(3) Lecture 16: Abdominal and Thoracic Injuries Flashcards
Common causes of abdominal and thoracic injuries
- high-velocity sports
- being struck w/ an object
- inadequate protective equipment
Thorax
- portion of the body btwn neck and diaphragm
- made up of spine posteriorly, ribs laterally and sternum anteriorly
FUNCTION: protect circulatory and resp. organs
Ribs as a ring
Ribs wrap around thorax + attach at front
Thoracic injuries
- most are due to BLUNT trauma but can happen due to forceful contractions
- RIB injuries are common - painful + debilitating
- heart + lung injuries are less common but serious
Rib contusions
- blow to FRONT/SIDE = rib contusion
- blow to back, usually paraspinal contusion
- LOCALIZED PAIN (during inspiration + w/ palpation)
- manipulation of rib at distance/ “through the ring”
does NOT increase pain
Rib Fractures
can be direct (fracture at site of trauma) or indirect (fracture way from impact due to COMPRESSION)
- Ribs 5-9 are MOST injured due to rigid fixation
- usually fractures at weakest point (posterior) angle of ribs
can be DISPLACED or UNDISPLACED
-if displaced (bone poking out), do an exam of internal structures – check ORGANS
- spleen trauma in 20% of lower L rib fracture (liver is less)
Symptoms of rib fractures
- pain w/ coughing and/or deep inspiration
- trunk movements increase pain
Signs of rib fractures
- may have visible contusion + palpable crepitus (creaking)
- athlete splints themselves/leans towards injured side
- pain w/ manipulation AWAY from injury, through ring
Intercostal muscle strain
- most common strain is intercostal muscles
- usually violent exertional forces/trauma
- overstretching via ROTATION
Symptoms of intercostal muscle strain
- pain over local area
- pain w/ inspiration and movement
Signs of intercostal muscle strain
- NO pain w/ pressure through ring
- positive STTT
- findings for manual muscle testing
- tender on palpation btwn ribs over muscle
Pain with fracture
indirect pressure causes pain w/ fracture
Management of rib injuries
- send for imaging if fracture is suspected
- POLICE/PEACE & LOVE
- stabilize/wrap - may predispose to hypostatic pneumonia (can’t take full breath if splinted too tight)
- pad for return to play
- usually out 4-8 weeks
Lung injuries
- NOT common but need to watch out for them
- pneumothorax
- tension pneumothorax
- hemothorax
Pneumothorax
PARTIAL collapse (can happen +/- rib fracture)
- happens when air enters pleural cavity btwn chest wall and lung
- can progress to complete collapse (tension pneumothorax)
Signs and symptoms
- difficulty breathing (dyspnea)
- shortness of breath
- cyanosis (pale, blue lips)
Tension pneumothorax
COMPLETE collapse
Pneumothorax PLUS
- pleural sac fills w/ air until lung collapses = DISPLACES lung and heart to other side
- TRACHEA MAY DEVIATE
CRITICAL
Hemothorax
- presence of blood in pleural cavity
- can happen +/- rib fracture
- difficulty breathing, shortness, of breath, cyanosis
coughing up FROTHY BLOOD
Commotio Cordis
Traumatic blunt trauma over heart = hit during narrow window of REPOLARIZATION
- results in cardiac arrest
- young athletes more at risk b/c of pliability of chest wall
- hockey, baseball, lacrosse, football
- get AED ASAP
- when defibrillation is delivered within ONE MIN, reported survival rate as high as 90%
Abdomen
- lies btwn diaphragm and pelvis
- lined by PARIETAL PERITONEUM
- organs are covered by visceral peritoneum
- enough room btwn organs to bleed to death
- injury to abdominal wall produces LOCAL PAIN
- injury to viscera often initially causes localized pain that may spread to entire abdomen if INTRAPERITONEAL irritation develops
Abdominal wall injuries
- muscular contusions
- abdominal muscle strain
- solar (celiac) plexus contusion
- intra-abdominal injuries (penetrating or blunt)
Muscular contusions
- LOCALIZED area of tenderness
- increased pain on contraction/decreased on relaxation
- with internal bleeding, abdominal wall NOT relax
- no referred pain (only pain at affected place)
- treat w/ cold pack and compression
- position of comfort: on side, curled up
Referred pain
NO pain @ affected organ BUT will feel pain elsewhere
- ex. during heart attack, feel pain in jaw or arm
Abdominal muscle strain
RECTUS ABDOMINUS is most commonly injured
- lower rib origin or pubic insertion
- may pull periosteum of pubic rami = osteitis pubis
- may be seen w/ INTERNAL/EXTERNAL OBLIQUES
- MOI: violent contraction/twisting or recurrent mcirotrauma
- LOCALIZED pain + spasm at sight of injury
- STTT positive
- manual muscle testing positive
Solar (Celiac) Plexus Contusion
- collection of nerves UNDER DIAPHRAGM
- trauma to relaxed abdominal wall or back
- “WIND KNOCKED OUT” = transitory paralysis of diaphragm
- make sure airway is clear
- loosen belt/restrictive clothing
- FLEX HIPS + BRING KNEES TO CHEST = take abs off stretch
- slow expiration, followed by short inspiration
Penetrating intra-abdominal injuries
- NOT COMMON
- usually superficial
- leave object in place unless ability to stop bleeding is compromised
- focus on CONTROLLING bleeding
Blunt intra-abdominal injuries
- MOST COMMON athletic trauma
- severity of symptoms varies
- possibility of PERITONEAL irritation from blood and/or bacterial/intra-abdominal contamination
Abdominal quadrants
RUQ, LUQ, RLQ, LLQ, Midline
RUQ abdominal quadrant
Liver
Right Kidney
Gall bladder
Colon
Pancreas
LUQ
Stomach
Left kidney
Spleen
Colon
Pancreas
RLQ
Appendix
Colon
Small intestine
Ureter
Major vein and artery to right leg
LLQ
Colon
Small Intestine
Ureter
Major vein and artery to left leg
Midline abdominal quadrants
Aorta
Pancrease
Small inetstine
Bladder
Spine
Signs of Peritoneal Irritation
aka PERITONEAL SIGNS = MEDICAL EMERGENCY
- abdominal rigidity (inability to relax muscles)
- guarding
- referred pain
- loss of bowel sounds
caused by BLOOD in peritoneal cavity/viscera
Heart and spleen referral
Left chest
Liver and gallbladder referral pattern
Right shoulder area and below left boob/chest
Pancreas referral pattern
Slightly left of stomach area and lower/to left of back middle
Stomach referral pattern
Middle of stomach on front and middle of bacl
Urinary bladder referral pattern
Above penis/ and btwn butt cheeks
Kidney referral pattern
Lower back and front area
Appendix referral pattern
Right area under stomach
Spleen
- deep to left 9-11 rib in LEFT UPPER quadrant (LUQ)
- injured w/ BLUNT trauma or primary to rib fracture
- spleen’s capsule can bleed + signs of splenic injury are often delayed = physical exam is unreliable
Order of most common organ injuries
- Spleen
- Liver
3.Kidney - Bladder
Most frequently injured organ in sports
Spleen
Most common cause of death due to abdominal trauma in athletics
Symptoms of spleen injuries
- slow onset b/c symptoms develop SECONDARY to bleeding
- LUQ pain/left shoulder pain caused by diaphragmatic irritation = KEHR’S SIGN
MEDICAL EMERGENCY
Kehr’s sign
LUQ pain/left shoulder pain due to diaphragmatic irritation
Liver
SECOND most commonly injured organ
- located in RUQ = RUQ pain
- REFERRED pain to RIGHT SHOULDER/SCAPULA
- occasional nausea + vomiting
Can be bruised or lacerated
- contusion: NO peritoneal signs
- lacerated: will SHOW peritoneal signs
MEDICAL EMERGENCY
Kidney
MOI: BLUNT trauma to flank or abdomen
- upper 1/2 of kidneys are above 12th rib
- flank/low back pain, tenderness, ecchymosis and hematuria (blood in urine)
- hematuria will also occur w/ repetitive microtrauma (jostling)
MEDICAL EMERGENCY
Hematuria
blood in urine
Bladder
- protected by pelvic ring
- DECREASED trauma w/ EMPTY bladder
- blunt trauma over pubic rami = INABILITY TO URINATE DESPITE URGE
- tenderness over supra-pubic region
- may have visible ecchymosis over pubic area
- hematuria
MEDICAL EMERGENCY
