An accurate account of events leading to an injury is important in establishing the diagnosis.

History and physical examination (PE) are sometimes unreliable, particularly in children and if there is an altered level of consciousness.

A seemingly minor trauma can cause delayed splenic rupture or other injuries; careful history-taking including past injuries, surgeries, and illnesses is paramount.

Previously undiagnosed preexisting condition such as inflammatory bowel disease, liver hemangioma, and infectious mononucleosis can cause major clinical symptoms after trauma to an affected organ.

Detailed history of the patient’s pain and the use of a pain scale upon initial presentation and during serial evaluations are useful; examples include the PQRST principles of evaluation of pain, and a visual analog pain scale ( Table 52.1 )

See Chapter 35 for a discussion of the cardiovascular examination; see Chapter 4 for a discussion of the initial evaluation of injuries to the thorax and abdomen.

If thoracic and abdominal injuries both present, thoracic injuries are usually more symptomatic and will distract attention from abdominal pain, which is usually less localized and specific.

Abdominal pain can be vague and diffuse or localized to a quadrant. Abdominal pain is sensitive but not specific to the presence of injury; 50% of individuals with pain have no significant abdominal injury. Always examine the chest and spine when evaluating an abdominal complaint, and consider examining the inguinal and pelvic regions.

Frequent monitoring of vital signs, including orthostatics, is important to gauge the cardiovascular status; in addition, respiratory rate, rhythm, and use of accessory respiratory muscles should be observed. If difficult to obtain blood pressure by auscultation, deflate the cuff until palpable return of the brachial or radial pulse; the systolic pressure obtained by auscultation is approximately 10 mmHg higher.

Observe the effort of breathing; listen for abnormal breathing sounds.

Look for asymmetry, deformity, swelling, bruising, lacerations, and scars.

Confirm that the trachea is in the midline and the chest has a normal anteroposterior (AP) diameter.

Evaluate the abdominal contour and signs of increasing abdominal girth; observe for peristaltic or pulsating movements.

Observe for splinting or guarding of torso and upper extremities (UEs) or any change in the neck position.

Auscultate both the posterior and anterior chest, comparing for asymmetry. If breath sounds are decreased, the normal lung has been displaced by air (suspect pneumothorax) or fluid (hemopneumothorax or pleural effusion).

Percuss the posterior and anterior chest, comparing both sides, and for normal diaphragmatic excursion with inspiration (symmetrical 3–5 cm). If hyperresonant, suspect pneumothorax; if dull, suspect fluid. Percuss all four quadrants; percuss the liver span (range 6–12 cm), and check for splenic enlargement.

Auscultate before palpating because bowel sounds can change with manipulation. Listen for bruits over the aorta and renal and iliac arteries. Start with gentle palpation to check for areas of tenderness, noting facial expression and any guarding. Follow with deep palpation to further delineate areas of pain or presence of abdominal masses. Include a complete evaluation of the genitourinary system.

For bony and soft tissue injuries of the thorax, perform neck, thoracic spine, and shoulder range of motion (ROM) and strength tests and palpate for crepitus, deformities, or tenderness.

Description: The incidence of associated intrathoracic trauma is high in acute injury, particularly rib fractures and soft tissue contusions. Incidence may be increasing: in a recent case series of 22 patients, 11 injuries were related to sports.

Mechanism of injury (MOI): High-impact injuries and acute hyperflexion of the cervicothoracic spine

Presentation: Chest pain (CP), localized tenderness over the sternum, and shortness of breath (SOB)

PE: Bruising, swelling, localized pleuritic pain palpable, or visible defect suggesting displacement

Differential diagnosis/associated injuries: Stress fracture of the sternum (develops when great stress placed on the upper body during wrestling or golf), manubriosternal joint dislocation, sternoclavicular or costochondral injury, or sternal contusion; associated injuries include myocardial contusion, injury of internal mammary vessels, retrosternal and mediastinal hematoma, pulmonary laceration or contusion, and rib and thoracic vertebrae fractures

Diagnostics: The lateral chest film is best to evaluate a fracture (upper fragment usually displaced anteriorly over lower fragment); posteroanterior (PA) radiograph to evaluate possible pneumothorax or widened mediastinum; cervical, thoracic, and lumbar spine radiographs if flexion/compression mechanism; computed tomography (CT) scan (axial cuts alone are not as sensitive; sagittal and coronal reconstruction views needed); routine CTs important to evaluate for cardiac and aortic injuries, which, although rare, are highly lethal if missed. Ultrasound (US) helps confirm radiologic diagnosis, but its use remains limited in the United States. If intrathoracic trauma is suspected, electrocardiogram (ECG) and chest X-ray (CXR) should be performed; consider repeat ECG in 24 hours.

Treatment: If displaced, reduction possible by lying supine and then lifting both arms above the head while hyperextending the thoracic spine at a level just below the scapular spines; because of a high incidence of associated intrathoracic trauma, observation in hospital with a cardiac monitor advisable during reduction and for at least 24 hours after injury . Displaced fractures may require open reduction and internal fixation (ORIF), particularly if respiration is compromised.

Prognosis and return to play (RTP): Nonunion of sternal fractures rare, but suspect when pain persists over the sternum; if an isolated fracture with no underlying thoracic injuries, progressive return to sport as limited by pain; avoid contact sports until the fracture healed and pain resolved (range 6–12 weeks); if the risk of re-injury is high, consider a chest protector during the sport

Description: Relatively infrequent, constituting <1% of somatic dislocations; only 50% of the clavicular joint surface contacts the sternal articular surface; the posterior sternoclavicular ligament is stronger than the anterior ligament; anterior disruption more common than posterior disruption (ratio ranges from 9 : 1 to 20 : 1); superior dislocation rare

Classification:

• •
  

  Type I: Sprain with no ligamentous damage or instability

  
  
• •
  

  Type II: Stretch or partial rupture of sternoclavicular and costoclavicular ligaments; joint is partially displaced

  
  
• •
  

  Type III: Dislocation with gross disruption of capsule and ligaments

MOI: Caused by direct or indirect trauma to the shoulder girdle; injury most often seen in contact sports (e.g., martial arts, football, and rugby); indirect trauma can be seen in gymnastics; for anterior dislocation, force applied at the anterolateral aspect of the shoulder or along the abducted arm is transmitted along the clavicle to the SCJ, compressing and rolling the shoulder back and displacing the clavicle. For posterior dislocation, force applied to the posterolateral aspect of the shoulder when the arm is adducted and flexed is transmitted to the SCJ, compressing and rolling the shoulder forward and displacing the clavicle ( Fig. 52.1 ). Posterior dislocation can also result from a direct blow on the anterior aspect of the medial end of the clavicle.

Posterior dislocation of sternoclavicular joint.

Presentation: Severe pain, particularly with any arm movement; pain exacerbated by coughing, sneezing, or deep breathing; because neck muscles spasm, the head is tilted toward the injured side. Increased discomfort in supine position. Other symptoms include hoarseness, dysphagia, dyspnea, numbness, and weakness or venous engorgement of the ipsilateral arm.

PE: Bruising, pain, and significant swelling at the joint; noticeable prominence of the medial end of the clavicle in anterior dislocation; in posterior dislocation, loss of normal prominence but often missed because of swelling; obtain vital signs; observe ease of respiration and neurologic/vascular status of the affected UE to rule out pressure on adjacent vital structures.

Differential diagnosis/associated injuries: SCJ sprain or subluxation; fracture of the medial clavicle, fracture of the medial physeal growth plate of the clavicle (fusion occurs between 22 and 25 years of age). In patients younger than 25 years, SCJ dislocations are classified as Salter–Harris type I or II fractures. More serious injuries are associated with posterior SCJ dislocations; a 30% incidence of injury to vital structures traversing thoracic outlet, including major vessels of neck, brachial plexus, dome of pleurae, trachea, esophagus, and larynx ; a 12.5% mortality rate in this group of injuries

Diagnostics: Plain radiographs with a 40-degree cephalic tilt view (“serendipity” view); tube distance for children, 45 inches; for thicker-chested athletes, 60 inches; CXR to rule out pneumothorax; axial CT images (3-mm cuts) have greater sensitivity and specificity and are an imaging modality of choice for the SCJ; can differentiate fractures from dislocations, and allow assessment of adjacent mediastinal structures if intravenous (IV) contrast used; coronal plane paraxial CT reconstruction if superior component of dislocation is suspected; the role of US in the diagnosis of SCJ injury is equivocal as the reported sensitivity is low; occasionally, arteriography/venography may be needed.

Treatment:

• •
  

  Type II injuries: Avoid stress to joint for at least 3–4 weeks for adequate healing; goal to avoid increased symptomatic mobility at joint

  
  
• •
  

  Type III injuries: Immediate closed reduction for posterior dislocations with impending airway or bleeding complications; otherwise, reduce in the operating room under anesthesia in the presence of a cardiothoracic surgeon. Closed reduction method has a reported 80% success rate. Anterior dislocations can be reduced in outpatient settings by applying gentle pressure over the displaced medial aspect of the clavicle. If closed reduction fails, open reduction can be considered in severe cases; however, an anteriorly displaced medial clavicle often becomes relatively asymptomatic with activities of daily living (ADLs). Chronic joint instability may cause pain and persistent functional limitation in active patients; this is an indication for surgical intervention.

  
  
• •
  

  For chronic SCJ dislocation: Check for hypermobility of surrounding structures (including acromioclavicular and glenohumeral joints). Consider a limited course of corticosteroid injections for symptomatic patients.

Prognosis and RTP: Despite 6–8 weeks of immobilization after successful reduction, healing can be inadequate and a mild SCJ instability may persist, with a propensity for recurrent subluxation. Osteomyelitis of the clavicle can be a late complication. Operative stabilization can be difficult with unpredictable results. In cases of recurrent stabilization failure or painful arthroses, resection of the medial clavicle as salvage procedure.

Description: Most common serious injury of chest; can be complete, incomplete, or stress fractures ( Fig. 52.2 ); often associated with other injuries, including other fractures and organ trauma; nondisplaced fractures more common; if displaced, other injuries include laceration of intercostal artery and pneumothorax; uncommon in children because thorax is more pliable

Thoracic cage injuries.

MOI:

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  Blunt trauma: Force usually applied in the AP plane; fractures located at the posterior angles of 5th–9th ribs

  
  
• •
  

  Direct force over a small area of the chest wall leads to fracture beneath the point of impact.

  
  
• •
  

  Violent muscle contraction: Floating rib or avulsion fractures of attachments of external oblique muscle to lower three ribs; reported in baseball pitchers and batters. Forceful contraction, against significant resistance, of other muscles that attach to the ribs can also result in fractures.

  
  
• •
  

  Fracture of 1st rib: Direct external trauma is rare cause because of protection of shoulder girdle. Other causes are indirect trauma from falling on outstretched arm, violent muscular pull (e.g., hyperabduction of arm), or repetitive stresses.

  
  
• •
  

  Stress fractures of the ribs: Caused by excessive forceful muscular traction at the attachments to ribs. Chronic opposing pulls of scalene muscles and upper digitations of serratus anterior may fracture the 1st rib at its thinnest and most anatomically weak segment, where the subclavian artery crosses (subclavian sulcus), as with weightlifting, pitching, and other throwers . Anterolateral stress fractures of 4th and 5th ribs, and other ribs have been reported in rowers because of excessive action of serratus anterior muscle (see Chapter 85 , Rowing).

Presentation: History of traumatic event with intense localized pain over involved rib. If 1st rib injured, may complain of shoulder, scapular, or neck pain; may complain of abdominal pain if lower ribs (11th and 12th) involved . With stress fractures, insidious onset of pain associated with specific activities, and possible radiation of pain. If fracture unstable, pain is acute and knifelike. Pain aggravated by deep inspiration, coughing, or sneezing and with twisting or side flexion (causing tension on fractured rib); may report dyspnea

PE: Localized tenderness, ecchymosis, and edema; crepitus over fracture site; palpable deformity of rib if fracture displaced; shallow and rapid breathing; with AP and transverse compression of rib cage, pain at the site of suspected injury; subcutaneous emphysema with pleural injury

Differential diagnosis/associated injuries:

• •
  

  Severe rib contusion, costochondral separation, muscle strain (e.g., forceful contraction of thoracic muscles during tennis serve), and other medical causes of CP (e.g., pneumothorax, pleurisy, and herpes zoster)

  
  
• •
  

  The more ribs that fracture, the greater the incidence of intrathoracic injuries

  
  
• •
  

  If the 1st rib fracture displaces posteriorly, check for vascular injury (e.g., subclavian artery and aorta).

  
  
• •
  

  Fracture of lower two ribs may damage the kidneys, liver, or spleen ; splenic trauma reported in up to 20% of left lower rib fractures; liver trauma in up to 10% of right lower rib fractures

  
  
• •
  

  Flail chest: Fracture of at least three consecutive ribs, each in two locations, causing free-floating segment of chest wall; high risk of internal injury, particularly lung and thoracic aorta. Paradoxical chest wall movement results in impaired ventilation and respiratory failure.

Diagnostics: CXR establishes diagnosis in 90% of cases if acute fracture; can also exclude complications, such as pneumothorax. Oblique views may detect anterior and lateral fractures. Bone scan if stress fracture suspected; US more sensitive than conventional radiography; CT scan most appropriate imaging modality if suspect posterior displacement of 1st rib; if cardiac complications possible, follow-up with ECG and echocardiogram. If upper thoracic ribs fractured, angiography may be indicated. If renal injury is suspected, IV pyelogram or other imaging modalities may be performed.

Treatment: Pain relief using ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and analgesics; bone stimulators have been approved by the Food and Drug Administration (FDA) for certain fractures and fracture sites, but no published data on use for acute rib fractures or stress fractures; intercostal nerve block for relief of severe pain; after aspirating, infiltrate just below the lower border of the rib, in close approximation to the intercostals vessels and nerve. The level of fracture along with two ribs above and below is infiltrated with 3–5 mL of lidocaine or bupivacaine; risk of causing pneumothorax; multiple fractures may require ORIF. Encourage deep breathing to prevent atelectasis and pneumonia; avoid/minimize rib belt or taping. Activity modification until symptoms resolve, then gradual resumption of training; changes in technique (if thought to contribute to cause of fracture); nutritional evaluation and pertinent laboratory tests if bone insufficiency suspected.

Prognosis and RTP: RTP when no pain on palpation, no use of analgesics, full ROM of thoracic cage, and ability to sprint/twist without significant discomfort; usually minimum 3 weeks and typically 6–8 weeks before return to contact sports; ability to protect fracture site should be considered; early return inadvisable because of danger of pneumothorax; close follow-up essential to avoid delayed complications (e.g., excessive callus formation of 1st rib can cause thoracic outlet syndrome [TOS] or Horner’s syndrome)

Description: Frequently occurs in contact sports such as football, ice hockey, wrestling, lacrosse, and rugby; weakness or separation of costal cartilage as it attaches to sternum (sternocostal ligament) or separation of anterior margin of the rib from anterior end of the costal cartilage (costochondral ligament), putting pressure on the intercostal nerve lying between it and the rib above; more frequently involves the 10th rib, followed by 9th or 8th.

MOI: Forced compression of the rib cage, twisting injury, or stretching injury to the joint when arm is forcefully pulled to the side; onset sometimes insidious, occurring long after initial trauma because loose ribs can cause further stretching of the supporting ligaments

Presentation: Often upper abdominal pain or lower CP; history of feeling a pop; initial sharp discomfort, with severe pain lasting for several days before slowly decreasing in intensity. Pain patterns can include a dull sensation, intermittent unilateral pain in anterior ends of lower costal cartilages, or severe sharp pain during bending maneuvers with a painful click as cartilage and bone override one another. Pain can radiate toward the epigastrium or spine.

PE: Localized swelling and tenderness at the involved joint; possible deformity because of cartilage displacement. Reproducible pain and sometimes clicking by hooking fingers under the costochondral junction in question and pulling the rib cage anteriorly (“hooking maneuver”)

Differential diagnosis/associated injuries:

• •
  

  Costochondritis or costosternal syndrome: Both traumatic and nontraumatic; self-limiting; multiple sites of tenderness (usually 2nd–6th costal cartilages) but without swelling

  
  
• •
  

  Tietze’s syndrome: Traumatic and nontraumatic; self-limiting; usually only the 2nd or 3rd costochondral junction involved with localized swelling

Diagnostics: CXR if chronic to rule out tumors, Paget’s disease, or rheumatoid arthritis; US of costal margin during abdominal muscle contraction to demonstrate abnormal mobility

Treatment: Ice and NSAIDs; injection of lidocaine or bupivacaine with or without corticosteroid at site of separation; rib block; physical therapy for correction of possible posterior dysfunction at corresponding costovertebral joint; surgical resection of the affected costochondral junction or repair of ribs and cartilage for intractable pain

Prognosis and RTP: May take 9–12 weeks to resolve (slow healing); subject to re-injury as complete healing is seldom seen

Description: Pectoralis major is the most important adductor and internal rotator of shoulder and cosmetically forms anterior wall of axilla. Ruptures can be partial (grades I and II) or complete (grade III). Excessive tension on muscle causes tear of muscle belly, musculotendinous junction, or tendinous insertion on humerus lateral to the bicipital groove; latter most common. Tears of proximal sternal origin are rare; may be associated with anabolic steroid use (muscle hypertrophy not accompanied by tendon adaptation); increased incidence over past several years

MOI: Excessive tension on maximally and eccentrically contracted muscles while the affected UE is externally rotated, extended, or abducted. Among athletes, the most often is seen in weightlifters during bench press; also reported during waterskiing, wrestling, boxing, football, and other sudden violent deceleration maneuvers with sudden stretching and co-contraction of muscle (attempting to grasp something to prevent fall, punching, and blocking with an outstretched arm)

Presentation: History of sudden stress or direct blow to shoulder while arm abducted and extended; sudden onset of extreme pain on medial aspect of the UEs or in the chest wall; tearing, snapping, or popping sensation; significant swelling and ecchymosis; painful limitation of motion; weakness of the involved UE; after resolution of swelling and ecchymosis, complaints of asymmetry and persistent weakness.

PE: Swelling and hemorrhage into arm and across the anterior chest wall; weakness and pain during resisted internal rotation, flexion, and adduction of arm; deformity of chest wall and palpable muscle bulge with resisted adduction; with abduction, defect in anterior axillary fold if tendon is avulsed at insertion; shoulder ROM limited by pain

Differential diagnosis/associated injuries: Pectoralis muscle tendonitis/tendinosis and congenital absence of pectoralis major muscle

Diagnostics: CXR reveals soft tissue swelling and absent pectoralis major muscle shadow but limited in diagnosis and characterization of ruptures; shoulder radiographs rule out bony avulsions/fractures. US shows uneven echogenicity and muscle thinning; useful when clinical examination is in question and prompt magnetic resonance imaging (MRI) not possible; MRI with appropriate sequences accurately defines extent of injury (grade), location, and amount of retraction; guides treatment plan

Treatment: Extent of tear may be difficult to diagnose because of ecchymosis, swelling, and extreme pain; serial examinations important; partial tear treated conservatively with initial ice, analgesia, sling for comfort, and activity restriction. Start with early protected ROM and gentle isometric strengthening. Regain full ROM to prevent further injuries, then resisted strengthening exercises by 6–8 weeks. Activities resumed slowly as allowed by pain and function; complete tear surgically repaired in competitive athletes, particularly those who depend on chest and shoulder strength; without surgical repair, weakness can result, particularly adduction and flexion; repair recommended in bodybuilders for improved cosmesis. Several cases present with delayed diagnosis and thus adhesions, muscle retraction, and atrophy, but late repair compatible with significant strength improvement. After surgery, immobilization for 4–6 weeks to protect repair; passive pendulum exercises and passive forward flexion with arm adducted to 130 degrees can begin immediately. Within 6–12 weeks, progress to full passive ROM and add an periscapular and isometric strengthening program (avoiding shoulder adduction, internal rotation, and horizontal adduction); by 12 weeks, resistive strengthening exercises begin; by 6 months, light free weights and push-ups

Prognosis and RTP: Surgical repair of distal pectoralis major tears results in almost full recovery of peak torque and work performed (97%). Full recovery of those managed nonsurgically 56%, but normal ADLs are not affected; nonsurgical management recommended for tears at sternoclavicular origin, although delayed repairs for persistent pain successful; RTP after surgery ranges 8 months to 1 year.

Description: Contusions, hematomas, runner’s/cyclist’s nipple, and breast pain

MOI and presentation: Contusions caused by direct trauma with resultant bleeding and swelling; common in softball and basketball; nipple chafing, pain, eczema, and occasional bleeding from friction and abrasion by clothing during prolonged activity or evaporation of perspiration over the chest (see Chapter 40 , Skin Problems); breast pain often experienced during athletic activity, particularly during running, because of strain on Cooper’s ligaments (connective tissue that holds and supports breast on chest wall); query if pain is cyclical, and if so, its duration

PE: Examine for additional signs suggestive of other breast conditions, such as a mass, skin changes, or bloody nipple discharge. In runner’s nipple, usually bilateral involvement with erythema, edema, oozing, crusting, and occasionally lichenification; systematically examine four breast quadrants in both lying and sitting positions with hands on hips and then above the head. Examine axillary, supraclavicular, and infraclavicular lymph nodes.

Differential diagnosis/associated injuries: Pectoralis major muscle strain, costochondritis, rib fractures if significant trauma, fibrocystic breast disease, cyclic mastalgia, contact dermatitis, bacterial or yeast infection of the nipple, Paget’s disease, and breast cancer

Up to 18% of women with newly diagnosed breast cancer had localized breast pain as a presenting symptom. Individuals with concomitant atopy are predisposed to develop jogger’s nipples. For those with breast augmentation and blunt chest trauma, implant rupture can lead to spherical capsular contracture.

Diagnostics: In general, diagnostic studies not required if no breast masses palpated and no nipple discharge; US should be considered if focal breast pain; mammography in women at a high risk of breast cancer

Treatment, prognosis, and RTP:

• •
  

  See Chapter 40 for information on runner’s nipple.

  
  
• •
  

  For contusions: Ice, NSAIDs, and appropriate support; added protective padding. Hematomas rarely require aspiration.

  
  
• •
  

  Can lead to posttraumatic scarring and retraction or thrombophlebitis of superficial veins (Mondor’s disease); follow-up closely to differentiate from breast carcinoma

  
  
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  Premenarchal athletic injuries to the breast bud (Tanner stages I–II; ages 10–11 years) can cause appreciable breast asymmetry (as much as one cup size or more).

  
  
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  Hormonal therapy may help diminish breast tenderness during phases of menstrual cycle.

  
  
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  Nicotine may increase breast pain; it increases epinephrine levels, which stimulates cyclic AMP, a regulator of mammary tissue metabolism.

  
  
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  During pregnancy, specialized breast support is imperative as breasts can enlarge by 800 mL.

Description: Blood and protein leak into alveoli and interstitial spaces, leading to atelectasis and consolidation ( Fig. 52.3 ).

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