CHEST TRAUMA IN UPPER EGYPT :

MECHANISMS OF INJURY AND METHODS

OF TREATMENT
THESIS
Submitted For Partial Fulfilment Of Master Degree
In General Sugery
Yasser Ali Kamal
( M.B.B.CH)
Resident Of Cardio-thoracic Surgery
El-Minia University
SUPERVISORS
Prof. All Mohamed Abd El-Waliab
Professor Of Cardio-thoracic Surgery - Assiut University
Prof. Mostafa Nagi EI-Sanadiki
Professor Of Vascular Surgery - El-Minia University
Dr. Alaa El-Din Ahmed Mohamed El-Moghazy
Assistant Professor Of Plastic Surgery - El-Minia University
El-Minia University
Faculty Of Medicine
2004
ACKNOWLEDGMENT
This work is dedicated to .n The most grateful and the most
merciful whose guidance, help and grace was instrumental in making this
work a reality.
I have many people to thank for their assistance. I would like to thank
Prof. Hamdy Mohamed Abo - Beeh f head of department of surgery, El-
Minia University, for his valuab le encouragement.
I would like to acknowledge with sincere thanks and deep
appreciation the help and scientific support of Prof. Ali Mohamed Ab d
EI-Waha b 9 professor of cardio-thoracic surgery, Assiut University .
It is a great pleasure to acknowledge the assistance I have received
from Prof. Moslafa Nagi El - Sanadiki , professor of vascular surgery,
El-Minia University, in preparing this work with his generous help.
Also, I antgrateful to Dr. Alaa El- Din Ahmed Mohamed El-
Moghazy assistant professor of plastic surgery, El-Minia University, for
his great support and encouragement.
Finnaly, I would like to express my thanks to all those who
participated, and supported directly or indirectly, to help me to provide this

work.

TAB LE OF CONTENTS
Title
Page
I NTRODUCTION 1
AIM OF THE WORK 2
REVIEW 3
Historical view
3
Thoracic anatomy and physiology
5
Mechanisms of chest trauma
1 2
Chest wall injuries
1 5
Rib fractures
15
Sternal fractures 1 7
Flail chest 1 8
Pulmonary injuries 20 .
Pulmonary lacerations 20
Pulmonary contusions 21
Traumatic pneumo-thorax 23
Traumatic hemo-thorax 25
Cardio-vascular injuries 27
Blunt cardiac trauma 27
Myocardial contusion 28
Cardic rupture 29
Penetrating cardiac injury 30
Thoracic central vascular injuries 31
Aortic injury 31
Injury to other great vessels 32
Diaphragmatic injury 33
Tracheo-b ronchial injury 36
Esophageal injury 39
Treatment of thoracic injuries 40
Initial treatment 43
Tube thoracostomy 44
Thoracotomy 46
Emergency thoracotomy 47
Abbreviated thoracotomy 5 1
Title Page
Thoracoscopy 5 2
Treatment of specific thoracic injuries 5 4
Treatment of rib fractures 5 4
Treatment of sternal fractures 55
Treatment offlail chest 5 7
7)-eatment of traumatic hemo- thorax and pneumo-thorax 60
Treatment of pulmonary injury 61
Treatment of cardiac injury 62
Treatment of great vessels injury 64
Treatment of diaphragmatic injury 67
Treatment of tracheo- bronchial injury 69
Treatment of esophageal injury 71
PATIENTS AND METHODS 73
RES ULTS 77
DIS CUS S ION 1 02
CONCLUS ION 1 20
S UMMARY 1 23
REFERENCES 1 26
ii
LIST OF TABLES
Title Page
Tab le (1 ): Incidence of chest trauma mechanisms. (Ceran, 2002). 1 2
Tab le (2): S pectrum of chest trauma. (Marc, et al., 2002). 1 4
Tab le (3): Indications of thoracotomy. (Marc, et al., 2002). 49
Tab le (4): Treatment of chest wall injuries. (David, et al., 2001 ). 5 8
Tab le (5 ): Different types of thoracic injuries with chest trauma in
M.& A. U. Hs., 2001 .
78
Tab le (6): Mechanisms of chest trauma in M. & A. U. Hs., 2001 . 79
Tab le (7): B lunt thoracic injuries in M. & A. U. Hs., 2001 . 80
Tab le (8): Treatment of b lunt injuries in M. & A. U. Hs., 2001 . 81
Tab le (9): Penetrating thoracic injuries in M. & A. U. Hs., 2001 . 82
Tab le (1 0): Different methods of treatment for Chest trauma in M.
& A. U. Hs., 2001 .
83
Tab le (1 1 ): Methods of treatment according to mechanism of injury
in M. & A. U. Hs., 2001 .
84
Tab le (1 2): Outcome after tub e thoracostomy in M. & A. U. Hs.,
2001 .
84
Tab le (1 3): Thoracic injuries treated b y thoracotomy in M. & A. U.
Hs., 2001 .
85
Tab le (1 4): Incidence of complications after Thoracotomy in M. &
A. U. Hs., 2001 .
85
Tab le (1 5 ): Injuries associated with rib fractures in M. & A. U.
Hs., 2001 .
87
Table(16): Methods of treatment for injuries associated with rib
fractures in M. & A. U.Hs., 2001 .
87
Tab le (1 7): Associated injuries and methods of treatment of flail
chest in M. & A. U. Hs.,2001.
88
I I I
Title Page
Tab le (1 8): Methods of treatment associated with hemo-thorax +1 -
Pnewno-thorax. in M. & A. U. Hs., 2001 .
91
Tab le (1 9): Thoracic injuries associated with hemo-thorax +/-
Pneumo-thorax in M. & A. U.Hs., 2001 .
91
Tab le (20) : Associated thoracic injuries with pulmonary injury in
M. & A. U. Hs., 2001 .
92
Tab le (21 ) : Treatment of lung lacerations in M. & A. U. Hs., 2001 . 93
Tab le (22): Types of traumatic cardiac injuries in M. & A. U. Hs.,
2001 .
94
Tab le (23): Types of tracheo-b ronchial injuries in M. & A. U. Hs.,
2001 .
95
Tab le (24): Treatment of tracheo-bronchial injuries in M. & A. U.
Hs., 2001 .
96
Tab le (25):Thoracic injuries associated with diaphragmatic injury
in M. & A. U. Hs., 2001 .
97
Tab le (26): Approach for diaphragmatic injury in M. & A. U. Hs.,
2001 .
97
Tab le (27): Types of diaphragmatic injury in M. & A. U. Hs.,
2001 .
97
Tab le (28): Types of ab dominal injury with thoracic trauma in M.
& A. U. Hs., 2001 .
1 00
Tab le (29): Non thoracic injuries with chest trauma in M. & A. U.
Hs., 2001 .
1 00
Tab le (30): Outcome of treatment of chest trauma in M. & A. U.
Hs., 2001 .
1 01
iv
LIST OF FIGURES
Title Page
Figure (1 ): Algorithm for management of chest trauma (Marc, et
al., 2002).
42
Figure (2): The most frequent thoracic injuries, i
77
Figure (3): CXR S howing Right Multiple Rib Fractures With
Pulmonary Contusions.
86
Figure(4): CXR showing Left multiple rib fractures, 7 88
Figure (5 ): CXR S howing Flail chest with Right Hemo-thorax. 89
Figure (6): CXR S howing Left side Hemo-pneumothorax after
chest trauma..
90
Figure (7): CXR showing S ignificant right-sided pulmonary
contusion.
93
Figure (8): Photographic picture showing a diaphragmatic
laceration.
98
Figure (9): CXR showing B lunt Left Diaphragm Rupture with
S tomach & S pleen herniation
98
Figure(10): Photographic picture showing Operative repair of
Diaphragmatic Injury.
99
LI ST OF ABBRE VI ATI ONS
AATS American Association of Thoracic S urgeons.
ABGs Arterial B lood Gases.
ACS American College of S urgeons.
ALTS Advanced Life Trauma S upport.
AVF Arterio-Venous Fistula,
B DI B lunt Diaphragmatic Injury.
CPR Cardio-Pulmonary Resuscitation.
CT Computed Tomography.
CXR Chest X - Ray
ECG Electro-Cardio-Graphy.
ED Emergency Department.
ER Emergency Room.
FC Flail Chest.
FRC Functional Residual Capacity.
GS Ws Gun S hot Wounds.
ICU Intensive Care Unit.
IS S Injury S everity S core.
I V Left Ventricle.
M &A U Hs Minia & Assiut University Hospitals.
MC Myocardial Contusion.
MCA Motor Car Accident.
MVAs Motor Vehicle Accidents.
OR Operative Room.
PaO2 Arterial Oxygen Pressure.
RTA Road Traffic Accidents.
RV Right Ventricle.
S F S ternal Fracture.
S Ws S tab Wounds.
TAD Traumatic Aortic Disruption.
TB D Tracheo-b ronchial Disruption.
TRD Traumatic Rupture of Diaphragm.
TT Tub e Thoracostomy.
VATS Video-Assisted Thoracoscopic S urgery.
VC Vital Capacity.
Vfib Ventricular Fib rilation.
vi

INTRODUCTION
INTRODUCTION
Trauma is one of the most sudden, dramatic and often irreversib le
medical conditions. Injury to the chest is one of the most important aspects
of trauma, playing a major role in 25 % of all trauma deaths (S egers, et a l.,
2001).
Thoracic injuries can b e classified as one of two types; penetrating or
b lunt. Most chest trauma seen in civilian populations is b lunt trauma and
most b lunt chest trauma is the result of Road Traffic Accidents(R.T.A).
Other possib le causes of b lunt thoracic injuries include falls, sports injuries,
crush injuries, and acts of violence. Gunshot and stab wounds are the most
common causes of penetrating thoracic injuries (Da vid, et a l., 2001).
Tra uma to the chest induces a variety of injuries to the b ony thorax,
pulmonary parenchyma, pleura, mediastinal structures and diaphragm.
Among victims sustaining thoracic trauma, more than 5 0% may have chest
wall injury ( Ma rc, et a l., 2002).
Most thoracic injuries are managed with simple procedures as clinical
ob servation, tub e thoracostomy, respiratory support, and adequate analgesia.
A minority of the patients may require thoracotomy (Ja mes, et a l., 2003).
1
AIM OF THE WORK
AIM OF
'HIE WORK
This work is a retrospective analysis of the files and all related
investigations of the patients who have b een admitted to EL-Minia and
Assiut University Hospitals (M. & A. U. H.) with chest trauma aiming
at detection of the most common mechanisms of chest trauma, the
different patholgical types of thoracic injury, and the variab le methods
of treatment.

2
7
REVI EW
HI STORI CAL BACKGROUND
The early history of thoracic surgery was limited to the management
of trauma. Until the 19th century, references to chest injury were either
descriptions of internal- injuries found at autopsy or treatment schemes of
chest wall injuries. Of 5 8 cases cited in the Edmund Smith Surgical Papyrus,
two involved injuries to the chest; one involved injury to the sternum, and
another involved fractured rib s. B y the 2nd century, Galen had describ ed
successful drainage of a post-traumatic sternal infection that required peri-
cardiotomy. In 1 5 79 Amb rose Pare describ ed 2 patients with sequelae of
traumatic diaphragmatic rupture (Meade, 1 961 ; and Near, 1 990).
Tourb y, in 1 642, discovered a spontenously healed heart in a man who
had b een stab led with a sword Injuries to great vessels were recognized as
early as 1 5 5 7, when Veaslius describ ed a b lunt thoracic aortic injury. In
1 81 4, Larrey comment on injuries of the thoracic outlet, particularly the
subclavian artery ( Meade, 1961).
Closure of the chest wounds without drainage and other conservative
forms of management of b loody collections in the chest were the accepted
treatment for many years. In 1 794, John Hunter advocated the creation ()fan
intercostal incision for drainage and management of the b loody collections
( Raseli & Ginsberg, 1999).
Chest tub e placement is a very common therapeutic procedure,
frequently performed in the emergency department in management of
3
r
REVIEW
traumatic hemothorax and pneumo-thorax. The first known chest tub e
placement with sealed drainage took place in 1 875 , as developed b y B ulan
(Nelly, 1 999).
Ludwig Rehn performed the first successful repair of a cardiac injury
in 1 896 in Frankfurt. He repaired an injury of the right ventricle. In Rome in
1 897, Parrozzani successfully repaired the left ventricle. Djanelidze
performed his historic repair of the ascending aorta in 1 91 3. This was the 1 st
successful repair describ ed in the world medical literature (Lilienthal,
192 5).
B rewer and B urford in 1 947 describ ed the successful repair of a
traumatic esophageal perforation. In 1 95 2, S atinsky and Kron successfully
performed esophagectomy for esophageal perforation (Brewer & Burford,
1965).
During World War II, the Army Medical Corps faced with many
severe chest injuries, developed standards for the managment of traumatic
hemo-thorax still accepted until( today. Also, the advent of antib iotics,
knowledge of pulmonary physiology, and emergence of intensive care units
at the middle of 20th century reduced the post-traumatic complications and
mortality (Valerie & Robert,
-
1999).
4
REVI EW

THORACIC ANATOMY AND PHYSIOLOGY
The thorax is an airtight, expansib le, cone-shaped cage. The chest
wall, an integral part of the ventilatory pump, consists of the b ony thoracic
cage (rib s, sternum, and verteb rae) and the various muscles of respiration
( Gray, et al., 1 985 ).
Thoracic inlet extends from the cricothyroid memb rane to the
manub rium and includes the axilla and the superior mediastinum. From front
to b ack, structures occupying the thoracic inlet include the upper portion of
the thymus gland, the right and left b rachiocephalic veins (which join b ehind
the right side of the manub rium to form the superior vena cava), the
common carotid arteries (lying immediately anterior to the sub clavian
arteries and medial to the sub clavian veins), the trachea (situated either in
the midline or slightly to the right or left immediately b ehind the great
vessels), the esophagus (located b ehind the trachea and in front of the Spine),
and the recurrent laryngeal nerves on either side of the esophagus ( Kenneth
& Matthew, 1996).
The lower trunk of the b rachial plexus is situated immediately b ehind
the sub clavian artery in relation to the first rib ; the vagus and phrenic nerves
enter the thorax in front of the subclavian arteries and b ehind the great veins.
The thoracic duct is situated along the left side of the esophagus, from which
point it arches anteriorly to terminate at the junction of the left internal
jugular and sub clavian veins. During expiration the pleura extends slightly
A I
REVIEW
into the root of the neck, so that, the structures within the thoracic inlet may
b e included in chest trauma, and care must b e taken on exposure of this area
to avoid injury of great vessels and nerves (Fraser, et al., 1999; and Gray,
et al., 1985).
The ribs are located close to the skin, they are commonly involved in
chest trauma. The first, second, l Oth, llth, and 1 2th rib s present variations
that require special consideration. The first rib is the most curved and the
shortest of the rib s. The upper surface of the b ody of the ls
t
rib is marked b y
the scalene tub ercle and the grooves, which transmits the subclavian vein,
the posterior sub clavian artery and the lowest trunk of the b rachial plexus.
B ehind the posterior groove is an attachment of the scalenus medics muscle.
The undersurface is smooth without a costal groove. The anterior portion of
the first rib is larger and thicker than the other rib s. Thus, S evere trauma
may lead to 1 st and 2nd rib fractures with injury of great vessels and nerves.
1 0th, 1 1 th, and 1 2th rib s are a floating rib s and well protected b y the
surrounding muscles (Bartolmne, 2 000; and Rom anes, 1989).
Each intercostal space has a neuro-vascular b undle lying b etween the
innermost and the inner intercostal muscles. Each space receives an anterior
primary ramus of a spinal nerve. The intercostal nerve supplies the muscles
of the space, the pleura lining the chest wall, and b y lateral and anterior
cutaneous b ranches supplies the skin. The nerves are' mixed nerves.
Posteriorly the posterior intercostal arteries gain access to the neurovascular
plane and curve around laterally at the lower b order of the rib . Anteriorly a
pair of small anterior intercostal arteries runs in the neurovascular plane of
each
space. The anterior intercostal arteries arise from the internal thoracic
REVIEW
The fractures are often missed on the postero-anterior radiograph
b ecause the lateral portions of the rib s are frequently affected and the
fracture line is not tangential to the x-ray b eam. The presence of fractures is
easier to detect on ob lique rib views. However, the presence or ab sence of
rib fractures per se is of limited clinical significance, the main value of the
radiograph b eing the detection of associated pleural and pulmonary
complications (B ansidhar, et al., 2002; and Collins, 2000).
Rib fracture fragments may directly damage the underlying pleura or
lung, which results in pneumo-thorax, hemo-thorax, pulmonary contusion,
and/ or parenchymal laceration. Other associated, potentially life-threatening
infra-thoracic injuries include b lunt cardiac rupture, b ronchial disruption,
and major vascular tears. Fractures of the lower rib s (the ninth, tenth, or
eleventh rib s) are uncommon b ecause of their mob ility, b ut when found they
raise concern for serious infra-abdominal hemorrhage due to associated liver,
spleen, or kidney injury (Liman, et al., 2003; and Collins, 2000).
Angiography is indicated in patients whose first and second ribs,are
fractured in the following circumstances: clinical evidence of vascular
injury, such as distal vascular insufficiency, radiographic evidence of

possib le aortic injury (e.g. widened niediastinum, silhouetting of the aortic

knob ), large apical hematoma, associated b rachial plexus injury, and
sub stantial displacement of fracture fragments (Gavelli, al., 2002; and
Rashid, et al., 2001 ).
16
REVIEW
( mammary) artery and form anastomoses with the posterior intercostal
arteries which arise from the thoracic aorta. The upper two intercostal spaces
are ab ove the level of the thoracic aorta and receive their supply from the
costocervical trunk. Thus, when it is necessary to introduce a drain through
an intercostal space, the neurovascular b undle should b e avoided. This can
b e accomplished b y passing the drain through the intercostal space just
ab ove the upper b order of the rib . Also, intercostal nerve b lock is indicated
to releive traumatic pain, a space ab ove and a space b elow the affected space
should b e also injected b y the anasthetics (Jon, et al., 1999).
The pleura consists of 2 layers of mesothelial cells with a smooth
semi-transparent appearance. The inner lining of the chest wall is the parietal
pleura. The visceral pleura invests the major thoracic organs. B etween the
visceral and parietal pleurae is a potential space, which, under normal
conditions, contains a small amount of fluid that serves mainly as a
lub ricant. S pace-occupying lesions, such as pneumothoraces, hemothoraces,
and hemopneumothoraces, interfere with oxygenation and ventilation b y
compressing otherwise healthy lung parenchyma. This can push mediastinal
contents toward the opposite hem ithorax. Distortion of the superior vena
cava b y this mediastinal shift can result in decreased b lood return to the
heart, circulatory compromise, and shock (Valerie & Robert, 1999; and
Kenneth & Matthew, 1996).
The mediastinum is the compartment b etween the pleural cavities. It
extends anteriorly from the supra-sternal notch to the xiphoid process and
posteriorly from the first to the eleventh thoracic verteb rae. It contains the
heart, trachea, esophagus, and the great thoracic vessels (Romanes, 1989).
7
REVIEW
The trachea enters through the thoracic inlet and descends to the
carina, where it divides into the right and left main stem b ronchi. Each main
stem b ronchus divides into lob ar b ronchi. The b ronchi continue to arb orize
to supply the pulmonary segments and sub segments. The trachea is tethered
at the thyroid cartilage such that rapid deceleration generates a shear force
and results in injury. S imilarly, shear forces from widening of the angle of
the carina can result in main-stem b ronchus injury (Patrick & Ernest, 1999;
and Rom anes, 1989)
The lungs occupy most of the volume of each hemithorax. The hilum
of the lung transmits the broncho-pulmonary segments to make up large lung
units called lob es. The right lung has 3 lob es, and the left lung has 2 lob es.
Each lob e is further divided into segments. The hilum of the lung lies near
the centre of the medial surface, It contains a principal b ronchus, a
pulmonary artery, superior and inferior pulmonary veins, lymph nodes and
vessels, b ronchial vessels and b ranches of vagus nerve and sympathetic
trunk. Each principal b ronchus divides secondary into lob ar b ronchi that
give segmental b ronchi supply broncho-pulmonary segments within which
the b ranches of pulmonary artery lie mainly on the posterior surface of the
b ronchi, however, the lob ular trib utaries of pulmonary veins lie on their
anterior surface. Understanding the lob ar and segmental anatomy of the lung
help decision of operative techniques for management of pulmonary
lacerations after chest trauma that may include pneumonectomy, lob ectomy,
b roncho-plasty, segmentectorny, or minor repairs ( Marc, et al., 2 002 ; and
Romanes, 1989).
8
REVIEW

The left lung is related to the aortic arch and descending aorta and on
its medial surface it is related to the anterior and left surfaces of the left
ventricle and auricle and the anterior part of the right ventricle. The postero-
medial surface may b e in contact with the esophagus and thoracic duct. The
right lung is related to the right subclavian artery, the superior vena cava and
on its medial surface it is related to the right auricle, right atrium and part of
the right ventricle. The azygos vein with the esophagus pass posteriorly to
the hilum. The b ase of the right lung is deeply concave due to the high
position of the diaphragm on the right, over the liver. Injury of these
structures must b e suspected and should b e excluded with pulmonary injury
(Romanes, 1989; and Gray, et al., 1985).
The pericardium is a conical fib ro-serous sac, in which the heart and
the roots of the great vessels are contained. It is placed b ehind the sternum
and the cartilages of the third, fourth, fifth, sixth, and seventh rib s of the left
side, in the mediastinal cavity. B ehind, the pericardium rests upon the
b ronchi, the esophagus, the descending thoracic aorta, and the posterior part
of the mediastinal surface of each lung. Laterally, it is covered b y the pleura,
and is in relation with the mediastinal surfaces of the lungs; the phrenic
nerve, with its accompanying vessels, descends b etween the pericardium and
pleura on either side. The parietal pericardium is tough and non compliant
b ut can enlarge to accommodate slowly accumulating fluid, rapid fluid
accumulation (e.g. massive hemo-pericardium due clardiac injury)
overwhelms the ab ility of pericardium to distend, however, the pressure
gradient increases, thus, the diastolic filling and stroke volume compromised
in traumatic pericardial tamponade. The conducting system of the heart
supplied b y the right coronary artery, thus, injury of this artey deteriorate the
9
REVIEW
function of conducting system (Fraser, et al., 1999; Romanes, 1989 ; and
Gray, et al., 1985 ).
The heart has two atria and two ventricles. The apex of the heart is
directed downward, forward, and to the left, and is overlapped b y the left
lung and pleura. The left atrium is rather smaller than the right, b ut its walls
are thicker, The left ventricle is longer and more conical in shape than the
right. It forms a small part of the sternocostal surface and a considerab le part
of the diaphragmatic surface of the heart; it also forms the apex of the heart.
Its walls are ab out three times as thick as those of the right ventricle. The
aortic valves are larger, thicker, and stronger than pulmonary valves. Thus,
injury to the left ventricle and aortic valve are rarely invloved in chest
trauma, and need a highly severe trauma (Fraser, et al., 1999; and
Romanes, 1989).
The great vessels that are commonly injured from b lunt trauma
include the innominate artery, pulmonary veins, venae cavae and, most
frequently, the descending thoracic aorta. The point of attachment of the
pulmonary veins and venae cavae and the immob ility of the descending
thoracic aorta at the ligamentum arteriosum and diaphragm enhance their
susceptib ility to b lunt rupture. B ecause of anatomy, stab wounds most
commonly injure the ascending aorta, whereas gunshot wounds usually
injure the descending thoracic aorta ( Wall, et al., 2001).
The esophagus is a muscular tub e that serves as a conduit for the
passage of food and fluids from the pharynx to the stomach, In the thorax,
the esophagus passes b ehind the aortic arch and the left main b ronchus,
10
REVIEW
enters the ab domen through the esophageal hiatus of the diaphragm, and
terminates in the fundus of the stomach. The esophagus is well protected b y
the thoracic cage, b ut it can b e involved either b y b lunt trauma (e.g.,
automob ile accidents) or b y penetrating missiles (e.g., gunshots or knife
wounds). Often the surgeon's attention is directed toward more life-
threatening damage to heart, lungs, or major b lood vessels, and a rent in the
esophagus may b e not overlooked and may b e followed b y mediastinitis
(James, et al., 2003; and S idney & Henry, 2000).
The diaphragm, the most important muscle of respiration, is shaped
like a thin dome and separates the thoracic and ab dominal cavities. It has
two components; the central non-contractile tendon and the muscle fib ers
that arise from it and radiate down and outward to insert distally in'the
circumferential caudal limits of the rib cage. The diaphragm rises as high as
the level of the nipple, and the upper part of the ab domen including the liver,
spleen, stomach, distal pancreas, and kidneys, is overlapped b y six of the ten
anterior rib s and the lower four posterior rib s. These anatomic facts are
important in management of patients with penetrating trauma. Lacerations
usually occur in the tendinous part, most often on the left side. The liver
provides protection to diaphragmatic injury on the right side except from
penetrating wounds (B artolome, 2000; and Valerie & Rob ert, 1 999).
11
REVIEW

ME CHANI SMS OF CHE ST TRAUMA
There are two b asic mechanisms of thoracic injury; b lunt and
penetrating. B oth cause injury b y kinetic energy transfer. B lunt chest trauma
are caused b y RTA in 80% of cases. Penetrating chest injuries from knife,
b ullets, etc, are almost as frequent as those from b lunt trauma. The death rate
in hospitalized patients with isolated chest injury is 4-8% (James, et al.,
2003; Crankson, et al., 2001 ; and Fraser, et al., 1 999).
In a recent study on 225 patients with chest trauma over a 17-year
period. The most common causes were b lunt injuries in 1 35 cases (60%),
stab wounds in 67 cases (29.77%) and gunshot wounds in 22 cases (9.77%)
as shown in table (1) ( Ceran, 2002).
Table (1): I ncidence of chest trauma mechanisms (Ceran, 2002).
NUMB ER PERCENTAGE (%)
B lunt trauma 1 35 60
S tab wounds 97 9.7
Gunshots 22 29.7
Common forces associated with motor vehicle crashes are
deceleration and acceleration forces. Deceleration is a decrease in the
velocity or speed of a moving ob ject, whereas acceleration
1
is an increase in
the velocity or speed of a moving ob ject. Deceleration forces create injury
when a moving vehicle comes to an ab rupt stop as a result of a crash. The
moving ob ject, such as a car or a b ody, decelerates rapidly, and the energy
12
REVIEW
on impact is dissipated and ab sorb ed b y the car and the b ody, resulting in
tissue injury. Acceleration forces are applied to a b ody or an ob ject when a
stationary or slowly moving b ody or ob ject is struck b y a faster moving
ob ject such as a car. The energy from the faster moving car is transferred to
the slower b ody or ob ject (person), creating an accelerating force. Shearing
forces occur across a plane, with structures slipping relative to each other
( Mary &S usan, 1 999).
Patients experiencing b lunt thoracic trauma may sustain multiple rib
fractures, flail chest, cardiac or pulmonary contusions, injury to the great
vessels, sternal fractures, clavicular fractures, neck injuries, and lacerations
of the liver and/ or spleen. Long-term scquelae from b lunt chest trauma
include chest wall deformities, persistent dyspnea, and cardiac, neurologic,
or esophageal complications (Yeo, 2001 ).
Penetrating wounds have direct injury from the wounding agent itself
(i.e. knife or b ullet), as well as injury caused b y energy transfer to the tissue,
which is largely related to the velocity of the wounding agent. High-velocity
gunshot wounds can result in devastating soft-tissue injury related to
cavitation, a 'shock-wave' effect. Low-velocity wounds (handgun or knife)
result in localized injury limited to the wound path. Penetrating wounds of
the thorax from a knife or b ullet frequently induce pneumo-thorax or hemo-
pneumo-thorax, although the searing effect of a b ullet ash passes through
the pleura may cauterize the tissues sufficiently to prevent escape of air into
the pleural space (Bokhari, et al., 2 002 ; and Patrick & Ernest, 1999).
13
REVIEW
Table (2) : Spectrumof chest trauma (Marc, et al., 2002).
SPECTRUM OF CHEST TRAUMA
BLUNT TRAUMA PENETRATING TRAUMA
CARDIAC PULMONRY OTHER CARDIAC PULMONARY OTHER
Tamponade
Chest wall:
- Fractures
- Tissue loss
Vascular:
- Aorta
- Other
l'amponade Chest wall:
- Fracture
- Flail chest
- Contusion
Vascular:
- Aorta
- Other
Rup ture:
- Free wall
- Valves
- Sep tum
- Coronary
artery
Pleural sp ace:
Pneumot h (ma x
- Minot horax
-Empyema
-Chylothorax
Diap hragm
Rup ture:
- Free wall
- Valves
- Sep tum
Pleural sp ace:
-Pricumothorax
-ilemothorax
-Empyema
Diap hragm
Parenchym a:
- Contusion
- Laceration
Esop hagus Contusion
Parenchym a:
- Contusion
- Laceration
-Pseudocyst
Esop hagus
Trachea &
Bronchi
Trachea &
13ronchi
14
1
REVIEW
CHE ST W ALL I NJURI E S
The most common type of thoracic injury is the chest wall injury
(approximately 5 0%). The spectrum of chest wall injuries ranges from minor
(1 0%), major (35 %), up to flail chest (5 %). S ignificant chest wall injury is
present in ab out one third of patients admitted after severe trauma. These
injuries are not always olivious and can easily b e overlooked (Mehmet, et
al., 2003; and Marc, et al., 2002).
S imple rib fractures are the most common form of significant chest
injury, b ecause the rib s are close to the skin surface and don't have as much
protection as other bouts_ Contusions of the chest wall are very common,
and costo-chondral separiitions also can occur. S ufficient trauma to the chest
can result in injury to the b ony thorax and soft tissues of the chest wall,
increasing patient morb idity acid mortality (Liman, et al., 2003; and Dei
& Duddy, 2000)
RIB FRACTURES
The diagnosis of fractured rib s can b e suspected clinically. Pain on
inspiration is usually clinical manifestation after simple rib
fractures. Other clinical signs associated with rib fractures include
tenderness to palpation, b ony crepitus, ecchymosis, and muscle spasm over
the rib b eing the most common findings. Also, compression of the involved
rib remote from the site of injury usually produces pain at the site of fracture
| Middelte , et al , 201 1 3; and (Hart, et al , 2002)
15
REVI EW
The fractures are often missed on the postero-anterior radiograph
b ecause the lateral portions of the rib s are frequently affected and the
fracture line is not tangential to the x-ray b eam. The presence of fractures is
easier to detect on ob lique rib views. However, the presence or ab sence of
rib fractures per se is of limited clinical significance, the main value of the
radiograph b eing the detection of associated pleural and pulmonary
complications |Ba idhar, et al , 2002; a d Celli , 2000)
Rib fracture fragments may directly damage the underlying pleura or
lung, which results in pneumo-thorax, hemo-thorax, pulmonary contusion,
and/ or parenchymal laceration. Other associated, potentially life-threatening
intra-thoracic injuries include b lunt cardiac rupture, b ronchial disruption,
and major vascular tears. Fractures of the lower rib s (the ninth, tenth, or
eleventh rib s) are uncommon b ecause of their mob ility, b ut when found they
raise concern for serious intra-abdominal hemorrhage due to associated liver,
spleen, or kidney injury ( Lima , 2003; a d Celli , et al , 2000)
Angiography is indicated in patients whose first and second rib s are
fractured in the following circumstances: clinical evidence of vascular
injury, such as distal vascular insufficiency, radiographic evidence of
possib le aortic injury (e.g. widened mediastinum, silhouetting of the aortic
knob ), large apical hematoma, associated b rachial plexus injury, and
sub stantial displacement of fracture fragments |Gavelli, et al , 2002; a d
Ra hid, et al , 200l)
16
REVIEW

S TERNAL FRACTURES
S ternal fractures accounted for 8% of admissions for thoracic trauma.
The main causes are motor vehicle collisions, falls or direct b lows.
Admission justified for the management of pain and treatment of cardiac

complications and concomitant injuries (Potaris, et al., 2002; and S adab a,

et al., 2000).
The presence of a fractured sternum implies a significant trauma to the
anterior chest Nva 11 with high-energy transfer. S igns and symptoms include
chest pain, particularly over the sternum, and crepitus. Most sternal
fractures are transverse, and a lateral radiographic view is diagnostic. These
fractures are often missed radiographically b ecause a lateral plain chest x-ray
fil m is not usually ob tained (luring the initial trauma evaluation. S ternal
a
fractures also constitute a marker for serious associated injuries, including
myocardial contusion, myocardial rupture, esophageal perforation, airway
injury, and thoracic aortic rupture. Associated mediastinal injuries are b est
diagnosed b y computed tomography (CT) scan of the chest. S ternal
fractures, associated with clinically silent myocardial contusion, are b est
visualized on chest CT (David, et al., 2001 ; and Collins, 2000).
Complications may arise from associated injuries. During evaluation
of .these patients, carefully assess for cardiac, pulmonary, mediastinal, and
thoracic spine injuries, as well as associated injuries unrelated to chest
trauma. Cardiac complications, occur in 1 .5 % to 6% of the cases. Cardiac
contusion is much less common than once thought; its incidence currently
ranges from 6-1 8% b ased upon severity of trauma. There is no association
17
REVIEW
b etween sternal fracture and aortic rupture. It occurs in fewer than 2% of
sternal fractures, a rate similar to that in patients with b lunt chest trauma
.without sternal fracture (Jua n, et a l., 2002; a nd Sa da ba , et a l., 2000).
Although sternal fractures may occur in the major b lunt chest trauma,
the presence of sternal fractures is not necessarily translated into major life-
threatening conditions, However, the associated mediastinal hematoma can
b e the more prob lematic issue. Mediastinal hematomas, whether or not
related to aortic injuries, can b e life-threatening. The dual prob lems of acute
b lood loss and sudden alterations in cardio-pulmonary physiology can result
in hemodynamic deterioration. In addition to circulatory collapse from
exsanguination, mediastinal hematomas can cause death from compression
of adjacent structures Olin Sung, 2003; a nd Velissa ris, et a l., 2003).
FLAI L CIIEST
Flail chest is produced b y doub le fractures of three or more adjacent
rib s or b y comb ined sternal and rib fractures, where a segment of the rib
cage that is disconnected From the rest of the chest wall and deforms
markedly with b reathing. The flail segment paradoxically moves inward
during inspiration. lie inellicient ventilation increases the work of
b reathing, which may worsen ventilation owing to the frequent association
with neuromuscular inI pairincnt (Swa n, et a l., 2001; a nd naltolome, 200,0).
It occurs in as m any us 25 % of patients with b lunt chest wall trauma.
The most common causes include fa lls a nd motor vehicle accidents.
However, Hail che:4 may also b e seen after over-aggressive chest
18
REVIEW
compression during cardio-pulmonary resuscitation, alter total sternectomy,
and, occasionally, with pathologic fractures such as those due to multiple
myeloma (Rich a rd & Courttney, 2000 ).
Flail chest is usually diagnosed b y physical examination. This requires
exposure of the patient's thorax and examination of the chest wall for
paradoxical motion. Pain, tenderness, and crepitus can direct the examiner.
In addition, the flail segment can sometimes b e visualized to move
separately and in an opposite direction 'from the rest of the thoracic cage
during the respiratory cycle. Multiple rib fractures can usually b e identified
on chest x-ray films. The diagnosis of flail chest is frequently missed; up to
30% are not appreciated within the first 6 hours of admission. CT scan is
much more accurate than plain films in evaluating for the presence and
extent of underlying injury and contusion to the lung parenchyma; it is b eing
utilized routinely in so me centers for all patients with major chest trauma
(Karmakar, 2003; a nd Sirma li, et a l., 2003).

19
REVIEW
PULMONARY I NJURI E S
The spectrum of pulmonary parenchymal injury following chest
trauma varies from isolated pulmonary contusion to traumatic pseudocysts,
frank laceration, and intra-parenchymal hematoma. Pulmonary contusion is
the most common finding (1 0-20% of adults hospitalized for b lunt chest
trauma) and is characterized b y localized interstitial and alveolar hemorrhage
with edema. The most common mechanisms are motor vehicle accidents
with direct chest impact, falling, and b eing kicked, that readily result in lung
damage. Gunshots and stab b ing can also result in significant pulmonary
inury (Ullman, 2003; and Fraser, et al., 1 999).
Acute respiratory distress syndrome is a manifestation of acute injury
to the lung, commonly resulting from sepsis, trauma, and severe pulmonary
infections. Clinically, it is characterized b y dyspnea, profound hypoxemia,
decreased lung compliance, and diffuse b ilateral infiltrates on chest
radiography. Complications such as pneumo-thorax, effusions, and focal
pneumonia should b e identified and promptly treated. In refractory cases,
advanced ventilator and novel techniques should b e considered, preferab ly in
the setting of clinical trials (Udohi, et al., 2003; and Richard & Courtney,
2000).
PULMONARY LACERATIONS

S imple lacerations of the lung are common after penetrating injuries

and rare after b lunt trauma. Patients usually have variab le degrees of
pneumo-thorax and hemo-thorax, which are common manifestations of non-
20
1
RE VI E W
penetrating trauma, and each may develop from a variety of causes (Huh, et
al., 2003).
Hemo-thorax may b e developed due to injury of the vessels of the
lung or the mediastinum. Pncumo-thorax most commonly develops as a
consequence of pulmonary interstitial emphysema (Kenneth, et al, 2003;
and Karmy, et al., 2001 ).
PULMONARY CONTUS IONS
Pulmonary contusion is reported to b e present in 30% to 75 % of
patients with significant b lunt chest trauma without rib fractures. It occurs in
75 % of patients with flail chest, most often from automob ile accidents with
rapid deceleration or pedstrian accident. Pulmonary contusion can also b e
caused due to sudden parenchymal concussion that occurs after b lunt trauma
or wounding with a high velocity missile and the high-energy shock waves
of an explosion in air or water. It is the most common significant chest
injury in children (James, et al., 2003; and Marc, et al., 2002).
B asically, a pulmonary contusion is a b ruise of the lung (traumatic
extravasation of b lood into the parenchyma of the lung un-accompanied b y
sub stantial tissue disruption). Direct impact results in small vessel and
alveolar disruption, which leads to b oth interstitial and alveolar hemorrhage
and edema. Early after injury, the contused lung is poorly perfused and shunt
is mini mal. Tissue inflammation rapidly follows, and a zone of surrounding
pulmonary edema is formed. This alters regional compliance and regional
airway resistance, which results in localized ventilation-perfusion mismatch
21
REVIEW
that progresses over 24-48 hours (Huh, et al., 2003; and David, et al.,
2001 ).
Clinical findings are seldom striking; in fact, symptoms may b e
entirely ab sent or may b e masked b y other injuries. Pain is not a prominent
feature, except in relation to other injuries. Hemoptysis is said to occur in
5 0% of cases, and there may b e mild fever; shortness of b reath may develop
in the presence of severe contusion. Rarely, the contused region is the site of
secondary infection Lacerations detected b y CT b ut not b y radiography are
of limited clinical significance (Liman, et al., 2003).
Respiratory failure occurs more often in patients with large
contusions, in the elderly, and in those with underlying chronic lung disease,
aggrevated b y inadequate pain control. Diagnosis is confirmed b y low
arterial oxygen pressure (Pa02) and b y a chest x-ray demonstrating a well-
defined infiltrate underlying the contused area on the chest wall. In some
cases, radiologic findings may not b e present upon admission, and these may
develop 24 to 48 hours after the initial injury. Pulmonary contusion may b e
confused with the adult respiratory distress syndrome or it may even b e
associated with it (James, et al., 2003; and Yeo, 2001 ).

22
REVIEW
TRAUMATI C PNE UMO- THORAX
A pneumo-thorax is an accumulation of air in the normally airless
pleural space b etween the lung and chest wall. Pneumo-thorax occurs in
1 5 % to 40% of patients with b lunt chest trauma. Traumatic (non-iatrogenic)
pneumo-thorax is caused b y penetrating or non-penetrating chest trauma.
Pneumo-thorax complicating trauma may occur without radiographic
evidence of rib fracture. When fracture is present, the likely mechanism is
laceration of the visceral pleura b y rib fragments; in such circumstances,
hemp-thorax may b e expected as a concomitant finding. When no fractures
are visib le, it is likely that pneumo-thorax is secondary to pulmonary
laceration (B asil & Ralph, 2001 ; and Fraser, et al., 1 999).
When a pneumo-thorax is small and the visceral pleural line is poorly
visualized, radiography at full expiration may reveal the partially collapsed
lung to b etter advantage. When a patient's condition does not warrant
radiography in the erect position, examination in the lateral decub itus
position permits identification of small quantities of air in the pleural space
(Dennis & Duddy, 2000; and Golden, 1 99).
Pneumo-thorax can b e divided into three classifications, depending on
whether air has direct access to the pleural cavity: simple, communicating,
and tension. A pneumo-thorax is considered simple when there is no
communication with the atmosphere or, any shift of the mediastinum or
hemi-diaphragm resulting. from the accumulation of air. It can b e graded
according to the degree of collapse as visualized on the chest radiograph
( Marc, et al., 2002).
23
REVIEW
Normally the pressure in the pleural space is negative with reference
to atmospheric and alveolar pressures. Therefore, if a communication exists
b etween the pleura and the atmosphere (e.g., after penetrating trauma) or
b etween the pleura and the lung (e.g., after rupture of an emphysematous
b ulla), air continues to enter the pleural space until pleural pressure b ecomes
atmospheric. This increased pleural pressure collapses the lung. It most
commonly occurs in comb at injuries (David, et al., 2001).
In some cases a b all-valve communication is formed in which air can
enter b ut cannot leave the pleural space. Intra-pleural pressure may then
exceed atmospheric pressure throughout expiration and often during
inspiration. This tension pneumo- thorax is life threatening b ecause it
compromises ventilation b y shifting mediastinal structures, impairing venous
return, and diminishing cardiac output. Patients with tension pneumo-thorax
are in distress, with dyspnea, tachypnea, and tachycardia often accompanied
b y distended neck veins, thready pulse, and hypotension. B ulging of the ipsi-
lateral intercostal spaces is sometimes ob served, and mediastinal shift may
b e signaled b y tracheal deviation to the contra-lateral side. The chest
radiograph is diagnostic b ecause the margin of the collapsed lung is
separated from the parietal pleura b y air (James, et al., 2003; and Basil &
Ralph, 2001).
24
REVIEW
TRAUMATIC HEMO-TIIORAX
Hemo-thorax is classified according to the amount of b lood into:
minimal (35 0 ml); moderate (35 0-1 5 00 ml); or massive, (1 5 00 ml or more).
The rate of b leeding alter (vacuation of the hemo-thorax is clinically even
more important. Pleural b lood often does not clot and can b e readily
removed b y lymphatics if the volume is small. Larger effusions require tub e
drainage. Persistent b leeding requires surgical correction |Jame , et al ,
2003; a d Barteleme, 20)0).
Hemo-thorax alone may b e difficult to detect. Patients can rapidly lose
30 to 40% of their b lood volume into the pleural space, with little resistance
from the compliant lung. They may then present primarily with signs of
shock. The presence of shock in a patient with a chest injury should also
raise the question ofperieard a I tainponade, which may not b e manifested b y
distended neck veins in the hypo-volemic patient |Barteleme, 2000; a d
Seth, l998)
The diagnosis of traumatic hemo-thorax should b e suspected in any
patient with penetrating or !: svcre b lunt thoracic injury. It should b e
emphasized that the hemo-iI a may not b e apparent on the initial chest
radiograph. B lunt chest trauma patients who are hemody;amically stab le
with a normal examilmtiLn do not require a routine chest radiograph.
penetrating trauma requirt
, chest X- ray as many will have hemo-pneumo-
25
REVIEW
thorax in the ab sence of clinical findings (B okhari, et al., 2002; and
Gavelli, et al., 2002).
Physical findings include dullness to percussion and decreased b reath
sounds on auscultation. Massive hemo-thorax typically presents with
hemodynamic instab ility, on the b asis of b oth hemorrhage and impaired
venous return. As with tension pneumo-thorax, jugular venous distension
may or may not b e evident. Tracheal deviation away from the injured side
may b e present (Richard & Coo trney, 2000; and Patrick & Ernest, 1 999).
The site of hemorrhage illfiuences the quantity of hemo-thorax. When
b leeding is from a vessel ill the chest wall, diaphragm, or mediastinum, the
hemo-thorax tends to increa;e despite the quantity of b lood present. B y
contrast, when the b lood originates in the pulmonary vasculature (which is
the most common cause u hemo-thorax) the expanding hemo-thorax
compresses the lung, with resultwit pulmonary vascular tamponade that may
produce hemostasis (self-IiiiiitinL) unless there is a major laceration. The
intercostal and internal mammary arteries causing hemo-thorax more often
than hilar or great vessels (Marc, et al., 2002; and Jon, et al., 1 999).

26
REVI EW
CARDIOASCULA l) J i J RIES
Thoracic injuries, espccially cardiac, vascular, and mediastinal
injuries, are amongst the most- lethal traumatic injuries. The selection of
patients for operation or olAservation can b e made b y clinical examination
and appropriate investigations (De unetriades & Velmahos, 2002).
Atrial or ventricular rupture is usually fatal, although the pericardium
may restrict b leeding enough to allow survival to the ER. The patient should
b e monitored in the ICU arid may require heparinization for coronary
thromb osis and anti-arrhythmic therapy (James, et al., 2003).
B LUNT CARDIAC TRAUMA
B lunt injury to Mc hurt tan occur after road traffic accident, fall from
height, external cardiac com p ression or an injury b y an animal. This may
result in fracture of
-
rib s cy si i
-
nitm, myocardial contusion and pericardial
tear with hemo-thorax leading to severe cardio-respiratory instab ility The
anterior surface is the most frequently injured area of the heart (Matsuda, et
al., 1 999).
B lunt cardiac traum a can manifest as myocardial concussion with an
associated low mortality at as cardiac rupture with an excessive mortality.
The spectrum of these iritiiitc :ranges from intra-myocardial hemorrhage
leading to myocardial leprecs I 1 tra-ventricular and atrio-ventricular
2 7
REVIEW
septal defects, acute cardiac valvular lesions, to the rupture of the heart
chamb er, depending upon the initial site of injury (Afzal & Aziz, 2002).
B lunt cardiac trauma may b e viewed as part of a continuous spectrum
(i.e., myocardial concussion, contusion, infarction, and rupture). Myocardial
concussion occurs when a b lunt injury to the interior chest produces a "stun"
response in the myocardium. No permanent cellular injury occurs, b ut
transient clinical effects may result (Marc, et al., 2002).
Myocardial contusion
Myocardial contusion is the least severe form of injury that can b e
demonstrated pathologically. Cellular injury occurs with extravasation of red
b lood cells into the muscle wall, along with localized myocardial cellular
necrosis. Permanent myocardial damage is rare. Traumatic myocardial
infarction (MI) results from either direct trauma to the coronary arteries or a
severe contusion of the myocardium, leading to irreversib le cellular injury
and ultimately cell death. A wide variety of atrial and ventricular
dysrhythmias result from myocardial contusion caused b y b lunt chest trauma
(James, et al., 2003; and Kaye & O'S ullivan, 2002).
S ignificant conduction system defects that result in various brady-
dysrhythmias and b undle b ranch b locks may occur. Reduction in cardiac
output may manifest in 5 0% to 75 % of patients with significant myocardial
contusion b ecause of extensive myocardial muscle injury. Congestive heart
failure and cardiogenic shock have b een describ ed. Trans-mural MI caused
b y coronary artery injury may occur (S yb randy, et al., 2003).
28
REVIEW
Cardiac rup ture
Myocardial rupture refrs to an acute traumatic perforation of the
ventricles or atria, b ut it may also include a pericardial rupture or laceration
or rupture of the inter-ventricular septum, inter-atrial septum, chordae,
papillary muscles, or valves. B lunt rupture of the pericardium is a rare
injury. Pericardial tears may also cause cardiac herniation with severe chest
pain and dyspnea with signs and symptoms of acute cardiac failure.
S ometimes the hole in the pericardium may not b e large enough to allow
egression of b lood from the pericardium leading to cardiac temponade or
localized intra-pericardial hematoma or ab scess formation (David, et al.,
2 001).
Traumatic pericardial rupture is difficult to diagnose pre-operatively
b ut should b e suspected whenever there is severe b lunt chest trauma. If
pericardial rupture is not recognized and treated promptly it could b e fatal
owing to cardiac herniation. S trangulated cardiac hernia following b lunt
trauma is one cause of reversib le cardiac arrest. Traumatic pericardial tears
usually have delayed diagnoses and carry high mortality rates (64%).
Clinical signs mimic cardiac tamponade during the primary survey (Janson,
et al., 2 003 ; and Collet, et al., 2 001).
PENETRATING CARDIAC INJURY
Penetrating cardiac injuries pose a tremendous challenge to any
trauma surgeon. Rapid transportation, immediate triage, open-minded use of
emergency room thoracotomy, incl aggressive surgical management with use
29
REVIEW
of sub -xiphisternal pericardial windows are important factors in improving
the survival of penetrating cardiac trauma.The physiologic status of the
patient with penetrating cardiac trauma at presentation, mechanism of injury,
and presence of a tamponade are significant prognostic factors in the patients
with penetrating cardiac injuries. Multiple-chamb er injuries, especially with
great vessel involvement, are associated with a high mortality rate
(Tyb ruski, et al., 2000; and
-
Von Oppell, et al., 2000).
Interpersonal violence accounts for the vast majority of penetrating
heart injuries with an approximately equal incidence of stab wounds (S Ws)
and gunshot wounds (G$ Ws) among patients who are transported to the ED.
The right ventricle (RV) is affected more often (43%) than the left ventricle
(LV) (34%) owing to its anterior anatomic location. The left or right atrium
is affected in 20% of cases. tint tlutd of penetrating cardiac wounds affect
multiple chamb ers, and survival is much worse in these cases. In 5 % of
cases a coronary artery is lacerated, although these injuries usually involve a
distal segment of the artery and rarely produce significant acute myocardial
infarction when they are ligated. More proximal coronary artery lacerations
require coronary b ypass (Riaz, et al., 2004; and Marc, et al., 2002).
The reported incidence of acute pericardial tamponade is
approximately 2% in 1)111e11!, with penetrating trauma to the chest and upper
ab domen. It is rarely seen alter b lunt chest trauma. Tamponade produces
distended neck veins, shock, and cyanosis. Immediate thoracotomy is
indicated The primary feature of a pericardial tamponade is an increase in
intra-pericardial pressure avid
-
volume. As the volume of the pericardial fluid
encroaches on the capacity of the atria and ventricles to fill adequately,
30
REVIEW
ventricular filling is meehmically limited and thus the stroke volume is
reduced. This results in (1,yre:i;ed cardiac output and ultimately diminished
arterial systolic b lood pressure a hd decreased pulse pressure. Concomitantly
central venous pressure rises b ecause of the mechanical b ackup of b lood into
the vena cava (Herbo ts, et a1 . , 2001 ).
THORACI C AND CENTRAL :VASCULAR I NJURI E S
Over 90% of thorack great-vessel injuries are caused b y penetrating
external or iatrogenic irautua. The great vessels that are commonly injured
from b lunt trauma include the suhcl.avian artery, pulmonary veins, venae
cavae and, most frequently, the descending thoracic aorta ( Ma tto x, 2002).
Lesions of the infe rior veha cava, left internal mammary artery, and
intercostal vessels may b e detected only at surgery. Early thoracotomy is
important for salvage of patients with chest-wall vascular injury (Ra sh id, et
a l., 2001).
Ao rtic injury
The magnitude of injury necessary to cause a traumatic aortic tear
often results in high 111,
,
Ortality. A ortic injuries contrib ute to 15% of deaths
following motor vehicle accidentc (MVAs). These injuries usually involve
the proximal descending (34/0 to 65 % of cases), b ut can involve other
segments. These other sites include the ascending aorta or transverse aortic
arch (1 0% to 1 4%), the mid- o r distal descending thoracic aorta (1 2%) or
31
REVIEW
multiple sites (1 3% to 1 8%) (Kasirajan, et al., 2003; and Wall, et al.,
2001).
In b lunt thoracic aortic injury with aortic intimal injuries smaller than
20 mm in hemodynamically stab le patients, b eta-b lockers have b een shown
to reduce the incidence of rupture, and their use is rarely contraindicated. A
working knowledge of the mechanisms of injury likely to produce this
lesion, commonly associated injuries, clinically relevant and easily
recognizab le chest film fitidinL;s, and appropriate use of b eta-b lockade can
have a significant impact on mortality ( Morgan & Buetcher, 2000).
Inj ury to other great thoracic vessels
The second most coni111011 Hunt thoracic vascular injury is a tear at the
origin of the innominate artery. The artery is either sheared off the aortic
arch, as with b lunt aortic in or "p inched" b etween the sternum and the
spine during frontal impact. B lunt innominate artery injury is, in fact, an
aortic injury b ecause operative repair requires ob taining control at the aortic
arch (David, et al., 2001).
The clinical presentation is similar to that of b lunt aortic injury in that
most patients are hemodynamieally stab le and asymptomatic . Innominate
artery, right common carotid or sub clavian artery, as well as left intra-
thoracic common carotid artery injuries are b est managed via median
sternotomy with appropriate, extension ( Wall, et al., 2001).
3 2
REVIEW
DIAPHRAGMATI C I NJURY
Diaphragmatic injuries me relatively rare and result from either b lunt
or penetrating trauma. The aric iritncc of diaphragmatic injury is estimated to
b e 1 % to 6% of all pati ms susiairn li g multiple trauma ( Hari, et al., 2004).
Diaphragmatic injuries arc- considered to b e a predictor of serious
associated injuries, However, as ninny as 1 0%-30% are missed during the
initial evaluation. A high indPic of suspicion of diaphragmatic injury is
required, Diagnostic aids should b e employed to reach early diagnosis to
avoid the sequelae of in ismui injuries (Abdel Hadi, et al., 2001 ).
Diaphragmatic rupture is diagnosed in 1 % to 4% of patients admitted
to the hospital with b lunt tratarlb and in ab out 5 % of patients undergoing
laparotomy or thoracoromy for 'trauma. 01 the penetrating injuries to the
lower chest, ab out a stall wounds and 45 % of gunshot wounds are
associated with this comfit( atitwr (Mihus, et al., 2003).
The mechanism of diaphragmatic injury in penetrating trauma is direct
violation of the diaphragm b y the penetrating ob ject or missile. In b lunt
trauma, increased intra-abdumitial. or Intra-thoracie pressure is transmitted to
the diaphragm, leading to rupture, "I 'he right hemi-diaphragm is protected b y
the liver, whereas the 1 pFti henli-diaphragm has littlt support from
surrounding structures and rs more vulnerab le to rupture (Marc, et al.,
2002).
1
33
REVI EW
The diagnosis is difficult, so is usually made intra-operatively. correct
preoperative diagnosis of t mumulic rupture of the diaphragm (TRD) needs a
high index of suspicion. It can he diagnosed intra-operatively b y explorative
laparotomy. Most ruptures ean b e repaired b y the ab dominal approach
(Cubukcu, et al., 2000).
In spite of the avitilal' ilily i, ewer diagnostic imagining techniques,
the initial chest radiograph is very reliab le in detecting most cases with b lunt
diaphragmatic rupture, and together with high index of suspicion and sound
clinical assessment remain the cornerstone in diagnosing these challenging
injuries (Pikoulis, et al., 2000),
Diaphragmatic injury should b e suspected in all thoraco-ab dominal
trauma. Lack or specific ;:i gu:; and symptoms is common and a high index of
suspicion is required. Routine chest radiograph remains the b est screening
test for diaphragmatic rupturt, Diaphragmatic injury may he a predictor of
severity of injury in blunt-trauma patient (Adegboye, et al., 2002).
Initial recognitioli ark) treatment of diaphragmatic rupture or injury is
important in avoidin
,,
, . quelae. Early diagnosis may b e difficult,
and complications cii,c I as visceral herniation may arise. Careful
interpretation of radiographic irryages and early surgical intervention are
essential in the MArIETeln
-
Kril
-
< YE patients with cllronie traumatic
diaphragmatic hernia (Ntitt, et -at, 200 I ).
,1 34
REVIEW
The hernial contents depend on the size and position of the rupture
and, can include the Omentum, stomach, small and large intestines, spleen,
!Kidney,
and even pancreas. S uch traumatic herniated material frequently
strangulates, particularly if the diagnosis is delayed b eyond 24 hours.
Although traumatic hernias account for only ab out 5 % of diaphragmatic
hernias (Grillo, et al., 2000).
The potential for herniation sets the stage for the three clinical phases
of diaphragmatic injuries. The acute phase b egins at injury. and ends With
apparent recovery from the primary injuries. During this phase, the
diaphragmatic injury is often overshadowed b y other associated injuries, and
only 22% of patients with traumatic diaphragmatic injury have the diagnosis
within this initial stage. If the diaphragmatic defect is not recognized and
repaired, the latent phase ensues. Diaphragmatic injury is diagnosed in a
delayed manner in ab out 1 8% of b lunt and 32% of penetrating trauma cases.
S ymptoms during this time are those of vague ab dominal distress caused b y
the intermittent entrapment of herniated ab dominal viscera with
incarceration or strangulation of ab dominal viscera within the defect. The
third, or ob structive, phase produces the complications caused b y vascular
compromise of the herniated, strangulating ab dominal viscera. During this
period, any structure found within the ab dominal cavity, including the
kidney, may herniate through the diaphragmatic defect. On the left side, the
colon, stomach, and spleen arc the organs most likely to herniate. The liver
is the most common organ to herniate on the right. The omentum and small
b owel have also b een reported to herniate, predominantly on the left side
(James, et al., 2003; and Marc, et al., 2002).
35
REVIEW
TRACHEO-BRONCHIAL INJURY
Injuries to the tracheo-bronchial tree are well-recognized sequelae of
massive b lunt or penetrating injuries of the neck or chest. Tracheo-b ronchial
injuries occur in fewer than 3% of patients with significant chest injury, yet
it carries an overall mortality of 30%, 50%' of whom will die within the first
hour (Richardson, 2004).
Tracheo-bronchial tear is usually related to b lunt trauma that involves
a partial or complete laceration or puncture of the tracheal or b ronchial wall..
Early diagnosis and operative intervention save lives. Associated injury is an
important mortality factor (B ald, et al., 2002).
Tracheo-bronchial injury may occur b y at least three different
mechanisms, the first is severe crush injury to the chest compressingThe
tracheo-b ronchial tree b etween the sternum and verteb ral column, the second
is rapid deceleration Causing a shearing effect on the b ronchus, the third
results from rapid increase in tracheo-b ronchial pressure against the closed
glottis, caused b y a crush injury to the chest. This mechanism results in
complicated b lowout injuries (Tina & Diana, 2001 ).
Among the five major de-celerational thoracic injuries [myocardial
contusion (MC), traumatic aortic disruption (TAD), steri
-
ial fracture (S F),
flail chest (IT), and tracheo-bronchial disruption (TB D)], coexisting injuries
are seemingly rare. When comb ined, the threat to life is potentiated. Death
occurs at the scene or shortly after arrival in the ER. The diagnosis of one
36
REVI EW
may help exclude the diagnosis of each of the other four (S wan, et al.,
2001 ).
Fractures of the b ronchi are more common than those of the trachea
and constitute ab out 80% of all tracheo-bronchial injuries. They are usually
parallel to the cartilage rings and involve the main b ronchi 1 to 2 cm distal to
the carina. The right side is affected more often than the left; pulmonary
vessels are rarely damaged. Fractures of the intra-thoracic trachea are
horizontal and usually occur just ab ove the carina. Occasionally, the
proximal trachea ruptures as a result of b lunt trauma to the throat, in which
case, other cervical structures are usually involved; the tracheal tear tends to
b e vertical in the memb ranous portion and can b e associated with vascular
damage (Richardson, 2004; and Fraser, et al., 1 999).
The trachea is tethered at the thyroid cartilage such that rapid
deceleration generates a shear force and results in injury. S imilarly, shear
forces from widening of the angle of the carina can result in mainstem
b ronchus injury. S udden increases in infra-tracheal pressure from a chest
impact can result in a 'b low-out' injury of the trachea, which usually involves
the memb ranous, posterior wall (James, et al., 2003).
Independent of mechanism or anatomic location of injury, delay in
diagnosis is the single most important factor influencing outcome. Early
recognition of tracheo-bronchial injury and expedient institution of
appropriate surgical intervention are essential in these potentially lethal
injuries (Cassada, et al., 1 995 ).
37
REVIEW
The typical clinical features include haemoptysis, dyspnea, and air
leak. If tracheo-bronchial injury is undetected and left untreated, it niay
cause persistent air leak which can render ventilation difficult and
inefficient. Diagnosis' of tracheo-b ronchial injury should b e made and
confirmed b y flexib le b ronchoscopy (Chu & Chen, 2002).
Tracheo-b ronchial injuries can have a highly variab le clinical
presentation, which may include cough, stridor, dyspnea, hemoptysis, and
voice changes. Cervical sub cutaneous emphysema and crepitus are often
present. Auscultation may reveal a mediastinal crunch from air in the
mediastinal soft tissue (Patrick & Ernest, 1 999).
Penetrating injuries tend to b e more ob vious b ecause of their nature,
alerting b oth the patient and physician, whereas b lunt injuries can b e occur.
Tracheo-b ronchial injuries caused b y knife wounds develop almost
exclusively from wounds in the cervical trachea, whereas gunshot wounds
may damage the tracheo-b ronchial tree at any point (Marc, et al., 2002).
On chest radiograph, the diagnosis of tracheo-bronchial tear is usually
suspected b ecause of the persistence of a pneumo-thorax after chest tab e
insertion. S ince this radiographic pattern is nonspecific, the diagnosis is
usually made b y bronChoscopy and delayed. The fallen-lung sign consists in
the fall of the collapsed lung away from the mediastinum octurring when the
normal central b ronchial anchoring attachment of the lung is disrupted. In
contrast to the persistent pneumo-thorax, this sign is specific b ut rarely
ob served. Also, esophageal perforation is a frequent finding in patients with
laryngeal or tracheal injuries |Ketai, et al , 2000; a d Tack, et al , 2000)
38
REVIEW
ESOPHAGEAL INJURY
The esophagus can b e involved either b y b lunt trauma (e.g.,
automob ile accidents) or b y penetrating missiles (e.g., gunshots or knife
wounds). Most esophageal injuries arc secondary to penetrating trauma and
may occur at any level Oames, et al., 2003).
Esophageal injury after b lunt trauma should b e considered in patients
with a pleural effusion without rib fractures, pain out of proportion to the
clinical findings, sub cutaneous emphysema, or pneumo-mediastinum
without an ob vious source, and gastric contents in the chest tub e. All
mediastinal traversing gunshot wounds or stab wounds near the posterior
midline should b e evaluated for possib le esophageal injury. The diagnosi,s , is
confirmed with esophagography and esophagoscopy. These tests have a
reported sensitivity varying from 5 0 to 90% (David , et al., 2001 ).
Air may enter the mediastinum through a tear in the esophagus or
tracheo-b ronchial tree or as dissecting air from ruptured alveoli. Air may
track to the neck and the b ody, producing sub cutaneous emphysema and/ or
pneumo-thorax. The patient complains of retrosternal pain and dyspnea.
S ub cutaneous emphysema may cause classic crepitus. Vomitus may contain
b lood. Auscultation may reveal a crunching sound synchronous withlhe
heart b eat (Hamman's sign). Rarely, cardiac function iscompromised. A
lateral chest radiograph is usually diagnostic (S idney & Henry, 2000).
39
REVIEW
TREATMENT OF THORACIC INJURIES
The major management. prob lems fall into two main categories: acute,
life-threatening conditions such as flail chest, open or persistent pneumo-
thorax, exsanguinating hemorrhage with massive hemo-thorax, mediastinal
emphysema, cardiac tamponade and intra-thoracic foreign b odies, and
chronic conditions such as clotted hemo-thorax, empyema, and libro-thorax.
S ome of such patients (i.e. those with flail chest, injuries of trachea and
primary b ronchi, esophagus, diaphram, vena cava, great lung vessels, heart
and aorta, or foreign b odies) may represent surgical emergencies and would
b e immediately candidates for major intervention; some leading rapidly to
death. Other require fast b ut diagnostic procedures, b ecause the choice of a
therapy is dependent upon a precise identification of the damage. B etter
treatment and prevention of the chronic conditions has greatly reduced
morb idity (Marc, et al., 2002; and B ellamy, et al., 2000).
The accurate diagnosis of pathologies consequent to b lunt chest
tratima depends on a complete knowledge of the different clinical and
radiological manifestations. The first diagnostic approach is classically
b ased on chest X- ray often carried out on supine position at the hospital
admission. B lunt chest trauma patients who are hemo-dynamically stab le
with a normal physical examination do not require a routine chest
radiograph. In contrast, all victims of penetrating trauLna require chest
radiographs b ecause many will have hemo-pneumo-thorax in the ab sence of
clinical findings (Bokhari, et al., 2002; and Cavern, et al., 2002).
I
40
REVIEW
A computed tomography (CT) study must then b e performed in all
chest trauma patients in whom there is even the smallest diagnostic doub t on
plain film. In arecent study, over 5 0% of patients with normal initial chest
radiograph showed multiple injuries on the CT scan, among which were also
two (8%) potentially fatal aortic lesions. Therefore, primary routine chest CT
scan in all patients with major chest trauma was recommended
(Exadaktylos, et al., 2001).
Penetrating injury to the lungs may b e associated with damage to
other intra-thoracic structures with corresponding radiologic and clinical
manifestations. For example, laceration of the esophagus results in pneumo-
mediastinum, mediastinitis, and pleural effusion. The diaphragm can b e
damaged without evidence of visceral injury and with negative radiographic
findings; patients usually complain of ab dominal pain, and examination
reveals tenderness and rigidity of the ab dominal wall. When present, the
radiographic ab normalities associated with penetrating diaphragmatic injury
are non-specific and consist of hemo-thorax, pneumo-thorax, or apparent
elevation of the hemi-diaphragm (Fraser, et al., 1999 ).
Patients with chest trauma may present with a spectrum of severity
ranging from severe life-threatening injury requiring urgent operative
intervention to hemo-dynamically stab le patients with a negative initial
evaluation as shown in Fig. (1) . Most patients presenting with penetrating
chest injuries are admitted to the hospital. Often, even those with a negative
initial evaluation are admitted to exclude serious injury to the heart, lungs,
and the major b lood vessels ( Marc, et al., 2002).
41
!3hn it Pe ne trating
Mcolmnism o f Irlilit
Co ns ide r stopping
r esuscitation
No
I

3e,
transport to
the OR
REVIEW
Fig. (1) : Algorithm for management of chest trauma (Marc, et al., 2002).
Che s t traum a:
p ul s e p re s e nt?
EGG activityY
Systolic.: lilotyl ple;--miro
<60 rum I Ig de s p ite
irigiessive re s us c itatio n?
ORS or Vril) As y s Io l
I No Yes
Tension priouluir . thorax"?
Bl o o d p re s s ure i uproved
by Kiertle rincorn .
)ression?
No I
[
ref icardiocentesis:
Po s itiv e tap ?
Bl o o d p re s s ure improved?
I
r. ll I
S igns o f l ife
at the scene?
I r ac he a IrliubEited? 1
I
Ye 3.
CPR
.
< 1 ) ruin? CPR <5 m in?
No :
Co ntinue s tn Em e rge nc y tho rac to m y with
re s us c itatio n v o l um e re p l ac e m e nt and ao rtic o c c l us io n!
Is p ul s e p al p abl e ?
A re go o d he art conlrEtclions p re s e nt?
/12
REVIEW
I NITIAL TREATMENT
The physical examination of the chest is extremely important in
identifying life-threatening situations that require immediate attention.
Immediate priorities include estab lishment of a patent airway, maintain
adequate ventilation, and diagnose and treatment of shock (David, et al.,
2001 ).
Advanced Life Trauma S upport (ALTS ) of American college of
surgeons refers to the initial treatment of trauma as the primary survey or A
B Cs Airway, with cervical spine protection, b reathing, and circulation
(Jon, et al., 1 999).
The estab lishment of an adequate airway has the highest priority. If
ventilatory failure occurs and an adequate airway can not b e ob tained readily
b y oro-tracheal or naso-tracheal intubation, surgical crico-thyroidectoThy
should b e performed as rapidly as possib le (James, et al., 2003).
It is important to maintain breathing and make an adequate
ventilation. When tension pneumo-thorax is diagnosed, a needle or a cannula
may b e left in place while a chest tub e is inserted. Patients with flail
segments will almost always require prompt endotracheal intub ation and
mchanical ventilation. Open pneumo-thorax may lead to fatal
hypoventilation, initial treatment requires sealing of the wound with sterile
or even non sterile dressing (Marc, et al., 2002).
4 3
REVIEW
With a secure airway and adequate ventilation, circuIation should b e
evaluated, external control of hemorrahge should b e ob tained b efore
restoring circulating volume. Early in the course of pericardial tamponade,
b lood pressure and cardiac output transiently improve with fluid
administration, pericardiocentesis should b e done with evacuation of as little
as 1 5 to 25 ml of b lood which dramatically improve the hemodynamic
profile (James, et al., 2003; and Jon, et al., 1 999).
TUB E THORACOSTOIV1Y
Tub e thoracostomy (IT) is a frequently performed life-saving
maneuver in trauma and is a standard procedure for the evacuation of air,
b lood, or other materials from the pleural space. In adult patients, large-b ore
chest tub es, usually 36-42.F, should b e used to achieve adequate drainage in
adults. S maller-calib er tub es are more likely to occlude. In pediatric patients,
chest tub e size varies with the size of the child. In patients older than 1 2
years, the chest tub e size used is usually the same as that for adults. In
smaller children, a 24-34 F chest tub e should b e used, depending on the size
of the child (S ingh & Kapila, 2002).
The proper site of insertion is in the fifth or sixth intercostal space in
the mid-axillary line. The index finger should b e inserted into the pleural
space b efore tub e placement to b e sure that the pleural %cavity has b een
entered and is free of adhesions and that intra-ab dominal organs have not
herniated through the diaphragm. The tub e should b e advanced posteriorly
and superiorly in the pleural cavity. Following insertion, the tub e should b e
secured in the skin of the chest wall and connected to a collection system
44
REVIEW
under suction. A chest x-ray is usually ob tained after chest tub e insertion to
confirm adequate plaCement.and positioning. General criteria for chest tub e
removal include ab sence of air leak and less than 1 00 ml of fluid drainage
over a 24- hour period (David, et al., 2 001).
After tub e thoracostomy is performed, a repeat chest radiograph
should always b e ob tained. This helps identify chest tub e position, helps
determine completeness of the hemothorax evacuation, and may reveal other
intra-thoracic pathology previously ob scured b y the hemothorax. If drainage
is incomplete as visualized on the post-thoracostomy chest radiograph,
placement of a second drainage tub e should b e considered (Golden, 1999).
Contraindications of tube thoracostom y
Tub e thoracostomy drainage is relatively contraindicated when
significant pleural adhesions are known to b e present. Incomplete drainage
or inab ility to effectively access the area is likely. Also, b lunt division of
pleural adhesions may cause additional b leeding and result in liing
laceration. If evacuation of such collections is mandated clinically,
thoracotomy with divtsion of adhesions under direct vision is the safer
application (Ullm an, 2 003 ; and David, et al., 2 001).
Com p lications of tube thoracostom y

S everal studies to assess the complication rate of tub e thoracostomy in

trauma have revealed no persuasive evidence to support a selective
reduction in the indications for tub e thoracostomy in trauma. Complicati6ns
45
REVI EW
of tub e thoracostomy, e.g., organ lesions and mal-positioned tub es, are not
uncommon. To date, techniques for tub e placement have b een non-
visualized. A fully visualized penetration of the thoracic wall layers should
help to avoid not only perforations and organ lesions b ut also functionally
mat-positioned tub es. A . modified endoscopic devices, allowing fully
visualized and optically controlled access to the pleural cavity for routine
chest tub e placement (B ailey, 2000; and S chwegler & S chlumpf, 2000).
Multiple factors contrib ute to the development of post-traumatic
empyema. These factors include the conditions under which the tub e is
inserted (emergent or urgent), the mechanism of injury, retained hemo-
thorax, and ventilator care. The incidence of empyema in placeb o groups
ranges b etween 0 and 1 8%. The administration of antib iotics for longer than
24''hours did not seem to significantly reduce this risk compared with a
shorter duration of administration, although the numb ers in each series were
small. Most reports found a significant reduction in pneumonitis' when
patients received prolonged prophylactic antib iotics. Use of antib iotics might
b e b etter describ ed as presumptive therapy rather than prophylactic
(Luchette, et al., 2000).
THORACOTOM Y
Operative management are required b y only 1 5 to' 20 per cent of
patients with thoracic trauma. For those patients requiring thoracotomy, the
operation may b e required acutely or on a delayed b asis. Acute thorac'otomy
may b e necessary urgently, b ut in most situations, it is performed after a
systematic evaluation has revealed specific symptoms and proved injuries.
46
REVI EW
S ome conditions should not lead automatically to thoracotomy unless other
indications. Managing thoracic vascular injuries is still difficult and
challenging for thoracic and trauma surgeons, Early thoracotomy is
important for salvage of patients with chest-wall vascular injury. Hemo-
thorax and persistent thoracic b leeding is frequently an indication Tor
thoracotomy after trauma. The risk for death increases linearly with total
chest hemorrhage after thoracic injury. Thoracotomy is indicated when total
chest tub e output exceeds 1 5 00 nil within 24 hours, regardless of injury
mechanism ( Karmy, et al., 2001 ; and Rashid, et al., 2001 ).
The selection of patients for operation or ob servation can b e made b y
clinical examination and appropriate investigations. The trauma ultrasound
has b ecome a valuab le first-line tool to rule out pericardial tamponade.
Minimally invasive techniques have found sound application in he
thoracoscopic evacuation of un-drained hemo-thorax and the laparoscopic
evaluation of diaphragmatic trauma. Knowledge of the new advancements in
the field of thoracic trauma will allow surgeons to provide expert care and
improved the real outcomes of surgery (Demetriades & Velhamos, 2002).
EMERGENCY TII(MACOTOMY
Most thoracic injuries are managed with simple procedures such as
clinical ob servation, thoracocentesis, respiratory support,. and adequate
analgesia. The remainimz IS to 20% of patients sustaining chest trauma
reqyire a thoracotomy for definitive repair of major intra-thoracic injuries
(David , et al., 2001 ).
47
REVIEW
The role of emergency thoracotomy in the management of trauma
remains poorly defined despite an increase in its use. The b est outcome can
b e expected in patients who have sustained penetrating cardiac and thoracic
injuries. Penetrating ab dominal wounds that are severe enough to require
thoracotomy in the emergency 1
.
00111 ; those patients who suffer from b lunt
thoraco-abdominal injuries are least fortunate. The anatomic location and
mode of injury greatly ialluence the outcome of these patients. and are useful
in determining when to perfOrm this procedure (Frezza & Mezgheb e,
1 99,9).
Indications of emergency thoracotomy
An emergent thoracotomy is indicated after chest trauma as shown in
Table 3 in the following situations: cardiac arrest (resuscitative
thoracotomy), massive Il emothorax (greater than 1 5 00 nil of b lood through
the chest tub e acutely or greater than 200 to 300 ml per hour after initial
drainage), penetrating injuries of the anterior chest with cardiac tamponade,
large open wounds ol" the thoracic cage, major thoracic vascular injuries in
the presence of hemodynamic instab ility, major tracheo-b ronchial injuries
and evidence of esophageal perforation. Patients with penetrating trauma
with signs of life in the field, even if only electrical activity on cardiac
monitor or agonal respirations, are also candidates for urgent thoracotomy_ if
transport times are le:;s than 1 0 minutes. Non-emergent indications for
thoracotomy include empyema not resolved with tub e thoracostomy, clotted
hemo-thorax, lung al
,
:;eess, thoracic duct injuries, tracheo-esophageal
48
REVIEW
fistulas and chronic scquelac of vascular injuries (pseudo-aneurysms and A-
V fistulas) (Marc, et al., 2002; and David, et al., 2001 ).
Table (3) : I ndications of thoracotomy (M arc, et al., 2002).
INDICATIONS OF URGENT THORACOTOMY
1 -Cardiac arrest (resuscitative thoracotomy).
2-Massive hemothorax (greater than 1 5 00 ml of b lood through the chest
tub e acutely or greater lium 200 to 300 nil per hour after initial drainage).
3-Penetrating injuries of the anterior chest with cardiac tamponade.
4-Large open wound; of t he thoracic cage.
5 - Major thoracic vascular injuries
6- Major tracheo-bronchial injuries.
7- Evidence of esoptincalpetforation.
Contraindications of emergency lhoracotomy
Urgent thoracotomy may b e contraindicated in certain situations;
B lunt injuries (111tinithalacie injuries with no witnessed cardiac activity and
Multiple b lunt trauma) Ahtl Syere head injury. Also,severe acidosis (pH <
6.8) or closed chest CPR for hilore than 1 0 minutes in an intub ated patient or
5 minutes in a non-iotubatrd patient, b ecause no neurologically functional
survivors were sound b eyond lhe5c li mits (Karniy, et al., 2001 ).
Approach of emergencyThoracatomy
If the patient
-
h modynninically unstab le, once control is achieved
and cardiac activity restored, the patient is transferred rapidly to the
49
REVIEW
operating room
.
for delinitive management A supine antero-lateral
thoracotomy is the accepted approach. A left sided approach is used in all
patients in traumatic arrest and with injuries to the left chest. Patients who
are not arrested b ut with profound hypotension and right sided injuries have
their right chest opened first. In b oth cases it may b ecome necessary to
extend the incision across the sternum to aid access and vision. With a right
sided thoracotomy, the left Chest will have to b e opened if internal cardiac
massage b ecomes ii(!c
,
n5ary. Gaining access to the thoracic cavity should
take no more tlian minute:;. After rapid skin preparation with large
antiseptic-soaked swAs, a slain incision is made in the 5 th intercostal space
from the b order of the 5tet
-
num to the mid-axillary line. This is continued
down through subcul;.11
,
.: ous tissues to reach the intercostal musculature. The
intercostal muscles arc incised with a comb ination of scalpel, heavy scissors
and b lunt dissection Vani
-
es, et nt., 2(1 03; and David, et al., 2001 ).
S urgeon should insert
.
the rib spreaders b etween the rib s and take care
not to lacerate the lung zWthis stage. If the thoracotomy has to b e extended to
the other side of the chest, ret at. the thoracotomy on the other side. To
divide the stern u m, a _ large p air of trauma shears (as used to cut the clothes
off patients) will easily golFirough the sternum. Otherwise the Gigli saw is
used to divide the sternum. bikvision of the sternum results in transection of
the internal maiiimary a)rttries. These will start to b leed once b lood pressure
is restored and will need clipping
-
and ligation sub sequently (Grove, et al.,
2002).
To relief card* ta nipurrAde, the pericardium is opened longitudinally
to avoid damage -to the phrellicnrve, which runs along its lateral b order. It
50
REVIEW
is difficult to visualize the phrenic nerve in the emergency thoracotomy.
Make a small incision in the pericardium with scissors and then tear the
pericardium longitudinally \\Hill your fingers - this will avoid lacerating the
phrenic nerve. Evacuate any b lood and clot from the pericardial cavity
(David, et al., 2001 ).
AB B REVIATED TBORACOTOMY
Ab b reviated thoracotomy is a useful strategy in the treatment of
severe chest trauma. Its use in situations of metab olic exhaustion or planned.
re-exploration may increase patient survival rates b y expediting transfer of
the patient from th operating room to the ICU, where homeostasis can b e
restored (Vargo, et aL, ZOO I).
Operative abbreviated thoracotomy techniques in thoracic trauma
include emergency center ihoraeotomy, ligation of major arterial b ranches,
packing the thoracic cav ity for diffuse b leeding, towel clip or B ogota b ag
closure of the chest, and pulinonary tractotomy. Pulmonary tractotomy with
selective vascular ligailich 'vas describ ed for deep through-and-
through lumi, injuries
-
that did not involve hilar vessels or airways.
Pulmonary tractotorny has eve! \f.. d into use as an ab b reviated thoracotomy
technique in patients wit+ 5;.'vere thoracic or multi,-visceral trauma.
Emergency lung vcsecticon
-
following penetrating chest trauma has b een
associated with motoility reites as high as 5 5 -1 00%. Pulmonary tractotomy is
advocated as a rapid al tern* iv e m ethod of dealing with deep lob ar injuries
(Gasparri, et al., 20(1 1 ; trid Will, et al., 2001 ).
51
REVIEW
THORACOS COPY
Thoracoscopy is a minimally invasive technique that is increasingly
used in the management of trauma victims. It has b een used for b oth
diagnostic and therapeutic purposes. The appropriate use of intercostal
drains and therapeutic thoracoscopy are important considerations in
penetrating non-cardiac thoracic trauma (B oulanger, et al., 2001 ; Li , et al.,
2000; and Von Oppell, et al., 2000).
Generally, Video-assisted thoracoscopic surgery (VATS ) has a
diagnostic and therapeutic roleAn the treatment of patients with chest trauma,
b ut the b asic rule of safety over technology must b e applied. Recent
improvements in video technology and endoscopic surgical instruments have
fostered renewed interest in VATS to diagnose and treat a variety of surgical
conditions of the chest, which classically were managed exclusively b y
thoracotomyit should b e considered as a procedure of choice; with
exceptional results in the following chest diseases; undiagnosed pleural
effusions, recurrent, post-traumatic, or complicated spontaneous pneumo-
thorax, stage II empyema, accurate staging of lung cancer, emergency
traumatic injuries of the chest, peripheral solitary pulmonary nodule < 3 cm,
and Lung b iopsy for pulmonary diffuse disease. Video-thoracoscopy has
reduced the numb er of thoracotomies performed, and hence, thoracotomy
can b e limited to massive b leeding with hemo-dynamic it Aiability, major air
leak, mediastinal enlargement or diaphragmatic rupture, or major antero-
lateral flail chest ( Mineo, et al., 1 999; and Petrakis, et al., 1 999).
52
REVI EW
VATS appears to b e a safe, accurate and reliab le operative therapy for
the assessment of diaphragmatic injuries, control of continued b leeding and
evacuation of clotted hemo-thorax, empyemas, and persistent air leaks in
selected hemo-dynamically stab le and asymptomatic patients, reducing the
hospital stay and possib le complications. Thoracoscopic repair of traumatic
diaphragmatic rupture can b e used safely when no ab dominal organ injuries
are found ( Pad, et al., 2002 ; Lornanto, et al., 2001 ; Martinez, et al.,
2001 ; and Lowdermilk & Naunheim, 2000).
Post-traumatic retained hemo-thorax complicated b y b lood clotting in
the thoracic cavity currently is b eing managed at most institutions b y VATS ,
with consistently good results. The success of the procedure is assured b y
early intervention in appropriately selected patients. CT is the ultimate test
on which to b ase decision-making (Carillo & Richardson, 1 998).
53
REVI EW
TRE ATME NT OF SPE CI FI C THORACI C I NJURI E S
TREATMENT OF RIB FRACTURES
The main stay of treatment is adequate analgesia coupled with
meticulous respiratory care in order to prevent complications. Treatment can
b e as an outpatient, b ut patients with more severe fractures may b e admitted
to hospital for oxygen therapy, ventilation, aggressive analgesic techniques
and physiotherapy as shown in table 4 ( Middelton, et al., 2003).
With simple fractures, pain on inspiration is the principal symptom;
treatment consists of providing an adequate analgesia. In cases of multiple
fractures, Analgesia could b e provided using systemic opioids,
transcutaneous electrical nerve stimulation or non steroidal anti-
inflammatory drugs. Alternatively, regional analgesic techniques such as
intercostal nerve b lock, epidural analgesia, intrathecal opioids, interpleural
analgesia and thoracic paraverteb ral b lock have b een used effectively.
Although invasive, in general, regional b locks tend to b e more effective than
systemic opioids, and produce less systemic side effects. Measures such as
strapping the chest wall with adhesive tape or the placement of elastic
b inders may interfere with adequate ventilation and may lead to the
development of atelectasis (James, et al., 2003; and karniakar, 2003).
Rapid mob ilization, and meticulous respiratory care can prevent
respiratory complications. Rapid mob ilization can include oscillation
therapy or b ody positioning in patients that are on b ed rest or intub ated. This
54
REVIEW
mob ilization can involve the patient's amb ulating, sitting up in b ed, or
getting out of b ed to move into a chair. Respiratory care entails incentive
spirometry, pulmonary toilet, and even mechanical ventilation, when
indicated. In splinting the fractures, adhesive strapping or chest b inders
should b e avoided in all patients b ut the very young (Kerr, et a l., 2003).
Patients with isolated rib fractures should b e hospitalized if the
numb er of fractured rib s is three or more. S urgical correction and internal
fixation indicated for rib s with multiple fractures per rib producing flail
segments or when the fractured rib s penetrate into the lung tissue and lead to
sub sequent injuries. Once exposed, the fractures can b e reduced and fixed
using either simple wire sutures or b y using kirschner wire as intra-
medullary p ins ( Mehmet, et a l., 2003).
TRE ATME NT OF STE RNAL FRACTURE S
Isolated sternal fractures have low associated morb idity and mortality.
Admission is justified for the management of pain and treatment of cardiac
complications and concomitant injuries. Taping or splinting of sternal
fractures is relatively contraindicated, as restriction of normal chest
expansion during respiration can lead to atelectasis and pulmonary
insufficiency. Primary treatment is an adequate analgesia with non-steroidal
anti-inflammatory drugs and opiates. S election of these should b e on the
b asis of relative indications and contraindications for each patient and
administration should b e in standard doses and routes. S ternal fractures can
55
REVIEW
take weeks to heal, offering only adequate analgesia for this recovery period
is widely recommended. Patients with significant chest wall instab ility
require open reduction and internal fixation (Duncan, et al., 2002).
Operative stab ilization using internal fixation is indicated in isolated
injuries to achieve analgesia or long-term cosmetic improvement. The main
concern of sternal injuries is the potential for associated underlying injuries
that can b e life threatening, such as aortic disruption, cardiac contusion, and
pericardial effusion. S erial electrocardiograms with cardiac enzymes and
echocardiography commonly are used to rule out these injuries (David, et
al., 2001 ).
An aggressive approach including early operative reduction may b e
recommended even for a stab le fracture to reduce the overhelming pain.
S ternal fracture with or without retrosternal heamatoma is not a reliab le
indicator of cardiac and aortic injuries, while mediastinal widening is still a
fairly reliab le clue that should indicate further investigation (Rashid, et al.,
2001 ).
Nonunion of sternal fractures is very rare. Transverse sternal nonunion
is a complication of sternal fracture or sternotomy, and requires surgical
treatment. Patients with repeated failure of standard sternal repair were
treated with a technique using metal plates and autogenous hone graft. Metal
plating of the sternum, accompanied b y autogenous b one graft, is an effective
method of treating transverse sternal nonunion (Min & S ung, 2003).
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REVIEW
Painful pseudo-arthrosis or overlap deformities may require delayed
surgical repair. The presence of a large hematoma, and another source of a
staphylococcal infection requires open deb ridement (Sa da ba , et a l., 2000).
TRE ATME NT OF FLAI L CHE ST
Flail chest can severely impair pulmonary functions; vital capacity
(VC ) and functional residual capacity ( FRC ), which can b e reduced to
5 0% of predicted. The initial reductions in FRC and VC after flail chest
.
can
b e attrib uted to disordered chest wall motion. VC either returns to its
b aseline value within 6 months or remains mildly reduced. In contrast,
patients with pulmonary contusion complicating flail chest may have
persistent reductions in FRC for up to 4 years, which may b e due to fib rous
changes in the contused area. Thus, flail chest without pulmonary contusion
may cause less long-term respiratory dysfunction (Rich a rd & Co urtney ,
2000 ).
In flail chest, Ventilation-perfusion mismatch and lung contusion
cause hypoxemia. In most cases, supportive care with attention to
oxygenation, clear airways, and infection prevention is the preferred therapy.
Artificial ventilation should b e reserved for patients with ventilatory failure.
When the flail segment is large, chest fixation may b e considered, as shown
in tabIe (4) (Bartolome, 2000).
57
1
REVIEW
Table (4) : Treatment of chest wall injuries (Bartolome, 2000).
FYPE OF
TRA UM A
Manifestations Managem ent
RI B
FRA CTURES
- Fractures of the first three ribs
are rare but deadly due to
laceration of the subclavian
artery.
- Fractures of the lower ribs are
associated with injury to the
sp leen and liver.
- The p atient m ay ex p erience
severe p ain, tenderness, and
m uscle sp asm over the site of the
fracture.
- There m ay be bruising around
the fracture site. A crackling
grating sound in the thorax m ay
be detected.
The goals of treatm ent are to
control p ain and detect and treat
the injury.
- Sedation is used to allow for
deep breathing and coughing.
Intercostal nerve block, ice to the
area, and a chest binder m ay also
be used to abate the p ain which
usually subsides in 5 to 7 days.
- Most fractures heal within 3 to 6
weeks.
- During insp iration, as the chest
ex p ands, the detached p art of the
rib segm ent (flail segm ent) will
m ove in a p aradox ical m anner in
that it is p ulled inward during
insp iration reducing the am ount
of air that can be taken into the
lungs.
- On ex p iration, the flail segm ent
will bulge outward im p airing the
p atient' s ability to ex hale.
- Lung contusion and atelectasis
often accom p any flail chest.
- Managem ent includes- p roviding
ventilatory sup p ort, clearing
secretions from the lungs, and
controlling p ain.
- The underlying p ulm onary
contusion is treated by restricting
fluid intake and p rescribing
diuretics, etc. while relieving chest
p ain.
- In severe flail chest, ET
intubation and m echanical
v entilation are p erform ed.
- The p atient will be m onitored
by serial chest x - rays, AnGs, p ulse
ox im etry, and p ulm onary function
study.
FLA I L CHEST
58
Antero-lateral flail chest injuries accompanied b y respiratory
insufficiency can b e effectively stab ilised using reconstruction plates. Early
restoration of the chest wall integrity and respiratory pump function may b e
cost effective through the prevention of prolonged mechanical ventilation
and restriction-related working incapacity (Lardinios, et al., 2001 ).
S urgical stab ilization of the flail chest is rarely necessary. S urgical
stab ilization is not routinely performed, S tab ilization of the chest wall has
b een attempted using weights and rib b inders, as well as fixation devices
such as pins and plates. Possib le candidates for external fixation include
patients not responding to analgesia and those who have no concurrent
prob lems for which they need prolonged mechanical ventilation. In addition,
young patients and patients with unstab le, large segments and b order line
pulmonary functions may b e candidates for external fixaion (David, et al.,
2001 ; and Dennis & Dudley, 2000).
Operative wire fixation is most commonly performed in patients
requiring a thoracotomy for other reasons or in cases of gross chest wall
deformity. Underlying pulmonary injury with respiratory insufficiency
resulting from changes in tidal volume and minute ventilation in these
patients is rare. Assessment of the severity of underlying pulmonary
contusion versus chest wall instab ility should direct the need for surgical
fixation. Pre-operatively, a doub le-lumen endotracheal tub e should b e
considered in patients undergoing fixation. Intra-operatively, b oth ends of a
fractured rib must b e stab ilized for operative intervention to b e most
59
REVIEW
effective. Routine postthoracotomy care with ICU or surgical step-down
level ob servation and close monitoring of respiratory parameters is crucial.
Follow up chest x-rays and pulmonary function tests determine resolution of
underlying pulmonary pathology and any possib le long-term disab ility as a
result of the initial condition (Liman, et al., 2003).
TREATMENT OF TRAUMATIC HEMO-THORAX AND PNEUM0-
THORAX
Tension pneumo-thorax must b e considered and treated appropriately.
If a tension pneumo-pericardium is suspected, then an immediate pericardio-
centesis with aspiration of air from the pericardial space may b e lifesaving.
Most traumatic pneumo-thoraces should b e treated with tub e thoracostomy.
If the patient has an occult pneumo-thorax or if the distance b etween the
lung and chest wall does not exceed 1 .5 cm, however, tub e thoracostomy is
prob ab ly not indicated unless the patient is receiving mechanical ventilation.
Two uncommon diagnoses, b oth of which are indications for immediate
thoracotomy, should b e considered for any patient with a traumatic pneumo-
thorax. Fracture of the trachea or a major b ronchus can lead to a pneumo-
thorax (Marc, et al., 2002; and Richard & Coutrney, 2000).
Hemo-thoraces are initially treated b y chest tub e placement (36
French tub e), b ut this requires a prolonged hospital stay and 20% of patients
treated continue to have a residual clot. In approximately 85 % of the cases,
the b leeding will stop as the lung is re-expanded b ecause of the low pressure
in the systemic circulation. A small numb er of cases will have continued
b leeding and will require a thoracotomy. These are usually injuries in
60
REVIEW
systemic arteries (intercostal arteries or internal mammary artery) or veins,
major pulmonary vessels, or cardiac in origin, and auto-transfusion should
b e considered in these circumstances (Da vid, et a l., 2001).
Approximately 20% of patients with hemo-thorax require
thoracotomy. Immediate thoracotomy is indicated for suspected cardiac
tamponade, vascular injury, pleural contamination, debridement of
devitalized tissue, sucking chest wounds, o r major b ronchial air leaks.
Continued pleural hemorrhage is another indication for prompt thoracotomy.
B efore thoracotomy is performed for this reason, it is important to ascertain
that the b leeding is not from a misplaced central venous catheter. This
diagnosis is readily estab lished b y examining the appearance of the pleural
drainage when the character of the infusion fluid is changed (Rich a rd &
Co urtney , 2000).
The main pleural complications of traumatic hemo-thorax are the
retention of clotted b lood in the pleural space, pleural infection, pleural
effusion, and libro-thorax. If more than 30% of the hemi-thorax is occupied
b y clotted b lood, the hemi-thorax should b e evacuated Residual thoracic
collections after thoracic trauma occur in 5 -30% of patients and are a major
risk factor for development of empyema (Paci, et a l., 2002; a nd Rich a rd &
Co urtney , 2000).
TRE ATME NT OF PULMONARY I NJURI E S
61
REVIEW
Management of pulmonary lacerations is directed toward maintaining
good oxygenation and adequate pulmonary toilet. Judicious crystalloid
infusion is important to avoid fluid overload and pulmonary edema;
however, intravascular volume depletion also should b e avoided to decrease
the risk of glob al ischemia and multiple organ failure. Patients with
persistent low Pa0
2
levels who do not respond to supplemental oxygen,
pulmonary toilet, and pain control should b e intub ated and mechanically
ventilated. Correction of acute anemia and coagulopathy, b y means of
transfusing packed red b lood cells and b lood products, is important to
minimize b lood loss and increase oxygen carrying capacity and delivery to
the tissues. No b enefits have b een demonstrated with the use of prophylactic
antib iotics or steroids (Da vid, et a l., 2001).
Management of pulmonary lacerations usually includes chest tub e
placement to drain b lood collection in the pleural space and re-expand the
lung. The operative techniques include pneumonectomy, lob ectomy,
b roncho-plasty, and minor repairs. Injury severity scores (IS S ) of 36 or
more show a trend toward a correlation with poor prognosis in patients with
lung lacerations. Thoracotomy decreases mortality rate of patients suffering
from lung lacerations resulting in hemo-thorax more than 300 ml/h (Huh , et
a l., 2003).
TRE ATME NT OF CARDI AC I NJURI E S
Most therapy for cardiac trauma requires an operating room,
preferab ly with cardio-pulmonary b ypass capab ility. B asic patient care
should occur en route to the treatment facility. The operative techniques used
62
REVIEW
may extend from simple suturing of the myocardial injury to emergency
aorto-coronary b ypass grafting |Argete, et al , 2002; a d Stewart, 2002)
If cardio-pulmonary arrest occurs b efore the patient with peri-cardial
tamponade can b e transported to the operating room, emergency room
thoracotomy with relief of the tamponade should b e performed |Jame , et
al , 2003)
The management of penetrating cardiac injuries has undergone a
transition from simple pericardio-centesis to cardiac ultrasound evaluatie in
the stab le patient, and an emergency thoracotomy and repair of myocardial
wounds in the hemodynamically unstab le patient in extremes. S tab le patients
should have a chest x-ray to identify other injuries and to determine the
trajectory of the missile in the case of gunshot wounds. Diagnosis usually is
made b y echocardiography, identifying ab normal amounts of pericardial
fluid, or more accurately b y performing a sub xiphoid pericardia window. If
the result is positive, a median sternotoniy is performed for definitive cardiac
repair |Harri , et al , 200l; a d Kari , et al , 200l)
For management of cardiac wounds which form a large holes, a 1 6F
foley catheter with a 30 n1 L ballon can b e inflated with 1 0 mL saline
solution, gentle traction on the catheter controls the hemorrhage.Clamping of
the superior and inferior venae cavae can b e performed for S hort peroids for
the treatnent of extensive or multiple injuries. Wounds in proximity to
coronary arteries must b e repaired with horizontal mattress sutures placed
under the artery to avoid infarctions distal to the repair, pledgeted sutures
may b e necessary to prevent the sutures from pulling through the
63
REVIEW
myocardium, particulary in rigid ventricles. The use of skin staplers for the
temporary control of the hemorrhage has b ecome popular and alternative to
the sutures (Saleldan, et a l., 2003).
S equelae or complications after cardiac repair include valvular
insufficiency or septal defects. Repair of these acquired lesions may involve
valve replacement or repair, or patch closure of septal lesions, and should b e
performed at a later time (Hibino, et a l., 2003).
TRE ATME NT OF GRE AT VE SSE LS I NJURY
Patients with thoracic vascular injuries fall into two groups: those who
are exsanguinating and require an empiric operation with a high mortality
and those with contained injuries that permit pre-operative evaluation. The
unstab le group requires judgment to determine the appropriate empiric
position, exposure, and operation. Unlike _ ab dominal trauma, which is
addressed b y way of a midline incision, penetrating injuries to the thoracic
outlet vessels present special access prob lems. There are multiple thoracic
incisions that can b e used to access thoracic vascular injuries. Patients with
perforating lesions with median sternotomy has to b e performed if
circulation is still functioning marginally. In a severe hemorrhagic shock it
can b e necessary to do an immediate emergency lateral thoracotomy (W a ll,

et a l., 2001).
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REVIEW

Known injuries to the ascending aorta and arch are exposed b y median
sternotomy, Known injuries to the descending thoracic aorta can b e exposed
through a postero-lateral thoracotomy. These injuries are more commonly
diagnosed through emergent exploration b y means of antero-lateral
thoracotomies. Pre-operative arteriography is extremely useful in managing
penetrating injuries to the thoracic outlet, as it allows the choice of
appropriate incisions for exposure and control. Innominate artery, right
common carotid or sub clavian artery, as well as left intra-thoracic common
carotid artery injuries are b est managed via median sternotomy with
appropriate extension. Left sub clavian arteries are managed with high left
antero-lateral thoracotomy for proximal control comb ined with supra-
clavicular incision. Distal sub clavian arteries are managed with proximal
control b y a supra-clavicular incision and distal control b y an infra-
clavicular incision. The b ypass principle is useful for managing innominate
or left carotid artery injuries. Ligation with brachio-cephalic b ypass can b e a
simple solution to a com p lex prob lem. S oft grafts, fine sutures, and minimal
mob ilization are the tecliiiiques of choice. Adjuncts such as Fogarty b alloon
catheters, Foley catheters, auto-transfusion, shunts, and pulmonary
tractotomy can b e useful in managing these injuries. Documentation of the
preoperative neurovascular status of the patient should b e performed, as well
as discussion with the patient and the family, if availab le, of the potential
outcome with appropriate documentation in the chart. Rehab ilitation services
should b e involved as appropriate to care for these patients. Ligation is
always an option to save the patient's life (James, et al., 2003; David, et
al., 2001 ; and Wall, et al., 2001 ).
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REVIEW

The accepted treatment for acute traumatic rupture of the thoracic
aorta has b een repair of the injury as soon as possib le. This form of
management, however, has b een accompanied b y a death rate of 0% to 5 4%
mortality, often related to the presence. of other injuries. The accepted
treatment for acute traumatic rupture of the thoracic aorta has b een repair of
the injury as soon as 1)()Sible. This form of management, however, has b een
accompanied b y a c1eath rate of 0% to 5 4% mortality, often related to the
presence of other injuries (5ymbas, et al., 2002).
The descending thoracic aorta is approached through a left postero-
lateral thoracotomy in the
-
fourth intercostal space. A midline sternotomy
with full cardiopulro ona ry b ypass is used for repair of the ascending aorta.
The standard operative repair of aortic injuries uses clamp and direct
reconstruction and can b e achieved b y using one of three adjuncts:
pharmacologic contr o l of central hypertension, a temporary passive shunt, or
pump-assisted atrio-fmoral b ypass (Orfo rd, et al., 2003; and Wall, et al.,
2001 ).
The use of encloviascular stent grafting may b e a safe and feasib le
method for the treAtmerit- of rupture of the descending thoracic aorta in
selected patients without infection. Its usefulness for long-term prognosis
appears to b e extretrwly li mited, especially in patients with infection (Ka to ,
et a l., 2003).
Ruptured thoracic aortic aneurysms can b e repaired with a gratifying
rate of salvage. Rapid diagnosis and triage for repair is necessary to avoid
progressive deterioration into shock. The incidence of myocardial infarction,
66
REVIEW
and the mortality associated with this event, underscores the need for
aggressive cardiac evaluation in the elective thoracic aneurysm patient. The
size at rupture also emphasizes the need for earlier referral for elective
aneurysm repair (Girardi, et al., 2002).
The operative management of the injured coronary artery is dependant
on the location of the injury and whether there is myocardial dysfunction.
Distal injuries with small myocardial infarction should b e treated b y ligation
alone. Proximal injury and those injuries associate with larger area of
ischaemia or iiifarction are b est treated with coronary artery b ypass. The role
of cardiopulmonary b ypass pump in these patients should b e evaluated
depending on the homodynamic stab ility of the patient (Karin, et al., 2001 ).
Laceration of intercostal or internal mammary arteries can b e life-
threatening and operative intervention b ased on chest tub e output. The
pulmonary vessels are rarely the source of major b leeding unless a hilar
vessel is injured. Isolated injuries of the pulmonary artery are amenab le to
surgical repair and have a good prognosis ( Fraser, et al., 1 999 ).
TREATMENT OF DIAPHRAGMATIC INJURIES
B lunt and penetrating diaphragmatic injuries have different clinical
characteristics. S o they should b e dealt with differently to reduce the
incidence - of complication and improve prognosis. B lunt diaphragmatic
injury (B DI) can easily b e missed in the ab sence of other indications for
prompt surgery, where a thorough examination of b oth hemi-diaphragms is
67
REVIEW
mandatory. A high index of suspicion comb ined with repeated and selective
radiologic evaluation is necessary (Athanassiadi, et al., 1 999).
With traumatic ruptures, the surgical approach depends on the timing
of the diagnosis with the surgical intervention. In the acute phase of trauma,
an ab dominal approach is preferred b ecause 89% of patients with traumatic
rupture have other associated intra-ab dominal injuries. In the latent phase of
trauma, a trans-thoracic approach may b e necessary b ecause patients often
have adhesions to intra-thoracic organs (Cameron , 2001 ).
, B lunt diaphragmatic rupture in the ab sence of other surgical injuries
carries low mortality. Repair of diaphragmatic rupture can b e deferred
without appreciab le increased mortality if no other indication mandates
immediate surgery (B ergeron, et al., 2002).
At the time of surgical exploration, the entire diaphragm should b e
inspected. Diaphragmatic injuries are repaired with interrupted horizontal
sutures. Larger defects may require use of a prosthetic material. Relatively
no contraindications exist for repair of an acquired diaphragmatic hernia. In
the, trauma setting, one must ensure the patient is adequately resuscitated
prior to proceeding to the operating room. Any time a diaphragmatic hernia
is present, it imposes a risk of incarceration of enteric contents and, as such,
requires operative intervention (Cameron , 2001 ; and David , et al., 2001).
Acute diaphragmatic rupture is usually repaired through a midline
ab dominal incision b ecause of the increased incidence of associated intra-
ab dominal injuries. The diaphragm should b e sutured with closely placed,
68
heavy, non ab sorb ab le sutures. Chronic defects discovered months or years
after the initial injury can b e treated through a trans-thoracic, an ab dominal,
or a comb ined approach. Thoracotomy with reduction of herniated organs
can b e performed safely with satisfactory results. Acute diaphragmatic
injuries are b est approached through the ab domen, as more than 89% of
patients with this injury have an associated intra-abdominal injury. Patients
with diaphragmatic rupture presenting in the latent phase have adhesion
b etween the herniated ab dominal and intra-thoracic organs, and thus the
rupture is b est approached via a thoracotomy (Haci, et al., 2004; and
Lornanto, et al., 2001 ).
TREATMENT OF TRACHEO-B RONCHIAL INJURY
Taking into account the size of the lesion and the resulting respiratory
status, surgical reconstruction of the injured airway is often necessary. More
severe injury may even require lob ectomy or pneumonectomy, Late
complications of untreated tracheo-b ronchial injury include b ronchial
stenosis, recurrent pneumonia and b ronchiectasis. Prompt treatment lead to
good recovery (Chu Chen, 2002).
Care must b e taken when attempting b lind incub ation to not place the
endotracheal tub e through a transected airway into the soft tissue or a false
passage. In most cases, thoracotomy with intra-operativetracheostomy and
surgical repair of the disrupted airway should b e performed as soon as
possib le (Marc, et al., 2002).
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REVIEW
Minor injuries of the upper airway alter b lunt trauma should b e treated
b y placing the endotracheal tub e b eyond the injury. If this is not possib le, a
tracheostomy should b e performed. More extensive wounds, greater than
one third of the circumference of the airway, are primarily repaired after the
contra-lateral b ronchus has b een selectively intubated (Richardson, et al.,
2004; and David , et al., 2001 ).
Injury to b ronchi and the thoracic trachea that do not cause a persistent
air leak, and where the lungs expand completely after insertion of chest
tub es, may b e managed conservatively. All other injuries to the tracheo-
b ronchial tree should b e repaired surgically as soon as feasib le (Tina &
Diana, 2001 ).
Conveniently localized short lacerations, especially if they do not
involve the whole thickness of the tracheal wall, can b e treated with
antib iotics and intub ation with the cuff inflated distal to the tear, avoiding
high intra-b ronchial pressUres also after eventual extub ation. In all other
cases surgical repair is to b e preferred (Gab or, et al., 2001 ).
Tracheo-b ronchial ruptures in children are rare. An early fib roscopy
holds an important place in the approach of this pathology. Treatment is
variab le, b ased on thoracic lesions, their tolerance b y the child, and
associated lesions. S urgery is not the only therapy b ecause conservative
treatment b y simple thoracic drainage or lesion intub ation has proved
effective. Appropriate pre-, intra-, and post-operative management is
mandatory for a satisfactOry functional outcome (Schrediler, et al., 2001 ;
and Still
-
lane, et al., 1 999).
7 0
REVIEW
Tears in the esophagus are common in patients with tracheal injuries,
and the esophagus has to b e assessed b y flexible and rigid esophagoscopy, as
well as b y direct examination through the incision. Esophageal injuries
should b e meticulously closed during the same procedure, and interposition
b etween the esophageal and laryngo-tracheal repairs b y strap muscle,
pericardium, pleura, or omentum is required (Tina & Dia na , 2001).
More severe tracheo-bronchial injury may even require lob ectomy or
pneumonectomy. Late complications of untreated tracheo-bronchial injury
include b ronchial sten
-
Osis, recurrent pneumonia and b ronchiectasis. Prompt
diagnosis and treatment generally lead to good functional recovery (Ch u &
Ch en, 2002).
Laryngo-tracheal and tracheo-b ronchial injuries should b e followed
for several months after the trauma with repeated endoscopies, and
dilatations or resections of stenotic areas should b e performed. Long-term
pulmonary function after tracheal and b ronchial anastomosis has b een shown
to b e excellent (Tina & Dia na , 2001).
TRE ATME NT OF E SOPHAGE AL PE RFORATI ON
Esophageal perforation is a highly lethal complication that demands
early surgical consultation. Non-operative approaches apply only to very
specific situations. Patients whose perforation was iatrogenic and discovered
early are the b est candidates for non-operative management. Perforations
7 1
REVIEW

into the ab dominal or pleural cavity require immediate surgical repair
(David & George, 2002).
Treatment consists of early deb ridement, primary repair, and drainage
if identified within 24 hours after injury, Injuries diagnosed after 24 hours
with mediastinal contamination are treated b y cervical esophagostomy and
distal feeding access. Esophageal resection is rarely needed, b ut may b e
indicated in esophageal necrosis or severe mediastinitis (David, et al.,
2001 ).
The b asic approach to injuries of the esophagus is to achieve primary
repair of the majority or injuries. The esophagus must b e sufficiently
mob ilized to allow !WI evaluation of the wound and careful deb ridement of
devitalized tissue. The injury should b e repaired primarily i ['possib le, either
b y the one-layer or two-layer technique. If there is sufficient tissue loss to
preclude primary repair, a cervical esophagostomy should b e done as a
temporizing measure, with plans for complex reconstruction of the
esophagus after the initial trauma has resolved. A drain should b e left in
place after all esophageal repairs. Leakage from the repair is not an
uncommon complication. If the fistula is well controlled, the clinical course
is generally b enign, whereas uncontrolled leakage into the neck can lead to
devastating infection. in cases operated upon after the first 1 2 hours, there is
estab lished infection arid inflammation. Under these circumstances, primary
repair is usually impossib le (Gupta & Ka ma n, 2004; a nd Ma rc, et a l.,
2002).
7 2
P
PAT IENT S AND M ET HODS
PATI E NTS AND ME THODS
Retrospective evaluation and analysis of all the files and investigation
papers of 41 1 patients who were admitted to El-Minia and Assiut University
Hospitals over a peroid of 1 2 months started at January 2001 are included in
this thesis. Data that ob tained were analysed according to the following
protocol :
I - Personal Data : I hese data include name, age, and sex that help
evaluation of the incidence of trauma according to age and sex.
2 - Adm ission Data :These data include the general condition of the patient
when admitted that determine mechanism of trauma, type and severity of
injury, and initial lines of treatment.
3 - Op erative Data :These data identify the surgical approaches, findings
dicscovered intra-operatively, and the surgical decisions to correct the
underlying injury.
4 - Consultation and referral sheets Data :These data give an idea ab out
the non surgical procedures and investigations for chest trauma, associated
non thoracic injuries, the post-operative complications, and the progress.
5 - Laboratory studies Data: A complete blood cell ((BC) count is a
routine lab oratory test for most trauma patients, the CBC count helps
gauge b lood loss. Arterial blood gas (AJ3G) determinations are an
73
PAT IENT S AND M ET HODS
ob jective measure of ventilation and oxygenation and their results help guide
therapeutic decisions such as the need for endotracheal intub ation. Patients
who are seriously injured and require fluid resuscitation should have
periodic monitoring of their electrolyte status.
6- Im aging studies Data: A chest radiography (CXR) is an important
adjunct in the diagnosis of many conditions, including chest wall Fractures,
pneumothorax, hemothorax, and injuries to the heart and great vessels (e.g.,
enlarged cardiac silhouette, widened mediastinum). Chest CT scans are more
sensitive than CXRs for the detection of injuries such as pneumothoraces
and pulmonary contusions. Ultrasound examinations of the pericardium,
heart, and thoracic cavities Pericardial effusions or tamponade can b e
reliab ly recognized, as can hemothoraces associated with trauma.
7- Diagnostic tests and p rocedures: Electro- cardiography (ECG ) findings
can help identify new cardiac ab normalities and help discover underlying
prob lems that may impact treatment decisions. Transthoracic
echocardiogram (TTE) i mages can help identify pericardial effusions or
hemorrhage and tamponade and can demonstrate valvular ab normalities and
disturb ances in cardiac wall motion.
8- Medication sheets : These data identify the decided treatment with
conservative measures or after surgical intervention.
9- Progress notes :These data identify the outcome of the nianagement that
include improvement, complications, or death.
74
PATIENTS AND METHODS

l0 Di charge Data :On discharge, patients were categorized as: patients
with improvement, patients referred to another department due to associated
non thoracic injury, patients who improved with morb idity, and patients
who died after treatment of chest trauma.
According to American Association of Thoracic S urgeons (A.A.T.S ),
our patients were classified as following:
l ) According to the machanism of trauma, patients were divided into
2 groups:
G roup I : B lunt chest trauma that was sub divided into road traffic
accidents, and fall from a height.
G roup II : Penetrating chest trauma that was sub divided into firearms
and stab s.
II ) According to the method of treatment, our cases were divided into
4 groups:-
Group I : Conservative management including pain control, external
fixation of fractures, and follow up.
G roup II : Tub e thoracostomy.
G roup III : Thoracotomy.
G roup IV : Other surgical procedures including tracheostomy for
tracheal injury and laparotomy for associated ab dominal injuries.
lll ) According to the pathological types of thoracic injury, patients
were divided into 9 groups, each group is studied for tho most common
mechanism of trauma, the method of treatment, and other associated thoracic
injuries :
75
PAT IENT S AND M ET HODS
G roup I : Chest wall injuries including rib fractures, flail chest, and sternal
fractures.
G roup II: Pulmonary injury including pulmonary lacerations and pulmonary
contusions.
G roup III : Hemo-thorax and/ or pneumo-thorax.
G roup IV : Cardiac injuries.
G roup V : Great vessels injury.
G roup VI : Diaphragmatic tear and post-traumatic hernia.
G roup VII: Tracheo-bronchial injury.
G roup VIII: Esophageal injury.
G roup IX : Associated injuries.
S tatistical Analysis
Descriptive statistics of all numeric variab les, including mean,
standard deviation, and minimum and maximum values, together with the
proportions of all categorical variab les, were calculated. Two independent
group means were compared b y use of S tudent's i-test for independent
groups. If the group variances were not homogeneous as evidenced b y
Levene's test, p values were adjusted. S tatistical significance was assigned to
two-sided p values of <0.05 . Differences b etween group proportions were
examined b y chi-square test. In 2 x 2 contingency tab les, when expected
values in the cells were found to b e <2 in any cell or <5 in more than half of
the cells, Fisher's exact test was used instead of the chi-square test.
76
RES ULT S
RESULTS
The results of this retrospective analysis of 41 1 patients who were
presentd with chest trauma showed that the age ranged b etween 4 and 72
years. 348 patients (84.6%) were males and 63 patients (1 5 .4%) were
females. As shown in Fg. . and tuIc 5, thoracic injuries were variab le, rib
fractures were found in 328 patients (79.8A), unstab le rib fractures with flail
chest in 44 patients (1 0.7%) , sternal fractures in 2 patients (0.5 %), lung
lacerations in 6 p atients (1 .5 %), and lung contusions in 5 9 patients (1 4.3 %).
Ilemo-thorax and/ or pneumo-thorax were found in 305 patients (74.2%).
Cardiac injuries were detected in 4 patients (0.9%), however, great
thoracic vascular injuries were detected in 2 patients (0.5 %). Fracheo-
bronchial injury were found in 4 patients (0.9 %), diaphragmatic injury in 6
patients (1 .5 % ), esophageal injury in one patient (0.2%), and ab dominal
injuries were associated with chest trauma in 8 patients ( 1 .9%).
Fig. (2): The most frequent thoracic injuries in M inia & A ssiut University
Hospitals (M .& A . U. Hs.), 2001.

0 Rib frac ture
0 I l e m o +/ -
p ne um o tho rax
0 Pul m o nary
c o ntus io n
Fl ail c he s t

7 9. 8%

7 7
RES ULT S

Table (5) : Different ty pes of thoracic injuries with chest trauma in M .& A .
U. Hs., 2001.
Type of injury NUMB ER
(N = 41 1 )
PERCENTAGE
( %)
P VALUE
Rib fracture 328 79.8 <0.0001
Hemo+/-
pneumothorax
305 74.2 <0.0001
Pulmonary
contusion
5 9 1 4.3 <0.0001
Flail chest 44 1 0.7 <0.0001
Ab dominal injury 8 1 .9 <0.0001
Pulmonary
laceration
6 1 .5 <0.0001
Diaphragmatic
injury
6 1 .5 <0.0001
Cardiac injury 4 0.9 <0.0001
Tracheo-b ronchial
injury
4 0.9 <0.0001
S ternal fracture 2 0.5 0.04
Great vascular
injury
2 0.5 0.04
Esophageal injury 1 0.2 N.S .
(Mean = 62.1. P Value is non signi/ica 7 1 (N.S.) P>0.05.) .
7 8
RES ULT S
B lunt chest trauma was present in 348 patients (84.6%), Road Traffic
Accidents (RTA) in 25 0 patients (60.8%), and fall from a height in 98
patients (23.8%). Penetrating chest trauma was present in 63 patients
(1 5 .4%), stab wounds in 34 patients (8.3%) and firearm injuries in 29
patients (7.1 %) patients as shown in tuIc 6.
Table (6) : M echanisms of chest trauma in M . & A . U. Hs., 2001.
MECHANIS M NUMB ER (N=41 1 ) PERCENTAGE %
RTA 25 0 60.8
Fall 98 23.8
S tab 34 8.3
Firearm
29
7.1
(P value is less than 0.0001. This difference is considered to he extremely statistically
significant) .
Road traffic accidents accounted for injury in 25 0 patients ( 71 .8%)
with b lunt chest trauma (n=348). 01 25 0 patients 21 6 patients (86.4%) had
rib fractures, 32 patients (1 3%) had unstab le rib fractures and flail chest,
and 2 patients (0.8%) had sternal fractures. Pulmonary injuries were
detected in 39 patients (1 5 .6 %), hemo-thorax and/ or pneumo-thorax were
found in 1 87 patients (75 %) , cardiac injury in 2 patients (0.8%), tracheo-
b ronchial injury in 3 patients (1 .2%), and diaphragmatic injury in 4 patients
(1 .6%) .
Fall from a height were found in 98 patients (28.1 %) with b lunt
trauma (n=348). 90 patients (95 %) had rib fractures, 1 2 patients (1 2.2%)
79
RES ULT S

had unstab le rib fractures and flail chest. Pulmonary injuries were detected
in 25 patients (25 .4%). Hemo-thorax and/ or pneumo-thorax were found in
63 patients (64.2%) as shown in table7.
Table (7) : Blunt thoracic injuries in M . & A . U. Hs., 2001.
ROAD TRAFFIC
ACCIDENTS (N=25 0)
FALL FROM A
I IEIGHT (N=98)
N. % N.
Rib fracture 21 6 86.5 90 95
Hemo+/-
pneumothorax
1 87 75 63 64.2
Pulmonary injury 39 1 5 .6 25 25 .4
Flail chest 32 1 3 1 2 1 2.2
Diaphragm 4 1 .6 - -
Trachea & b ronchi 3 1 .2 - -
Cardiac 2 0.8 -
S ternal fracture 2 0.8 -
aIueti difference i con idered tati ticaIIy 11017 ignificant
Different methods were involved in the treatment of b lunt thoracic
injuries. 5 7 patients (22.8%) of 25 0 patients with RTA were treated
conservatively. Tub e lhoracostomy was done in 1 81 patients (72.4%),
thoracotomy was done in 6 patients (2.4%), and wire fixation for sternal
injuries and flail chest in 3 patients (1 .2%). 32 patients of 98
80
RES ULT S
patients (32.6%) with fall from a height were treated conservatively, tub e
thoracostomy was done in 63 patients ( 64.2%), and thoracotomy was done
only in one patient (1 .02 %) as shown in table 8.
Table (8): Treatment of blunt injuries in M. & A. U. Hs., 2001.
RTA (N=25 0) FALL (N=98)
N.
%
N.
%
Tub e
thoracostomy
1 81 72.4 63 64.2
Conservation 5 7 22.8 32 32.6
Thoracotomy 6 2.4 1 1 .02
Wire fixation 3 1 .2 - -
Laparotomy 3 1 .2 2 2.04
( The p value of this result is 0.48, that is statistical' N S) .
Twenty patients of 34 patients with stab wounds (5 8.8%) were
b elow the age of 1 8. Hemo-thorax and/ or pneumo-thorax were found in
29 patients (85 .2%), cardiac injuries in 2 patients (5 .8%), diaphragmatic
injury in another 2 patients ( 5 .8%), and great vascular injury in one
patient (2.9%). Tub e thoracostomy was done in 26 patients (76.4%),
thoracotomy was done in 4 patients (1 1 .6%), and conservative
measures, also, were performed in 4 patients (1 1 .6%). Of victims with
firearm injury (n=29), 22 patients (75 .8%) had rib fractures. Hemo-thorax
and/ or pneumo-thorax were found in 26 patients (89.6%), pulmonary
laceration in one patient (3.4%), tracheal and esophageal injury in
another patients (3.4%) and great vascular injury was also, found in one
patient ( 3.4%) as shown in table 9. Tub e thoracostomy was done in 23
81
RESULTS
patients (79.3%), thoracotomy done in 2 patients (6.8%), and
conservative measures in 4 patients (1 3.6%).
Table (9) : P enetrating thoracic injuries in M . & A . U. Hs., 2001.
S TAB WOUNDS
(N=34)
FIREARM INJURY
(N=29)
N. % N. 'Yo
Hemo+/-
pncumothorax
29 85 .2 26 89.6
Cardiac 2 5 .8 - -
Diaphragm 2 5 .8 - -
Great vessels I 2.9 1 3.4
Lung laceration - - 1 3.4
Tracheo- b ronchial
& Esophagus
- 1 3.4
(The probability () Phis result is 0.609 That is statistic* N S) .
As shown in table 10, different methods of treatment were
performed for treatment of chest trauma. Conservative measures in the
form of follow up, pain control, wound treatment, and external fixation
of b ony fractures were done in 94 patients ( 22.6%). 91.5 % of
conservative treatment were clone with b lunt trauma, and 8.5 % with
penetrating trauma. 81 patients (87%) improved after conservative
measures, and 1 2 patients (1 3%) had complications, 9 patients with
pneumonia and 3 patients with wound infection.
82
RES ULT S
T abl e (10) : Diffe re nt m e tho ds o f tre atm e nt fo r Che s t traum a in M . & A. U.
Hs . , 2001.
METHOD OF TREATMENT NUMB ER
(N=41 1 )
PERCENTAGE (%)
Tub e thoracostomy 293 71 .2
Conservative 94 22.6
Thoracotomy 1 3 3.1
Laparotomy 8 1 .9
Internal fixation 3 0.7
(p value is < or = 0 .0 0 0 1 that is statisticaly signific ant).
Tub e thoracostomy was done in 71 .2% (293 patients). It was done
for the management of hemo-thorax and/ or pneumo-thorax associated with
b lunt thoracic injuries in 244 patients(83.2%) and with penetrating injuries
in 49 patients (1 6.8%) as shown in table 11. 21 2 patients ( 72.3%)
improved after insertion of an intercostal tub e, b ut 81 patients (27.7%) had
complications in the form of pneumonia in 5 0 patients (1 7%), empyema in
1 2 patients (4%), and wound infection in 1 9 patients (6.4%) as shown in
table 12.
II
83
RESULTS
Table (11) : M ethods of treatment according to mechanism of injury in M . &
A . U. Hs., 2001.
INJURY TUB E
THORACOSTOMY
CONS ERVATION (N-94)
(N=293)
N.
%
N. Rio
B lunt injury 244 83.2 86 91 .5
Penetrating
injury
49 1 6.8 8 8.5
(P aIue 4 T i difference i conideI ed to be not u
.
te tati ticaIIy ignificant)
Table (12) : O utcome after tube thoracostomy in M . & A . U. Hs., 2001.
OUTCOME NUMB ER (N=293) PERCENTAGE %
Improvment 21 2 72.3
Pneumonia 5 0 1 7
Wound infection 1 9 6.4
Empyema 1 2 4
( T e re uIt are tatiticaIy ignificant)
Thoracotomy was done in 1 3 patients (3.1 % ). S even patients
(5 4%) with b lunt trauma, and 6 patients (46%) with penetrating
trauma. It was done for management of pulmonary, injuries in 6
patients (46%), cardiac injury in 2 (1 5 .3 %), vascular injury in
another 2 patients ( 1 5 .3%), tracheo-b ronchial injury in .(23 % ), and
diaphragmatic injury in 2 patients (1 5 .3% ) as shown in table 13 . S ix
patients (46%) improved after thoracotomy. 7 patients (5 4%) had a
84
RES ULT S
complications in the form of pneumonia in 3 patients (23% ), empyema in
one patient (7.6% ), and wound infection in 3 patients (23% ) as shown in
tabIe4
Table (13) : Thoracic injuries treated by thoracotomy in M . & A . U. Hs., 2001.
INJURY NUMB ER PERCENTAGE %
(N=1 3)
Isolated pulmonary 4 30.6
tracheo- b ronchial 3 23
Diaphragm 2 1 5 .3
Vascular 2 1 5 .3
Cardiac 2 1 5 .3
(p aIue t e e difference are conide ed to be ery tati ticaIIy ignificant)
Table (14) : I ncidence of complications after Thoracotomy in M . & A . U. Hs.,
2001.
OUTCOME NUMB ER (N=1 3) PERCENTAGE %
I mprovment 6 46
Pneumonia 3 23
Wound infection 3 23
Empyema 1 7.6
(Re uIt of epyona i tatiticaIy non ignificant (fiaII
The results revealed that chest wall injuries were found in 374
patients (90%), 303 patients (94.1 % ) with b lunt chest trauma, and 32
85
RES ULT S
patients (5 .9%) with penetrating chest trauma. Rib fractures were found in
328 patients (87.7%) with chest wall injuries. Rib fractures were associated
with pulmonary lacerations in 6 patients(1.8% ), pulmonary contusions in
1 9 patients (5 .7%) as shown in Fg. , hemo-thorax and/ or pneumo-thorax in
231 patients (70.4% ), cardiac injuries in 2 patients (0.6% ), ab dominal
injury in 3(0.9%), and diaphragmatic injury in 4 patients (1 .2% ) as shown
in table 15. Conservative measures in the form of pain control , external
fixation, and follow up were done in 80 patients (24.3%), tub e thoracostomy
in 231 patients (70.4%), thoracotomy was indicated in 9 patients (2.7%) ,
and laparotomy was indicated in 8 patients (2.4%) as shown in table16.
Fig. (3): CXR Showing tight _Multiple 'tib fractures With pulmonary
Contusions.
86
RES ULT S
Table (15) : I njuries associated with rib fractures in M .& A . U. Hs.
INJURY NUMB ER PERCENTAGE %
(N=328)
I lemo-thorax +/- pneumo-thorax 231 70.4
Isolated rib fractures 66 20.1
Pulmonary 25 7.5
Diaphragm 4 l .2
Cardiac 2 0.6
(P value is less than 0.0001, that is statistically significant) .
Table(16) : M ethods of treatment for injuries associated with rib fractures in
M . & A . U. Hs., 2001.
TREATMENT NUMB ER PERCENTAGE %
(N=328)
Tub e thoracostomy 231 70.4
Conservation 80 24.3
Thoracotomy
9
2.7
Laparotomy 8 2.4
(p value is statistical)) significant) .
Flail chest detected in 44 patients(10.7%) with chest wall injuries, 32
patients (72.7%) due to RTA, and 1 2 patients (27.3%) due to fall from
height as shown in Fig. 4. Tub e thoracostomy indicated in 43 patients(97.8
%), thoracotomy with wire fixation was done in one patient (2.2%).
Artficial ventiltion was indicated in all patients. As shown in table 17 . Flail
chest associated with severe pulmonary contusions in 40 patients (91 % ),
87
CXR showing Fig.(4):
RES ULT S
and hemo-thorax and/ or pneumo-thorax in all cases as shown in Fig. 5. 3
patients (6.9%) with flail chest improved after treatment, and the mortality
rate was 93.1 % (41 patients).
Table (17) : A ssociated injuries and methods of treatment of flail chest in
M . & A . U. Hs., 2001.
ASSOCIATED
INJURY
FLAIL CHEST (N=44) P VALUE
N.
Isolated
pulmonary
4 9 <0.0001
Hemo- +/ -
Pneumothorax
40 91 <0.0001
TREATMENT N.
%
P value
Tub e
thoracostomy
43 97.8 NS
Thoracotomy 1 2.2 NS
Left multiple rib fractures.
88
RES ULT S
Fig. (5): CXR Showing flail chest with Tight hemo-thorax .
S ternal fractures were found in 2 patients(1.3 %) with chest wall
injuries, due to b lunt trauma; (RTA). Wire fixation was indicated and done
in all of them. S ternal fractures were associated with rib fracture in one
patient ( 5 0%), myocardial contusion in another 5 0%, and hemo-thorax
and/ or pneumo-thorax also in 5 0 %.
Hemo-thorax and/ or pneu othorax were found in 305
patients(74.2%), 5 5 patients
,
(18%)with penetrating trauma, and 25 0 patients
(81.9%)with b lunt trauma. Memo-thorax only was found in 1 06 patients
(35 % ) , pneumo-thorax only in 1 6 patients (5 %), and hemQ-pneumo-thorax
in 1 83 patients (60%) as shown in Fg.6. Tub e thoracostoiny was the only
method of treatment in 283 patients (92.7%) with hemo-thorax and/ or
pneumo-thorax, thoracotomy due to major thoracic injuries indicated in 1 3
patients (4.2%), and laparotomy was done in 9 patients (2.9%) as shown in
89
RES ULT S
table 18. 276 patients (90.4%) of hemo-thorax and/ or pneumo-thorax were
associated with chest wall injury, 231 patients (75.7A) rib fractures , 44
patients (1 4.4%) flail chest , 0.3 %(one patient) sternal fracture, 6 patients
(1 .8%) pulmonary injuries , 3 patients . (0.9 %) cardiac injury , 2 patients
(0.6%)great vessels 'injury ; 3 patients ( 0.9%)tracheo-b ronchial injury , and
6 patients (1.8%) with diaphragmatic injury as shown in table 19.
Fig. (6): CXR Showing Left side Hemo-pneumothorax after chest trauma.

90
RES ULT S

Table (18) : Methods of treatment associated with
hemo-thorax
+1-
Pneumo- thorax in M. & A. U. Hs., 2001.
TREATMENT NUMB ER
( N=305 )
PERCENTAGE %
Tub e thoracostomy 283 92.7
I horacotomy 1 3 4.2
Laparotomy 9 2.9
(P value of reasults <0.0001 that of statistical significance) .
Table (19) : Thoracic injuries associated with hemo-thorax +1- Pneumo-
thorax, in M. & A. U. Hs., 2001.
INJURY
NUMB ER
PERCENTAGE %
Rib fracture 231 75 .7
Flail chest 44 1 4.4
S ternal fracture 1 0.3
Pulmonary 6 1 .8
Cardiac 3 0.9
Trachea & b ronchi 3 0.9
Diaphragm 20 6
(P value of sternal fractures = 0.3 17 3 . considered statistically N S) .
Pulmonary injuries were present in 65 patients(1 5 .8%) with chest
trauma, 64 patients (98.7 %) due to b lunt trauma, and one patient only
(1 .3%) due to penetrating trauma (firearm injury). Pulmonary contusions
were found in 5 9 patients (90.7%) of those with pulmonary injury due to
b lunt trauma as shown in Fig. 7. Contusions associated with chest wall
injury ; 1 9 patients (32.2%) rib fractures , and 40 patients ( 67.7 %) with
91
RES ULT S
flail chest .5 5 patients (93.2%) were associated with Demo-thorax and/ or
pneumo-thorax as shown in tabIe Treatment was done in the form of
fluid supplement, follow up, and managment of associated injuries. Intensive
care admission and artificial ventiltion were required in 44 patients (74.5 %)
with moderate to severe pulmonary contusions. Tub e thoracostomy was
done for associated hemo-thorax and/ or pneumo-thorax in 5 5 patients
(93.2%).
Table (20) : A ssociated thoracic injuries with pulmonary injury in M . & A . U.
Hs., 2001.
AS S OCIATED
INJURIES
PULMONARY
CONTUS IONS (N=5 9)
PULMONARY
LACERATIONS (N=6)
N. % N.
Flail chest 40 5 9 - -
Rib fracture 1 9 40.6 6 1 00
TREATMENT N. % N.
Tub e
thoracostomy
5 5 93.2 - -
Tlioracotomy 1 00
Conservation 4 6.8
_P aIue . that i con idered to be tati ticaIIy ignificant)
92
RES ULT S
Fig. (7) : CXR showing Significant right- sided pulmonary contusion noted
by the opacity (arrow)
Pulmonary lacerations were detected in 6 patients (9.3 %) with
pulmonary injury (n=65 ), one patient (1 6.6%)with penetrating trauma, and
5 patients (83.8 %)with b lunt trauma. Pulmonary lacerations associated with
patients(66.6%), lob ectomy in one patient(16.6%), and pneumonectoy in
rib fractures in all cases, and 2 patients (33.3%) had a b ronchial injury.
Hemo-thorax and/ or pneumo-thorax found in all patients. Thoracotomy was
indicated and done in all patients: minor repair was done in 4
Mean=2, P value of lobectomy & Plle1(117017edOnly are N S) .
another patient(1 6.6%) as shown in tabIe
Table (21) : Treatment of lung lacerations in M . & A . U. Hs., 2001.
_
93
TREATMENT NUMB ER (N=6) PERCENTAGE %
Minor repair 4 66.6
Lob ectomy 1 1 6.6
Pneumonectomy 1 1 6.6
RES ULT S

Cardiac injuries were present in 4 patients ( 0.9%) with chest trauma,
2 patients (5 0 %)with penetrating trauma due to stab b ing, and another 2
patients (5 0 %) with b lunt trauma due to RTA. 3 patients (75 %) had hemo-
thorax and/ or pneumo-thorax , 2 patients ( 5 0%) with rib fractures , and
one patients(25 %) with sternal fractures. Thoracotomy was indicated in 2
patients (5 0%) , and conservation also in 2 patients (5 0%). Hemo-
pericardium detected in one patient (25 %), myocardial contusion in another
patient (25 %), and ventricular injury in 2 patients ( 5 0%) as shown in table
22. Repair of injury was done in 2 patients(50%). 3 patients (75 %) with
cardiac injury improved after treatment, and the mortality rate was 25 %
(one patient).
Table (22): Ty pes of traumatic cardiac injuries in M . & A . U. Hs., 2001.
INJURY NUMB ER (N=4) PERCENTAGE %
Ventricular
.
2 5 0
Hemo-pericardium 1 25
Myocardial contusion 1 25
(Results of hemp-pericardium and contusion are statistical)
,
17011 significant) .
Great thoracic vascular injury was found in 2 patients (0.5 %) with
chest trauma, all were due to penetrating trauma, and all were associated
with hemo-thorax. Thoracotomy was done in the two patients. Injury of
internal mammary vessels was detected in one patient (5 0%), and injury of
sub clavian artery in another one (5 0% ). Ligation of the injuried vessel with
hemostasis was done in b oth cases. One patient (5 0 %) with vascular injury
improved after treatment, and the second one died.
94
RESULTS
Tracheo-b rochial injuries were found in 4 patients (0.9 %) with chest
trauma, one patient(25%)with penetrating trauma(fireartn), and 3 patients
( 75 %)with b lunt trauma (RTAs). 3 patients (75 %) were associated with
hemo-thorax and/ or pneumo-thorax, 3 patients (75 %) with rib fracture, and
one patient (25 %) with an esophageal injury. Tracheal injury was detected in
one patient (25 %), right b ronchial injury in 2 patients (5 0%), and left main
b ronchial injury in one patient (25 %) as shown in table 23 . Tracheostomy
was done in one patient (25 %), thoracotomy was indicated in 3 patients
(75 %) ; repair was done in 2 patients (5 0%), and b ronchoplasty was done in
one patient (25 %) as shown in table 24.
Table (23) : Ty pes of tracheo-bronchial injuries in M . & A . U. Hs., 2001.
INJURY NUMB ER (N=4) PERCENTAGE %
Right B ronchial 2 5 0
Left B ronchial 1 25
Tracheal 1 25
(Results of left bronchial and tracheal injury are statisticaly non significant) .

95
RES ULT S
Table (24) : Treatment of tracheo- bronchial injuries in M . & A . U. Hs., 2001.
TREATMENT NUMB ER (N=4) PERCENTAGE %
Minor repair 2 5 0
B ronchoplasty I 25
Trachcostomy 1 25
(Mean . P aIue of broncopIaty iraceoioy are NS)
Diaphragmatic injuries were present in 6 patients (1 .5 %) with chest
trauma, 4 patients (66.6%)with b lunt trauma, and 2 patients (33.3%)with
penetrating trauma on the left side. All were associated with hemo-thorax
and/ or pneumo-thorax , 4 patients (66.6 %) with rib fracture , and 3 patients
(5 0%) with ab dominal injuries, 2 patients (33.3%) liver injuries and one
patient(I6.6%) with splenic rupture as shown in table 25. Diaphragmatic tear
as shown in Fig. 8 was detected in 4 patients (66.6%); right sided in 2
patients ( 33.3% ), and left sided in another 2 patients (33.3%).
Diaphragmatic hernia as shown in Fig.9 was noticed in 2 patients (33.3%)
all of them on the left side as shown in table 26. Most common organs to
herniate were the colon, spleen, and stomach. Thoracotomy was done in 2
patients (33.3%) , and laparotomy for repair of diaphragmatic injury and
associated abdom inal injuries was done in 4 patients ( 66.6%) as shown in
Fig. 10 and table 27 .
96
RES ULT S
Table (25) : Thoracic injuries associated with diaphragmatic injury in M . &
A . U. Hs., 2001.
INJURY NUMBER
(N=6)
PERCENTAGE
hemothorax +/ - pneumothorax 6 1 00
Rib fractures 4 66.6
Liver 2 33.3
S pleen 1 1 6.6
(Re uIt are tatiiticaIy ignificant)
Table (26) : A pproach for diaphragmatic injury in M . & A . U. Hs., 2001.
APPROACH NUMBER(N=6) PERCENTAGE %
Thoracotomy 2 3 3 .3
Laparotomy 4 66.6
(T i re uIt i tatiticaIy ignificant)
Table (27) : Ty pes of diaphragmatic injury in M . & A . U. Hs., 2001.
INJURY
NUMB ER (N=6) PERCENTAGE %
Left side tear without
herniation
2 33.3
Right side Tear 2 33.3
Diaphragmatic Hernia 2 33.3
(i re uIt i statistical); ignificant)
97
RES ULT S
Fig. (8) :
P hotographic picture showing a diaphragmatic laceration.
Fig. (9)
CXR showing blunt 1 eft diaphragm rupture with Stomach &
Spleen herniation.
98
RES ULT S
Fig. (10) : P hotographic picture showing O perative repair of diaphragmatic
injury .
Esophageal injury was detected in one patient (0.24%) with chest
trauma, with penetrating trauma (firearm), and associated with hemo-
pneumo-thorax , and tracheal injury. Repair of the injury was done. The
patient improved after treatment, complications developed in the form of
wound infection.
Associated injuries with chest trauma were detected in 1 5 8 patients.
These include ab dominal injuries in 8 patients , liver injury was detected in
3 patients of them (37.5 %), splenic injury in 4 patients (5 0%), and gastric
injury with renal injury in one patient (1 2.5 %), as shown in table 28.
Laparotomy was done in all cases with ab dominal injuries. Head and neck
injury were found in 1 1 0 patients (27 %), and injuy of b oth limb s were
found in 40 patients (9%) as shown in table 29.
99
Table (28) : Ty pes of abdominal injury with thoracic trauma in M . & A . U.
Hs., 2001
AB DOMINAL ORGAN NUMB ER
(N=8)
PERCENTAGE %
S pleen 4 5 0
Liver 3 37.5
S tomach & kidney I 1 2.5
(Results of injury of stomach and kidney are statistic* non significant).
Table (29): Non thoracic injuries with chest trauma in M . & A . U. Hs., 2001.
INJURY N. (N=1 5 8) ( %) OF ALL ( %) OF NON
PATIENTS (N 'THORACIC
=411) 1NJURIES(N=158)
llead & Neck 110 2 7 69.6
B oth limb s 40 9 2 5.3
Ab domen 8 1 .9 5 .1
(This result is statistical); significant) .
The outcome of treatment for chest trauma was complete
improvement in 267 patients (64.9%), complications in 1 00 patients
(24.3%), and the mortality rate was 1 0.4% (44 patients). Complications
after thoracotomy were found in 7 patients ( 1 .7%). Complications after tub e
thoracostomy were found in 81 patients (1 9.7%), and in 1 2 patients (2.9% )
after conservative measures. Pneumonia developed in 62 patients (1 5 %),
wound infection in 25 patients (6%), and empyema in 1 3 patients (3.1 %).
100
RES ULT S
Mortality rate flail chest was 10%(41 patients ). Mortality after cardiac
injury or great vessels injury was 0.24% (one patient) as shown in tuIc 0.
Table (30) : O utcome of treatment of chest trauma in M . & A . U. Hs., 2001.
OUTCOME
NUMB ER
(N=41 1 )
P ERCENTA GE %
Improvement 267 66
Complications with thoracostomy 81 1 9.7
Pneumonia 62 1 5
Mortality with flail chest 41 9.9
Wound infection 25 4.9
Empyern a 1 3 3.1
Complications with thoracotomy 7 1 .7
Mortality with vascular injury 1 0.24
Mortality with cardiac injury 1 0.24
(ReuIt of ortaIity iit
ignificant)
cardiac injury and a cuIar injury are tati ticaIy non

101
I

1. 01111111.111
DIS CUS S ION
DI SCUSSI ON
In our study, b lunt trauma was the most common mechanism
of thoracic injury detected in 84.6% of patients. Road traffic
accidents had a high frequency (60.8%) that was attrib uted to the
high speed and the neglegence in the use of seat b elt, followed b y
fall from a height in 23.8% of cases. Penetrating injuries were
detected in 1 5 .4%. The most frequent penetrating trauma was
stab b ing in 8.2%. Thus, firearm injury was not the most common
cause as thought in the past, this may show the change in the pattern
of penetrating injury. Most of the cases with stab wounds (5 8.8%)
were adolescents b elow the age of 1 8.
In a study of Ab dul Latif and Khamash, to identify common
causes of chest injuries among 90 patients admitted to King
Hussein Medical Center in Jordan, road traffic accidents were the
most common cause of injuries in 66.6% (N=60), followed b y
b ullet injuries in 23.3% (n=21 ) central venous cannulation in 5 .6%
(n=5 ). In the study of Raju, et al., b lunt injuries were seen in 5 6
(62.2%) and penetrating injuries in 34 (37.7%). Marc, et al.,
reviewed that the most common chest trauma seen in civilian
populations is b lunt chest trauma (63-78%) and most Illunt chest
trauma is the result of motor vehicle accidents, while falls account
for b etween 1 0% to 1 7% (Abdul La tif Khamash, 2002; Ra ju,
et a t., 2002; a nd Ma rc, et a l., 2002).
102
DIS CUS S ION

B lunt trauma, especially motor vehicle accidents (72.2%) and
falls (1 7.1 %), were the most frequent causes of chest injury (95 .8%)
seen b y S egers, et al. The most common causes of thoracic injuries
that were noticed b y Ceran, et al., were b lunt injuries in 1 35 cases
(60%) of 225 with chest trauma, stab wounds in 67 cases (29.77%)
and gunshot wounds in 22 cases (9.77%). Cekan, et al., stated that
72% of chest injuries were related to b lunt trauma and 28%
sustained penetrating trauma. Also, in a study of Demirhan, et al.,
while traffic accidents (72%) were determined as the most common
ethiological factor for b lunt thoracic trauma, penetrating and cutting
instruments injuries (82%) were the most common factor for
penetrating thoracic trauma (Ceran, et al., 2002; Cakan, et al.,
2001 ; Demirhan, et al., 2001 ; and S egers, et al., 2001 ).
Many studies show different mechanisms of chest trauma
according to the region of trauma center (urb an or rural area). In a 5
year Canadian study of patients admitted to an urb an trauma unit,
96.3% had sustained blunt trauma while the remaining 3:7% were
injured with a penetrating mechanism. The causes of b lunt injuries
were attrib uted to motor vehicle accidents (70%), suicides (1 0%),
falls (8%), homicides (7%) and others (5 %) (Hill, et al., 1 990).
Our results proved that b lunt injury to the chest can affect
any one or all components of the chest wall and thoracic cavity.
These include the rib s, sternum, lungs, pleurae, tracheob ronchial
103
DIS CUS S ION

tree, and heart. Our patients with b lunt thoracic injuries (n=348)
were treated mainly with tub e thoracostomy 70.1 % (n=244),
conservative measures in 24.1%(n=84), thoracotomy was done only
in 2%(n=7), and internal fixation for sternal fractures and flail
chest in 1 %(1=3).
In the study of Galan, et al., road traffic accidents were the
main cause of injury followed b y falls. Of 1 696 patients with b lunt
chest trauma, 923 patients (5 4.4%) were clinically ob served and/ or
medically treated. An intercostal tub e was inserted in 638 patients
(37.6%). Thoracotomy was undertaken in 1 05 patients (6.1 %).
S urgical fixation for flail chest was carried out in 29 patients
(1 .7%). In a study of B alkan, et al., 964 patients had thoracic
trauma, 745 (77.3%) sustained b lunt injury and 29 of these patients
(3.9%) required emergency thoracotomy (B alkan, et al., 2002; and
Galan, et al., 2001 ).
In a Japanese study on 161 patients with b lunt thoracic
trauma, the most common cause was traffic accidents in 80.7%
followed b y falls in 1 8% and crushing in 1 .3%. Rib fractures were
the most common thoracic injuries followed b y hemo-thorax and
pulmonary contusion. Thoracotomy was done in 3.7 (Miura, et al.,
1 998).

In western European countries most b lunt chest traumas are

associated with motor vehicles and sport related accidents. In
switzerland, 39 of 1 0,000 inhab itants were involved and severly
104
DIS CUS S ION
injuried in road traffic accidents, 5 2% of them suffered from b lunt
chest trauma ( Wicky, et al., 2000).
In our study, hemo-thorax and/ or pneumo-thorax were
present in 87.3% (n=5 5 / 63) of penetrating thoracic injuries. The
decision to open the patient surgically or not was the corner stone in
the management of penetrating injuries. Most of the patients were
managed b y immediate insertion of an intercostal tub e that removed
witin 2-3 days with no need for further operative interference. Thus,
early tub e drainage b efore clotting of b lood and b efore fib rob last
invasion from periphery is mandatory. Thoracotomy was done only
in 6 patients (9.5 %) after excessive drainage revealed b y the
intercostal tub e with an amount more than 1 5 00 ml of b lood or
more than 200m1/h over 4 hours that required an operative control
of b leeding.
Inci, et al., stated that the most common penetrating thoracic
injury was hemothorax 25 .1 % (n 1 90/ 75 5 ), followed b y
hemopneumothorax 24.3% (n 1 84/ 75 5 ). Nonoperative
management was sufficient in 92% of the patients. Thoracotomy
was performed in 8.1 % ( Nei, et al., 2003).
In an analysis of a consecutive series of 3049 patients with
penetrating thoracic injury encountered in urb an medical centers in
US A over 24-years, there were 5 5 % of patients with firearm
wounds and 45 % with stab wounds. In an European study b y Val-
carreres, et al., stab wounds were the most common cause of open
105
DIS CUS S ION
chest wounds, with an incidence far higher than either wounds
caused b y firearms. The most common underlying injuries with stab
wounds were hemo-thorax and/ or pneumo-thorax in 5 4%, mainly
due to cardiac injury in 4% | Madal & Saui, 200l; a d al
Carrere, et al , 200l)
In an analysis of 5 89 patients with penetrating chest injuries
in S outh Africa b y Madib a, et al., there were 90% stab wounds and
1 0% firearm injuries. Hemo-thoraces and/ or pneumo-thoraces were
similar in b oth groups. Cardiac injuries caused only b y stab b ing,
and associated ab dominal injuries occurred in 8% of stab and 34%
of firearm injuries | Madiba, et al , 200l)
In our study, thoracic trauma often involved multiple organ
systems and several anatomic regions. S erious chest trauma results
in injury to the sternum; the rib s; and the heart, aorta, and lungs.
Our results shows that chest wall injuries are the most frequent
thoracic lesions after chest trauma, were present in 90% of patients.
Rib fractures presented in 79% of patients, followed b y hemo-
thorax and/ or pneumo-thorax in 74%, pulmonary contusions in
1 4.4%, and flail chest in 1 0.4% .
The presence of chest wall trauma is a marker for severe
injury. In our study, rib fractures were noticed in 79% of chest
trauma, and in 87.7% of chest wall injuries. S imple rib fractures
was the most common form of thoracic injury. Rib fracture
fragments may directly damage the underlying pleura or lung that
106
DIS CUS S ION
result in hemo-thorax and/ or pneumo-thorax in (70.4%), pulmonary
contusions in (5 .7%), and pulmonary lacerations in (1 .8%).
Fractures of lower rib s were uncommon, b ut when found they raise
concern for serious intra-abdominal hemorrhage due to liver,
spleen, stomach, or kidney injury. S evere trauma results in injury
of the b ony thorax and soft tissues increasing the patients morb idity
and mortality due to unstab le rib fracture. The mortality rate was
(93.1 %) with unstab le flail fractures.
Rib fractures were found in 5 2% as reviewed b y Tekinbas, et
al. In a study of _ Raju, et al., multiple rib fractures with
hemopneumothorax was the most frequent chest injuries among 90
patients with chest trauma (Tekinb as, et al., 2003; and Raju, et
al., 2002).
In a retrospective analysis of 1 87 cases of thoracic trauma b y
S egers, et al., rib fractures 71 .5 %(n = 1 33), and pulmonary
contusion 59.1%(1 1 1 0), were the most frequent lesions. S irmali,
et al., noted retrospectively 1 41 7 cases presented with thoracic
trauma. 5 48 (38.7%) of the cases had rib fracture. Pulmonary
complications such as pneumothorax (37.2%), hemothorax (26.8%),
hemo-pneumothorax (1 5 .3%), pulmonary contusion (1 7.2%), and
flail chest (5 .8%) were noted. 27 patients required surgery. In a
study of Galan, et al., thoracic wall fractures were present in
(83.6%) 1 41 9 patients. Flail chest was diagnosed in 1 40 patients
(8.2%) and pulmonary contusion in 275 (1 6.2%) (Sirmali,et al.,
2003; Galan,et al., 2001 ; and S egers,et al., 2001 ).
107
DIS CUS S ION
In US A, rib fractures are estimated to b e present in 1 0% of
all traumatic injuries and 1 4% of all chest wall injuries (B ansidhar,
et al., 2002). Hemo-thorax and/ or pneumo-thorax presented in
70.4% of patients with rib fractures, and detected in all patients
with flail chest. Liman, et al. reviewed that the rate of development
of pneumothorax and/ or hemothorax was 24.9% in patients with
rib fractures and 81 .4% in patients with flail chest (Liman,et
al.,2003).
In our study, ab dominal injuries noticed in 3 patients with rib
fractures, 2 on the left side with splenic injury, and one on the right
side with liver injury. S hweiki , et al., steted that the prob ab ility of
liver injury increased with the presence of any right-sided rib
fracture, and any low rib fracture. The prob ab ility of splenic injury
increased with the presence of left-sided rib fractures only, and any
low rib fracture (S hweiki, et al., 2001 ).
In our study, unstab le rib fractures lead to flail segments that
paradoxically move during inspiration in 1 0.4% of patients, mostly
due to road traffic accidents, associated with severe pulmonary
contusions in 90.9%, and hemo-thorax and/ or pneumo-thorax in
all cases. Thus, endotracheal intubation and positive pressure were
required to splint the chest wall. In most cases, supportive care with
attention to oxygenation, clear airways, and infection prevention
were the preferred therapy. Wire fixation was done only in 2.2%.
108
DIS CUS S ION
The exact incidence of flail chest is not precisely known. The
Major Trauma Outcome S tudy of 5 0,000 patients documented
ab out 75 patients with flail chest injuries. From 1 971 -1 982,
Landercasper et al documented 62 consecutive patients. From 1 981 -
1 987, the Detroit Receiving Hospital noted 5 7 patients with flail
chest. B ased on these articles, an average American College of
S urgeons (ACS )-verified level I or level 2 trauma center will see
ab out 1 -2 cases per month. The incidence of flail chest at
nontrauma center facilities is unknown (Champion et al, 1 990;
and Landercasper et al., 1 984).
In a study of Ciraulo, et al., the records of 92 patients
with flail chest injury treated at a Level I trauma center were
analysed. Associated intrathoracic injuries included pulmonary
contusion (46 %) and pneumothorax or hemothorax, or b oth
(70 %). In a study of Velhamos, et al., on 22 patients with flail
chest. It was reported that flail chest was an independent marker of
poor outcome among patients with thoracic cage trauma. The
majority of patients with flail chest need mechanical ventilatory
support and develop significant respiratory complications. In the
presence of associated injuries, intub ation was unavoidab le and
should b e done under controlled conditions early after arrival to
avoid morb idity related to sudden respiratory decompensation
(Velhamos, et al., 2002; and Ciraulo, et al., 1 994).
109
DIS CUS S ION
In a study of Ahmed and Mohyuddin, a total of 426 patients
with major chest trauma were treated in two major hospitals in Ab u
Dhab i, United Arab Emirates, during a 1 0-year period. In 64 (1 5 %)
of 426 patients, flail chest injury was the dominant factor among
other injuries that were insignificant. Among 64 cases of flail chest
injury, 25 (39%)were managed b y internal fixation of rib s, whereas
the remaining 39 (61 %) were managed b y endotracheal intub ation
and intermittent positive-pressure ventilation alone ( Ahmed &
Mohyuddin, 2001 ).
Our results detected sternal fractures in 2 patients (0.5 %) due
to road traffic accidents who underwent wire fixation and surgical
correction. The presence of fractured sternum implies the presence
of a severe trauma to the anterior chest wall with a high energy
transfer. S ternal fractures constitute a marker of serious associated
injuries, mostly due to myocardial contusion that was found in
(5 0%) of our patients with fracture stertnum.
In a retrospective study of 41 8 b lunt chest trauma patients,
Rashid et al. reported that sternal fractures were more common than
previously reported. Potaris, et al., noted that sternal fractures
accounted for 8% of admissions for thoracic trauma. The causes
were motor vehicle collisions in 21 5 patients (90%) arrd falls or
-
direct b lows in 24 (1 0%) (Potaris, et al., 2002; and Rashid, et al.,
2001 ).
110
DIS CUS S ION
In a study of Velissaris, et al., on 73 patients with sternal
fractures, three patients only (4%) had severely displaced sternal
fractures and complex co-morb idities required surgical correction.
Follow-up revealed no significant complications (Velissaris, et al,
2003).
Athanassiadi, et al., noted 1 00 patients with sternal fractures
(S F), 7 patients underwent operation, two for ab dominal b leeding,
two for chest wall and sternal stab ilization, two for open
pneumothorax, and one for massive hemothorax. Eight patients
needed ventilatory support. Four of them died from respiratory
insufficiency, myocardial infarction, and heart and lung contusion.
Although an isolated S F carries a good prognosis, careful
evaluation and clinical ob servation are essential (Athanassiadi, et
al., 2002).
In our study, it is proved that traumatic rupture of the
diaphragm is a rare event that is usually found in polytrauma
cases. Diaphragmatic injury was noticed in 1 .5 %, mostly due to
b lunt trauma (mainly motor car accidents), most of them on the left
side b ecause the right hemi-diaphragm is protected b y liver,
whereas the left hemi-diaphragm has little support from the
surrounding structures. In pentrating stab wounds injury,
diaphragmatic injury was common on the left side and anterior that
attrib uted to the use of the right hand of the assault. Clinical
suggestion of diaphragmatic injury should b e decided in all cases
with chest trauma b elow the 4'
h
intercostal space. Diaphragmatic
111
DISCUSSION
injury is a predicator of serious associated injuries, 5 0% of our
cases were associated with ab dominal injury. Thus, diaphragmatic
injury should b e suspected in all thoraco-ab dominal trauma.
Laparotomy was indicated in 66.6%. Most cases were diagnosed
during exploration for associated injuries. In some patients with
diaphragmatic injury, ab dominal viscera herniate into the chest in
33.3% all of them on the left side. Most common organs to herniate
were the colon, spleen, and stomach. Thus, suspescion could b e
made on diagnostic radiological findings that include the presence
of gastric gases within the thoracic cavity with raised left copula of
the diaphragm and evidence of the ab normal presence of the ryle
tub e within the chest after its insertion.
Adegb oye, et al., noted 1 1 6 patients with diaphragmatic
injuries. This was 6.5 % of 1 778 chest trauma patients. The
commonest mechanisms of injury were motor vehicle accidents
(48.8%) for b lunt and gunshot wounds (5 6.3%) for penetrating
diaphragmatic injuries. The left diaphragm was most commonly
involved (86.9% for b lunt, 5 9.4% for penetration), 1 2.5 % of the
patients with penetrating chest injury had b ilateral diaphragmatic
injuries. There were no b ilateral diaphragmatic injuries amongst the
patients with b lunt chest injury. S urgical approaches were mainly
thoracotomy (49.1 %, 5 7 patients), laparotomy (14.6`)/0,17"patients),
laparotomy and thoracotomy (1 7.2%, 20 patients) (Adegb oye, et
al., 2002).
1 1 2
DIS CUS S ION
Patselas and Gallagher reported 1 3 American patients who
sustained injuries to the left (77%) and right (23%) diaphragm
respectively as a result of road traffic accidents (69%), penetrating
trauma (30%). Mihos,et al., reported 65 patients with traumaic
diaphragmatic injury, rupture of the diaphragm was left-sided in 43
patients (66%), right-sided in 21 (32%), and b ilateral in 1 (1 .5 %).
B lunt trauma accounted for the injuries of 5 2 patients (80%)
(Mihos, et al., 2003; and Patselas and Gallagher, 2002).
In a study of Job b o, 30 patients were included in the study
carried out at Al-Yarmouk Teaching Hospital, B aghdad, Iraq, over
a 9 year period. 21 patients (70%) had civilian diaphragmatic
penetrating injuries, while 9 (30%) suffered b lunt trauma. Most
cases are diagnosed during exploration for associated injuries. Also,
in a Turkish study of Kucuk, et al., there was penetrating injury in
69% and b lunt injury in 31 % of patients. There was associated
organ injury in 83.3% and isolated diaphragm injury in 1 6.6% of
patients (Jobbo N, 2003; and Kucuk, et al., 2002).
In a retrospective case note analysis of 480 patients with
traumatic diaphragmatic ruptures admitted in a major teaching
hospital in UK. B lunt trauma accounted for 81 % of injuries. The
left hemidiaphragm was ruptuered in 87.5 % and there were visceral
herniation in 5 0% (S impson, et al., 2000).
In a clinical review of recent experience at King Fand
Hospital, Al-Khob ar University, in S audi Arab ia. Diaphragmatic
113
DIS CUS S ION
injuries occurred in 2% of chest trauma victims, mainly on left side
in 71 .5 %. 84% of injuries were due too b lunt trauma (Abdel Hadi,
et al., 2001).
01 patients with proven diaphragmatic hernias seen at Asir
Central Hospital of S outh S audi Arab ia. 70% seen on left side and
30% seen on the right side. Common herniated organs were liver,
stomach, spleen and large intestine, and the most common approach
to management was laparotomy ( Grillo, et al., 2000).
In our study, cardiac injuries were identified in ab out 1 % of
our patients, 5 0 % with penetrating trauma due to stab wounds, and
5 0 % with b lunt trauma due to RTA. 5 0% underwent thoracotomy
with repair of ventricular injuries all of them due to penetrating
trauma, and the survival rate was 5 0%. B lunt cardiac trauma as
myocardial contusions was associated with low mortality. Cardiac,
vascular, and mediastinal injuries were the most lethal penetrating
injuries. The anterior surface of the heart is the most frequently
injuried area. In our study, aggressive surgical management of
penetrating cardiac injuries was an important factor in improving
the survival of penetrating cardiac trauma. The right ventricle was
affected more often than the left ventricle owing to its anterior
anatomic location. The atria were not affected, and injury of them
was not detected in our group of patients.
114
DIS CUS S ION
In a study of Tyb uriski, et al., to determine factors affecting
prognosis for patients with penetrating wounds of the heart, there
were 1 48 patients with gunshot wounds (GS W) and 1 5 4 patients
with stab wounds with 23% and 5 8% survival rates, respectively
(Tyburiski, et a1.,2000).
S ternal Fractures may herald serious b lunt cardiac injury. In
our study sternal fracture lead to myocardial contusion that need
only conservative measures in 25 % of cardiac injuries. In a recent
review of 37 consecutive patients with sternal fractures, S adab a et
al reported that b lunt chest wall trauma patients who are otherwise
well and have normal electrocardiogram (ECG) and chest
radiographs on presentation, can b e safely discharged home on oral
analgesics without further investigation (S adab a, et al., 2000).
In our study, the spectrum of pulmonary parenchymal injury
varied from isolated pulmonary contusions in (90.7%), to frank
lacerations in (9.3%). The most common mechanisms were motor
vehicle accidents and fall from aheight in (98.7%). Gunshots and
stab b ing result in lung injury in (1 .3%). Patients usually had
a variab le degrees of pneumo-thorax and/ or hemo-thorax.
Pulmonary contusions were associated with unstab le rib fractures in
most of cases. Thus, artificial ventilation was requiredwith large
severe contusions. Minor repair for pulmonary injuries was done in
(66.6%), lob ectomy in (1 6.6 %), and pneumenectomy in (1 6.6%).
115
DIS CUS S ION
Of 2,45 5 patients with chest trauma analysed by Kenneth, et al.,
32 (1 .3%) required pulmonary resection. Operative interference
consisted of wedge resection (1 9 patients), lob ectomy (9), and
pneumonectomy (4) ( Kenneth , et al., 2003).
In a western trauma multicenters review, management of
traumatic lung injury categorized a s "minor" (suture, wedge resection,
tractotomy) or "major" (lob ectomy or pneumonectomy). S uture alone
done in 95 ; tractotomy in 1 3%; wedge resection in 30%; lobectomy in
43%; and pneumonectomy in 5 0% (Karmy J, et al., 2001 ).
In our study, fractures of the b ronchi were more common than
those of the trachea. Tracheo-b ronchial injuries were suspected and
treated after persistent air leak and inefficient ventilation with
persistence of pneumo-thorax alter insertion of a chest tub e. Isolated
tracheo-bronchial injuries were rarely found, associated injuries with
tracheo-b ronchial injury detected in 75 %, most frequently in the lung
parenchyma and esophagus.
In a study to evaluate the surgical treatment of post-traumatic
tracheo-b ronchial injuries, 5 9% were penetrating and 41 % were b lunt,
associated injuries were seen in 68.7% most frequently in the lung
parenchyma and esophagus. Ten patients were seen in Northern S yria
with tracheo-b ronchial injuries and were noted b y B armada and
Gib b ons. B lunt and penetrating trauma had an equal frequency.
Associated injuries were noticed in 90% (B ald, et al., 2002; and
Barmada & Gib b ons, 2000).
116
DIS CUS S ION
In our study, patients with chest trauma presented with a
spectrum of severity ranging from life threatening injuries requiring
urgent surgical interference to hemodynamically stab le patients with a
negative initial evaluation. Often, even those with a negative initial
evaluation should b e admitted to exclude serious injury to the heart,
lung, and major vessels. Most of our patients were treated with chest
drains (71 .2%) that considered as a life-saving manoeuver and a
standard procedure for evacuation of air, b lood, and other materials
from the pleural space. Most of patients with tub e thoracostomy
improved, and removal of the tub e was decided after ab sence of air
leak and decreased fluid drainage with no need for surgical
interference, however, complications were detected in (27.7%).
Multiple factors contrib ute to the development of complicatins after
tub e thoracostomy include the condition under which the tub e was
inserted(emergent or urgent), the mechanism of injury (b lunt or
penetrating), retained hemo-thorax, and ventilator care.
In our study, thoracotomy done in 3.1 %, it was done for
management of pulmonary injuries in 46%, cardiac injury in 1 5 .3
%, vascular injury in 1 5 .3%, tracheo-b ronchial injury in 23 %,
and diaphragmatic injury in 1 5 .3%. The surgical procedures
depended on the type and extent of the thoracic and general injuries,
for example, the choice of surgical approach for "repair of
diaphragmatic injury (laparotomy or thoracotomy) depended on the
clinical and diagnostic findings.
117
DIS CUS S ION
In the study of Raju, et al., the majority (5 4.4%) were treated
with a chest drain only emergency or delayed thoracotomy was
required in 24.4%. Only 1 0-1 5 % of b lunt trauma require thoracic
surgery, and 1 5 -30% of the penetrating chest trauma require open
thoracotomy. 85 % of patients with thoracic trauma, can b e managed
b y simple lifesaving manoeuvre that do not require surgical
treatment (Tekinbas, et al., 2003; and Raju, et al., 2002).
In a report on 1 1 3 patients with chest injuries sub jected to
treatment in the town hospital of S ab ha, Lib ya, most of the patients
(5 6.7%) had hemo-pneumothorax with pleural drainage b eing the
only treatment applied. In 1 5 .9% thoracotomy, laparotomy or
thoracotomy plus laparotomy were used (Dakov & Alderadi,
2000).
As recorded b y Cakan, et al., 402 (41 %) of 71 0 patients
underwent tub e thoracostomy only. While majority of patients (5 5 3
patients, 5 6%) were managed conservatively, only 32 (3%)
underwent thoracotomy. In the study of Demirhan, et al., the
treatment noticed as 5 8% tub e thoracostomy, 32.5 % conservative
measures, and 7.1 % thoracotomy (Cakan, et al., 2000; and
Demirhan, et a1.,2001).
In the study of S egers, et al., a minority of the patients
required thoracotomy (n = 1 9/ 1 87, 1 0.2%). The main indications
for thoracotomy were pulmonary laceration in 26.3% (n = 5 ), aortic
118
DIS CUS S ION
rupture in 1 5 .7%(n = 3) and rupture of the diaphragm in 1 5 .7% (n
= 3). For the majority of cases, ob servation and/ or tub e
thoracostomy (5 2.4%) and/ or mechanical ventilation (61 .0%) were
sufficient (S egers, et a1.,2001).
In an Indian study of 35 0 consecutive patients with chest
injuries 300 (85 .71 %) were treated conservatively. Forty-eight
(1 3.7 %) patients underwent surgical exploration (thoracotomy in
34 and laparotomy in 1 4 patients) with 8 death. Remaining 2
patients died in the casualty soon after arrival. The overall mortality
was 8.5 7 % (B eg, et al., 2001 ).
In our study, the outcome of treatment of chest trauma was
complete improvement in 64.9%, complications in 24.3%, and the
mortality rate was 1 0.4%. Pneumonia was the most common
complication, followed b y wound infection and empyema. In the
study of Raju, et al., The mortality rate was 6.7%. It was 6.8% in
the study of Dermihan. In the study of Ab dul Latif and Khamash,
the mortality rate was 8.8% In a study of S egers, et al., pneumonia
was the most common complications (38.0 % ). In the study of
Cakan, et al., the complication rate was 4.6% and the most
frequently atelectasis was seen. 1 3 patients (1 .3%) died due to
trauma related causes. In the town hospital of Sabhs, Lib ya.
Complications with chest trauma were recorded in 7.1 %, with a
mortality rate of 2.7% (Ab dul Lath'
.
& Khamash, 2002; Raju, et
al., 2002 ; Cakan, et al., 2001 ; Demirhan, et al., 2001 ; S egers, et
al., 2001 ; and Dakov Alderadi, 2000).
119
SION
CONCLUS ION
CONCLUSION
Traumatic thoracic injuries are variab le in El-Minia and Assiut
university hospitals. Rib fracture was the m ost common pathological type of
injury that was found in 79.8% of patients, followed b y hemo-thorax and/ or
pneumo-thorax in 74.2%, lung contusions in 1 4.3 %, unstab le rib fractures
in 1 0.7%, lung lacerations in 1 .5 %, and diaphragmatic injury in 1 .5 %.
Cardiac injuries, great thoracic vascular injuries, and tracheo-bronchial
injury each of these was evident in 0.9% of patients with chest trauma.
B lunt chest trauma was the most frequent cause of thoracic injury
that lead to injury in 84.6%. Penetrating chest trauma lead to injury in
1 5 .4%. Road traffic accidents was the most common cause of b lunt trauma
that is found in 60.8%, however, fall from a height was found in 23.8%.
Penetrating chest trauma lead to injury in 1 5 %. S tab b ing was the most
common cause of penetrating trauma that was found in 8% of patients with
chest trauma, and firearm injury was found 7% .
Different methods of treatment were performed for treatment of chest
trauma. Conservative measures were p erform ed in 22.6%, tub e
thoracostomy is performed in 71 .2%. Thoracotomy was performed in 3.1
%, laparotmy for diaphragmatic and ab dominal injuries was performed in
2.1 %, and wire Fixation for sternal and unstab le rib fractures was performed
in 0.7% of thoracic injuries. Thoracotomy was performed for management of
pulmonary injuries in 46%, tracheo-b ronchial injury in 23 %. Cardiac
injury, vascular injury, and diaphragmatic injury were detected 15.3 % of
thoracotomies. After thoracotomy, 46% of patients improved, 5 4% had
120
CONCLUS ION
complications in the form of pneumonia and wound infection in 23%. After
tub e thoracostomy 72.3% of the patients improved, and 27.7% had
complications in the form of pneumonia in 1 7%, empyema in 4%, and
wound infection in 6.4%.
Rib fractures was the most frequent chest wall injury that was
associated with hemo-thorax and/ or pneumo-thorax in 70.4%, pulmonary
contusions in 5 .7%, pulmonary lacerations in 1 .8%, diaphragmatic injury
in 1 .2%, ab dominal injury in 1 %, and cardiac injuries in 0.6%. Tub e
thoracostomy was the only line of treatment in 67.6% of patients,
conservative measures were performed in 24.3%, thoracotomy was
indicated in 2.7% , and laparotomy was indicated in 2.1 % for management
of ab dominal injuries associated with rib fractures. All patients with unstab le
rib fractures had hemo-thorax and/ or pneumo-thorax, and 91 % of them had a
pulmonary contusions. Artificial ventilation was indicated in all patients, and
tub e thoracostomy was performed in 97.8% of patients with unstab le rib
fractures. In the patients with hemo-thorax and/ or pneumo-thorax tub e
thoracostomy was the only method of treatment in 92.7% of them,
thoracotomy due to major thoracic injuries was indicated in 4.2%, and
laparotomy was performed in 2.9%. Of those patients 75 .7% had simple
rib fractures, 1 4.4% had flail chest, 1 .8% had pulmonary injuries or
diaphragmatic injury, ab out 1 % had cardiac injury o r tracheo-b ronchial
injury, and 0.6% had great vessels injury. Pulmonary contusions associated
with hemo-thorax and/ or pneumo-thorax in 93.2% , flail chest in 67.7 %,
and simple rib fractures in 32.2%. Tub e thoracostomy was done for
associated hemo-thorax and/ or pneumo-thorax was found in 93.2%.
Pulmonary lacerations were associated with rib fractures and hemo-thorax
121
CONCLUS ION
and/ or pneumo-thorax in all cases, and 33.3% had an associated b ronchial
injury. Thoracotomy was indicated in all patients; minor repair was done in
66.6%.
Cardiac injuries were ventricular in 5 0% of cases, and the treatment
was performed through minor repair in 5 0%. B ronchial injury was evident in
75 % of patients with tracheo-bronchial injuries, mainly on the right side in
5 0%. Minor repair only was performed in 5 0% of patients with tracheo-
b ronchial injuries. Diaphragmatic injuries were associated with hemo-thorax
and/ or pneumo-thorax in all patients , 66.6 % were associated with rib
fracture , and 33.3 A associated with liver injuries. Diaphragmatic tear was
detected in 66.6%; right sided in 33.3%, and left sided in another 33.3%.
Diaphragmatic hernia was evident in 33.3% of patients with diaphragmatic
injuries, all of them on the left side. Laparotomy for repair of diaphragmatic
injury and associated ab dominal injuries was indicated in 66.6%, and
thoracotomy was indicated only in 33.3%.
Associated injuries with chest trauma included ab dominal injuries in
1 .9%. S plenic injury was detected in 0.9%, and liver injury in 0.7%. Head
and neck injuries were found in 27 % and injury of b oth limb s was found in
9%. The outcome of treatment for chest trauma was complete improvement
in 64.9%, complications in 24.3%, and the mortality in 1 0.4%.
Complications after thoracotomy were found in 7 patients ( 1 .7%).
Complications after tub e thoracostomy were found in 1 9.7%, and in 2.9%
after conservative measures . Pneumonia was developed in 1 5 %, wound
infection in 6%, and empyema in 3.1 % of patients with chest trauma.
Mortality after traumatic flail chest was estimated to b e 1 0%.
122
S UM M ARY
SUMMARY
This work had b een conducted in El-Minia and Assiut university
hospitals to evaluate the most common mechanisms of chest trauma, the
different pathological types of thoracic injury, and the methods of
treatment of chest trauma over a peroid of 1 2 months started at January
2001 , on 41 1 patients, most of them were male patients.
As regard the different mechanisms of chest trauma, B lunt chest
trauma was the most frequent cause of thoracic injury, and road traffic
accident was the most common cause of b lunt trauma followed b y fall from
a height. S tab b ing was the most common cause of penetrating trauma
followed b y firearm injuries. In the past, it was thought that firearm injuries
were the most common cause of penetrating thoracic injury. Our results were
similar to the results of many recent studies.
As regard the methods of treatment of chest trauma, conservative
treatment was the most accepted method, followed b y tub e thoracostomy.
Thoracotomy and laparotmy were indicated in a little numb er of patients.
Thoracotomy was performed mainly for the management of pulmonary
injuries, followed b y tracheo-b ronchial injury, cardiac injury, vascular
injury, and diaphragmatic injuryin alittle extent. After thoracotomy,
complete recovery was not a rule, many complications in the form of
pneumonia and wound infection mainly were reported. After tub e
thoracostomy, most of the patients improved, and some of them had
complications in the form of pneumonia, empyema, and wound infection.
123
S UM M ARY
As regard the pathological types of injury, traumatic thoracic injuries
were .. variable. Rib fracture was the most common pathological type of
injury, followed respectively b y hemo-thorax and/ or pneumo-thorax, lung
contusions, unstab le rib fractures, lung lacerations, diaphragmatic injuries,
cardiac injuries, great thoracic vascular injuries, and tracheo-bronchial
injuries.
Rib fractures was the most frequent chest wall injury that was
associated respectively with hemo-thorax and/ or pneumo-thorax, pulmonary
contusions, pulmonary lacerations, diaphragmatic, ab dominal injury, and
cardiac injuries. Tub e thoracostomy was the most frequent method of
treatment, followed b y conservative measures, thoracotomy, and
laparotomy for management of injuries associated with rib fractures. All
patients with unstab le rib fractures have hemo-thorax and/ or pneumo-thorax,
and most of them have a pulmonary contusions. Artificial ventilation was
indicated in all patients, and tub e thoracostomy was indicated for
management of associated hemo-thorax and/ or pneumo-thorax.
In the patients with hemo-thorax and/ or pneumo-thorax, tub e
thoracostomy was the only method of treatment in most of them,
thoracotomy due to major thoracic injuries is indicated for a little extent.
Those patients had different pathological types of thoracic injuries in the
form of simple rib fractures, flail chest, pulmonary injuries, 'diaphragmatic
injury, cardiac injury, tracheo-bronchial injury, and great vessels injury
respectively.
124
S UM M ARY
Pulmonary contusions associated with other injuries as hemo-thorax
and/ or pneumo-thorax, flail chest in most of patients. Tub e thoracostomy
was done for associated hemo-thorax and/ or pneumo-thorax. Pulmonary
lacerations associated with rib fractures and hemo-thorax and/ or pneumo-
thorax in all cases. Thoracotomy was indicated in all patients and minor
repair was the most frequent surgical procedure.
Ventricular injury was the most common cardiac injury, and the
treatment was performed mainly through minor repair. B ronchial injury was
evident in most of patients with tracheo-b ronchial injuries, mainly on the
right side. Minor repair only was performed in most of patients with
tracheo-b ronchial injuries. Diaphragmatic injuries associated with 'wino-
thorax and/ or pneumo-thorax in all patients, and most of these injuries
associated with rib fracture, and ab dominal injuries. Diaphragmatic hernia
was evident in 33.3% of patients with diaphragmatic injuries,all of them on
the left side. Laparotomy for repair of diaphragmatic injury and associated
ab dominal injuries is indicated in most of cases, and thoracotomy was
indicated in some of them.
Associated injuries with chest trauma included ab dominal injury that
include mainly splenic and liver injury. Head and neck injury was the most
frequent injury with chest trauma, followed b y the injuy of extremites. The
outcome of treatment for chest trauma was complete improvement in most
of the patients, however, complications and mortality were reported in many
patients. Complications developed respectively in the form of pneumonia,
wound infection, and cinpyema .
125
I I
I
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