PANCE Blueprint Musculoskeletal (8%)

• Less common types of chest wall abnormalities including Poland's syndrome, Jeune's syndrome, and defects of the ribs and sternum
• Suspected from visual examination of the anterior chest and chest x-rays are useful in the diagnosis

Treatment includes orthotic bracing, physical exercise, and surgery

Blunt trauma refers to mechanisms causing increased intrathoracic pressure such as car collisions (the most common cause of thoracic trauma) and falls

• Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are most frequently involved. Patients usually report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tenderness and crepitus over the site of the fracture.
• Flail chest involves three or more consecutive rib fractures in two or more places, which produce a free-floating, unstable segment of chest wall
• Sternal fractures - pain, tenderness, bruising, and swelling over the fracture site. CPR has also been known to cause thoracic injury
• Pulmonary contusion resulting from blunt trauma to chest causing interstitial edema that impairs compliance and gas exchange
• Ruptured diaphragm - should be considered in patients who sustain a blow to the abdomen and present with dyspnea or respiratory distress
• Blunt myocardial injury - dysrhythmias, ST changes
• Pneumothoraces in blunt thoracic trauma are most frequently caused when a fractured rib penetrates the lung parenchyma

Penetrating trauma largely refers to gunshot and stab wounds, occasionally impalement

• Hemothorax - blood in the pleural cavity
• Pneumothorax- air in the chest cavity
• Hemopneumothorax - two conditions: pneumothorax (air in the chest cavity) and hemothorax (blood in the chest cavity)
• Ruptured diaphragm - CXR: abnormal peridiaphragmatic anatomy. CT scan and endoscopy if further workup needed
• Pulmonary contusion - CXR: opacification of the lung within 6 hours
• Rib fracture - Fewer than 2 fractures, 16; more than 2 fractures, 13
• Subcutaneous emphysema - air trapped in subcutaneous tissue as a result of penetrating trauma
• Pneumomediastinum - abnormal presence of air in the mediastinum escaping from the lungs into the chest cavity
• Thoracic wall lacerations
• Sternal fracture

Symptoms:

• Pain in the chest that gets worse when laughing, coughing, or sneezing, deep inspiration and overhead activities
• Difficulty breathing
• Tenderness, bruising, and swelling

Diagnosis:

Chest radiography remains the basis for initiating other investigations

• CT, aortography, bronchoscopy/endoscopy
• Hemoglobin or hematocrit values and arterial blood gas determinations offer the most useful information for treating these patients
• ECG
• Bone scan may be indicated when x-rays are negative and clinical suspicion remains

Treatment involves immediate airway management: intubate early if airway compromise suspected

• Rib fractures - the majority heal uneventfully with rest, analgesia, cessation of inciting activity for ~4-6 weeks
• Needle thoracostomy - Use large bore needle at 2nd intercostal space in the midclavicular line - the best initial step in the management of tension pneumothorax
• Tube thoracostomy - chest tube at 5th intercostal space in anterior axillary line - next step in management after needle placement in tension pneumothorax
• Oxygenation - positive pressure ventilation for flail chest
• Thoracotomy indications
  • > 1500 ml total blood loss
  • > 200 ml/h continued drainage of blood for > 3 hours
• Surgical repair as needed