INJURIES OF CHEST
Dr. Ravi Gadani
Introduction
Two types
1. Closed
2. Open
Civil injuries- RTA, gun shots, stab wounds
War injuries- 10% of injuries and 25 % of
deaths
Chest injury -Outline
Fracture of ribs
Surgical emphysema
Traumatic pneumothorax
Traumatic hemothorax
Stove in chest and flail chest
Lung contusion and laceration
Diaphragmatic injuries
Mediastinal emphysema
Injuries to heart and pericardium
Traumatic chylothorax
Fracture of ribs
Incidence – closed injury, blunt injuries
Less commonly fractured -1st and 2nd rib protection from
clavicle, 11th and 12th –floating ribs
Causes
Direct trauma – blunt injury, 1-2 ribs fractured
Crush injury- RTA , multiple rib fractures
Fractured at curvature of ribs anterior or posterior
Steering wheelinjury- sternum and
bilateral rib fractures
Minor trauma – elderly , coughing
Types of rib fracture
Uncomplicated- not associated with any
complication
Complicated – associated with some
complication like pneumothorax etc.
Uncomplicated rib fracture
Main complaint- pain while taking deep breath
Exaggerated on coughing and sneezing
Inspection – slight bruising at site of injury
Palpation- local body irregularity, tenderness,
crepitus
Compression test – positive
X-Ray - confirmatory
Treatment
Aim –to reduce pain , fracture heals by itself
requires no treatment
Systemic analgesics for 2-4 days followed by
oral analgesics
Local injection of anaesthetic agent like
lignocaine at site of fracture
Intercostal nerve blocks
Straping – to be avoided
Complicated rib fractures
Associated with
Shock
Local complications
Emphysema
Pneumothorax
Hemothorax
Flail chest
Pulmonary contusion/ laceration
Injury to heart and pericardium
Traumatic asphyxia
Injury to diaphragm and sub diaphragmatic structures
Surgical emphysema
Air in subcutaneous tissue (subcutaneous
emphysema)
Mechanism – fracture end of ribs forced
into the lungs- air leak into muscles and
subcutaneous tissue- fractured ends
come back to normal position
Clinical features
Pain due to fracture
Inspection – bruised skin with slight
swelling due to air
Palpation- crepitations
Percussion- resonant note
Auscultation- crepitus with absent breath
sounds if associated with pnuemothorax
Investigation
X-Ray:
1. Fracture ribs
2. Presence of air in soft tissue
3. Pneumothorax may be present
Treatment
No treatment for surgical emphysema
Treat rib fracture
Treat associated pneumothorax with
intercostal drainage tube
Traumatic pneumothorax
Air in pleural cavity
3 types
1. Closed pneumothorax
2. Open pneumothorax
3. Tension pneumothorax
Closed or Simple Pneumothorax
Air in the pleural cavity
Blunt injury that disrupts the parietal or visceral
pleura
Unilateral signs: movement and breath sounds,
hyper resonant to percussion
Confirmed by CXR
Rx: chest drain
Pneumothorax
Open Pneumothorax
Defect in chest wall provides a direct
communication between the pleural space
and the environment
Result of penetrating injury
Lung collapse and paroxysmal shifting of
mediastinum with each respiratory effort
“Sucking chest wound”
Rx: ABCs…closure of wound…chest
drain
Tension Pneumothorax
Air enters pleural space and cannot escape
Lacerated lung communicates with a branch
of bronchiole
Chest pain, dyspnoea
Dx: - respiratory distress ,tracheal deviation
(away) absence of breath sounds, distended
neck veins, hypotension, cyanosis
Surgical emergency
Rx: emergency decompression before CXR
Either large bore cannula in 2nd inter
costal space ,mid clavicular line
Insert chest tube
CXR to confirm site of insertion
Traumatic hemothorax
Accumulation of blood in pleural cavity
Blood comes from
1. Contusion of lungs
2. Injury to parietal vessels (intercostal /
internal mammary)
3. Rupture of intrapleural adhesions
4. Injury to heart and great vessels
Clinical features
Symptoms same as pneumothorax
Dullness on percussion, weak breath
sounds, shifting of apex beat to opposite
side
X-Ray confirmatory
Treatment
Simple aspiration -Small hemothorax
Intercostal tube drainage-
done in 6th to 8th intercostal space for drainage of blood
ICD tube is under water seal
Thoracotomy-
1. > 200 ml bleed for 4 hours or more
2. Initial 1000ml and> 200ml there after
3. Associated injuries of oesophagus, heart
4. Infected hemothorax
5. Hemothorax not clearing due to fibrin clot
Stove-in chest/ flail chest
Stove-in chest- extensive localized
crushing force producing multiple rib
fractures
Resulting in depression of the area
Relative immobility- accumulation of
bronchopulmonary secretions –
pneumonia
If associated with depressed clavicular
fracture- serious
Flail chest
Multiple fractures anteriorly at or near
costochondral junction
And posteriorly near the angle of ribs
Segment of chest –unstable: nobony
connection
Floating segment moves in during
inspiration and moves out during
expiration (paradoxical respiration)
Leads to accumulation of carbondioxide
into lungs
Hypoxia accentuated with the pain of
fractures
Types of flail chest
1. Lateral type- multiple rib fractures fractured
anteriorly and posteriorly
2. Anterior type- anterior ends of few ribs on both
sides fractured so sternum along with anterior
fragments becoming floating
3. Posterior type- multiple rib fractures at
posterior angles on both sides so spinal column
along with posterior angle of ribs are floating
Effects of paradoxical respiration
1. Causes imperfect ventilation-hypoxia
2. Mediastinal flutter-mediastinum moves towards sound
side during inspiration and affected side during
expiration-shock
3. Inspired air –flows back in healthy lung during inspiration
and same air would reach affected side during expiration
—stagnation of air thus diminish amount of air into the
lungs
4. Accumulation of bronchopulmonary secretions
5. Post traumatic insufficiency or wet lung
Flail Chest
Treatment
Immediate hospitalization
Check airway breathing circulation
Start IV fluids
IV antibiotic for prevention of infection
Relaxant drugs for pain relief
Endotracheal tube intubation- 5 days
Tracheostomy if >5 days
Reduces the dead space
Brochopulmonary toilet
Treatment cont.
Mechanical ventilation
Fixation of floating ribs
Strapping
External fixation
Stainless steel wire fixation
Kischner wire fixation after thoracotomy
THANK YOU
