Thoracic trauma/ Dr.

Yousif Al-Jubori

THORACIC TRAUMA

FRACTURES OF THE RIBS

The most common injury to the chest is fracture of the ribs by a direct blow. The most
commonly affected ribs are the eighth, ninth, and tenth ribs at their shafts.
Clinical features:
The patient complains of pain in the chest overlying the fracture and this pain is
increased by springing the ribs with gentle but sharp pressure on the sternum. Chest X-
ray may confirm rib fractures.
Treatment:
1. Anaelgesia: Pain relief is achieved by non-steroidal anti-inflammatory drugs
(NSAID), or by regional anaesthesia to block the intercostal nerves.
2. Rib fixation, is indicated only when multiple ribs are fractured and displaced.

FLAIL CHEST
Flail chest is a serious condition. It occurs in either of the following two conditions:
1. Several ribs are fractured in two places at one side of the chest.
2. Several ribs are fractured in one place at both sides of the chest. So, the sternum
becomes loose.
Paradoxical movement:
1. On inspiration, the flail part of the chest wall is sucked inward, and the rest of the
thoracic cage becomes expanded.
2. On expiration, the flail part of the chest wall is pushed out and, the rest of the
thoracic cage becomes contracted.
Clinical features:
The patient is grossly hypoxic due to shunting of deoxygenated air from the lung on the
affected side into the normal side.
Treatment:
1. Anaelgesia is applied for good pain control.
2. Support the flail segment in an emergency room by a firm pad to stop the
paradoxical movement and air shunting.
3. Endotracheal intubation and positive pressure ventilation will stop the
paradoxical movement, as the chest wall now moves as a single functional unit.
The treatment is continued for 10 days until fixation of the ribs is performed.

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 Thoracic trauma/ Dr. Yousif Al-Jubori

PNEUMOTHORAX
Definition:
A collection of air into the pleural cavity is called pneumothorax.
Aetiology of pneumothorax:
Air is trapped in the pleural cavity on inspiration and cannot escape on expiration.
1. Sucking wound of the chest wall: The lips of a penetrating wound of the chest
wall (knife stab or gunshot wound) may have a valvular effect, so that air is
sucked into the pleural cavity at each inspiration but cannot escape on expiration.
2. Tension pneumothorax: If a bony spicule of a rib penetrates the lung, and a
valvular pleural tear is produced, allowing air to be sucked into the pleural cavity
at each inspiration but preventing air returning to the bronchi on expiration.
Clinical features:
The patient develops rapidly increasing dyspnoea, and obstructive shock. The trachea
and the apex beat of the heart are displaced away from the side of the pneumothorax.
The chest on the affected side becomes hyper-resonant on percussion with diminished
breathing sounds on auscultation.
Treatment:
1. Administer oxygen.
2. Apply dressings to the chest wound to prevent sucking of air.
3. Urgent insertion of a chest tube into the pleural cavity at the second intercostal
space with the midclavicular line, which has been connected to underwater seal.

HAEMOTHORAX
Definition:
A collection of blood into the pleural cavity is called haemothorax. When it is associated
with a pneumothorax, it is called haemo-pneumothorax.
Aetiology:
1. Lacerated chest wall.
2. Underlying injured lung.
3. Injury to the heart or a great blood vessel.
Clinical features:
A haemothorax produces rapid dyspnoea and hypovolaemic/ and obstructive shock. The
trachea and the apex beat of the heart are displaced away from the side of the
haemothorax. The chest on the affected side becomes dull on percussion with
diminished breathing sounds on auscultation.
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 Thoracic trauma/ Dr. Yousif Al-Jubori

Treatment:
Hypoxia and shock must be treated actively by oxygen and blood. Haemothorax should
be drained by inserting a chest tube, which has been connected to underwater seal; the
fifth intercostal space at the midaxillary line is being preferred. Continued bleeding is
an indication for exploratory thoracotomy.

CHEST TUBE
A chest drain is inserted into the pleural cavity via an intercostal space, and connected
to under water seal apparatus.
Site:
1. Air collection (pneumothorax): The second intercostal space at the midclavicular
line.
2. Fluid collection (haemothorax, and pleural effusion or empyema): The fifth
intercostal space at the midaxillary line.
3. Dressing of every wound in the chest to prevent sucking of air.
Functions of chest tube:
1. It is indicated to drain air, blood, fluid, or pus collected in the pleural cavity to
prevent lung collapse.
2. It assists lung expansion.
3. Request chest-X ray after insertion of the tube to ensure the tube in the correct
position, and functioning well.
Functions of underwater seal:
1. On expiration: As the pressure in the pleural space is increased, the air escapes
from the pleural cavity to the water.
2. On inspiration: The air cannot inter the chest because it is prevented by the water.
3. The water bottle is placed below the level of the chest to ensure fluid does not
reflux into the thoracic cavity.
After placement of chest tube and follow-up:
1. Anaelgesia.
2. Antibiotics.
3. Breathing exercises are done by deep inspirations, and inflation of a ballon.
4. Removal of the chest tube is done after 7-10 days.
5. Re-arrange new chest-X ray after removal of the tube.