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Common types of chest injury

Traumatic injuries of the thorax are classified in severity and extent of damage in the underlying tissues. Injuries are classified as superficial, deep, open, closed, with or without fracture. With light injuries the prognosis is usually positive and the time in which the contusion is completely cured is relatively short. Depending on the circumstances of the accident, the damage can vary. This could be bruising, burns, torn wounds, bruises, broken bones (fractures) and others. 

Types of chest and thorax trauma include: 

• Fractures of the ribs
• Injuries to the mammary gland
• Injuries to the chest wall
• Other injuries

Flail Chest 

When a segment of the thoracic cage is separated from the chest wall, a flail chest occurs. A flail chest segment becomes unable to support lung expansion. This usually happens when there are at least two fractures per rib, which are producing a free floating segment. Bigger flail segments usually involve a greater proportion of the chest wall. They may extend bilaterally and/or involve the sternum. The disruption of normal pulmonary mechanics could be large enough to require supported (mechanical) ventilation. The major significance in case of a flail chest is that the condition could indicate the presence of an underlying pulmonary injury. The management of flail chest includes standard management of rib fractures as well as the underlying pulmonary contusions.

Minor chest contusion 

Usually a blow to the chest can be the cause of either a minor or serious injury. After a chest injury it is important to determine whether the pain is caused by a heart problem. The patient could experience chest wall pain after an injury to the chest. Pain can occur when the arm or shoulder are moved, as well as pain and swelling in the rib cage. Even a minor injury can cause outbursts of chest pain for a few days after the accident. Deep breathing, coughing and sneezing tend to increase the pain, as well as pressing down on or lying on the area. In case of minor chest injuries home treatment can usually relieve the pain and discomfort. Even in such cases it’s strongly advised to visit a doctor.

Serious chest injuries

If the injured person feels significant pain or has continuous difficulty breathing, that could be a sign of internal damage to the organs. In case of an accident immediately call a doctor. Use the emergency number – 112 within the EU. A thorough examination of the chest, lungs, heart, blood vessels should be performed in a hospital. Other symptoms usually develop rapidly: there could be shortness of breath, pain, shock, difficulty of movement and so on. A blunt trauma or a forceful blow to the chest can cause trauma of the internal organs in the chest and upper abdomen. A blow of the frontal chest and sternum can cause heart injury or large blood vessels and esophagus contusion, lungs or trachea injury. A blow to the back of the chest can cause a kidney injury. A side blow or a blow in the lower part of the chest could injure the liver or the spleen.

Fracture of the ribs

An injury to the chest may cause breaking or crack of one or more ribs, and could also cause injury of the rib cage cartilage. Ribs are most affected by trauma of the rib cage. Rib fractures are more common in adults, but under certain conditions (e.g. traffic accidents) can also be found in young patients.

Symptoms of a bruised or broken rib include: 

• Severe, sharp pain in the damaged area
• Pain gets worse when breathing or coughing
• Pain gets worse when the injured area is pressed on
• Pain gets worse when the injured person lies on the damaged area

Rib fractures are usually very painful but in most cases can be treated at home after first aid medical attention.

Surface chest injuries 

Surface injuries can be caused by direct or indirect impact to the chest or pressure from external force. They may occur with or without the presence of damaged skin (e.g. an open wound).

Open chest injuries (open wounds in chest area) 

An open injury means there is a visible open wound and tear of the skin in the chest area. This could be caused by a serious fracture, where a fragment of the broken bone punctures the skin of the chest wall. 

Traumatic injury to the blood vessels in the chest area 

Damage to blood vessels often occurs when chest injury is present. This condition can be fatal to the patient because of the increased blood flow coming from the aorta (which is the largest artery in the body), located in the chest area. 

Traumatic injury to the heart 

One of the most important organs in the human body - the heart - is located in the chest area.

The injuries of the heart are classified as closed (around 90% of total cases) and open (nearly 10%). It is important to know that indoor injuries usually occur in cases of traffic accidents, as well as fall from heights. Open injuries (with wounds) are common in penetrating injuries to the chest. 

Other and unspecified injuries of the chest and organs in the chest cavity 

A serious damage to the muscles and ligaments of the chest may occur in an accident. In severe cases a multiple impairment or organ failure is present. Some of the more common conditions are haemothorax (collecting blood) and air/gas (pneumothorax) in the pleural cavity. 

Traumatic amputation, crushing of the chest 

Closed thoracic injuries usually occur as a result of road traffic accidents (RTA), as well as a fall from heights, domestic (household) and employment (industrial) accidents. According to their location, they can be unilateral or bilateral.

Symptoms  of chest injury may vary, depending on the type of contusion.

However, some of the most common signs and symptoms are: 

• pain in the chest (usually gets worse with laughing, coughing, sneezing)
• significant difficulty breathing
• tenderness
• visible bruising
• visible swelling

In case of severe injury, there may be internal bleeding present. This could be visible and obvious (coughing up blood), or not (clammy, pale, nausea, feeling of thirst). If you have doubts that you have internal bleeding, you should call 112 and get medical help (an ambulance) immediately.

First Aid Treatment

Treatment of chest injuries should be performed in safe medical environment (e.g. a hospital).

Here’s a short list of first aid procedures and directions that could be important in case of an accident:  

• In many cases CPR is necessary and should be performed ASAP
• Do not remove an object that remains in the chest injury
• Use an airtight dressing (tin foil, plastic sack) as quickly as possible to cover any opening or hole that extends into the chest cavity
• The injured person should be put in a position where the affected side is looking down
• Immobilize the neck and back of the injured person

Diagnosis 

Most significant chest wall injuries are to be identified by physical examination by a trained professional – a medical doctor. In most cases bruising, slashes, grazes or seat-belt signs are clearly visible on inspection. Palpation may reveal the crepitus, usually associated with broken ribs.

Clinical overview

Chest trauma is a significant source of morbidity and mortality in Bulgaria, as well as the EU. Blunt chest trauma affects one or more components of the chest wall and the thoracic cavity. These include the bony skeleton (clavicles, scapulae, ribs, and the sternum), and also the lungs, pleurae, tracheobronchial tree, esophagus, heart and internal organs. Blunt chest  injuries also affect the great vessels of the chest, as well as the diaphragm.

Morbidity and mortality of chest trauma and injuries

Trauma is among the leading causes of death, morbidity, hospitalization and disability in people from young age to senior citizens and is a major health care problem.Pathophysiology Among the major pathophysiologies which are encountered in cases of blunt chest trauma are derangements in the air flow, blood flow, or both. Sepsis due to leakage of alimentary tract contents (e.g. esophageal perforations) must also be considered.

The second stage of chest trauma treatment consists of a specialized rehabilitation program. This may contain various complexes of secondary care and exercise depending on the type and severity of the lesion, as well as other conditions, such as specific diseases of the patient.

Some of the best practices for recovery from chest injury include rest, applying cold compresses and taking non-steroidal anti-inflammatory drugs for pain relief (on prescription). Deep breathing exercises are recommended to reduce the risk of atelectasis and pneumonia. The rehabilitation program should be guided by medical doctor or physiotherapist within subsequent monitoring of the general condition of the patient.

Always use the recommended personal protective equipment while working with machinery or while performing specific activities in the workplace. The use of seat belts while driving helps greatly reduce the risk of fractures and other injuries in road accidents.

In general, elder patients' main predisposing factor for fractures is osteoporosis, which makes even minor injuries complications potentially dangerous.

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