Blunt thoracic injury

What is a blunt thoracic injury?

A blunt thoracic injury is a trauma to the chest caused by blunt force. In contrast to an open chest injury, the skin remains intact and there is no open wound in the chest, for example due to an object penetrating the chest such as a knife or projectile from a weapon. Nevertheless, blunt chest trauma can result in internal injuries.

The causes of blunt chest injuries are often traffic accidents. When motor vehicles collide, enormous acceleration forces are exerted on the rib cage. But occupational and household accidents can also cause blunt thoracic injuries, such as a fall from a ladder while cleaning windows or from scaffolding. Sometimes a violent punch or kick is also responsible for blunt chest trauma.

In principle, all organs, bones, tissue and vessels in the chest can be damaged: Ribs, sternum, collarbones and vertebrae, but also the lungs, heart, esophagus and windpipe, diaphragm or large vessels that run through there. Particularly dangerous are, for example, pulmonary contusions, pneumothorax (especially tension pneumothorax), hematothorax or a tear in the aorta.

Even if the heart and lungs are not directly injured, their function can still be impaired due to the disruption of gas exchange and blood circulation. In many patients, not only is the chest injured, but we also find injuries to the lumbar cavity, brain, pelvis or long tubular bones – we speak of a polytrauma.

The symptoms depend on which organs in the chest are injured and how extensively, and whether other organs and tissues outside the chest have been damaged. Accident victims often have chest pain, breathing is painful and they suffer from shortness of breath. Without prompt treatment, a severe blunt thoracic injury can be life-threatening. A traffic accident with thoracic trauma usually belongs in the hands of a trauma surgeon.

Blunt thoracic injury – frequency and age

Thoracic trauma is a blunt injury in more than 90 percent of cases. It is therefore much more common than the open thoracic injury. Traffic accidents are a particularly frequent cause. An impact at high speed can exert enormous acceleration forces on the rib cage. In principle, chest injuries can affect people of any age – babies, adolescents, adults or the elderly.

Blunt thoracic injury: usually caused by traffic accidents

Blunt thoracic injuries can have several causes. The most common reasons are traffic accidents involving cars, trucks, motorcycles, scooters, bicycles or pedestrians. An impact to the chest can cause bruising and contusions with organ injuries to the thorax.

Accidents at home or at work are also possible causes of blunt thoracic injuries. Examples include a fall from a great height from a ladder or scaffolding (e.g. when cleaning windows, cleaning gutters, painting or scaffolding work). Other possible causes of blunt chest injuries are sports (ball sports), fights and abuse (punches, kicks) or burial (earthquakes, avalanches). Here too, considerable forces can act on the rib cage.

The following organs, tissues and vessels are particularly often damaged:

• Chest wall: fractures of ribs, sternum, collarbones, shoulder blades or vertebrae
• Lung: lung contusion, lung contusion, lung rupture, lung collapse
• Heart: heart contusion, heart contusion, heart rupture (heart rupture)
• Rupture of the aorta and other vessels
• Bronchus rupture from the lung/trachea
• Rupture of the esophagus (esophageal rupture)
• Other injuries, usually to the abdomen, head, pelvis or long tubular bones (polytrauma)

Symptoms: Blunt thoracic injury not always immediately visible

A blunt thoracic injury can cause a number of different symptoms. They range from minor pain to life-threatening shock symptoms. The decisive factor is the type of injury and how serious it is. The symptoms also depend on which and how many organs, tissues and structures in the chest are damaged and whether there are other injuries, such as in the abdomen or brain.

No bony structures are damaged in a thoracic contusion. It can manifest itself in the following symptoms, for example:

• In around 80 percent of those affected, no external signs of injury are initially recognizable.
• Later, so-called bruise marks appear, for example from the seatbelt, the steering wheel or the airbag. Bruise marks are bruises where the forces have been applied.
• Severe pain when pressure is applied to the affected region
• Pain when breathing (many people show signs of light breathing); pain with other movements of the chest, for example when coughing, sneezing or laughing

Organs in the chest are damaged if the patient is subjected to severe violence. The following injuries and symptoms can occur, for example:

• Broken ribs (fractures): Pain in the chest with every breath and every movement
• Contusion of the lung (pulmonary contusion): Damage to the lung tissue, followed by water retention or bleeding into the lungs (pulmonary edema)
• Shortness of breath up to respiratory failure after hours or days

Blunt thoracic injury: diagnosis with us

In the case of a blunt thoracic injury, the trauma surgeon tries to make the diagnosis as quickly as possible. The patient’s medical history is briefly recorded and, if they are responsive, they are asked about the cause of the accident (traffic accident, domestic accident, occupational accident, fight) and their symptoms. Sometimes bystanders or eyewitnesses can also provide information about what exactly happened and how.

The patient then undergoes a physical examination. Look for visually recognizable signs of injury, such as bruising from the seatbelt, bruises or abrasions. In addition, the chest is carefully palpated and checked to see whether this is painful for the accident victim. For example, we obtain indications of fractures of the ribs, collarbones or sternum. On palpation, bone fractures usually cause painful and audible noises when the bones rub against each other. With intubated patients in particular, you can also feel whether the bones are unstable.

• Listening to the heart and lungs: Unusual breathing or heart sounds provide us with further information. They indicate that the lungs or heart are also injured. Reduced breath sounds indicate, for example, a pneumothorax (air in the pleural cavity) or a hemothorax (accumulation of blood in the chest). We also observe the movements of the rib cage when breathing.
• Pulse oximetry and blood pressure measurement: We also measure oxygen saturation in the blood (pulse oximetry) and blood pressure to check the function of the heart and circulation.
• Electrocardiogram: An ECG records the heart current curve and shows whether the heart activity is normal.
• Blood test: A blood test is routine, in which we determine the heart enzymes, among other things.

Imaging procedures are used in hospital to provide information about the type and extent of the blunt thoracic injury. They also show whether accompanying organs in the abdominal cavity or the brain are also injured. Such multiple injuries (polytrauma) are not uncommon in accidents and are particularly dangerous. Important examination methods are, for example

• X-ray examination of the chest (chest X-ray): It provides indications of injuries (fractures, breaks) to the bones, for example ribs or collarbones, as well as indications of pneumothorax or hematothorax
• Ultrasound examination (Sonography): an initial focused ultrasound examination of the chest is often performed in the trauma room with the aim of diagnosing a pneumothorax or hematothorax.
• Computed tomography (CT): This examination is the gold standard for serious chest injuries. This X-ray examination can reveal damage to the organs and soft structures. For example, accumulations of air in the chest are visible, for example due to a ruptured lung.

Blunt thoracic injury: prevention, early detection, prognosis

There are no special measures for the prevention and early detection of blunt thoracic injury. Prevention consists of adhering to speed limits, wearing seat belts, airbags, avoiding alcohol in road traffic, etc.

Course and prognosis of blunt thoracic injury

The course and prognosis depend on the type and severity of the blunt thoracic injury. Although a mild chest contusion is painful, in most cases it heals on its own and the prognosis is favorable. However, the healing process can take months. Nevertheless, even a simple chest contusion can become dangerous due to the pain-induced reduced breathing: The secretion builds up in the lungs, bacteria can colonize and pneumonia develops.

Serious injuries such as a heart rupture, rupture of the aorta or esophagus are associated with a high mortality rate. Immediate, comprehensive treatment is necessary if organs, tissue and structures in the thorax are damaged and there are other concomitant injuries, for example in the abdomen or brain. We have to treat these injuries quickly, otherwise the chest injury can be fatal. Around 25 percent of all deaths following an accident are associated with a thoracic injury.

Blunt thoracic injury: treatment depends on the severity

The treatment of blunt chest injuries depends on the extent of the injury. For example, it is important to know whether there are any broken bones or damage to the lungs, heart or major vessels. We must also treat other injuries outside the chest immediately.

Pain medication is usually sufficient for minor chest injuries. This allows patients to breathe or move without pain. Breathing exercises, which you can learn from a physiotherapist, are helpful. This reduces the risk of pneumonia. Bandages over the chest are usually useless.

Smaller accumulations of air or blood (minor pneumothorax/hematothorax) are initially checked regularly in an inpatient setting using x-rays and clinical examinations. We observe whether they recede. If not, a chest drain will help to remove air or fluid.

Emergency care for seriously injured patients generally includes the following therapies:

• Securing the oxygen supply: oxygen administration, intubation, ventilation (link to treatment details can be set here)
• Chest drainage: We place a drain in the chest to remove fluid, for example in the case of a tension pneumothorax. (Link to details of the treatment can be set here)
• Volume therapy: We compensate for any volume deficiency, usually by administering infusions. (Link to details of the treatment can be set here)

Surgery is occasionally necessary for more severe blunt thoracic injuries. These include insertion of a chest drain in moderate cases, a thoracoscopy in moderate cases or a chest opening in severe cases. We then monitor the patient for some time in the intensive care unit.