Thoracic injury: a review of 276 cases

OBJECTIVE: Chest injury, one of the most important aspects of trauma, directly accounts for 25% of all trauma-related deaths and plays a major contributing role in another 25% of trauma deaths. This paper aimed to explore the spectrum and outcome of thoracic injuries seen in a multi centric study of trauma patients. METHODS: A total of 276 consecutive trauma patients in 6 general hospitals were analyzed. The feature of injury, injury severity score (ISS), clinical treatment and mortality were recorded in a prospective manner and analyzed retrospectively. Multiple logistic regression analysis was used to determine the independent predictors of mortality following the chest trauma. RESULTS: There were 246 males (89.1%) and 30 females (10.9%) ranging from 3 to 80 years with a mean age of (34+/-17) years. Road traffic accident was the main cause of injury, especially for pedestrians, followed by stab wound (89 cases, 32.1%) and falling injuries (32 cases, 11.6%), respectively. Haemothorax or pneumothorax (50.4%) and rib fracture (38.6%) were the most common types of chest injury. Extremity fracture was the most common associated injury with the rate of 37% ( 85/230), followed by head injury (25.2%) and abdominal trauma (19.6%). These injuries contributed significantly to the morbidity and mortality of trauma patients. CONCLUSIONS: According to the results, most patients with chest injury can be treated conservatively with close observation and tube thoracostomy. The presence of blunt trauma, head injury and abdominal injury independently adversely affect mortality after chest trauma. It is necessary to investigate the causes and patterns of injuries resulting from stab wound for effective prevention.     

Blunt chest trauma in childhood

BACKGROUND: Although thoracic injuries are uncommon in children, their rate of morbidity and mortality is high. The aim of this study was to evaluate the clinical features of children with blunt chest injury and to investigate the predictive accuracy of their paediatric trauma scores (PTS). METHODS: Between September 1996 and September 2006, children with blunt thoracic trauma were evaluated retrospectively. Clinical features and PTS of the patients were recorded. RESULTS: There were 27 male and 17 female patients. The mean age was 7.1 +/- 3.4 years, and the mean PTS was 7.6 +/- 2.4. Nineteen cases were injuries caused by motor vehicle/pedestrian accidents, 11 motor vehicle accidents, 8 falls and 6 motor vehicle/bicycle or motorbike accidents. The following were noted: 28 pulmonary contusions, 12 pneumothoraxes, 10 haemothoraxes, 9 rib fractures, 7 haemopneumothoraxes, 5 clavicle fractures and 2 flail chests, 1 diaphragmatic rupture and 1 pneumatocele case. The cut-off value of PTS to discriminate mortality was found to be < or = 4, at which point sensitivity was 75.0% and specificity was 92.5%. Twenty-seven patients were treated non-operatively, 17 were treated with a tube thoracostomy and two were treated with a thoracotomy. Four patients who suffered head and abdominal injuries died (9.09%). CONCLUSION: Thoracic injuries in children expose a high mortality rate as a consequence of head or abdominal injuries. PTS may be helpful to identify mortality in children with blunt chest trauma. Blunt thoracic injuries in children can be treated with a non-operative approach and a tube thoracostomy.     

Blunt thoracic trauma in children: review of 137 cases.

OBJECTIVE: Thoracic injuries are uncommon in children and few report present on blunt ones. METHODS: Between 1994 and 2003, 137 children with blunt thoracic injury were reviewed. RESULTS: The mean age of children was 6.9+/-7.3 (1-16) years. Etiology was falls in 46.7%, traffical accidents in 51% and abuse in 2.2%. Average height in fallen-down cases was 6.4+/-2 (range: 3-11) m. Calculated mean kinetic energy transfer to body was 1923+/-1056 J. When first seen, 70% (82/117) of the patients had vital signs that were within normal limits. Forty-two (35.9%) children had isolated thoracic injury. Associated injuries were present in 75 (64.1%) children. Head injury was the most common associated injury present in 33 (28.2%). Pulmonary contusion was the most common thoracic injury with 68 (49.6%). Seventeen (12.4%) required surgery, 11 (8%) of them were thoracic (4 for diaphragmatic tear, 2 for flail chest, 2 for tracheobronchial injuries, 2 for laceration, 1 for esophageal rupture). Surgical group had higher ISS (26.8 vs 36.2, P = 0.001). Fifteen were lost (10.9%): There were lethal injuries in 7; chest tube treatment in 3; intensive care unit management in 2; mechanical support in 2 and observation in 1 patient. No death occurred for operations. Mortality rate was the lowest at injuries to chest alone and the highest for multi-system injuries (P < 0.05). The hospital length of stay for averaged 13.4+/-8.8 (range: 4-49) days. CONCLUSION: Associated injury is the most important mortality factor. Thoracic operations can be performed with minimal morbidity and without mortality in children with blunt thoracic trauma.     

Chest trauma in Jammu region an institutional study

Background Chest trauma is a commonly encountered surgical emergency, constitutes about 10% of the total trauma, however 25% of fatalities are because of chest trauma. The aims of this study is to evaluate and document the causes modes of presentation, dignosis and modalities of treatment for chest trauma. Patient and Methods Prospetive study was done at Govt. Medical College (GMC) Jammu for a period of one year on cases of chest trauma. A total number of 2571 patients were admitted in Surgery department with poly trauma, 240 (9.3%) had chest injuries. Majority (78.7%) were males, with a mean age of 34.4 years. The mean hospital stay was 6.4 days and majority cases reached hospital with in 4 hours after injury. 81.7% cases had blunt trauma chest with Road Traffic Accidents (RTA) being the mode of injury and gunshot injury was the commonest among penetratting chest trauma victims. Clinical presentation and physical examination was sufficient for the dignosis, although some investigations, especially chest x-rays and thoracic Computed Tomographic (CT) scans were necessary in most of cases. Observations Only 16 (8.8%) patients required surgery and rest 91.2% managed on conservative line only. Rib fracture was the commonest injury (60%) followed by hemopneumothorax (51.7%), surgical emphysema (37.9), lung contusion (10.4%), flail chest (6.2%) etc. Associated injuries were seen in 117 (48.8%), with head injury the commonest one. Overall motality rate was 12%, which was higher in blunt chest trauma as compared to penetrating injuries. All these patients were managed by a protocol, which was standardized by postgraduate department of surgery of this institution. Coclusion The evaluation of thoracic injuries is important aspect of the total assessment of a severely injured patient, the incidence as high as 10%. Both diagnostic and therapeutic procedures go hand in hand most thoracic injuries can be treated adequately by intercostal tube drainage. Operative intervention has been found necessary in 6.75 of cases only     

Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

Chest injuries in children: an analysis of 100 cases of blunt chest trauma from motor vehicle accidents.

One hundred twenty-eight cases of chest injury were seen in a Paediatric Trauma Unit over a 5 1/2-year period. One hundred patients sustained motor vehicle accident (MVA)-related blunt chest injuries, 91 of them as pedestrians. Nine children had blunt chest injuries from falls, 10 had stab wounds (3 assault, 7 accidental), and 9 had gunshot injuries (6 from birdshot used by police during civil disturbance). MVA-related injuries were studied separately, as an etiologically homogeneous group. Sixty-five of these patients were under the age of 6. All but 3 also had serious extrathoracic injuries. The mean injury severity score (ISS) in MVA-related injuries was 25. Eight patients died, all with an ISS of 34 or more, 7 of whom had fatal head injuries. In MVA-related injuries, pulmonary contusion (n = 73) was the most frequent lesion seen, followed by rib fracture (n = 62), posttraumatic effusion (n = 58), pneumothorax (n = 38), and pneumatocele (n = 5). In MVA-related injuries, 18 children required ventilation. Thirty-nine (69%) of 56 children with radiologically evident posttraumatic pleural effusion had intercostal chest drainage. Analysis suggests that lung injury is a central event in MVA-related blunt chest trauma. Primary lung injury, radiologically visible as contusion, is complicated by hematoma, posttraumatic effusion, and pneumothorax.     

Diaphragmatic injury in children.

Injury to the diaphragm is rare in children. From 1972 to 1990, 13 children were treated for diaphragmatic injury at Ste-Justine and Montreal Children's hospitals. There were seven boys and six girls, ranging in age from 1 to 15 years (average, 7.5 years). Eight patients sustained penetrating trauma and five patients sustained blunt trauma. Nine patients had associated injuries, most commonly involving the liver. All thirteen patients underwent exploratory laparotomy with repair of the diaphragm. There were two deaths, both unrelated to the diaphragmatic trauma. All surviving patients recovered without sequelae. One patient underwent cosmetic repair of a chest wall deformity 9 years after injury. Diaphragmatic injury must be considered in any child suffering blunt or penetrating thoracoabdominal trauma. Because of the increased compliance of the thoracic cage in children, rupture of the diaphragm can occur without signs of external injury. Morbidity and mortality can be minimized by a high index of suspicion, prompt recognition, and surgical repair of even the smallest diaphragmatic injury.     

Blunt thoracic trauma. Analysis of 515 patients.

A retrospective analysis of 515 cases of blunt chest trauma is presented. The overall thoracic morbidity rate was 36% and mortality rate was 15.5%. Atelectasis was the most common complication. Severe chest trauma can be present in the absence of rib or other thoracic bony fractures. Emergency thoracotomies for resuscitation of the patient with blunt chest trauma with absent vital signs proved unsuccessful in 39 of 39 patients. A high index of suspicion for blunt chest injury occurring in blunt trauma, coupled with an aggressive diagnostic and therapeutic approach, remains the cornerstone of treatment to minimize the morbidity and mortality of such injuries.     

The trend of using computed tomography in the detection of acute thoracic aortic and branch vessel injury after blunt thoracic trauma: single-center experience over 13 years

BACKGROUND: The purpose of this study was to review the trend of using chest computed tomography (CT) and aortography in evaluating patients with blunt thoracic trauma. METHODS: A total of 85 patients who had blunt aortic injury diagnosed by chest CT, aortography, or both were included in this study. RESULTS: Aortography was the dominant modality before 1998, and the use of chest CT has increased to 50% of patients with aortic injuries as of 2001. Isolated aortic, branch vessel, or combined injuries were found in 71 (84%), 11 (13%), and 3 (4%) patients, respectively. All 14 patients with branch vessel injuries were diagnosed by aortography. Ninety-eight percent of patients with aortography were true-positives, and 20% of patients with chest CT had indirect signs of aortic injury. CONCLUSION: Our institution has increased the use of chest CT to evaluate blunt thoracic trauma. Patients with indirect signs of aortic injuries shown on chest CT require further evaluation. In our experience, angiography remains the optimal diagnostic modality for evaluating aortic branch vessel injuries.     

Acute tracheobronchial injury

We reviewed our experience with tracheal and bronchial trauma from 1977 to 1988. There were 22 patients with tracheobronchial injuries treated in this period. Seventeen (77%) of the injuries were due to penetrating trauma and five (23%) were due to blunt trauma. Thirteen patients had major associated injuries, including six esophageal injuries. The most common physical findings were tachypnea (13 patients) and subcutaneous emphysema (nine patients). Eight patients presented with airway obstruction. All patients with penetrating cervical tracheal injuries underwent neck exploration and primary repair. All blunt injuries were diagnosed by bronchoscopy. Three patients with blunt injuries were treated with primary repair. Two patients with blunt chest trauma and small bronchial tears were treated nonoperatively with good results. All three deaths (14% mortality rate) were due to associated injuries. We conclude that patients with penetrating tracheobronchial injuries should be managed by surgical exploration and primary repair, although selected patients with blunt injury may be treated nonoperatively.     

An Analysis of Presentation,Pattern and Outcome of Chest Trauma Patients at an Urban Level 1 Trauma Center

Chest trauma is an important public health problem accounting for a substantial proportion of all trauma admissions and deaths. It directly account for 20–25 % of deaths due to trauma. Therefore, this study was conducted to analyze the presentation, patterns, and outcome of chest trauma in a level-1 urban trauma center. It was a prospective observational study of all patients presented with chest trauma to an urban level 1-trauma center over a period of 3 years. Demographic profile, mechanism of injury, injury severity scores (ISS), associated injuries, hospital stay, etc. were recorded. Morbidity and mortality rates were analyzed and compared with the published literature. Chest injuries comprised 30.9 % of all trauma admissions and the mechanism was blunt in majority (83.5 %) of the cases. Vehicular crashes (59.7 %) followed by assault were the most common modes of injury. Rib fracture was the most common chest injury seen in 724 of the 1258 patients while abdominal visceral injuries were the commonest associated injuries in polytrauma cases. Majority of the patients were managed non-operatively. Inter costal tube drainage (ICD) was the main stay of treatment in 75 % of the cases, whereas, thoracotomy was required only in 5.56 % of the patients. Overall mortality was 11 % and it was found to be significantly higher following blunt chest trauma. We observed that associated extra thoracic injuries resulted in higher mortality as compared to isolated chest injuries. Thoracic injuries can be readily diagnosed in the emergency department by meticulous and repeated clinical evaluation and majority require simple surgical procedures to prevent immediate mortality and long-term morbidity.     

Management of blunt thoracic aortic injuries: endovascular stents versus open repair

BACKGROUND: Endovascular stent graft (EV) technology has been successfully adapted to the repair of blunt traumatic aortic injuries. The purpose of this study was to compare the outcomes of patients treated with EV repair and open repair after blunt thoracic aortic trauma. METHODS: A review of a tertiary trauma center's prospective trauma registry identified all patients who suffered a blunt traumatic thoracic aortic injury over an 11-year period (1991-2002). Operative interventions and outcomes were then compared. RESULTS: Over an 11-year period, 18 patients underwent repair of a blunt thoracic aortic injury (EV, 6; open, 12). There were no significant differences in demographics, injury, or crash statistics between groups. The open group had a 17% early mortality rate (n = 2), a paraplegia rate of 16% (n = 2), and an 8.3% incidence of recurrent laryngeal nerve injury (n = 1). This is in contrast to a 0% rate of mortality, paraplegia, and recurrent laryngeal nerve injury in the EV group. A definite trend toward decreased morbidity, mortality, intensive care unit length of stay, and number of ventilator-dependent days was seen with EV repair. CONCLUSION: We observed a clear trend toward improved outcomes after EV repair of thoracic aortic injuries compared with standard open repair. EV repair is emerging as the preferred method of repairing blunt thoracic aortic injuries in trauma patients with multiple injuries.     

Role of CT in diagnosis of major arterial injury after blunt thoracic trauma

The role of computed tomography (CT) in the diagnosis of blunt thoracic vascular injury is controversial. Several recent reports have advocated the use of CT to exclude aortic and major branch injuries in hemodynamically stable patients with blunt trauma. This approach potentially avoids invasive angiography and unnecessary treatment delays in multiply injured patients but risks missed aortic transections if the CT or its interpretation is not accurate. We prospectively evaluated 153 consecutive trauma patients in whom we suspected blunt aortic injury between September 1985 and August 1988. All hemodynamically stable patients underwent contrast-enhanced chest CT followed by immediate aortic arch angiography. Forty-nine unstable patients underwent immediate angiography without chest CT, and 11 (22%) had major thoracic arterial injuries. Data from the remaining 104 stable patients indicate that the sensitivity of chest CT for diagnosis of major thoracic injury is 55%; specificity, 65%. If the chest CT had been used as a screening modality to perform aortic angiography, two transected aortas and three major aortic branch injuries would have been missed. We conclude that chest CT has no screening role in the evaluation of blunt trauma patients with possible major vascular injury.     

CT as a first-line modality in elderly patients with stable blunt chest trauma

Purpose: Blunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients. Methods: A retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay. Results: There are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18-64 years; group 2: 184 patients were included and aged 65-99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR. Conclusion: Chest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.     

Current indications and results of VATS in the evaluation and management of hemodynamically stable thoracic injuries

Objective: Thoracic injuries are among the most severe forms of trauma and also a leading cause of morbidity and mortality. Video Assisted Thoracic Surgery (VATS) has recently provided an alternative method to simultaneously diagnose and manage patients sustaining chest injuries. We analyze our experience with VATS in the setting of thoracic trauma detailing indications for exploration, procedures performed and results of surgery. Methods: A 6-year single institution review of patients undergoing VATS due to injuries sustained from both blunt and penetrating chest trauma at a Level I trauma center and university teaching hospital. Comparisons were made between groups of blunt and penetrating trauma as to Injury Severity Score (ISS), presence of extra-thoracic injuries, initial thoracostomy drainage and length of postoperative stay. Results: VATS was successfully performed in 19 consecutive patients without conversion to thoracotomy. Indications for exploration included acute hemorrhage, retained hemothorax, suspected diaphragmatic injuries (DI), suspected cardiac injury, intra-thoracic foreign body, persistent airleak and chronic empyema. Procedures performed consisted of evacuation of retained hemothorax, hemostasis of intra-thoracic bleeders, repair of DI, wedge lung resections and decortication. Mean postoperative length of stay was 5.86 days. There were no morbidities. One patient with severe intra-abdominal injuries expired on the first postoperative day. Conclusion: In hemodynamically stable patients with thoracic injuries, VATS provides an accurate assessment of intra-thoracic organ injury and can be utilized to definitively and effectively manage injuries sustained as a result of blunt or penetrating thoracic trauma. VATS should be used with caution in patients sustaining severe and life threatening intra-abdominal injuries.     

Blunt trauma related chest wall and pulmonary injuries: An overview

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.     

Trauma to the gallbladder is associated with concurrent injuries to the extra hepatic biliary system: A South African experience

IntroductionGallbladder trauma is a rare injury. This study aimed to describe the significance of these injuries and the appropriate management strategies.MethodsA retrospective study was undertaken at a major trauma centre in South Africa and included all patients diagnosed with a gallbladder injury between January 2012 and October 2020.ResultsA total of 51 cases were included (88% male, mean age: 38 years), with 44 (86%) penetrating trauma cases [28 stab wounds (SW), 16 sustained gunshot wounds (GSW)]. Of the 7 (13%) blunt trauma cases, five were involved in a motor vehicle crash, and two were injured via assault. All patients underwent laparotomy. Full-thickness gallbladder laceration or perforation was the most common type of injury (84%) and all patients with a gallbladder perforation or laceration had a cholecystectomy at index operation. Two out of 5 patients with a gallbladder contusion were managed conservatively without a cholecystectomy and the remaining three had evidence of gallbladder necrosis which were managed with cholecystectomy. Associated extrahepatic bile duct injuries occurred in 4% of cases, and 18 cases (35%) required intensive care unit (ICU) admission. The overall mortality was 8%.ConclusionGallbladder injury is rare but when encountered implies a significant degree of trauma. Although cholecystectomy is usually definitive, there is an association with other occult extra-hepatic biliary tract injuries. The severity of the associated injuries usually determines patient outcomes.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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The significance of first rib fractures in children

Purpose

The purpose of the study was to determine if first rib fractures are associated with an increased incidence of thoracic vascular injury in pediatric patients.

Methods

The medical records of all children diagnosed with a first rib fracture or a central vascular injury after blunt trauma treated at a state-designated level 1 pediatric trauma center from 2000 to 2009 were reviewed.

Results

Thirty-three children (0.27% of patients; mean age, 10.9 ± 0.9 years) were identified with either a first rib fracture or thoracic vascular injury owing to blunt trauma. Thirty-two children had a first rib fracture, and only 1 child (3%) had significant thoracic vascular injury. Mediastinal abnormalities (indistinct aortic knob) were identified in 3 children, 2 with first rib fracture on initial chest radiograph. Despite a normal cardiovascular examination result, 25 (74%) children with a normal mediastinum on screening chest radiograph underwent computed tomography. No child with a normal mediastinum on initial chest radiograph was found to have associated intrathoracic injuries requiring further intervention. In children with first rib fractures and a normal mediastinum by screening chest x-ray, the negative predictive value for thoracic vascular injury was 100%.

Conclusions

Children with first rib fractures without mediastinal abnormality on chest radiograph require no further workup for thoracic vascular injury.