What is the most common medical intervention required for patient with thoracic trauma?

Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are the ones most frequently involved. Patients usually report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tenderness and crepitus over the site of the fracture. If a pneumothorax is present, breath sounds may be decreased and resonance to percussion may be increased.

Rib fractures may also be a marker for other associated significant injury, both intrathoracic and extrathoracic. In one report, 50% of patients with blunt cardiac injury have rib fractures. Fractures of ribs 8-12 should raise the suggestion of associated abdominal injuries. Lee et al reported a 1.4- and 1.7-fold increase in the incidence of splenic and hepatic injury, respectively, in those with rib fractures.

Elderly patients with three or more rib fractures have been shown to have a fivefold increase in mortality and a fourfold increase in the incidence of pneumonia.

Effective pain control is the cornerstone of medical therapy for patients with rib fractures. For most patients, this consists of oral or parenteral analgesic agents. Intercostal nerve blocks may be feasible for those with severe pain who do not have numerous rib fractures. A local anesthetic with a relatively long duration of action (eg, bupivacaine) can be used. Patients with multiple rib fractures whose pain is difficult to control can be treated with epidural analgesia.

Adjunctive measures in the care of these patients include early mobilization and aggressive pulmonary toilet. Rib fractures typically do not require surgery. Pain relief and the establishment of adequate ventilation are the therapeutic goals.

There has been increasing interest in open reduction and internal fixation (ORIF) in selected patients with rib fractures, [29] though the patient subset that would benefit most has not been fully defined. The Eastern Association for the Surgery of Trauma (EAST) conditionally recommended ORIF of rib fractures in adult patients with flail chest to reduce mortality, duration of mechanical ventilation, length of stay in the hospital or intensive care unit (ICU), incidence of pneumonia, and need for tracheostomy. [30] ; no recommendation was made for pain control or for any of the outcomes in patients without flail chest. It remains to be determined what role operative fixation may play in this setting. [31]

Rarely, a fractured rib lacerates an intercostal artery or other vessel, resulting in the need for surgical control to achieve hemostasis acutely. In the chronic phase, nonunion and persistent pain may also necessitate an operation.

A flail chest, by definition, involves three or more consecutive rib fractures in two or more places, which produce a free-floating, unstable segment of chest wall. Separation of the bony ribs from their cartilaginous attachments, termed costochondral separation, can also cause flail chest.

Patients report pain at the fracture sites, pain upon inspiration, and, frequently, dyspnea. Physical examination reveals paradoxical motion of the flail segment. The chest wall moves inward with inspiration and outward with expiration. Tenderness at the fracture sites is the rule. Dyspnea, tachypnea, and tachycardia may be present. The patient may overtly exhibit labored respiration due to the increased work of breathing induced by the paradoxical motion of the flail segment.

A significant amount of force is required to produce a flail segment. Therefore, associated injuries are common and should be aggressively sought. The clinician should specifically be aware of the high incidence of associated thoracic injuries such as pulmonary contusions and closed head injuries, which, in combination, significantly increase the mortality associated with flail chest.

All of the treatments mentioned above for rib fractures are suitable for flail chest. Respiratory distress or insufficiency can ensue in some patients with flail chest because of severe pain secondary to the multiple rib fractures, the increased work of breathing, and the associated pulmonary contusion. This may necessitate endotracheal intubation and positive-pressure mechanical ventilation. Intravenous fluids are administered judiciously; fluid overloading can precipitate respiratory failure, especially in those with significant pulmonary contusions.

To stabilize the chest wall and avoid endotracheal intubation and mechanical ventilation, various operations have been devised for correcting flail chest (eg, pericostal sutures, application of external fixation devices, and placement of plates or pins for internal fixation). With improved understanding of pulmonary mechanics and better mechanical ventilatory support, surgical therapy has not proved superior to supportive and medical measures. [31] Most authors, however, would agree that stabilization is warranted if thoracotomy is indicated for another reason.

The EAST has published a practice management guideline on the management of flail chest and pulmonary contusion. [32]  (See Guidelines.)

First- and second-rib fractures are considered a separate entity from other rib fractures because of the excessive energy transfer required to injure these sturdy and well-protected structures. First- and second-rib fractures are harbingers of associated cranial, major vascular, thoracic, and abdominal injuries. The clinician should aggressively seek to exclude the presence of these other injuries.

Pain control and pulmonary toilet are the specific treatment measures for rib fractures. First- and second-rib fractures do not require surgical therapy. An exception to this would be the need to excise a greatly displaced bone fragment.

Clavicular fractures are among the most common injuries to the shoulder-girdle area. Common mechanisms include a direct blow to the shaft of the bone, a fall on an outstretched hand, and a direct lateral fall against the shoulder. Approximately 75-80% of clavicular fractures occur in the middle third of the bone. Patients report tenderness over the fracture site and pain with movement of the ipsilateral shoulder or arm.

Physical findings include anteroinferior positioning of the ipsilateral arm as compared with the contralateral arm. The proximal segment of the clavicle is displaced superiorly because of the action of the sternocleidomastoid.

Nearly all clavicular fractures can be managed without surgery. Primary treatment consists of immobilization with a figure-eight dressing, a clavicle strap, or a similar dressing or sling. Oral analgesics can be used to control pain. Surgery is rarely indicated. Surgical intervention is occasionally indicated for the reduction of a badly displaced fracture.

Strong lateral compressive forces against the shoulder can cause sternoclavicular joint dislocation. Anterior dislocation is more common than posterior dislocation. Patients report pain with arm motion or when a compressive force is applied against the affected shoulder. The ipsilateral arm and shoulder may be anteroinferiorly displaced. With anterior dislocations, the medial end of the clavicle can become more prominent. With posterior dislocations, a depression may be discernible adjacent to the sternum. Associated injuries to the trachea, subclavian vessels, or brachial plexus can occur with posterior dislocations.

Closed or open reduction is generally advised. Treatment strategies depend on whether the patient has an anterior or posterior dislocation.

For anterior dislocations, local anesthesia and sedative medications are administered, and lateral traction is applied to the affected arm that is placed in abduction and extension. This maneuver, combined with direct pressure over the medial clavicle, can occasionally reduce an anterior dislocation. For posterior dislocations, a penetrating towel clip can be used to grasp the medial clavicle to provide the necessary purchase for anterior manual traction to reduce the joint. Proper levels of pain control, up to and including general anesthesia, are provided. If closed reduction fails, open reduction is performed.

Most sternal fractures are caused by motor vehicle accidents (MVAs). The upper and middle thirds of the bone are most commonly affected in a transverse fashion. Patients report pain around the injured area. Inspiratory pain or a sense of dyspnea may be present. Physical examination reveals local tenderness and swelling. Ecchymosis is noted in the area around the fracture. A palpable defect or fracture-related crepitus may be present.

Associated injuries occur in 55-70% of patients with sternal fractures. The most common associated injuries are rib fractures, long-bone fractures, and closed head injuries. The association of blunt cardiac injuries with sternal fractures has been a source of great debate. Blunt cardiac injuries are diagnosed in fewer than 20% of patients with sternal fractures. Caution should be exercised before myocardial injury is completely excluded. The workup should begin with electrocardiography (ECG).

Most sternal fractures require no therapy specifically directed at correcting the injury. Patients are treated with analgesics and are advised to minimize activities that involve the use of pectoral and shoulder-girdle muscles. The most important aspect of the care for these patients is to exclude blunt myocardial and other associated injuries.

Patients who are experiencing severe pain related to the fracture and those with a badly displaced fracture are candidates for ORIF. Various techniques have been described, including wire suturing and the placement of plates and screws. The latter technique is associated with better outcomes.

Scapular fractures are uncommon. Their main clinical importance is the high-energy forces required to produce them and the attendant high incidence of associated injuries. The rate of associated injuries is 75-100%, most commonly involving the head, chest, or abdomen.

Patients with scapular fractures report pain around the scapula. Tenderness, swelling, ecchymosis, and fracture-related crepitus can all be present. The fracture is most frequently located in the body or neck of the scapula. More than 30% of scapular fractures are missed during the initial patient evaluation. The discovery of a scapular fracture should prompt a concerted effort to exclude major vascular injuries and injuries of the thorax, abdomen, and neurovascular bundle of the ipsilateral arm.

Shoulder immobilization is the standard initial treatment. This can be accomplished by placing the arm in a sling or shoulder harness. Range-of-motion (ROM) exercises are started as soon as possible to help prevent loss of shoulder mobility. Surgery is infrequently indicated. Involvement of the glenoid, acromion, or coracoid may require ORIF with the goal of maintaining proper shoulder mobility.

Sometimes called flail shoulder, this rare injury occurs when very strong traction forces pull the scapula and other elements of the shoulder girdle away from the thorax. The muscular, vascular, and nervous components of the shoulder and arm are severely compromised. Physical findings include significant hematoma formation and edema in the shoulder area. Neurologic deficits include loss of sensation and motor function distal to the shoulder. Pulses in the arm are typically decreased or lost as a consequence of axillary artery thrombosis.

No specific medical therapy has been developed for this devastating injury. Surgery is rarely indicated early in the course of the injury. If the affected limb retains sufficient neurovascular integrity and function, operative fixation may be indicated to restore shoulder stability. Many scapulothoracic dissociations result in a flail limb that is insensate or is associated with severe pain due to proximal brachial plexus injury. An above-elbow amputation may be the best approach for these patients.

The management of large open chest-wall defects initially requires irrigation and debridement of devitalized tissue to prevent progression into a necrotizing wound infection. Once the infection is under control, subsequent treatment depends on the severity and level of defect. Reconstructive options range from skin grafting to well-vascularized flaps to a variety of meshes with or without methylmethacrylate. The choice of reconstruction depends upon the depth of the defect.

The curious clinical constellation known as traumatic asphyxia is the result of thoracic injury due to a strong crushing mechanism, such as might occur when an individual is pinned under a very heavy object. Some effects of the injury are compounded if the glottis is closed during application of the crushing force.

Patients present with cyanosis of the head and neck, subconjunctival hemorrhage, periorbital ecchymosis, and petechiae of the head and neck. The face frequently appears very edematous or moonlike. Epistaxis and hemotympanum may be present. A history of loss of consciousness, seizures, or blindness may be elicited. Neurologic sequelae are usually transient. Recognition of this syndrome should prompt a search for associated thoracic and abdominal injuries.

The head of the patient's bed should be elevated to approximately 30° to decrease transmission of pressure to the head. Adequate airway and ventilatory status must be assured, and the patient is given supplemental oxygen. Serial neurologic examinations are performed while the patient is monitored in an intensive care setting. No specific surgical therapy is indicated for traumatic asphyxia. Associated injuries to the torso and head frequently necessitate surgical intervention.

Diaphragmatic injuries are relatively uncommon. Blunt mechanisms, usually a result of high-speed MVAs, cause approximately 33% of diaphragmatic injuries. Most diaphragmatic injuries recognized clinically involve the left side, though autopsy and computed tomography (CT)-based investigations suggest a roughly equal incidence for both sides.

This injury should be considered in patients who sustain a blow to the abdomen and present with dyspnea or respiratory distress. Because of the very high incidence of associated injuries (eg, major splenic or hepatic trauma), it is not unusual for these patients to present with hypovolemic shock.

Most diaphragmatic injuries are diagnosed incidentally at the time of laparotomy or thoracotomy for associated intra-abdominal or intrathoracic injuries. Initial chest radiographs are normal. Findings suggestive of diaphragmatic disruption on chest radiographs may include abnormal location of the nasogastric tube in the chest, ipsilateral hemidiaphragm elevation, or abdominal visceral herniation into the chest.

In a patient with multiple injuries, CT is not very accurate, and magnetic resonance imaging (MRI) is not very realistic. Bedside emergency ultrasonography is gaining popularity, and case reports in the literature have supported its use in the evaluation of the diaphragm. Diagnostic laparoscopy and thoracoscopy have also been reported to be successful in the identification of diaphragmatic injury.

A confirmed diagnosis or the suggestion of blunt diaphragmatic injury is an indication for surgery. Blunt diaphragmatic injuries typically produce large tears measuring 5-10 cm or longer. Most injuries are best approached via laparotomy. An abdominal approach facilitates exposure of the injury and allows exploration for associated abdominal organ injuries. The exception to this rule is a posterolateral injury of the right hemidiaphragm. This injury is best approached through the chest because the liver obscures the abdominal approach.

Most injuries can be repaired primarily with a continuous or interrupted braided suture (1-0 or larger). Centrally located injuries are most easily repaired. Lateral injuries near the chest wall may require reattachment of the diaphragm to the chest wall by encirclement of the ribs with suture during the repair. Synthetic mesh made of polypropylene or Dacron is occasionally needed to repair large defects. [33, 34]