Physical Examination

Expeditious inspection and palpation of the chest will provide much information regarding the patient’s injuries (Figure 1). Auscultation and percussion tend to be less reliable due to the high ambient noise of the trauma ED. Hypotension, tachycardia, pallor, or cyanosis suggests shock. In the presence of a known or suspected thoracic injury, shock must be assumed to be from an intrathoracic source. Inspection of the chest itself should include assessment of use of the accessory muscles suggestive of airway obstruction, the symmetry of the chest wall, number and location of wounds, presence of open chest wounds, subcutaneous emphysema, and the presence of “flail” segments. While tracheal deviation in the neck is also frequently cited as a sign of tension pneumothorax, in reality it is rarely if ever seen, even in patients with gross mediastinal deviation on chest x-ray. Palpation can reveal mobile segments of chest wall and further allows appreciation of the symmetry of chest wall motion and of crepitance. Auscultation in trauma has a high specificity but very poor sensitivity, so focus should be placed only on the presence and symmetry of air entry. Heart sounds, such as the muffled heartbeat in Beck’s triad or the “mediastinal crunch” of Hamman’s sign, are also difficult to obtain clearly in the trauma bay. The absence or asymmetry of breath sounds, however, is very suggestive of significant pathology; in the unstable patient, this is an indication for intervention on clinical grounds and a contraindication for imaging studies. Thoracic percussion, even more than auscultation, is difficult to interpret in the trauma setting and is rarely useful.

Figure 1 Physical examination of the chest in a driver of a motor vehicle discloses marked asymmetry of the right and left hemithoraces.

Physical examination often, but not always, reveals the presence of a hemopneumothorax. It may be suspected in hemodynamically unstable patients by physical exam. In the patient with greatly diminished or absent breath sounds on the affected side, the diagnosis is quickly made on clinical grounds. In the noisy trauma bay, however, auscultation can unreliable even in the presence of a sizeable hemothorax or pneumothorax. In addition, breath sounds can be well-transmitted from the contralateral lung, further obscuring the results of auscultation. The finding of any subcutaneous emphysema following blunt trauma or at some distance from a penetrating wound is ample evidence of a pneumothorax that requires treatment. An open pneumothorax, of course, is readily appreciated on examination. Confirmation of the hemothorax or pneumothorax occurs with the placement of a chest tube with evacuation of blood and/or air.

Radiographic Studies

The supine AP CXR is the initial and sometimes most important study in the management of chest trauma. The trauma surgeon must be comfortable interpreting these films, which are often sub-optimal due to the patient’s body habitus, supine position, the presence of a spine board, and the use of portable x-ray machines. Still, the portable AP CXR can diagnose or exclude a number of life-threatening injuries, and it must be obtained and reviewed before the patient is transported for any other imaging or procedures.

Interpretation of the CXR should begin with review of the lung parenchyma and pleura. Lung expansion, pulmonary infiltrates or contusions, the position of the endotracheal tube if present, and the presence of hemothoraces or pneumothoraces should be noted. The mediastinum should be evaluated for evidence of great vessel injury, which is suggested by mediastinal widening, blunting of the aortic knob, apical capping, or a medial displacement of the left mainstem bronchus or of the nasogastric tube. Diaphragmatic elevation or injury should also be noted. Finally, any fractures of the bony thorax—ribs, clavicles, and scapulae—should be sought. Alignment of the thoracic vertebrae can be appreciated on CXR, but full imaging of the spine as well as specific radiographs of the bony thoracic structures should be deferred until the patient’s airway, respiratory, and cardiovascular status has been stabilized.

Radiographic imaging is extremely useful in the diagnosis of a hemothorax or pneumothorax. Indeed, in a hemodynamically stable patient, the diagnosis is often made on the portable AP CXR obtained for the secondary survey. In the supine position the AP CXR will reveal hemothorax only when at least 200–300 ml of blood is present in the pleural space, and is suggested by an overall opacification or haziness compared to the contralateral hemithorax as the fluid will layer posteriorly (Figure 2). False “negative”–appearing CXR may occur in the setting of bilateral hemothoraces (no difference between the two sides) or when there is a simultaneous anterior pneumothorax (decreasing the relative density more similar to the other side). In the patient with penetrating chest trauma, the CXR is best taken with the patient upright which increases the sensitivity for both hemothoraces and pneumothoraces. Chest ultrasound may help to identify the presence of pleural fluid, but its sensitivity and specificity for this purpose have not been well-defined.

Figure 2 Supine chest radiograph demonstrating overall hazy appearance that is diagnostic of a right hemothorax (in this case incompletely drained by a tube thoracostomy). Note the difference between the right and left sides.

As routine truncal (chest, abdomen, and pelvis) CT scanning has become more prevalent, many patients with blunt trauma have been found to have significant anterior pneumothoraces not seen on plain CXR. The incidence of missed pneumothoraces on supine AP CXR has been estimated to be between 20%–35%. A patient with a relatively minor pneumothorax on CXR who nonetheless develops dyspnea and hypoxia may thus in fact have a significant pneumothorax that is better visualized by chest CT. In stable patients, CT scanning will reveal also pleural fluid collections and help to distinguish them from parenchymal injury such as pulmonary contusion.

The appropriate management of the patient with “CT-only” pneumothorax is a matter of some controversy (Figure 3). The reported incidence of these pneumothoraces in blunt trauma patients is 2%–8%.^10,11 The available literature suggests that 20% of these patients will require tube thoracostomy. The decision to place a chest tube, however, should be dictated by the patient’s overall status. Patients who are multiply injured, are in hemorrhagic shock, or have sustained a traumatic brain injury will not tolerate progression of even a small pneumothorax (see Figure 3). These patients would benefit from tube thoracostomy. In patients where the clinical picture appears stable, observation can be undertaken, with serial radiographs taken at 6 and 24 hours after diagnosis.

Figure 3 CT scan (A) demonstrating small bilateral “CT-only” pneumothoraces. Chest radiograph of the same patient (B), following mechanical ventilation. Note the large left pneumothorax, demonstrating the somewhat unpredictable outcome of these small pneumothoraces. The patient never developed a pneumothorax on the right. CT, Computed tomography.

Computed tomography (CT) of the chest has become increasingly accepted in the early management of trauma. CT can reveal injuries not seen on initial CXR in about two-thirds of major trauma patients¹² and can lead to therapeutic changes in 5%–30% of cases^13,14 (Figure 4). In addition, CT scanning may reveal additional findings that are only suggested by an abnormal CXR (Figure 5). There are a number of specific situations in which chest CT contributes significantly to trauma management. CT of the thoracic spine is the “gold-standard” imaging modality for assessing vertebral body as well as posterior element fractures, and is also helpful in imaging the spine at the cervicothoracic junction.^12,14,15 In patients with the nonspecific finding of a widened mediastinum on CXR, use of CT can help to limit the use of aortography to assess aortic injuries.^16–18 As CT technology improves and as further studies become available, the role of CT in chest trauma will become better-defined.

Figure 4 Chest radiograph of patient ejected from a motor vehicle at high rate of speed (A). The lung fields are essentially clear, although the mediastinal contour is abnormal. CT scan (B) of the same patient demonstrating significant pulmonary contusions, which helped explain the patient’s clinical hypoxemia. In addition, an injury to the descending aorta is also visualized. CT, Computed tomography.

Figure 5 (A) The impact of CT scanning with more obvious severe chest trauma following a motor vehicle collision. Physical examination demonstrated no paradoxical motion in the upper right hemithorax. There are multiple (seven) rib fractures, a haziness over the entire right hemithorax and subcutaneous emphysema but no obvious pneumothorax. (B) CT scan of the same patient. A chest tube was inserted based on the marked subcutaneous emphysema present on physical exam that drained no air on insertion and minimal amount of blood. The haziness turned out to be only a modest pulmonary contusion with a minimal hemothorax. The scan revealed a total of 18 distinct rib fractures with considerably more displacement than was noted on the plain radiograph. The reason for the lack of paradoxical motion is explained by the posterior nature of the flail segments. In addition, a nondisplaced scapula fracture and six thoracic transverse process fractures were identified. CT, Computed tomography.

Ultrasonography has become important in the assessment of intra-abdominal hemorrhage and pericardial fluid collections in the trauma patient. Recent reports also suggest that it might be useful to assess the pleural spaces for pneumothoraces and hemothoraces.^19–21 The pleural space is interrogated by placing the ultrasound probe between the ribs and looking for the characteristic signs of pneumothorax.^19,22

Chest Wall Defects

Chest wall defects create open pneumothoraces and are potentially rapidly lethal. Large sucking chest wounds can allow rapid equilibration of pleural and atmospheric pressure, preventing lung inflation and alveolar ventilation and causing death by asphyxia. As a result, patients sustaining chest wall defects with significant tissue loss rarely survive long enough to be seen in the trauma bay. Patients who do come to medical attention are usually found to have penetrating injuries such as close shotgun blasts or impalements.

The field approach to the relatively small chest wall defect is placement of an occlusive dressing taped on three sides to allow gas to exit from, but not to enter, the thorax. Subsequent treatment consists of tube thoracostomy through clean nontraumatized skin, after which the primary wound may be temporarily closed or dressed with an occlusive dressing. Definitive wound closure is then performed in the operating room.

In large chest wall defects, the occlusive dressing is of no value. These patients must be endotracheally intubated with positive pressure ventilation. Operative management then focuses on control of hemorrhage from the chest wall and from any associated injuries. Chest wall hemorrhage in these cases may be life-threatening and may mandate emergent thoracotomy. “Damage control” with packing may be the optimal initial management of these patients. The chest defect can be temporarily closed with skin or prosthetic material. The definitive closure of these defects, which may require tissue-transfer procedures, is best deferred until the patient is fully resuscitated, physiologically sound, and able to tolerate a lengthy operation.

Rib Fractures and Flail Chest

Rib fractures can result in chest wall pain, chest wall hemorrhage, and less commonly, chest wall instability. A flail chest is said to exist when three or more adjacent ribs are segmentally fractured. The resultant chest wall instability combined with underlying pulmonary contusion is responsible for the respiratory insufficiency that develops in patients after this injury. The pathophysiology and treatment of flail chest injuries are covered in greater detail on pages 269–277.

Failure to provide sufficient analgesia in the setting of chest wall injuries has been shown to result in hypoventilation, retained secretions, increased atelectasis and lobar collapse, pneumonia, and respiratory failure.²⁴ Persistence of pain may perpetuate the stress response to injury and may have a negative impact on post-traumatic immune function.²⁵ Poor pain control will hamper the ability of mechanically ventilated patients to be weaned and extubated. The pharmacological approach to pain management in chest injury has consisted of the use of narcotics with or without regional anesthesia. The addition of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac have also proven effective in relieving pain from mild to moderate injuries.

Narcotics

Narcotics are the mainstay for pain control in the majority of trauma patients. Narcotic preparations can be given orally, intramuscularly, or intravenously. But whereas intramuscular administration has been the standard for decades, we strongly advise against this route of administration because it is both painful to the patient and results in unreliable absorption of the narcotic. With the exception of meperidine (Demerol) however, which narcotic chosen is far less important than ensuring adequate dosing for pain control.²⁶ The amount of narcotic required for pain control may vary greatly depending upon previous or current narcotic use, age, and other factors that alter the patient’s perception of pain.

The use of pain scales in combination with performance on incentive spirometry can be very effective in determining the adequacy of pain control.²⁷ Our current approach is to begin most awake patients on a patient-controlled analgesia (PCA) regimen using morphine or fentanyl. Later, patients are transitioned to long-acting narcotic preparations such as OxyContin or MS-contin with the use of oxycodone for breakthrough pain. The addition of an NSAID may reduce inflammation and augment the effect of the oral narcotics. It is also important to avoid narcotic induced constipation. This can result in severe abdominal pain, nausea, and vomiting in patients requiring long-term opioids.

Regional Anesthesia

Rib blocks can be accomplished using a mixture of 1%–2% lidocaine with 0.25% bupivacaine to decrease the pain of rib fractures. This simple technique involves the administration of 2–3 ml of the anesthetic mixture to the inferior rib margin several centimeters posterior to the site of the rib fracture. Optimal analgesia requires blocking at least one rib above and one rib below the fracture. The limitations of the technique are that the pain control is short-lived and that it can only be used for patients with mid or lower rib fractures. Last, in our experience the results vary widely and the risks of pneumothorax in patients without a chest tube are real.²⁸

Epidural analgesia/anesthesia is the delivery mode that has been shown to have the greatest impact on pulmonary mechanics following moderate to severe chest trauma, especially in patients with bilateral injuries.²⁹ There are various combinations of local anesthetics and narcotics which have been employed. In our institution, the most common combination is fentanyl with bupivacaine. Combination therapy can be advantageous because it works via two different mechanisms of action. Opioids modulate presynaptic and postsynaptic nerve transmission in dorsal horn neurons by effects on their specific receptors. Local anesthetics work by blocking sodium channels. Thus, the analgesic effects of the two classes of drug are synergistic. Moreover, the potential for side effects is lessened in combination therapy because the doses of each drug used can be lower than the amount used if either were administered alone.

Epidural analgesia has significant practical problems including ileus, pruritus, and urinary retention as well as transient hypotension. The use of epidural analgesia requires that the spine be documented to be free of injury, which may be difficult to accomplish for several days in severely injured patients. Also, the concomitant use of low-molecular-weight heparin (LMWH) in patients with an epidural catheter has been implicated in the development of spinal epidural hematomas with resultant neurologic deficits. Last, epidural catheters can only be left in place safely for 7–10 days because of the possibility of epidural abscess formation. Thus, it is strongly recommended that epidural catheters not be placed in mechanically ventilated patients until they are ready to be weaned.

The data supporting the use of epidural analgesia is strong. Mackersie et al.³⁰ demonstrated that the use of epidural fentanyl was associated with significant improvements in pulmonary mechanics with 85% of the patients requiring no additional parenteral narcotics. Intravenous narcotics were associated with increases in PaCO₂ and decreases in PaO₂ that were not observed in the epidural group. In a randomized prospective trial, Bulger et al.³¹ reported epidural analgesia was associated with half the number of ventilator days compared to patients in the opioid group. They also point out that the technique was limited in trauma patients due to the presence of exclusion criteria in over 50%. Despite these limitations the use of epidural analgesia, when feasible, is of considerable benefit to patients following severe chest injury, as it has been strongly associated with a decrease in the rate of nosocomial pneumonia and a shorter duration of mechanical ventilation.

Pneumothorax and Hemothorax

Rib fractures can also cause injury to the underlying lung parenchyma, with resultant hemothoraces or pneumothoraces, although these can also occur without evidence of rib fractures. The severity of pneumothorax ranges from clinically insignificant to life-threatening. Pneumothoraces can be categorized as simple, open, and tension. A simple pneumothorax is a collection of air arising from leakage of air from an injured lung into the pleural space. An open pneumothorax arises when air enters the thoracic cavity from an open chest wound, with equalization of pressure between the thorax and the atmosphere. A tension pneumothorax occurs from a “ball-and-valve” effect in which air enters but does not exit the thoracic cavity, causing intrapleural pressure to exceed atmospheric pressure. The resultant pressure can cause the heart and great vessels to shift away from the side of injury and result in progressive circulatory compromise (see Figure 3).

Hemothorax, the presence of blood in the pleural space, can arise from either thoracic or abdominal sources. Bleeding from thoracic sources can occur from injured lung parenchyma, lacerated intercostal or internal mammary arteries, or the heart and great vessels. Hemothorax from an abdominal source occurs in the setting of diaphragmatic injury with associated abdominal injury, most commonly the liver or spleen.

Treatment of pneumothorax depends upon the type. Small simple pneumothoraces can generally be observed, though larger ones require tube thoracostomy. If the patient is stable and a simple pneumothorax is suspected, a CXR is obtained before any intervention. This (1) confirms the diagnosis and prevents unnecessary chest tube placement, (2) helps to exclude unexpected pathology such as a diaphragmatic rupture, and (3) may demonstrate other findings (such as a large hemothorax or chest wall hematoma) that would affect the size or location of chest tube placement. Patients with small pneumothoraces who are stable from the hemodynamic and respiratory standpoints may be observed with serial radiographs. Supplemental oxygen may be administered to enhance reabsorption of the pneumothorax. Patients with larger pneumothoraces may be treated either with standard tube thoracostomy or in select patients a “pigtail” catheter.

Open and tension pneumothoraces require urgent treatment. The treatment of open pneumothoraces requires temporary closure of the defect, tube thoracostomy, and then definitive operative closure of the chest wall defect. Tension pneumothorax is treated with needle decompression followed by tube thoracostomy. If a tension pneumothorax is suspected and the patient manifests any respiratory distress or hemodynamic instability, decompression should be performed without awaiting radiologic imaging. Emergent chest decompression is performed by inserting a 14-gauge IV catheter in the second or third intercostal space (approximately two finger-breadths below the clavicle) in the midclavicular line. A large chest tube is then placed (see below).

The treatment goal for hemothoraces, as for pneumothoraces, is evacuation of the pleural space and re-expansion of the lung. This is accomplished initially through tube thoracostomy. Apposition of the visceral and parietal pleurae generally provides definitive control of hemorrhage, and thoracotomy is required in less than 10%–15% of all chest trauma patients. Patients may occasionally present to the trauma bay several hours after injury with a large amount of initial drainage from the chest tube. This usually represents the slow accumulation of blood rather than rapid active bleeding, particularly in the patient who remains hemodynamically stable. If the hemothorax cannot be adequately drained by one chest tube, another one may need to be placed. CXR should be obtained immediately after tube thoracostomy to demonstrate successful drainage of the pleural space and lung re-expansion. If residual blood in the pleural space is still suspected and the patient is stable, CT of the chest may help to resolve the issue. If an acute hemothorax cannot be adequately drained because the chest tube is clotted, operative drainage may be necessary as continued bleeding cannot be assessed (Figure 6). Operative treatment can be accomplished either through thoracotomy or, in selected stable patients, through video-assisted thoracoscopic surgery (VATS).

Figure 6 Computed tomography scan of patient in Figure 2. The large right retained hemothorax (*) is easily seen and can be easily differentiated from the lung parenchyma. The clotted hemothorax was successfully evacuated by video-assisted thoracoscopic surgery.

The chest tube output from any moderate- to large-sized acute hemothorax should be collected and auto-transfused. Collection systems should be readily available in the trauma emergency department (ED), as the largest amount of blood loss occurs immediately upon placement of the chest tube. Autotransfusion in our experience appears to diminish the coagulopathy and inflammatory response to injury in these patients.

For patients with hemopneumothoraces, admission to a monitored setting and observation are appropriate for patients who remain hemodynamically stable, have little or no further hemorrhage from the chest tube, demonstrate evacuation of the pleural space on CXR, and have no other emergent operative indications. Rapid active bleeding or persistent brisk bleeding suggests a significant lung injury. The need for emergent thoracotomy is strongly suggested when more than a liter of blood is immediately evacuated on placement of a chest tube. In patients in whom a lower initial volume is drained, continued chest tube output of 200 ml/hr for 4 hours is an indication for thoracotomy. Observation of patients in this latter group should include a repeat CXR to ensure that the slowing of chest tube output is not resulting from a clotted hemothorax.

Tube Thoracostomy: Technique and Management

Once the decision is made to place a chest tube, the patient should be positioned to allow easy access to the midaxillary line in the fifth or sixth intercostal space. This location is preferred because (1) it is usually safely above the diaphragm and (2) the chest wall musculature is thinnest in this area, thus facilitating the procedure. The chest should be cleansed with an antiseptic solution and anesthetized with 10 ml of 1% lidocaine in all layers of the chest wall down to the pleura. There should be no fear of entering the pleural space when inserting a tube thoracostomy! To provide longer analgesia and increase patient comfort following insertion we suggest mixing the lidocaine with an equal volume of 0.25% bupivacaine. Conscious sedation may be administered if the patient’s hemodynamic and respiratory status permits. A 2-cm skin incision is made over the rib immediately below the interspace selected for tube insertion. Sharp dissection proceeds directly to the rib, and the pleural space is entered at its superior margin, care being taken to avoid the intercostal neurovascular bundle at the inferior border of the adjacent superior rib. While a clamp is commonly used to “pop” through the pleural space, we advocate continuing with the scalpel as it is both easier and less painful to the patient. Once the pleural space is entered, digital exploration will confirm entry into the thorax rather than the lung or abdominal cavity. The presence or absence of adhesions should be noted as well. Digital exploration is particularly important in the patient who may have a diaphragmatic rupture or who has a history of thoracic surgery or pulmonary infection. If no adhesions, diaphragmatic injury, or pulmonary pathology is encountered, the chest tube can be safely placed. The blind placement of chest tubes with trocars is illadvised.

Chest tubes, like most medical devices, have markings to aid in placement. Unfortunately, in our experience these are too often ignored by residents placing the tube in the heat of battle, which results in tubes that may be poorly positioned. One of the most common mistakes is to insert the tube too far in to ensure that it will not “fall out.” The tube will often bend at the last hole, which will prevent adequate drainage (see Figure 2). To prevent this type of malposition, the mark at the skin should be evaluated. If the tube is place in the midaxillary line at the fifth interspace, the mark at the skin level in most patients should be between 10 and 12. A tube placed deeper is likely to be kinked. In addition, once the tube is positioned it should be rotated 360 degrees before securing it in place. A tube that cannot be rotated freely is presumably kinked or otherwise malpositioned.

Once inserted, the chest tube is connected to suction with an underwater seal at a negative pressure of 20 cm of water. A chest radiograph should be obtained after tube placement to confirm placement, evacuation of air or fluid, and proper re-expansion of the lung. If intrapleural air or fluid remains, a second chest tube should be placed. Complete evacuation of the pleural space with full pulmonary re-expansion will help to decrease bleeding and air leaks, as well as the risk of a post-traumatic empyema. Early surgical intervention is indicated for retained blood in the pleural space.

Chest radiographs should be obtained daily to confirm resolution of the hemopneumothorax. It is not our practice to use prophylactic antibiotics with tube thoracostomies, although opinion in the literature is divided on this issue.^32,33 The chest tube can subsequently be removed when there is no air leak and when there is less than 100–150 ml of drainage over 24 hours. A prospective study has shown that a 6–8 hour trial of water seal decreases the incidence of recurrent pneumothorax when compared to chest tube removal with no water seal.³⁴

Should a new air leak be discovered or the lung fails to re-expand, several potential causes should be investigated. The connections between chest tube, canisters, and wall suction should be inspected for leaks. The chest tube must be checked to ensure that the last hole has not migrated out of the chest wall. If the chest tube is noted to be “out” immediately after placement, it can be re-prepped and advanced a small distance; if detection is delayed, however, the chest tube should be removed and replaced at a different site. Placement of the tube into the major fissure may result in inadequate re-expansion, and parenchymal tube placement will result in continuing air leaks. These will also require removal and replacement. It is not uncommon for pleural space to become loculated or the chest tube occluded some time following injury and a tension pneumothorax is always a possibility in a patient on mechanical ventilation even in the presence of a chest tube.

Sternal Fractures

Sternal fractures are relatively uncommon and occur most often following blunt trauma. The usual mechanism of injury involves an unrestrained driver who strikes the sternum against the steering column of an automobile in a deceleration crash. A fall or other direct impact to the chest may also cause a sternal fracture. Most sternal fractures occur in the upper or mid-portion of the bone.³⁵ As with scapular fractures, the presence of a sternal fracture should be regarded as a marker of potential severe multiple trauma, including rib fractures (40%), long-bone fractures (25%), and head injuries (18%).

The fracture itself often needs no treatment acutely, and more than 95% of patients are treated nonoperatively. While a baseline EKG should be obtained, particularly in patients over 40 years of age, the need for continuous cardiac monitoring is determined by the associated injuries and the patient’s cardiac status rather than by the presence of the sternal fracture itself. Most patients will be found to have a transient right ventricular dysfunction. The patient with an isolated sternal fracture and otherwise normal ED evaluation may be discharged.^36–38 Similar to rib fractures, the management of sternal fractures is symptomatic and consists of analgesic administration and the avoidance of motion. Occasionally, patients who have grossly displaced fractures or who have persistent pain due to nonunion may require operative reduction and internal fixation (ORIF). Sternal repair can be accomplished though various techniques utilizing wires or small plates.

Scapular Fractures

Fractures of the scapula are uncommon, occurring with an incidence of 1%–3% in blunt trauma.³⁹ Because of its location and structure, the scapula requires considerable direct force to fracture. As a result, associated injuries are common (80%–98%), and a patient with a scapular fracture should be considered to have sustained a severe chest trauma. Careful examination for thoracic, neurologic, vascular, and abdominal injuries, as well as other orthopedic injuries, should be undertaken. Findings on physical examination include local pain or tenderness, swelling, and crepitus. Although most scapular fractures will be seen on initial CXR, they may be obscured or overlooked. Many scapular fractures may have hitherto gone undetected, with increasing detection of nondisplaced fractures with the increasing use of modern CT technology⁴⁰ (see Figure 5). CT of the shoulder may be necessary to evaluate the fracture and to look for extension into the shoulder joint.

Management of scapular fractures in the vast majority of cases consists of analgesic administration and immobilization initially, followed by progressive physical therapy. Surgical intervention is rarely required and is undertaken primarily for those fractures that will likely cause significant disability. Minimally displaced fractures of the scapular body, neck, coracoid, acromion, and scapular spine are treated nonoperatively and typically result in healing with normal or near-normal function. Glenoid fracture-dislocations, unstable fractures of the neck, and significantly displaced fractures of the coracoid, acromion, and scapular spine, on the other hand, will require operative fixation for restoration of function. Other indications for operative treatment of scapular fractures include intra-articular fractures with step-off of greater than 5 mm or with instability, angulation of greater than 40 degrees of the glenoid neck, displacement of greater than 1–2 cm, or disruption of the superior suspensory complex of the shoulder.

Scapulothoracic Dissociation

Scapulothoracic dissociation results from severe blunt trauma with traction to the shoulder girdle causing the scapula, humerus, musculature of the shoulder, and neurovascular structures to be pulled away from the body. While this injury is relatively rare, it can be dramatic, involving not only the structures of the shoulder girdle, but also thoracic, craniocerebral, and spinal injuries. Damschen et al.,⁴¹ in a review of 58 cases, reported complete brachial plexus injury in 81% of patients and partial injury in 13%; subclavian or axillary artery disruption was found in 88%. Because these patients almost universally have severe neurologic deficits in the affected limb, the likelihood of a good functional outcome is low. This should be borne in mind before extensive reconstruction to salvage an essentially defunctionalized limb is undertaken.

Clavicular Fractures

Clavicular fractures, unlike scapular or sternal fractures, often occur in isolation. They also occur in association with thoracic and extrathoracic trauma. The clavicle is most commonly fractured in the middle third (80%) after a fall or lateral blow to the shoulder. Clinical findings include local tenderness, crepitus, and deformity. If the fracture is displaced, the shoulder may be found to be positioned inferiorly and medially. Most of these fractures are readily appreciated on AP CXR. The majority (85%) of mid-shaft clavicular fractures will heal without intervention, and initial management consists of immobilization with a figure-of-eight dressing or shoulder immobilizer.

Operative reduction and fixation of the clavicle is indicated in open fractures, displaced fractures with tenting of the overlying skin, and those associated with neurologic or vascular injury. Fractures with greater than 2 cm of shortening, widely displaced fragments with associated chest injuries, a floating shoulder (combined clavicular and scapular fractures), and nonunion are relative indications for operative intervention. Operative treatment consists of either intramedullary fixation or placement of fixation plates.

Empyema

Empyema has been reported to have an incidence of 0%–18%.^33,42–44 At least some of the culture-negative “empyemas” in blunt trauma patients are probably sterile pleural collections that, being rich in inflammatory mediators, produce systemic effects clinically indistinguishable from true empyema collections.^45,46 The true empyema rate in major trauma patients is probably closer to 5%, although, with the increasing survival of severely injured patients, the incidence of this complication may be increasing. Risk factors for the development of empyema include an inadequately drained pleural collection, mechanism of injury, location and number of chest tubes, presence of pulmonary contusion, and pneumonia.

The clinical presentation of empyema includes unexplained fever, elevated white count, and respiratory failure. Most patients in whom an empyema is suspected are critically ill. AP CXR in this group may be of little or no help, and liberal use of CT scanning can more easily identify pathology that is not evident on plain films (Figure 7). Early use of CT can prevent the diagnostic delay that may result in the need for more extensive surgical procedures.

Figure 7 (A, B) Computed tomography scans of a loculated empyema of the chest in a patient 2 weeks following a gunshot wound to the chest and evacuation of a hemothorax. Note the enhancement around the collections. Patient was successfully treated with a thoracotomy and decortication.

Treatment includes (1) drainage via chest tube or CT-guided catheter, (2) chest tube drainage with intrapleural fibrinolytic therapy, (3) VATS, or (4) thoracotomy and decortication. As the empyema progresses from an exudative effusion to a loculated effusion and then to an organized empyema, the pleural fluid becomes increasingly more viscous, and the intervention required becomes more invasive. Early diagnosis and treatment is thus important.

In those patients undergoing decortication, the initial postoperative CXR may look worse rather than better initially. The patient, however, will begin to improve even though the CXR does not. Vigorous pulmonary toilet, suctioning, and culture-specific antibiotics should be administered to all patients.

Pneumatocele

A post-traumatic cyst or pneumatocele can occur after chest trauma. This is usually an air collection within the lung that arises after airway disruption without connection to the pleural space. Most such lesions require no specific treatment and resolve after weaning from the ventilator. If the lesion is large, continues to enlarge, or becomes infected, CT-guided percutaneous drainage is an effective treatment.

Persistent Air Leaks and Bronchopleural Fistula

Air leaks are not uncommon after chest trauma, and typically resolve with tube thoracostomy. A large air leak, however, requires workup for a tracheobronchial injury. If such injury is excluded, then complete lung expansion is the cornerstone of therapy. Air leaks may persist for days or even weeks in patients requiring mechanical ventilation with high positive end-expiratory pressure (PEEP); only with weaning from the ventilator will air leaks begin to seal. Tracheostomy can, by decreasing the anatomic dead space, help to lower the peak airway pressures and thus at least slow the air leak. VATS can also help in those hemodynamically stable patients with prolonged air leaks.

Complications of Bony Injuries

Complications of bony injuries to the chest are most commonly related to pain. Sternal fractures in isolation or with only mild associated injury appear to have a relatively low incidence of post-injury sequelae; in one study, only 3% of patients at a 6-week follow-up had complaints requiring further intervention, including surgical intervention for a displaced fracture.⁴⁸ Twenty-one percent of patients in that same study reported pain at 6 weeks but required no further intervention.

Scapular fractures are rarely associated with nonunion, but can cause chronic pain. Pain and disability are particularly associated with the degree of glenoid angulation and displacement if the fracture is treated nonoperatively.⁴⁹

Clavicular fractures, by contrast, do carry an incidence of nonunion, though that number is somewhat in dispute. Early studies of nonoperative treatment of clavicle fractures revealed a nonunion rate as low as 0.1%.⁵⁰ The nonunion rate has in more recent studies been reported to be much higher, with a rate of 15% for conservative treatment of displaced middle-third fractures.⁵¹ Even with operative fixation, some nonunion occurs. An analysis of 8 studies and 14 case series of midshaft clavicle fractures revealed an overall nonunion rate of 4.2%. Nonoperative treatment resulted in a nonunion rate of 5.9%. When results for displaced fractures were identified, a nonunion rate of 4.8% was noted with IM fixation, while displaced fractures treated nonoperatively had a nonunion rate of 15.1%.⁵²

Other long-term sequelae of clavicular fractures include pain, cosmetic deformity, or thoracic outlet compression. For these patients, ORIF can successfully manage severe symptoms.

Scapulothoracic dissociation, as would be expected, has significant long-term sequelae. A retrospective cohort study with a mean follow-up over 12 years revealed that patients with a complete brachial plexus avulsion had significant physical and mental impairments as measured by the standard SF-36 questionnaire.⁵³ Primary amputation of the affected limb, though a difficult decision, should be considered to avoid a defunctionalized limb where complete brachial avulsion has occurred.