Chest Wall Injuries - Causes, Types, Symptoms, and Management

Introduction

The chest wall, also known as the thoracic wall comprises the skin, bones, muscles, and other tissues in the area between the neck and the abdomen (thoracic area). The chest wall protects main organs like the heart, lungs, liver, and major blood vessels. In addition to protecting the internal organs, the chest wall also helps in breathing, movement of upper arms, and other functions related to the thoracic region.

What Are Chest Wall Injuries?

The chest wall is the area from the shoulders to the bottom of the ribs. Any injuries in this area are called chest wall injuries. Injuries to the chest wall occur due to impact trauma to the chest. Some of the incidents which can cause chest wall injuries include road accidents, falling from a height, impact sports injury, and other penetrating injuries like gunshot wounds. Chest wall injuries include rib fractures, flail chest, traumatic pneumothorax, hemothorax, lacerations, fracture of the sternum, etc.

What Causes Chest Wall Injuries?

Two types of trauma can cause chest wall injuries.

• Blunt Trauma includes physical assault, falling from a height, motor vehicle accidents, and blunt instrument injury.

• Penetrating Trauma includes gunshot wounds, stab wounds, pellet gunshots, etc. these injuries are more severe than blunt injuries and may result in life-threatening complications.

What Are the Signs and Symptoms of Chest Wall Injuries?

Chest wall injuries may result in a range of symptoms depending on the severity of the injury. Some of the symptoms include:

• Pain and tenderness in the affected area. Pain may be dull, sharp, or stabbing in nature.

• Swelling in the affected region along with bruising(chest wall contusion).

• Abnormal vital signs like tachycardia (increased heart rate) and hypotension.

• Perforations and lacerations.

• Difficulty in breathing and shortness of breath. Irregular breathing sounds.

• Chest deformities like visible sunken or protruding chest.

• Pain during coughing and laughing.

• Difficulty in moving the upper arm if the injury is in the upper part of the chest.

• Cyanosis (bluish discoloration) of lips, face, or fingers.

• Hemoptysis (blood in sputum).

• Signs of shock.

• Paradoxical respiration (reverse breathing movements) and respiratory distress in severe cases.

• Distended (bulging) neck veins.

• Tracheal deviation (trachea pushed to one side).

What Are the Different Chest Wall Injuries?

• Rib and Other Thoracic Cage Fractures

  • A rib fracture is the most common injury during a chest wall trauma. Rib fractures are often associated with other complications and also fractures of the sternum and clavicle.

  • The first two ribs are more difficult to break since they are strongly attached to the muscles. Fracture of the first two ribs indicates injury to underlying blood vessels, and injury to the trachea, lungs, and heart.

  • Middle zone ribs(4 to 9) are the ones that are mostly injured during the chest wall injury. Middle-zone rib fractures are often associated with lacerations, hemothorax, pulmonary contusion, pneumothorax, and other pulmonary complications.

  • The last two ribs are less prone to fracture since they are more mobile. Fracture in the last ribs is associated with injuries in the liver, spleen, and kidney.

  • Pain is the main symptom of rib fractures. Pain increases during breathing.

  • Fractures of the sternum may occur due to the trauma from the steering wheel during vehicle accidents. Sternal fractures are often associated with injuries in the heart and lungs.

• Costochondral Separation

  • One or more ribs when separated from the sternum(at the costochondral joint) result in costochondral separation. It is a very painful condition associated with chest wall trauma.

• Flail Chest

  • A flail chest is a condition in which three or more ribs situated next to each other are fractured in two parts.

  • In a flail chest, a segment of the chest wall becomes unstable as it becomes disconnected from the rest of the chest wall.

  • An important sign of a flail chest is the paradoxical movements of the chest wall during inspiration and expiration.

  • A flail chest is often associated with serious complications like shock, organ injuries, and blood loss.

• Traumatic Pneumothorax

  • Pneumothorax is a condition in which air is trapped between the chest wall and the lung. It is a life-threatening condition with varying symptoms from chest pain to cardiovascular collapse.

• Traumatic Hemothorax

  • Chest wall trauma may cause blood to collect in the space between the lung and the chest wall. This condition is called hemothorax.

How Are Chest Wall Injuries Diagnosed and Managed?

Rapid diagnosis and treatment are very important for chest wall injuries.

• Primary Evaluation

  • The first step after injury should be evaluating the condition of the patient using the ABCDE approach.

  • The airway is checked if it is patent and functioning.

  • The breathing of the patient is assessed. The rate, pattern, and depth of breathing are checked.

  • Circulation is checked by assessing the skin color, pulse rate, blood pressure, ECG, etc.

  • Disability - level of consciousness is assessed.

  • Exposure - The patient’s clothing is removed for a better assessment of the trauma, bleeding, and other skin reactions.

• History and Physical Examination

  • The mechanism of trauma or the history of injury may help in the rapid diagnosis and treatment of the injury.

  • The chest is examined for asymmetry.

  • Palpation and auscultation are done.

  • Patients who show no serious symptoms and are clinically stable should also be followed up for two weeks after the injury to eliminate any delayed symptoms.

• Emergency Management

  • Monitoring vital signs is done frequently.

  • Chest tube drainage for pneumothorax is done.

  • Optimal ventilation and respiratory support are done to prevent respiratory failure.

  • Proper fluid resuscitation is given to compensate for the blood loss.

  • Rapid mobilization of the patients is done to prevent further complications.

  • CT scans and ultrasound assist in the diagnosis of the injuries.

  • Electrocardiography is performed to monitor cardiac events.

  • Pulmonary physiotherapy is done to prevent complications like pneumonia and atelectasis.

• Pain Control

  • Combinations of NSAIDs and opioids are used for pain control.

  • Regional analgesia methods like an intercostal nerve block, epidural analgesia, and intrapleural analgesia can be used for pain control.

  • Improper pain management may often lead to chronic pain and posttraumatic stress in patients.

• Antibiotics

  • Prophylactic antibiotics are administered to prevent unwanted infections and wound contamination.

• Surgical Management

  • Open reduction and fixation of fractures and flail chest are done.

  • Video-assisted thoracoscopic surgery is done to manage the space between the chest wall and the lungs in hemothorax and pneumothorax.

  • Other surgical procedures are done if needed and if the case is severe.

Conclusion

Based on the severity of the trauma and the extent of the injury, the prognosis also varies. The immediate diagnosis and elimination of serious complications by immediate treatment may improve the outcomes of the trauma. Isolated rib fractures have a better prognosis when not involved with other complications.