Blunt Chest Trauma
Blunt chest trauma is a non-penetrating traumatic injury to the thoracic cavity. Thoracic
traumatic injuries are classified according to the mechanism of injury as blunt or
penetrating injuries. Different structures can be injured including the chest wall (ribs,
sternum), lungs, heart, major blood vessels, and the esophagus. The extent and specific
type of thoracic traumatic injury can be identified by a proper history and physical
examination supported by adequate imaging studies. Management depends on the
specific type of injury.
Last updated: July 26, 2023
CONTENTS
Overview
Initial Approach to the Trauma Patient
Injury to the Chest Wall
Injury to the Lungs
Injury to the Airway
Injury to the Heart
Injury to a Blood Vessel
Injury to the Esophagus or Diaphragm
Clinical Relevance
References
Overview
Definition
Blunt chest trauma is injury and consequential pathology arising from application
of significant kinetic forces to the chest that do not cause penetration of the
thoracic cavity.
Epidemiology
United States incidence: 12:1,000,000 each day
33% require hospital admission.
Responsible for 20%–25% of all deaths (from motor vehicle collisions)
Risk factors associated with a poor outcome:
Older age
Higher injury severity scores (ISS)
Etiology
Motor vehicle accidents are the most common cause (80%).
Other common causes:
Falls
Vehicles striking pedestrians
Acts of violence
Blast injuries
Classification
Direct blunt force: object striking the chest wall (e.g., fist or bat in assault)
Acceleration or deceleration: rapid changes in kinetic energy (e.g., car stopping
rapidly)
Shear force: forces pushing different parts of the body in opposing directions,
often a combination of acceleration and deceleration (e.g., a head-on collision of 2
moving cars)
Compression: crush injury (e.g., heavy object falling on a person)
Blasts: transfer of energy into chest tissue from concussive wave (e.g., close
explosion)
Pathophysiology
The chest wall is composed of:
Bone: ribs and intercostal cartilage
Musculature: intercostal and pectoral muscle groups
Neurovasculature: intercostal nerves, arteries, and veins
Connective tissues: visceral and parietal pleura
The chest wall's function is to absorb trauma and protect underlying vulnerable
structures from damage:
Chest wall structures:
Fractures of ribs, clavicles, or cartilage
Ecchymosis, laceration, or crush injury of musculature and skin
Accumulation of blood or air in the potential pleural space
Underlying structures:
Injury to the aorta and other major blood vessels
Bruising of the lungs
Bruising/laceration of the heart
Initial Approach to the Trauma Patient
Physical exam
The suspected mechanism of injury should prompt suspicion for blunt chest trauma.
Treatment algorithms and guidelines direct evaluation:
Primary survey—airway, breathing, and circulation (ABC):
Airway:
Look for foreign objects blocking airway (loose teeth are common
foreign bodies in high-force trauma).
Assess for injury to the trachea (tracheal injury means intubation will be
complex).
Listen for unusual breathing sounds (stridor suggests narrowing by a
foreign body or edema).
Breathing:
Look at chest wall movement for even and spontaneous breathing
(uneven chest movement suggests “flail chest”).
Listen to breath sounds (muffled or uneven may suggest pneumothorax
or hemothorax).
Circulation:
Palpate pulses on all 4 extremities (tachycardia suggests hemodynamic
instability or pneumothorax).
Assess capillary refill on extremities.
Secondary survey:
Mechanism of injury:
Helps determine severity of injury
May indicate what chest structures are injured
Close inspection of the chest wall: Seatbelt or steering wheel imprint
suggests severe injury.
Imaging
While the initial approach to stabilizing a patient with chest trauma is standardized,
further imaging and testing is dependent on the injury discovered during the initial
assessment.
Choosing the best imaging studies depends on the patient's hemodynamic stability:
Chest X-ray and focused assessment with sonography in trauma (FAST) → initial
diagnostic studies
Only stable patients can undergo a computed tomography (CT) scan.
Unstable patients → emergent surgery must be considered
Injury to the Chest Wall
Rib fracture
Clinical features:
Pain is localized and reproducible by taking a deep breath.
Location of pain points to possible further underlying injury:
1st rib: possible trauma of lung apices, subclavian vessels
2nd rib: possible ascending aorta, superior vena cava trauma
10th rib: possible diaphragmatic, liver, splenic injury
11th rib: possible diaphragmatic, liver, splenic injury
12th rib: possible renal injury
Physical exam findings:
Point tenderness to palpation
Possible visible bruising or deformity
Crepitus may be audible.
Imaging:
X-ray (appropriate for stable patients):
Posteroanterior (PA) chest X-ray
Poor sensitivity, but useful to identify associated pneumothorax,
hemothorax, pulmonary contusion
CT scan (suggested for more severe injury):
Usually not performed if only rib fracture is suspected
Higher sensitivity
Useful for more detailed anatomy
Ultrasound:
Less commonly used
Useful in detailing extent of associated pneumothorax, hemothorax,
pulmonary contusion
Management:
Pain control:
Allows patients to take deep breaths, decreases associated pneumonia
Nerve blocks, opioids, or non-steroidal anti-inflammatory drug (NSAID)
choice based on severity of pain
Respiratory therapy: incentive spirometry
Surgical fixation:
Rarely necessary with a simple fracture
Performed when there is associated chest wall deformity, flail chest, or
symptomatic non-union
Flail chest
Clinical features:
Tachypnea
Tachycardia
Hypoxia
Physical exam findings:
Similar finding to simple rib fractures
3 or more adjacent ribs are each fractured in 2 places.
Segment of thoracic wall moves opposite to the rest during breathing
(paradoxic movement).
Imaging:
X-ray may show multiple rib fractures.
CT is usually employed for better anatomic detail.
Management:
Supplemental oxygen
Pain control
Positive pressure ventilation (PPV) for respiratory failure
Flail chest: fractured ribs that move paradoxically in comparison to the chest wall
Image by Lecturio.
Clavicle fracture
Clinical features:
Localized pain to palpation
Pain on rotation of shoulder
Sensation of cracking/popping with movement
Physical exam findings:
Visible localized deformity or swelling
Palpable crepitus
Localized pain to palpation
Imaging: X-ray is sufficient to define the location and severity of injury.
Management:
Pain management/icing
Immobilization with brace restricting shoulder motion to < 30° of abduction,
forward flexion, or extension
Indications for surgery include:
Open fracture
Bone displacement
Neurovascular injury
Skin tenting
Sternal fractures
Clinical features:
Localized pain to sternum
Very strong forces necessary, so usually associated with other internal
injuries
Physical exam findings:
Pain and tenderness to palpation of sternal area
Bony crepitus or deformity
Imaging:
Ultrasound is used to screen.
Chest X-ray has poor sensitivity.
CT chest and electrocardiogram (ECG) should be performed for possible
associated injuries.
Management:
Stable patients with isolated sternal fractures: Outpatient management is
reasonable.
More complex fractures with associated pathology: require surgical
consultation for management
Chest CT showing comminuted sternal fracture:
Fractures of the sternum can occur during high-energy chest traumas and can be simple (meaning
a single fracture) or comminuted (where the bone breaks into multiple fragments). Usually, fractures
of the sternum are associated with underlying injury of the lungs or heart.
Image: “Sternal fracture CT” by Monkhouse SJ, Kelly MD. License: CC BY 2.0
Injury to the Lungs
Pulmonary contusion
Clinical features:
Develop gradually within 24 hours of trauma
Tachypnea, tachycardia, hypoxemia
Physical exam findings:
Contusion or deformity of the chest wall
Lack of chest wall findings does not rule out pulmonary contusion.
Imaging:
X-ray shows irregular, non-lobular, homogenous opacification of lung fields.
May lag behind or not be visible on X-ray
CT can provide better anatomic detail.
Management:
Oxygen
Pain control
Chest physiotherapy
Mechanical ventilation in severe cases
Simple pneumothorax
Clinical features:
Acute dyspnea
Sudden-onset, unilateral (usually) chest pain corresponding to side of
collapsed lung
Physical exam findings:
↓ Breath sounds
Hyper-resonance on percussion
↓ Tactile vocal fremitus
Imaging: chest X-ray
Modality of choice
Hyperlucency
No tracheal deviation or mediastinal shift
Management:
Small (≤ 2-cm) stable pneumothoraces:
Self-resolve without intervention
Support with oxygen as needed.
Emergent symptomatic: needle decompression
Symptomatic or small pneumothoraces that fail to self-resolve: chest
tube placement
Chest radiograph demonstrating a left pneumothorax:
The green line outlines the pleural line. Notice the lack of bronchovascular markings beyond that
line.
Image: “Anteroposterior expired X-ray” by Mikael Häggström, M.D. License: CC0, edited by Lecturio.
Tension pneumothorax
Clinical features:
Acute dyspnea
Sudden-onset, unilateral (usually) chest pain corresponding to side of
collapsed lung
Physical exam findings:
↓ Breath sounds
Hyper-resonance on percussion
Mediastinal shift away from tension pneumothorax
↓ Tactile vocal fremitus
Jugular venous distention
Imaging: chest X-ray
Modality of choice
Hyperlucency
Tracheal deviation or mediastinal shift away from collapsed lung
Management:
Emergent needle decompression
Thoracostomy tube placement to prevent re-accumulation of air
Tension pneumothorax:
Spontaneous and traumatic pneumothoraces can develop into a tension pneumothorax if the
defect that allows air into the pleural space becomes a 1-way valve (air enters during inspiration,
but cannot escape during expiration), which causes rising pressure in the pleural cavity, shifting the
mediastinum to the contralateral side.
Image by Lecturio.
Hemothorax
Clinical features:
Chest pain
Acute onset dyspnea
Physical exam findings:
↓ Breath sounds
Dullness on percussion
Tracheal deviation, mediastinal shift
↓ Tactile vocal fremitus
Signs of hemorrhagic shock in large hemothoraces:
Hypotension
Tachycardia
Tachypnea
↓ Jugular venous pressure
Imaging:
Chest X-ray:
Best initial diagnostic study
Upright imaging shows layering of blood.
Supine imaging shows haziness or opacity (whiteout).
May also show free air if pneumothorax is present
Ultrasound of lungs:
Part of extended focused assessment with sonography in trauma (
e-FAST) exam
Able to be obtained quickly
Can show complex fluid in pleural cavity
More sensitive than chest X-ray in detecting hemothorax, but is
technician dependent
Chest CT definitive imaging choice:
Should only be obtained if patient is stable
CT can show other associated pathology.
CT angiogram can show the source of bleeding.
Management:
Chest tube
Thoracotomy (if > 1.5 L blood drained directly or continuous high output)
Injury to the Airway
Tracheobronchial tear
Clinical features:
Airway obstruction causing stridor, marked dyspnea, and respiratory failure
Hemoptysis
Failure of pneumothorax to resolve even when chest tube is placed (due to
continuous air leak)
Physical exam findings:
Sternal tenderness
Subcutaneous emphysema
Hamman sign: audible crepitus on cardiac auscultation
Imaging:
Chest X-ray or CT depending on availability
Pneumomediastinum (air trapping in center of chest cavity)
Hyoid bone elevation above the 3rd cervical vertebrae
Management:
Bronchoscopy to evaluate extent of injury
Surgical repair even with stable patients given risk for developing airway
stenosis
Tracheobronchial tear
Injury to the trachea or the bronchi is often seen with high energy chest trauma.
Image: “Tracheobronchial rupture 3D CT 3” by Morgan Le Guen, Catherine Beigelman, Belaid Bouhemad, Yang
Wenjïe, Frederic Marmion. License: CC BY 2.0
Injury to the Heart
Cardiac tamponade
Clinical features:
Symptoms of cardiogenic shock
Dyspnea and tachypnea
Chest discomfort or pressure
Physical exam findings:
Beck's triad:
Hypotension
↑ JVP
Muffled heart sounds
Pulsus paradoxus: disproportionately large drop in systolic blood pressure on
inspiration
Pericardial rub: audible crescendo-decrescendo extra heart sound, often
described as grating noise
Imaging:
Chest X-ray:
Enlarged and globular cardiac silhouette ("water bottle" heart shape)
Clear lung fields
Echocardiogram: fluid around heart
Management: Echocardiography-guided pericardiocentesis is both diagnostic and
therapeutic.
Myocardial contusion
Clinical features:
Associated sternal fracture
Symptoms of cardiac failure:
Dyspnea
Chest pain
Physical exam findings: may have signs of heart failure
Imaging: FAST
Management:
Sustain cerebral perfusion with fluid resuscitation or medication as needed.
Needle pericardiocentesis may be helpful when associated with
pericardial effusion.
Traumatic cardiac arrest (commotio cordis)
Clinical features:
Cardiac arrest that occurs in a subsection of predisposed patients when the
chest over the heart is struck during a specific portion of the cardiac cycle
Clinical history of collapse after chest trauma
Absence of history of other cardiac disease
ECG:
Asystole
Ventricular fibrillation
Management: Cardiopulmonary resuscitation (CPR) and defibrillation following
basic life support (BLS) recommendations
Commotio cordis risk window:
Commotio cordis is a cardiac arrest that occurs when the chest over the heart is struck during the
portion of the cardiac cycle corresponding with the upstroke of the T wave on ECG.
Image: “Commotio Cordis” by Agateller. License: Public Domain
Injury to a Blood Vessel
Traumatic aortic rupture
Clinical features:
Interscapular pain
Difficulty breathing
Altered mental status
Often seen in the setting of a rapid deceleration
Physical exam findings:
Sign of significant high-force trauma to the chest (e.g., steering wheel imprint)
Left-sided subclavicular hematoma
New cardiac murmur
Imaging:
Chest X-ray often obtained per trauma protocol, can show:
Mediastinal widening and deviation
Distorted aortic arch outline
Hemothorax, especially above left lung apex
Chest CT and transesophageal echocardiogram (TEE) are definitive
diagnostic modalities.
Management:
Antihypertensive therapy
Emergent operative repair
Injury to the Esophagus or Diaphragm
Diaphragmatic rupture
Clinical features:
Respiratory distress
Nausea/vomiting
Physical exam findings:
Should be suspected based on location of injury → diaphragm reaches up to
the 4th intercostal space during exhalation
Bowel sounds in chest due to bowel herniation through the diaphragm
Decreased lung sounds
Dullness on percussion
Findings more common on left side (right side is protected by liver)
Imaging—found incidentally on X-ray, CT, and ultrasound performed for trauma
evaluation:
Elevation of hemidiaphragm
Small bowel in lungs
Management: surgical closure
Diaphragmatic rupture:
Rupture of the diaphragm secondary to chest trauma seen on chest X-ray as bowel contents in the
thoracic cavity. Arrow labeled X points to portion of the spleen herniating into the chest cavity
through a diaphragmatic rupture.
Image: “Diaphragmatic rupture” by Hariharan D, Singhal R, Kinra S, Chilton A. License: CC BY 2.0
Esophageal rupture
Clinical features—no specific findings, but the following have been seen:
Chest pain
Difficulty swallowing
Physical exam findings:
Subcutaneous crepitus
Neck hematoma
Imaging:
Chest X-ray or CT:
Pneumomediastinum
Pleural effusion
Water-soluble contrast esophagography is diagnostic.
Management:
Antibiotics and supportive care
Surgical repair to reduce the risk of significant leakage that can cause a
systemic inflammatory response
Clinical Relevance
Flail chest: a condition that occurs when 3 or more contiguous ribs are fractured in
2 or more different locations. Marked by chest pain, tachypnea, hypoxemia, and
paradoxic thoracic wall movement. Management includes oxygen supplementation,
pain control, and PPV if respiratory failure presents.
Hemothorax: a collection of blood in the pleural cavity. Usually occurs following
chest trauma, which leads to lung laceration or damage to intercostal arteries.
Symptoms include shortness of breath and chest pain. Signs include hypotension,
tachycardia, decreased air entry, tracheal deviation, and dullness on percussion.
Management is chest tube insertion. Thoracotomy may be indicated.
Pulmonary contusion: a traumatic parenchymal lung injury. Patients present with
tachypnea, tachycardia, and hypoxemia. Imaging studies show patchy alveolar
infiltrates not restricted by anatomic borders (non-lobar opacification). Management
involves oxygen administration, pain control, chest physiotherapy, and mechanical
ventilation in severe cases.
Pneumothorax: an abnormal collection of air in the pleural space. Types of
pneumothoraces include simple and tension pneumothorax. Pneumothoraces can
be spontaneous, iatrogenic, or traumatic. Exam shows decreased breath sounds,
hyper-resonance on percussion, tracheal deviation, mediastinal shift (away from
tension pneumothorax), decreased tactile vocal fremitus, and distended jugular
veins. Treatment includes needle decompression and thoracotomy.
Cardiac tamponade: an accumulation of fluid in the pericardial space, resulting in
reduced ventricular filling and subsequent hemodynamic compromise. Cardiac
tamponade is a severe form of a pericardial effusion. In a trauma setting, the fluid is
blood. Physical examination findings include Beck's triad (hypotension, jugular
venous distention, and muffled heart sounds). Treatment is pericardiocentesis.
Aortic dissection: occurs when a fissure develops in the inner coat (tunica intima)
of the aortic wall, which causes blood to enter the media layer. Marked by severe
pain, characteristically known as a “tearing pain.” Aortic dissection is a serious
medical emergency that needs urgent diagnosis and management. Risk factors
include hypertension, genetic diseases, and trauma. Treatment starts with blood
pressure control and often requires cardiovascular surgery for stenting of the aorta.
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