Lecture 20: Abdominal and Thoracic Injuries

What are Abdominal and thoracic injuries?

result from high velocity sports, being struck with an object or use of inadequate protective equipment

What type of injuries are rare in sport?

Injury to the abdomen is rare in sports

Ten percent of all abdominal injuries are reported to result from sport-related trauma

What area are occasionally injured?

stomach, small bowel and intestines are injured

What is the thorax?

Thorax is portion of the body that lies between the neck and the diaghragm

- This is made up of the spine posteriorly, the ribs laterally and the sternum anteriorly

What is the main function of the thorax?

Its main function is to protect circulatory and respiratory organs

What are thoracic injuries due to?

Most occur due to blunt trauma but can occur as a result of forceful contractions

what are common thoracic injuries?

• Rib injuries are common

• usually very painful and debilitating

What are injuries that are less common?

Heart and lung injuries less common but are serious and require immediate attention

What is the cause of rib contusions?

• Blow to front/side usually leads to rib contusion

• Blow to back, usually paraspinal contusion

What are the signs and symptoms of rib contusions?

• Localized pain

• During inspiration

• With palpation

• Manipulation of rib at distance / "through the ring", does not increase pain

What are rib fractures?

• Can be direct or indirect

• Fracture at site of trauma- kick/punch

• Fracture away from impact as a result of compression- football, wrestling

What ribs are commonly injuried?

• Ribs 5-9 are most commonly injured, due to rigid fixation

• Usually fractures at weakest point (posterior) Angle of ribs

What are two types of placement for rib fractures?

Can be displaced or undisplaced

• If displaced, then an examination of internal structures should be conducted • spleen trauma reported in 20% of lower L rib fracture

• Liver trauma in 10% of lower R rib fracture

What are the symptoms of rib fractures?

• Pain with coughing and/or deep inspiration

• Trunk movements increase pain

What are the signs of ribs fractures?

• May have visible contusion and palpable crepitus

• Usually find athlete splinting themselves/ leaning towards the injured side

• Pain with manipulation away from injury, through ring

What are intercostal muscle strain?

• The most common strain is the intercostal muscles

• Usually violent exertional forces/trauma

• Overstretching via rotation

What are the symptoms of a an intercostal muscle strain?

• Pain over local area

• Pain with inspiration and movement

What are the signs of an intercostal muscle strain?

• NO pain with pressure through ring • Positive STTT

• Findings for mannul muscle testing

• TOP between the ribs over the muscles

What is the management of rib injuries?

• Send for imaging if fracture is suspected or can't be ruled-out

• POLICE/ PEACE and Love

• Stabilize/wrap

• Watch out may predispose to hypostatic pneumonia • Pad for return to play • Usually out 4-8 weeks

What are lung injuries?

• These are NOT common, but you need to watch out for them!

• Know what to look for.

• Refer for emergency assessment if you cannot rule them out

What is a Pneumothorax?

(Partial collapse)

• Occurs when air enters the pleural cavity located between the chest wall and the lung

• This can progress to a complete collapse (tension pneumothorax)

• Signs and Symptoms • Difficulty breathing (dyspnea), shortness of breath and cyanosis

What is a Tension Pneumothorax?

(Complete Collapse)

• As per pneumothorax plus:

• Pleural sac continues to fill with air until lung collapses

• Displaces lung and heart to other side

• Trachea may deviate • This is critical

What is a hemothorax?

• is presence of blood in pleural cavity

• Can happen with/without rib fracture

• difficulty breathing, shortness of breath and cyanosis

• Coughing up frothy blood

What is commotio cordis?

• Traumatic blunt trauma over the heart • Hit during narrow window of heart ______________________

• Results in cardiac arrest

• Young athletes more at risk due to pliability of chest wall

• Hockey, baseball, lacrosse

How bad is commotio cordis?

• Immediate death in 50% of cases

• 50% brief period of consciousness prior to collapse

• Resuscitation seldom successful

• Get ASD ASAP

• When defibrillation is delivered within one minute, the reported survival rate can be as high as 90%.

• resuscitation within 3 minutes resulted in a survival rate of 25%

• when resuscitation was prolonged beyond 3 minutes, the survival rate dropped to 3%

• The total survival rate is approximately 15%, which has improved from 10% in 2001.

Where is the abdomen located?

• Abdomen lies between the diaphragm and the pelvis

What is the abdomen?

• Lined by the parietal peritoneum

• Organs are covered by visceral peritoneum

• This makes a cavity for abdominal organs to move freely

• Enough room between organs to bleed to death!

• Injury to the abdominal wall usually produces local pain

• Injury to the viscera often initially causes localized pain that may spread to the entire abdomen if intraperitoneal irritation develops.

What are abdominal wall contusion injuries?

• Localized area of tenderness

• Increased pain on contraction/decreased on relaxation

• With internal bleeding, abdominal wall Will not relax

• No referred pain

• Treat with cold pack and compression

What are abdomimal musclue strain injuries?

• Rectus abdominus most commonly injured

• Lower rib origin or pubic insertion

• May pull periosteum of pubic rami-lead to osteitis pubis

• May also be seen with internal/external obliques

• MOI is sudden violent contraction/twisting or recurrent microtrauma

• Localized pain and spasm at sight of injury • STTT positive

• Manual Muscle testing positive

What is a Solar (Celiac) Plexus Contusion?

• Collection of nerves under diaphragm

• Trauma to relaxed abdominal wall or back

- wind knocked out

• Make sure airway is clear

• Loosen belt/restrictive clothing/ assure person they will live!

• Flex hips and bring knees to chest

• Slow expiration, followed by short inspiration

What Intra-Abdominal Injuries Penetrating?

• Not very common

• Usually superficial

• Leave the object in place unless ability to stop bleeding is compromised

• Focus on controlling bleeding

What are Intra-Abdominal Injuries blunt?

• Most common athletic trauma

• Severity of symptoms will vary widely

• Possibility of peritoneal irritation from blood and/or bacterial/intra-abdominal contamination

What are the four signs of a peritoneal irritation?

• Abdominal Rigidity

• Guarding

• Referred pain

• Loss of bowel sounds Caused by blood in the peritoneal cavity/viscera

What are injuries to the spleen?

• Located deep to the left 9-11 rib in the left upper quadrant

• Injured with blunt trauma or 20 to rib fracture

• The spleen's capsule can contain bleeding, the signs of splenic injury are often delayed, thereby rendering physical examination unreliable • The spleen is the most frequently injured organ in sport, and the most common cause of death due to abdominal trauma in athletics. • Medical emergency

What are symptoms of a speen injury?

• Symptoms

• Slow onset because symptoms develop 20 to bleeding

• Left upper quadrant pain/left shoulder pain caused by diaphragmatic irritation- Kehr's sign

What are liver injuries?

• Second most commonly injured organ

• Located in right upper quadrant

• Right upper quadrant pain

• Referred pain to right shoulder/scapula • Occasional nausea and vomiting

What are the two types of injuries to the kidney?

• Can be bruised or lacerated

• Contusion- no peritoneal signs

• Lacerated- will display peritoneal signs

What are injuries to the kidney?

• MOI- blunt trauma to flank or abdomen

• Upper 1/2 of kidneys are above 12th rib

• Flank/ low back pain, tenderness, ecchymosis and hematuria (blood in urine)

• Hematuria will also occur with repetitive microtrauma (jostling)

What are injuries to the bladder?

• Protected by pelvic ring

•Decreased trauma with empty bladder •Blunt trauma over pubic rami

• Inability to urinate despite urge

• Tenderness over supra-pubic region

• May have visible ecchymosis over pubic area

• Hematuria •Medical Emergency