom for rib contusion. Respiratory movements may exacerbate pain and cause dyspnea. [symptoma.com]
Chest Wall Pain
When spinal injuries are the source of chest wall pain they have to be addressed separately. Weight reduction can also decrease chest wall pain in obese patients. [piedmontpmr.com]
Illustration by Emily Roberts, Verywell Common Causes of Chest Wall Pain Chest wall pain is caused by problems affecting the muscles, bones and/or nerves of the chest wall. [verywell.com]
Epidural analgesia is the most common regional therapy used for chest wall pain management. [musculoskeletalkey.com]
What Is Chest Wall Pain? If you suffer from chest wall pain, it can be a scary experience. This is because some types of chest pain mimic the same symptoms of a heart attack or other heart condition. [paindoctor.com]
Chest Wall Tenderness
Non-Cardiac Chest Pain
One of the more frequent causes of non-cardiac chest pain is chest wall pain, or musculoskeletal chest pain. [verywell.com]
Liver, Gall & Pancreas
The diagnosis of cardiac injury can be difficult in the setting of chest wall trauma as the usual findings of chest pain, cardiac enzyme assay and ECG are unreliable diagnostic tools. [ncbi.nlm.nih.gov]
Chest pain is a common complaint in athletes and has a number of possible underlying causes. [sportsinjurybulletin.com]
Typical symptoms include sharp, stabbing and radiating chest pain that may mimic myocardial infarction. Tachycardia and hypotension may be noted. [symptoma.com]
One of the more frequent causes of non-cardiac chest pain is chest wall pain, or musculoskeletal chest pain. [verywell.com]
As much anamnestic data as possible should be collected to allow for an estimation of the extent and localization of injuries. Patients need to undergo a complete physical examination. Detection of an intrathoracic hemorrhage does not rule out another, potentially life-threatening intracranial or intraabdominal bleeding. Moreover, partial damage to certain organs may not cause symptoms at the time of initial presentation, but an overlooked esophageal lesion may rupture later and lead to fatal sepsis.
Pulse oximetry, laboratory analysis of blood samples, subsequent evalution of the hemogram (and blood biochemistry), as well as diagnostic imaging are standard procedures applied in CWI patients. Rib fractures are generally visible on plain radiographic images and this also applies to the majority of sternal, vertebral, clavicular or scapular fractures. Moreover, plain radiography may reveal accumulation of air, blood and/or lymph inside the pleural space. The latter may also be visualized sonographically and electrocardiography is the technique of choice to evaluate the heart's condition. Computed tomography scans or magnetic resonance imaging may become necessary to assess the lungs. Of note, computed tomography may be the more sensitive approach to diagnosis of bone fractures, too.
Emergency stabilization measures will have to be carried out simultaneously to the above described diagnostic measures.
- In most severe cases, cardiopulmonary resuscitation will be a necessary life-saving measure. In order to achieve resuscitation, thoracotomy may be unavoidable.
- Open pneumothorax and tension pneumothorax indicate immediate decompression by assuring thoracic drainage with needle, trocar or by tube thoracostomy. Hemothorax is treated similarly.
- Patients diagnosed with flail chest are in need of potent analgesics and mechanical ventilation.
- Massive hemorrhages may lead to shock and require fluid volume substitution and possibly blood transfusion. The source of the hemorrhage has to be identified and the bleeding needs to be stopped as fast as possible.
- Cardiac tamponade is treated by means of pericardiocentesis .
Additionally, most patients presenting with moderate to severe CWI should be intubated to maintain patent airways.
Further therapeutic procedures depend on the specific injuries sustained by the individual patient.
Severe complications may develop several hours or even days after the primary survey - respiratory distress syndrome in patients showing signs of lung contusion, for instance - and thus, continued close monitoring is recommended.
Prognosis largely depends on the severity of trauma and ranges from excellent to infaust. The presence of rib fractures has been proposed as a prognostic factor and mortality rates of 1%, 5% and 17% have been observed in patients presenting to the emergency room with up to two rib fractures, more than two rib fractures and flail chest, respectively .
The majority of CWI patients presents with mild lesions, possibly with bruised ribs, but without pulmonary or cardiovascular injury. Their prognosis is very good and sequelae are not to be expected. In contrast, increasing rates of mortality are associated with pneumothorax, tension pneumothorax and thoracic aortic rupture. Any delay of medical attention increments the likelihood of death in these cases, but many patients die within minutes after sustaining CWI. In fact, trauma is the leading cause of death in minors and young adults.
Significant morbidity may result from CWI that comprise nerve injury.
CWI is a common consequence of thoracic trauma. In general, CWI lesions result from the impact of physical forces that exceed the local resistance of those tissues comprising the thoracic wall. Thus, greater forces are usually associated with more severe damage. However, parameters like distribution of forces, type of trauma and previously existing comorbidities also affect the susceptibility of a patient for thoracic lesions.
Most CWI are caused by blunt, non-perforating trauma sustained during falls, sports accidents or motor vehicle accidents, whereby the latter accounts for the vast majority of severe CWI. In rare cases, stab or incisional wounds may be the cause of CWI. Differences observed between patients presenting with blunt thoracic trauma and those who sustained a penetrating lesion clearly illustrate the above described effect of force distribution:
- Blunt traumas are generally absorbed by large parts of the chest wall, e.g., by the whole ventral thorax upon contact with an inflating airbag. With regards to the chest wall itself, this often results in bruises, contusions and rib fractures. The intrathoracic organs are subjected to sudden and intense deceleration forces that may provoke cardiovascular injury and in fact, thoracic aortic injury is a common consequence of motor vehicle accidents and results in death at the site of the accident in up to 90% of all cases . By the way, patients who suffer from thoracic aortic aneurysm have very high risks of aortic rupture if they sustain a thoracic trauma. Rupture of the thoracic duct is less frequently observed, but has also been described . Pleura and lungs may be injured in blunt chest trauma patients and such lesions may provoke a closed pneumothorax.
- This type of injury, however, is even more characteristic for penetrating CWI. Here, strong physical forces concentrate in a very small area of the chest wall, dissect it and establish an open connection between the pleural space and the atmosphere that allows for entry of air and development of an open pneumothorax. Of note, air escaping from damaged lungs may contribute to pneumothorax in penetrating CWI, too. Additionally, direct lesion of cardiovascular structures is possible.
Chest trauma is a very common lesion and patients of any race, both genders and any age may sustain thoracic trauma and present with CWI. However, an adult's thoracic wall is much more resistant than that of a child. Thus, it may absorb significant forces and the adult patient is more likely to sustain fractures of ribs or other bones. In contrast, mechanical forces are more easily transmitted to the intrathoracic organs in pediatric patients. Because CWI-related morbidity and mortality primarily depend on the degree of internal injuries, the outcome may be worse for children .
Pathophysiological events following CWI depend on severity and localization of tissue damage. Common consequences of blunt chest trauma are dyspnea, tachycardia, hypotension and possibly hypovolemic shock. Less often, leakage of esophageal content leads to sepsis.
Respiratory complaints may result from pneumothorax, i.e., of an accumulation of air in the pleural space. This condition causes visceral and parietal pleura to detach from each other. Consequently, the respective lobe of the lung does not follow thoracic expansion during inspiration and atelectasis develops. Fortunately, the pleural space is divided by the mediastinum and patients suffering from an unilateral pneumothorax may still rely on their contralateral lung for oxygen supply.
In case of tension pneumothorax, symptoms aggravate rapidly. Here, the amount of air inside the pleural space continues to increase, possibly due to valve-like effects mediated by CWI or because of positive pressure ventilation. Eventually, the mediastinum may be displaced towards the contralateral hemithorax, thus interfering with lung function on this side of the body.
Pulmonary function impairment may also be provoked by accumulation of blood or lymph within the pleural space. Symptoms associated with hemothorax or chylothorax are similar to those related to pneumothorax, but considerable hemorrhages may also lead to hypovolemic shock and circulatory failure.
Patients diagnosed with presumably minor or moderate CWI and lung contusion may develop severe complications like adult respiratory distress syndrome . This risk is even higher if the patient sustained major CWI, is aged over 65 years, required great amounts of red blood cell transfusions or suffered from hypovolemic shock . Presumably, inflammatory and coagulopathic mechanisms are involved here, but the pathogenesis of respiratory distress syndrome ensuing from blunt chest trauma is incompletely understood.
According to the etiological factors described above, implementation of safety measures in traffic, work, sports activities and leisure time are the most effective form to prevent CWI. Because severe CWI is mostly caused by motor vehicle accidents, the individual risk of such traumatic lesions can be significantly reduced by using seat belts, complying with speed limits, by careful driving in adverse weather conditions and by adhering to the requirement not to drink when driving.
Chest wall injury (CWI) is a rather broad term and virtually any traumatic lesion of the thorax may be considered in this context. The chest wall consists of skin, muscles and bones and protects those organs located in the thoracic cavity. Consequently, the following anatomic structures may be affected in patients presenting with CWI:
- Skin and, particularly in women, breasts
- Respiratory muscles like costal muscles, transversus thoracic muscle and diaphragm; dorsal musculature
- Bony skeleton: ribs, sternum, thoracic vertebral spine, clavicles and scapulae
- Pleura, lungs, tracheobronchial tree
- Heart and emerging blood vessels
- Thoracic duct
- Other vascular structures
- Nervous tissue such as brachial plexus, phrenic nerve and vagus nerve
Virtually any thoracic trauma may lead to CWI. However, the vast majority of cases is provoked by blunt trauma, usually sustained in motor vehicle accidents. Consequently, most CWI patients present with multiple lesions. Any of the above mentioned tissues may be compromised as well as anatomical structures in other parts of the human body. Thorough anamnesis and physical examination are required to detect all lesions; high morbidity and mortality may result from overlooking certain injuries while focusing on the correct treatment of others .
The thoracic wall consists of skin, muscles and bone, and the most frequent types of CWI are rib contusion and rib fracture. Although these may be painful conditions, they are rarely life-threatening and are generally associated with an excellent prognosis.
However, the chest wall protects several vital organs, e.g., lungs, tracheobronchial tree, heart, major blood vessels and esophagus. Severe CWI may interfere with lung function, cause difficulties to breathe, hypotension and hemorrhagic or hypovolemic shock. Such symptoms may be noted even though no major lesion of the thoracic wall is observed. They require immediate medical attention and any delay of treatment may significantly worsen the outcome; the patient may die.
Strict implementation of safety measures in traffic, work, sports activities and leisure time are the most effective form to prevent CWI.
- Crönlein M, Sandmann GH, Beirer M, Wunderlich S, Biberthaler P, Huber-Wagner S. Traumatic bilateral carotid artery dissection following severe blunt trauma: a case report on the difficulties in diagnosis and therapy of an often overlooked life-threatening injury. Eur J Med Res. 2015; 20:62.
- Sznol JA, Koru-Sengul T, Graygo J, Murakhovsky D, Bahouth G, Schulman CI. Etiology of fatal thoracic aortic injuries: Secondary data analysis. Traffic Inj Prev. 2016; 17(2):209-216.
- Seitelman E, Arellano JJ, Takabe K, Barrett L, Faust G, Angus LD. Chylothorax after blunt trauma. J Thorac Dis. 2012; 4(3):327-330.
- Skinner DL, den Hollander D, Laing GL, Rodseth RN, Muckart DJ. Severe blunt thoracic trauma: differences between adults and children in a level I trauma centre. S Afr Med J. 2015; 105(1):47-51.
- Daurat A, Millet I, Roustan JP, et al. Thoracic Trauma Severity score on admission allows to determine the risk of delayed ARDS in trauma patients with pulmonary contusion. Injury. 2016; 47(1):147-153.
- Watkins TR, Nathens AB, Cooke CR, et al. Acute respiratory distress syndrome after trauma: development and validation of a predictive model. Crit Care Med. 2012; 40(8):2295-2303.
- Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003; 23(3):374-378.
- Kumar A, Kumar K, Zeltser R, Makaryus AN. Nearly Asymptomatic Eight-Month Thoracic Aortic Dissection. Clin Med Insights Cardiol. 2016; 10:75-78.
- Cedeño A, Echeverría K, Vázquez J, Delgado A, Rodríguez-Ortiz P. Intrathoracic esophageal rupture distal to the carina after blunt chest trauma: Case-report. Int J Surg Case Rep. 2015; 16:184-186.
- Fitzgerald M, Spencer J, Johnson F, Marasco S, Atkin C, Kossmann T. Definitive management of acute cardiac tamponade secondary to blunt trauma. Emerg Med Australas. 2005; 17(5-6):494-499.