Injuries to the Thorax and Abdomen

Stacie Nettles Elwood, ATC, SCAT

Thoracoabdominal Trauma in Sport

¨ Reduced by adequate protective equipment

¨ Damaged viscera difficult to assess

¨ High index of suspicion is necessary

¨ Repeated exam more efficient than single exam

¨ Undetected, may lead to uncontrolled bleeding, shock, sepsis (infection)

VITAL SIGNS

¨ Respirations

– Rate

– Rhythm

– Depth

– Overall Effectiveness

– Auscultation

– Percussion

¨ Blood Pressure

– Systolic

– Diastolic

¨ Pulse

– Rate

– Rhythm

– Strength

¨ Temperature

– Oral/Axillary

¨ Pupil Response

– Equal

– Reactive

– Corollary Response

SHOCK

¨ Gradual Onset

¨ Early Stages

– Shivering

– Thirst

– Defective vision

– Ear noises

¨ Rapid, shallow respirations with occasional deep sigh

¨ Fast, feeble pulse

¨ Pale, cold, clammy skin

¨ Equal and dilated pupils

¨ Listlessness progressing to LOC

¨ No paralysis

¨ No convulsions

Anterior Throat Injuries

¨ Muscle Strain

¨ Contusion

¨ Medical Concerns

Muscle Strain

¨ Sternocleidomastoid primarily involved

¨ MVA

¨ Poor sleep positioning

¨ Upper-cut impact during sport

Contusion

¨ Swallowing

¨ Hoarseness

¨ Inability to speak

(aphasia)

¨ Shortness of breath (SOB)

¨ Resume to activity when return of:

– Normal speech

– Normal breathing

Medical Concerns

¨ Thyroid

¨ Lymph Nodes

¨ Esophagitis

¨ Pharyngitis/Laryngitis

¨ Tonsillitis

¨ Cause for limited/no participation

– Temp >100.5

– Compromised Airway

THORAX

¨ Superficial injuries most common

– Contusion

– Skin Irritation

¨ Visceral Injuries/conditions Uncommon, but are serious and life threatening when they do happen

– Chest Pain

– Bony Injury

– Visceral Injury

Thorax Contusions

¨ Chest Wall Contusion

– Localized tenderness

– Swelling??

– Usually no pain in breathing or restricted rib cage motion, except in deep respirations

¨ Breast Contusion

– Direct Blow: Fibrous scarring (lump)

– Excessive movement: contusion/stretching of Cooper’s ligaments (premature sagging)

Thoracic Skin Irritations

¨ Runner’s Nipple

– Particularly Males

– Irritation of nipple rubbing on jersey top

¨ Underarm Chafe

– Particularly with well-developed musculature

¨ Posterior

prominences causing irritation during abdominal work

– Particularly females

– Spinous processes

– Bra closure

Chest Pain

¨ URGENT

– Cardiac

• Sudden Death Syndrome

• Cardiac Contusion

– Pneumothorax

• Spontaneous

• Tension

– Hemothorax

¨ NON-EMERGENT

– Upper Respiratory Illness (Pleuritic pain)

– Asthma (usually)

– “Stitch in the side”

– “Athlete’s Heart”

– Muscle Spasm

Cardiac Conditions

¨ Cardiac S/Sx

– Palpitations/flutters

– Referred pain to left shoulder/arm, substernal, back/neck

– Profuse sweating/paleness

– Feeling of heavy weight/chest tightness

– SOB/syncope/murmurs

– Nausea/malaise/fever

– Distended neck veins

– Deviated trachea

– Altered chest sounds

– Pulse rapid or irregular

– Blood pressure low

¨ Sudden Death Syndrome

– Hypertrophic Cardiomyopathy (HCM)

– Marfan’s Syndrome/MVP

– Myocarditis

Hypertrophic Cardiomyopathy

¨ ?Asymptomatic

– Syncopal episodes

– Chest pain

– Palpitation

– SOB

¨ Thickened cardiac muscle

¨ No evidence of chamber enlargement

¨ Extensive myocardial scarring

¨ Increased frequency of ventricular arrhythmia

Marfan’s Syndrome/MVP

¨ Marfan’s Syndrome

– Connective tissue abnormality

– Weakened aorta and cardiac valves

– Rupture of valve or aorta

– Extreme length deformities

¨ Mitral Valve Prolapse

– Systolic murmur/click

– Irregular heart rate

– PVCs

– Dizziness or fainting

– Chest pain with exercise

– ECG changes

Full workup require prior to return to participation

Myocarditis

¨ Inflammation of the heart muscle

¨ Associated with viral condition

¨ One reason for concern/monitoring of athlete during viral illnessàlimited activity status?

Exercise Induced Asthma (EIA)

¨ Symptoms

– Associated only with cardiovascularly demanding physical exertion

– Wheezing

– SOB

– Chest tightness

¨ Precursors

– Exercise Intensity

– Temperature

– Relative Humidity

– > with colder, drier air

EIA

¨ Bouts last 5-15’ up to 60’

¨ Typically, resolves spontaneously

¨ Asthma (obstructive respiratory disease) can cause sudden death due to drug toxicity or undertreatment

¨ Adjust variables:

– Scarf/mask over nose/mouth(especially cold weather)

– Breath slowly through nose

– Increase exposure/tolerance starting with 6-minute spurts of exercise

– Facilitate control by medication

Athlete’s Heart

¨ Ability to generate efficient, increased cardiac output with activity

¨ Left ventricular enlargement

¨ Thick left ventricular walls

¨ Slower resting pulse (sinus bradycardia)

¨ ECG changes

Musculoskeletal Chest Wall Pain

¨ Hx of repetitive minor trauma or unaccustomed physical activity

¨ Pain: sharp, nagging, localized to affected side

¨ Positional component to pain; worsened by twisting, deep breathing, or arm movements

¨ Localized chest wall tenderness

Bony Injuries

¨ Fracture (Fx)

– Sternum

• ? Underlying cardiac contusion

– Clavicle

– ? Trauma to subclavian artery/vein

– Rib (5-9 most often)

• Pneumothorax, et al.

• Flail Chest

Flail Chest

¨ Direct fx: outward force pushes bone inward

¨ Indirect fx: internal or crushing force pushes bone outward

¨ Flail Chest:

– Involves three or more ribs, each fractured in 2 or more places.

Paradoxical Motion
(in Flail Chest)

Pleural Injury

¨ Spontaneous pneumothorax

¨ Tension pneumothorax

¨ Hemothorax

– Hemopneumothorax

Pneumothorax

¨ Spontaneous

– Sudden unrelieved SOB after intense exertion

– Shoulder tip pain

– Associated vague or sharp chest discomfort

Tension Pneumothorax

¨ Air leaks into pleural space with each inspiration

¨ Unable to fully disperse with expiration

¨ Gradual buildup of tension in hemi-thorax

¨ Pressure pushes collapsed lung and trachea over (mediastinal shift)

¨ Impedes air entry to non-injured lung

¨ May impede venous return

Hemothorax

¨ Hemothorax

¨ Hemopneumothorax

– Blood and air fill pleural space

Bony Injury

¨ Costochondral separation

– Focal pain at side of costochondral junction

– Particularly debilitating

Stitch in the Side

¨ Causes

– Idiopathic

– ?Local anoxia to respiratory muscles

– ?Diaphragm spasm

– ?Eating/elimination of habits

¨ Characteristics

– Pain increased on inspirationàrapid

– Deconditioned athletes more susceptible

¨ Management

– Lean over affected side

– Press fingers into the site of pain

– Take deep breaths

– Expire slowly through pursed lips

– Expel air from lungs forcefully

– Run with arm (affected side) stretched above head

– Lay down, knees bent, both arms raised

– Repeated, build exercise tolerance more slowly

Celiac (Solar) Plexus Contusion

¨ Celiac Plexus: network of nerves behind stomach controlling diaphragm

¨ Cause: Blow to upper abdomen below sternum causes transitory paralysis of diaphragm

¨ Result: Interrupted breathing, “getting the wind knocked out”

¨ Concerns: Not a medical emergency

– UNLESS s/sx do not disappear rapidly within minutes OR s/sx of shock appear

– ?Direct blow=other organ trauma

¨ Management: Lie down/legs elevated; calm/reassure; loosen restrictive clothing

Abdominal Quadrants

Quadrants

¨ Right Upper

– Liver

– Gall bladder

– Right Kidney

¨ Right Lower

– Portions of intestines and bowels

¨ Left Upper

– Spleen

– Stomach (majority)

– Left Kidney

¨ Left Lower

– Bladder

– Portions of intestines

– Colon

Abdominal Landmark

¨ McBurney’s Point

– Midway between umbilicus and ASIS on lower right side

– Exquisite pain at this location may indicate appendicitis

Abdominal Muscles

¨ Protection of underlying organs

¨ Muscle Strains

¨ Abdominal Hernia

Hip Pointer

¨ “Hip Pointer”

¨ Abdominal Muscle Strain at Iliac Insertion (?bony injury)

Organ Trauma

Blunt Abdominal Injury

¨ Absence of normal respiratory motion of abdomen

¨ Guarding on palpation

¨ Localized tenderness on palpation

¨ Rebound pain with release of deep pressure

¨ Absence of normal bowel sounds

¨ Referred pain to shoulder tip or back

¨ Falling BP, increasing pulse rate

¨ S/Sx of significant intra-abdominal injury will persist.

Kidney

¨ Shock

¨ Nausea/Vomiting

¨ Rigidity of back muscles

¨ Blood in urine (hematuria)

Spleen

¨ Infectious Mononucleosis

– Rest for duration of fever

– Spleen vulnerable to trauma for ~21 days

– Return to training after lymphadenopathy resolved and energy levels increase

– Contact sports when spleen size (US), liver enzymes, CBC, and urinalysis return to normal

– After return to sport, report acute abdominal discomfort immediately

Liver

¨ Organs generally are insensitive to pain (few nerves), Except the liver

¨ Pain due to hemorrhage into organ capsule or peritoneum

Urinary Bladder

¨ Hollow organ when empty

¨ Solid organ when full, more susceptible to direct blow

Hernia

¨ Protrusion of abdominal viscera through a portion of abdominal wall

– Abdominal

– Femoral

– Inguinal

¨ Pain, prolonged discomfort, feeling of weakness/pulling in groin

¨ ?Palpable protrusion

Hernia

¨ Generally Not caused by athletic activity, but is aggravated by it

¨ Intra-abdominal pressure increases in weight training/strenuous activityàs/sx associated with hernia

¨ Referral: any time s/sx exacerbated by athletic activity

If you see this…

And you see this…

You should evaluate for these…

¨ Scrotal Contusion

¨ Hydrocele

¨ Hematocele

¨ Spermatic cord torsion

¨ These require close, if not emergent, attention to prevent permanent reproductive injury!!

Scrotal Contusion

¨ Hemorrhage, fluid effusion, and muscle spasm

¨ Intensity dependent on impact to tissue

¨ Muscle spasm must be relieved ASAP

¨ ***Pain >15-20 minutes must be referred to MD

Hydrocele

¨ Clear fluid collection in scrotal sac

¨ Trans-illuminates well

¨ Any tense swelling should be assessed by someone with experience due to the implications regarding permanent testicular damage

Hematocele

¨ Bloody fluid collection in scrotal sac

¨ Any tense swelling should be assessed by someone with experience due to the implications regarding permanent testicular damage

Spermatic Cord Torsion

¨ Palpable

¨ Most painful of all

¨ Of most immediate concern

OB/GYN Concerns

¨ Typically medical issues much more common than trauma

– Amenorrhea

– Ovarian cyst

– Endometriosis

– Pregnancy

QUESTIONS?????