![]() Among severely injured (ISS >15) blunt trauma patients approximately 27% had pulmonary contusion (6) and in children pulmonary contusion represents a large proportion of thoracic injuries (7). The most common injury to the pulmonary parenchyma in BCT is pulmonary contusion. Hemothorax usually results from disruption of an intercostal artery (see Chapter 32). It is notable that in patients with flail segments the morbidity and mortality are increased when compared to patients with a similar numbers of fractures without a flail segment (5).īlunt trauma may result in pneumothorax, hemothorax, or hemopneumothorax, usually secondary to a rib fracture penetrating the visceral pleura and lung parenchyma. Palpation of the chest can help detect the injury. In some patients who are splinting or in those on positive-pressure ventilation, the flail segment may not be readily apparent. All patients experience significant pain secondary to the respiratory movement of multiple rib fracture fragments and will often have tenderness, crepitus, and paradoxical movement of the chest wall. However, in patients with large flail segments, the normal thoracic physiology is disrupted, causing respiratory failure requiring mechanical ventilation. In these patients, respiratory compromise is related to the degree of pulmonary contusion, which almost inevitably occurs when force is significant enough to cause a flail chest. There is usually no significant ventilatory compromise caused by the flail segment per se. In a patient who is breathing spontaneously, the negative intrathoracic pressure with inspiratory effort results in a paradoxical movement of the chest wall (the flail segment moves in during inspiration and out during expiration). Patient may have point tenderness on their sternum, hematoma, or deformity.įlail chest occurs when three or more ribs are fractured in two or more places. This force may result in a sternal fracture or costochondral separation and, in rare instances, an anterior flail chest when the sternum is disarticulated from the ribs. This force most commonly occurs from motor vehicle collisions in which the chest strikes the steering wheel, dashboard, or shoulder belt at high velocity. Sternal fractures usually result from high-energy forces to the midanterior chest wall. Anteroposterior compression of the thorax produces referred pain to the fracture site if fracture is absent, there should not be referred pain to the localized area of tenderness. Multiple rib fractures or the presence of a flail chest wall segment may be associated with intrathoracic injury, usually a pulmonary contusion.Ĭlinical findings typically include pleuritic pain, tachypnea, splinting, and point tenderness intensified by deep breathing or coughing. Although the fourth through the ninth ribs are most commonly involved, there is a fourfold increase in splenic injuries with left-sided rib fractures 9 to 11 and a threefold increase risk of liver injuries in right-sided rib fracture 9 to 11 (4). Elderly patients have a higher morbidity and mortality associated with rib fractures than younger patients with each additional fracture increasing the risk of death by 19% and increasing the risk of developing pneumonia by 27% (3). ![]() In fact the presence of rib fracture in children should raise the suspicion of child abuse and heighten the concern for coexisting intrathoracic injury (3). Fractures are more common in adults than children because of the relative inelasticity of the mature thorax. Fractures typically occur at the site of the impact or the posterior angle where the rib is structurally the weakest. Rib fractures make breathing painful and can increase the patient’s morbidity and mortality by adversely affecting ventilation. ![]() Therefore, BCT must be evaluated in the context of these other injuries and, at times, more imminent life threats.Ĭhest wall contusions and rib fractures account for the majority of blunt chest wall trauma (2). BCT is often associated with multiple system trauma including injury to the abdomen, head, spine, and extremities. Injury kinetics include acceleration and deceleration forces as well as transmission of blunt force to internal structures. Unlike penetrating injuries, BCT usually occurs when a large force is applied to a relatively larger area. Most of these injuries are the result of motor vehicle collisions or pedestrians who are stuck by automobiles. BCT is involved in nearly one-third of admissions to trauma centers and accounts for about 25% of all trauma-related deaths in the United States (1). ![]() The trauma can range from the most minor chest wall contusion to catastrophic and fatal intrathoracic injury. ![]() Blunt chest trauma (BCT) is a common emergency department (ED) presentation. ![]()
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