CHEST AND ABDOMINAL CONDITIONS

Chest Trauma in Athletic Medicine

Nicholas R. Phillips, MD1 and Derek E. Kunz, MD2

ysis of high school athletics found only

Abstract 4.9 injuries to the torso V including
While overall sports participation continues at high rates, chest injuries chest, thoracic spine, and abdomen V per
occur relatively infrequently. Many conditions of chest injury are benign, 100,000 athletic exposures. Most of
related to simple contusions and strains, but the more rare, severe injuries these injuries were benign and related to
carry a much higher risk of morbidity and mortality than the typical issues contusion or muscle strain, but around
encountered in athletic medicine. Missed or delayed diagnosis can prove to half of all torso injuries still required
be catastrophic. Sports medicine providers must be prepared to encounter a further diagnostic workup. Additional-
wide range of traumatic conditions relating to the torso, varying from the ly, only 42.3% of all athletes returned to
benign chest wall contusion to the life-threatening tension pneumothorax. sport within a week after a torso injury
Basic field-side management should be rapid and focused, using the stan- (7). Prompt identification and treatment
dardized approach of Advanced Traumatic Life Support protocol. Early and can mean a significant difference in out-
appropriate diagnosis and management can help allow safe and enjoyable come. Sports medicine providers must be
sports participation. aware of the spectrum of injuries that can
occur, from the mundane to the deadly,
and be ready to act appropriately.

Introduction Basic Treatment

The volume of people involved in sports in the United States
continues to occur at a very high level throughout various age
groups. Each year greater than 7.8 million high school students
and 60 million youth older than 6 yr participate in organized
athletics (1,2). Meanwhile, adults are showing increased par-
ticipation in higher risk activities with extreme action and ad-
venture sports totaling 22 million participants and obstacle
racing adding 4.5 million annually (3,4). With the large overall
numbers and increasing adult participation in riskier activity,
it is likely that the sideline physician will be increasingly
exposed to chest trauma.
In general, chest and torso trauma related to sports is rel-
atively rare. It can be caused by rapid deceleration or direct
impact to the thorax. While infrequent, however, these inju-
ries run the risk of being extremely serious and even life-
threatening. In overall trauma mortality, thoracic injuries
account for about 25% of all early-trauma related deaths, but
some studies have shown sports causing only about 2% of
those chest injuries requiring treatment (5,6). A recent anal-
1
Samaritan Athletic Medicine at Oregon State University, Samaritan Health
Services, Corvallis, OR; and 2Saint Alphonsus Sports Medicine, Boise, ID
Address for correspondence: Nicholas R. Phillips, MD, Samaritan Athletic
Medicine at Oregon State University, Samaritan Health Services, 845, SW
30th St, Corvallis, OR 97331; E-mail: nphillips@samhealth.org.
1537-890X/1703/90Y96
Current Sports Medicine Reports
Copyright * 2018 by the American College of Sports Medicine
Evaluation should begin with the basic principles of any
initial injury encounter. While Advanced Traumatic Life Sup-
port (ATLS) cannot fully be performed field-side, its guidelines
provide an appropriate outline for action. The common ac-
ronym of ‘‘ABC’’ V indicating airway, breathing, and circu-
lation V is often used. Patient assessment should begin with
an evaluation of airway patency. Any cause of obstruction
should be addressed immediately, with a jaw thrust being
appropriate in most instances. Breathing status is evaluated
by inspection and auscultation. If deficient, the primary cause
should be treated per the specific interventions indicated be-
low, along with supplemental oxygen and positive pressure
ventilation with bag valve mask. Circulation is assessed with
evaluation of pulse presence/quality, heart rate, and blood
pressure. Circulatory collapse can occur through hemor-
rhagic shock related to intrathoracic blood loss. Additionally,
obstructive shock can be related to impeded venous return
due to elevated intrathoracic pressure (as in tension pneu-
mothorax) or inadequate cardiac filling (as in cardiac
tamponade). Any life-threatening abnormality of airway,
breathing, or circulation failure must be treated as it is dis-
covered. Less severe conditions are more thoroughly evalu-
ated/treated on a less emergent basis once the athlete is
confirmed as stable.
The primary survey is often expanded to ‘‘ABCDE’’ to in-
clude disability and exposure. Disability evaluation consti-
tutes a basic assessment of neurologic status, while exposure
serves as a reminder to examine the patient fully from head to
toe to ensure that no injuries are missed.

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 While this focus resides on chest trauma, one must also
consider associated injury, specifically intra-abdominal trauma.
Although specific abdominal conditions and treatments are
beyond the scope of this article, basic trauma assessment and
appropriate triage protocols apply.
Continuing Developments
The increased utilization of bedside and field-side ultrasound
provides an evolving aspect of this topic. Bedside ultrasound has
been used in emergency medicine and trauma surgery for
some time with good accuracy in diagnosis of chest trauma
(8Y11). This modality provides added benefit of portability,
relatively low cost, and avoidance of ionizing radiation. As
sports medicine providers become more adept at the use of
ultrasound within the musculoskeletal realm, expansion to
more nonmusculoskeletal applications is a natural step. Op-
portunities for expedited diagnosis using portable ultraso-
nography will be highlighted throughout this overview.
Acute Life-Threatening Emergencies
Pneumothorax
A pneumothorax occurs when air becomes trapped be-
tween the visceral pleura of the lung and the parietal pleura
of the chest wall. This can occur spontaneously or with
trauma. Spontaneous pneumothorax most often occurs in
young, tall males (12). It has been described as occurring in
noncontact sports such as scuba diving, weight lifting, and
running (6). Additionally, it can occur in older people with
underlying pulmonary disease. Pneumothorax in trauma
typically results from rib fracture that leads to direct injury
of the pleura; however, sports-related traumatic pneumo-
thorax in the absence of rib fracture has been reported (13).
Simple pneumothorax itself is rarely life-threatening, but it
can develop into and must be distinguished from tension
pneumothorax, which can quickly lead to death.
Diagnosis of pneumothorax is based initially on clinical
signs and symptoms. Patients usually complain of a pleuritic
chest pain and shortness of breath. Breath sounds may be
decreased, and lung fields may be hyper-resonant with per-
cussion. Subcutaneous emphysema also may be appreciated.
Hypoxia can be seen in more severe cases. However, even in
the absence of physical exam signs, suspicion must remain
high, as clinical diagnosis can be difficult.
While chest X-ray has historically been the first line in
evaluation for the condition, ultrasound has gained popular-
ity in the acute setting for an expedient diagnosis of pneu-
mothorax. This modality has been found to be extremely
accurate and is now being considered the preferred first-line
tool for diagnosis in critical care settings (14). Studies have
demonstrated better sensitivity and similar specificity when
comparing ultrasound to standard chest X-ray (8). Specific-
ities have been found to be greater than 99% (9). Pneumo-
thorax on ultrasound demonstrates lack of normal lung
sliding, absence of B-lines (also known as comet tail artifacts),
and possible presence of a lung point/transition point.
M-mode utilization allows for visualization of lung sliding
using a static image (Fig. 1A, B). Further workup with formal
chest X-ray is still indicated when appropriately removed from
the athletic venue. This can quantify the size of the pneumo-
thorax and evaluate for associated bony injury. If the diagnosis
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is in question, computerized tomography (CT) scanning of the
chest can be used, which is still considered the gold standard.
Tension pneumothorax is a clinical diagnosis that should
be made before the attempt at any diagnostic imaging, as the
delay in management can prove fatal. This condition leads to
a severe increase in intrathoracic pressure that impedes venous
return and ultimately decreases cardiac output. The patient
usually appears to be in distress, and signs typically involve
hypotension, a deviated trachea away from the side of injury,
distended neck veins, and decreased or absent breath sounds.
Management of pneumothorax depends on the extent of
the ailment and the condition of the patient. For a small,
simple pneumothorax with stable vital signs and no distress,
observation alone is usually sufficient. Depending upon pro-
vider and patient comfort, this can be performed in the in-
patient or outpatient setting. Serial imaging will confirm the
resolution and return to play timeline. Air travel should be
avoided when pneumothorax is suspected or confirmed.
Though no strict guidelines exist for timeline on resuming air
travel after resolution of pneumothorax, it is felt that flying
should be avoided for at least the first 2 wk after confirmed
resolution (15).
With more notable pneumothoracies, tube thoracostomy is
often performed to aid in resolution and healing. For tension
pneumothorax, immediate needle decompression is critical.
Though it is anxiety-inducing, this procedure should be within
the scope of all sports medicine practitioners who provide care
on the sidelines. Using a large bore catheter, the second in-
tercostal space in the midclavicular line on the side of injury
should be punctured. Typically a large release of air is ap-
preciated when the pleural space is entered. The needle should
then be removed and the catheter secured in place while
transport for definitive care is arranged.
Pericardial Effusion, Cardiac Tamponade
A pericardial effusion occurs when there is an increased
accumulation of fluid in the pericardial sac surrounding the
heart. There are numerous causes of pericardial effusions
occurring under conditions that are infectious, inflammatory
(e.g., rheumatoid arthritis, Sjogren syndrome, systemic lupus
erythematosus), neoplastic, cardiac, idiopathic, or traumatic.
Under normal physiologic conditions, the pericardial sac con-
tains 15 to 50 milliliters of serous fluid (16). Cardiac tamponade
occurs when fluid accumulation reaches a point at which
ventricular filling is reduced and hemodynamic compromise
is observed. In the acute setting with pericardial effusion oc-
curring due to trauma, cardiac tamponade can be seen with as
little as 200 to 300 ml of fluid accumulated in the pericardial
space (17). Any athlete sustaining chest trauma could po-
tentially develop a pericardial effusion/cardiac tamponade.
However, given the wide variety of other causes, athletes
with any of the underlying medical conditions known to be
a risk factor could develop a pericardial effusion/cardiac
tamponade spontaneously.
The diagnosis of pericardial effusion should be based on
clinic presentation and diagnostic imaging. Some patients
with pericardial effusion may be asymptomatic, but those
with symptoms may report chest pain and dyspnea that
worsen when lying flat and improve while in an upright po-
sition. On physical exam, the athlete may have findings de-
scribed as Beck’s Triad, which includes hypotension, jugular
Current Sports Medicine Reports 91
Figure 1: Panel A. Normal lung ultrasound. Using M-mode analysis allows for visualization and documentation of lung sliding over time
using a static image. This image demonstrates normal chest wall tissue that is not moving depicted by horizontal lines superficially. The
pleural line appears hyperechoic (arrow) and the image deep to the pleural line demonstrates a granular appears due to the sliding of lung. This
constitutes the ‘‘seashore sign’’ whereas the superficial linear pattern makes up the waves and the granular artifact pattern deep to the pleural line
makes up the sand. (Image courtesy of Charles Price, OMS-III. College of Osteopathic Medicine of the Pacific-Northwest). Panel B. Pneumothorax. On
this image, the tissue deep to the pleural line continues to demonstrate a horizontal linear pattern, indicating lack of normal lung sliding. In real-time,
dynamic images confirm this lack of lung sliding. Normal and pathologic examples of this can be seen in supplemental digital content videos 1 to 3.
(http://links.lww.com/CSMR/A16, http://links.lww.com/CSMR/A17, and http://links.lww.com/CSMR/A18). (Image courtesy of Elias Jaffa, MD.
Duke University Medical Center, Division of Emergency Medicine).

venous distention, and muffled heart sounds. Beck’s Triad is
seen in a minority of individuals with pericardial effusion/
cardiac tamponade, but more commonly in the setting of
acute chest trauma (18). Electrocardiogram findings may in-
clude electrical alternans, which describes consecutive, nor-
mally conducted QRS complexes alternating in height. Chest
X-ray findings may include the heart appearing boot- or water
bottle-shaped.
Pericardial effusions can certainly be seen on a CT/MRI,
but echocardiography is the diagnostic modality of choice
(16). Echocardiography can dynamically assess the pericar-
dial effusion, providing the size of the effusion and evaluation
of abnormal filling patterns suggestive of cardiac tamponade.
A pericardial effusion appears as an anechoic fluid collection
within the pericardial sac surrounding the heart (Fig. 2). On
dynamic ultrasound, cardiac tamponade appears as patho-
logic collapse of the right ventricle during diastole. Certainly
with ultrasound becoming an increasingly common practice
in sports medicine, the ability to quickly assess the pericardial
space with bedside ultrasound could be a valuable diagnostic

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Figure 2: Pericardial effusion. This image demonstrates hypoechoic fluid around the heart. During real-time ultrasound, diastolic collapse
of the right ventricle is noted in cases of cardiac tamponade. Videos of this finding can be seen in the supplemental digital content videos 4
and 5 (http://links.lww.com/CSMR/A19, http://links.lww.com/CSMR/A20). (Image courtesy of Elias Jaffa, MD. Duke University Medical
Center, Division of Emergency Medicine).
tool when suspicion for pericardial effusion/cardiac tamponade
is high.
The treatment of pericardial effusions ranges from obser-
vation to emergent intervention and is dependent on the clini-
cal status of the patient, underlying etiology, and expected
clinical course. Small effusions, if not causing symptoms, can
often be observed. If signs of cardiac tamponade are present,
emergent treatment with drainage is needed. These tech-
niques include needle pericardiocentesis, percutaneous ballon
pericardiotomy, video-assisted thoracoscopic surgery (VATS)
approach, surgical pericardial window, and emergent thora-
cotomy (19). Though needle pericardiocentesis would rarely
be required in the acute athletic setting, one should be aware
of this procedure, as it could prove to be lifesaving.
Commotio Cordis
Though it is initiated by trauma, this condition does not
involve any traumatic structural damage, but instead relates
to an initiation of abnormal function of the heart. Commotio
cordis occurs after acute direct trauma to the precordium. It is
thought that the likely precipitating factor is impact during an
extremely narrow segment of the T-wave upstroke portion of
the cardiac cycles, which initiates arryhthmogenic changes,
leading to ventricular fibrillation (20). Diagnosis relates to
the recognition of typical signs of arrhythmia leading to car-
diac arrest after an appropriate traumatic event. The specifics
of the traumatic impact can vary quite widely, but most fre-
quently involves direct anterior chest wall impact from a
firm, small ball (such as baseball or lacrosse ball) in a child or
adolescent (21). Treatment should follow usual ACLS guide-
lines and sideline management of cardiac arrest. Use of early
defibrillation in this condition has been shown to be the most
critical component of treatment. Though survival rate has
been improving over recent years, it is still extremely low overall
at 15% and drops to 3% if initial attempt at resuscitation is
delayed beyond 3 min (22).
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Flail Chest
Flail chest occurs when there is an unstable portion of the
chest wall secondary to multiple rib fractures. This condi-
tion requires segmental rib fracturesVat least two locations
of the same ribVof at least three consecutive ribs. This
condition is unlikely to be encountered in sport-related injury,
but it should be present among the differential diagnoses of
chest trauma.
Flail chest is characterized by paradoxical breathing wherein
the flail segment of the chest falls during the expected chest
expansion of inhalation and rises during the anticipated de-
pression of exhalation. Management requires aggressive pain
control to allow for full expansion of the lungs and can re-
quire mechanical ventilation. There has been some increasing
interest regarding surgical fixation of rib fracture to allow for
earlier recovery (23,24).
Sternoclavicular Dislocation
The overall rate of sternoclavicular dislocation is low. His-
torical studies reported the condition to be involved in less
than 5% of all shoulder girdle injuries, though some authors
feel this may have underreported the condition (25,26). An-
terior instability is much more common than its posterior
counterpart, but posterior dislocation carries the risk of in-
creased injury to associated mediastinal structures (27). Injury
usually occurs with indirect contact after lateral compression
to the shoulder. Direction of the instability will be related to
the point of impact and the position of the shoulder at the
time of impact. Direct injury can occur after impact being
placed to the medial clavicle, usually resulting in a posterior
dislocation (28).
Diagnosis can be suspected by clinical palpation of the
area, though subtle depression of posterior dislocation can be
difficult to discern. Plain film radiography lacks adequate sen-
sitivity due to the overlapping anatomic structures seen on im-
aging, including medial clavicle, ribs, sternum, and vertebrae.
Current Sports Medicine Reports 93
Serendipity view, with the X-ray beam directed 40 degrees
cranially, can enhance visualization of isolated sternoclavicular
dislocation. Definitive confirmation often requires CT and
this allows for assessment of associated injuries.
Early management consists of primary identification and
transfer for definitive care in severe cases. Anterior dislocations
can be managed conservatively, but typically warrant an at-
tempt at reduction. Ideally, these should be reduced within
24 h and can often be achieved by closed reduction (29).
Closed reduction of posterior dislocations should not be routinely
considered, and current recommendations direct toward
open reduction (26). This often uses an orthopedist comfort-
able in the management of the injury, with on-site availability
of trauma and/or thoracic surgery. In the rare event of posterior
dislocation with severe hemodynamic or airway compromise,
emergent reduction can be considered. Several techniques have
been described. One potential technique involves placing a
bolster between the shoulder blades of the supine patient,
with subsequent posteriorly directed pressure applied to the
shoulder in order to lever the clavicle on the first rib. Alter-
natively from this position, traction can be pulled on the arm
while moving it into abduction and extension. Manual trac-
tion on the medial clavicle with the provider’s fingers or a
sterile towel clip also can be used (26,28).
Aortic Injury
Blunt aortic injury is an often fatal condition that is seen in
the setting of severe chest trauma. For those individuals suf-
fering blunt aortic injury, as many as 80% will die before
arrival in the hospital (30). The majority of blunt aortic in-
juries occur in the setting of motor vehicle crashes. However,
in the sport setting, blunt aortic injury could occur under any
circumstance in which sudden deceleration occurs. Various
research articles have described aortic injuries sustained from
sporting events ranging from rugby to skiing (31,32). This
injury occurs when sudden deceleration leads to significant
forces being applied to the fixed and mobile portions of the
aorta, potentially causing tears.
The diagnosis of blunt aortic injury is based on imaging
(30). However, if an athlete suffers severe chest trauma and
complains of chest pain and/or if hemodynamic compromise
is present, aortic injury should certainly be on the differential
diagnosis. Chest X-ray imaging may reveal indistinct medi-
astinal silhouette and loss of normal contour of the aorta.
Although it is easy to complete, chest X-ray has an unaccept-
able rate of missed injury (30). For many years, aortography
was considered the best diagnostic test, but given its re-
quirement for special personnel and the fact that it is highly
invasive, it has been replaced by CT as the diagnostic imaging
test of choice for blunt aortic injury.
Treatment of blunt aortic injury depends on severity and
ranges from medical therapy to operative repair. Medical
management revolves around beta-blockers and antihyper-
tensive medications to decrease shear force on the aortic wall.
When intervention is deemed to be necessary, surgical options
range from a clamp-and-sew to shunt-bypass technique. Over
the past 50 yr, there has been a great deal of advancement in
endovascular grafting for aortic injury repair. More and more,
this mode of treatment is becoming the intervention of choice
in the setting of blunt aortic injury (33).
94 Volume 17 & Number 3 & March 2018
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Urgent and Subacute Issues
Chest wall contusion
Overall, contusion is the most common outcome of chest
trauma and accounts for nearly 50% of all injuries to the torso
(7). Diagnosis is primarily clinical by appropriate history and
examination but can require further workup to evaluate for
more severe associated conditions. Symptoms and examina-
tion findings can easily overlap those seen with rib fracture,
pulmonary contusion, and pneumothorax. Once other con-
ditions have been ruled out, treatment includes pain control
modalities with ice, analgesics, and anti-inflammatories.
Rib Fracture
Rib fracture is one of the more common types of chest
trauma (34). Though it is not acutely life-threatening by itself,
rib fracture can be associated with several of the potentially
fatal conditions listed above. Concomitant injuries must be
considered, especially with extra vigilance for pneumothorax.
Diagnosis is typically made by chest X-ray and/or rib series
X-ray, which can be supported by physical exam with focal
rib tenderness, bony crepitus, or mobile rib segments. Ultra-
sound also can be used for diagnosis. A fracture appears as a
cortical irregularity of the hyperechoic bony cortex of the rib
(Fig. 3). Ultrasound has been found to be accurate and routinely
more sensitive than standard radiography (10,11).
Once associated emergency conditions have been ruled out,
acute management of rib fracture centers around pain man-
agement and pulmonary hygiene to prevent secondary com-
plications. Inadequate initial treatment can lead to self-splinting
and resultant atelectasis with the risk of subsequent pneumo-
nia. Pain control often requires the use of narcotics, in addition
to acetaminophen and nonsteroidal anti-inflammatories.
Additionally, nerve blocks can be employed in the appropri-
ate setting.
Isolated rib fractures in the young, healthy athlete can typi-
cally be treated as an outpatient after demonstration of ade-
quate pain control and lack of respiratory distress. Hospital
admission is often recommended in the elderly and those with
significant comorbid illnesses. Hospitalization can be con-
sidered for a patient with 3 or more rib fractures and should
be suggested if there are any signs of respiratory compromise.
This can be indicated by oxygen saturation less than 92% on
room air, failure to achieve incentive spirometry greater than
1000 cc or 15 ccIkgj1, and vital capacity less than 55% of
predicted (35).
Pulmonary Contusion
Pulmonary contusion is a relatively common finding in major
blunt trauma such as motor vehicle accidents and severe falls,
but reports have indicated that it can also occur in collegiate
football players (36,37). Additionally, there have been case
reports occurring in divers after direct chest wall impact to
water (38).
Presenting signs and symptoms of the condition are vague
and nonspecific. Patients usually complain of shortness of
breath and chest pain. Physical exam can include tachypnea,
wheezing, decreased breath sounds, or crackles, or exam may
be completely normal (39). Hemoptysis may be present. Any
of the signs and symptoms may develop immediately or can
present in a delayed fashion.
Chest Trauma in Athletic Medicine
Figure 3: Rib fracture. This image demonstrates discontinuity of the normally smooth bony cortex of the rib. (Image courtesy of Chris-
topher Moore, MD. Yale University School of Medicine, Department of Emergency Medicine).
Chest X-ray is typically normal immediately after injury, but
appearance of infiltrates will often develop later, anywhere
from 4 to 48 h after injury. CT scan is considered the gold
standard for evaluation and will demonstrate pathologic
changes immediately (40). Management consists of supportive
care with analgesia and pulmonary hygiene. Hypoxia is treated
with supplemental oxygen, and close vigilance must be
maintained, as the condition can rarely evolve into Adult Re-
spiratory Distress Syndrome (ARDS), which often requires
mechanical ventilation.
Cardiac Contusion
Cardiac contusion is a relatively rare result of blunt chest
impact in sports. It is more commonly seen in high-velocity
trauma, such as in a motor vehicle accident, but it has been
reported in various sporting activities, including professional
soccer (41). In sports, this injury is most commonly caused by
direct injury to the precordium.
Though the mechanism is similar to that of commotio cordis,
this injury, in contrast, does lead to structural changes in the
heart. These changes vary on a spectrum of severity but demon-
strate indicators of myocardial damage. Symptoms can be mild
and may consist of only vague chest pain and palpitations.
Initial evaluation includes electrocardiography and echo-
cardiography, though these can be normal, and demonstrate
only nonspecific findings when abnormal. Labs will demon-
strate elevation in cardiac enzymes, and magnetic resonance
imaging (MRI) is likely useful in confirming diagnosis. Ex-
pectant management is usually uneventful, though compli-
cations of arrhythmia and heart failure can be seen and must
be monitored for (42).
Conclusion
Overall, chest injuries in sports are relatively rare, and the
majority of injuries that do occur are largely benign and
self-limiting. Thoracic injuries, however, have many similar
overlapping signs and symptoms, and several conditions
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can often occur concomitantly. Additionally, the more sig-
nificant injuries can have dire complications, especially if
diagnosis is missed or delayed. Sports medicine providers
must be aware of the conditions on the severe end of the
spectrum that often necessitate further evaluation. As sports
medicine providers become more comfortable with the use
of field-side ultrasound, expanding its use beyond muscu-
loskeletal pathology toward the ability to assess potential
traumatic chest injuries could be extremely valuable. When
the severe injuries do occur, providers must be comfortable
in trauma protocol and aware of lifesaving procedures that
may need to be performed.
References
1. Associations NFHS. 2015Y2016 High School Athletics Participation Survery
[cited 2017 Aug 13]. 2016; Available from: http://www.nfhs.org/
ParticipationStatistics/PDF/2015-16_Sports_Participation_Survey.pdf.
2. National Council of Youth Sports. Report on trends and participation in
organized youth sports 2008 [cited 2017 Aug 13]. Available from: http://www.
ncys.org/pdfs/2008/2008-ncysmarket-research-report.pdf.
3. Thorpe H, Wheaton B. Generation X Games, action sports and the Olympic
movement: understanding the cultural politics of incorporation. Sociology.
2011; 45:830Y47.
4. Perez AJ. ‘‘Obstacle races going mainstream, more popular than marathons.’’
USA Today Sports, USA Today. 2015. [cited 2017 Aug 13]. Available from:
http://www.usatoday.com/story/sports/2015/11/02/obstacle-races-going-
mainstream-more-popular-than-marathons/73743474/.
5. Nathens AB, Meredith JW. National trauma data bank 2009: Annual Report.
Chicago: American College of Surgeons, 2009.
6. Partridge RA, Coley A, Bowie R, Woolard RH. Sports-related pneumothorax.
Ann. Emerg. Med. 1997; 30:539Y41.
7. Johnson BK, Comsock RD. Epidemiology of chest, rib thoracic spine, and
abdomen injuries among United States high school athletes, 2005/06 to
2013/14. Clin. J. Sport Med. 2017; 27:388Y93.
8. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography
for detecting post-traumatic pneumothoraces: the Extended Focused Assess-
ment with Sonography for Trauma (EFAST). J. Trauma. 2004; 57:288Y95.
9. Ianniello S, Di Giacoma V, Sessa B, Miele V. First line sonographic diagnosis
of pneumothorax in major trauma: accurace of e-FAST and comparison with
multi-detector computed tomography. Radiol. Med. 2014; 119:674Y80.
10. Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures.
Am. J. Emerg. Med. 2009; 27:617Y20.
Current Sports Medicine Reports 95
11. Turk F, Kurt AB, Saglam S. Evaluation by ultrasound of traumatic rib fractures
missed by radiography. Emerg. Radiol. 2010; 17:473Y7.
12. Dotson K, Johnson LH. Pediatric spontaneous pneumothorax. Pediatr. Emerg.
Care. 2012; 28:715Y20.
13. Soundappan SV, Holland AJ, Browne G. Sports-related pneumothorax in
children. Pediatr. Emerg. Care. 2005; 21:259Y60.
14. Yarmus L, Feller-Kopman D. Pneumothorax in the critically ill patient. Chest.
2012; 141:1098Y105.
15. Aerospace Medical Association Medical Guidelines Task Force. Medical
guidelines for airline travel, 2nd ed. Aviat. Space Environ. Med. 2003;
74(Suppl 5):A1Y19.
16. Willner DA, Bhimji SS. Pericardial Effusion. (2017, February 07). [cited 2017
Sept 9]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431089/.
17. Kumar V, Abbas AK, Fausto N. The pathological basis of disease. 7th ed. London:
Harcourt Ltd., 1994.
18. Stolz L, Valenzuela J, Situ-LaCasse E. Clinical and historical features of
emergency department patients with pericardial effusions. World J. Emerg.
Med. 2017; 8:29Y33.
19. Khandaker MH, Espinosa RE, Nishimura RA, et al. Pericardial disease: di-
agnosis and management. Mayo Clin. Proc. 2010; 85:572Y93.
20. McCrory P. Commotio cordis. Br. J. Sports Med. 2002; 36:236Y7.
21. Maron BJ, Estes NA 3rd. Commotio cordis. N. Engl. J. Med. 2010; 362:917Y27.
22. Palacio LE, Link MS. Commotio cordis. Sports Health. 2009; 1:174Y9.
23. Bottlang M, Long WB, Phelan D, et al. Surgical stabilization of flail chest
injuries with MatrixRIB implants: a prospective observational study. Injury.
2013; 44:232Y8.
24. Bhatnagar A, Mayberry J, Nirula R. Rib fracture fixation for flail chest: what
is the benefit? J. Am. Coll. Surg. 2012; 215:201Y5.
25. Nettles JL, Linscheid RL. Sternoclavicular dislocations. J. Trauma. 1968; 8:158Y64.
26. Chaudhry S. Pediatric posterior sternoclavicular joint injuries. J. Am. Acad.
Orthop. Surg. 2015; 23:468Y75.
27. Camara EH, Bousso A, Tall M, Sy MH. Posterior sternoclavicular dislocations.
Eur. J. Orthop. Surg. Traumatol. 2009; 19:7Y9.
96 Volume 17 & Number 3 & March 2018
Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
28. Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries.
J. Am. Acad. Orthop. Surg. 2011; 19:1Y7.
29. Legome E. Initial evaluation and management of blunt trauma in adults. In:
UpToDate. Grayzel J (Ed), UpToDate, Waltham, MA, 2017.
30. Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N. Engl.
J. Med. 2008; 359:1708Y16.
31. Singhal P, Kejriwal N. Ascending aortic tear with severe aortic regurgitation
following rugby injury. Heart Lung Circ. 2009; 18:150Y1.
32. Heller G, Immer FF, Savolainen H, et al. Aortic rupture in high-speed skiing
crashes. J. Trauma. 2006; 61:979Y80.
33. Challoumas D, Dimitrakakis G. Blunt thoracic aortic injuries: new perspectives
in management. Open Cardiovasc. Med. J. 2015; 9:69Y72.
34. Platz JJ, Fabricant L, Norotsky M. Thoracic trauma: injuries, evaluation, and
treatment. Surg. Clin. North Am. 2017; 97:783Y99.
35. Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association
Critical Decisions in Trauma: management of rib fractures. J. Trauma Acute
Care Surg. 2017; 82:200Y3.
36. Meese MA, Wayne JS. Pulmonary contusion secondary to blunt trauma in a
collegiate football player. Clin. J. Sport Med. 1997; 7:309Y10.
37. Lively MW, Stone D. Pulmonary contusion in football players. Clin. J. Sport
Med. 2006; 16:177Y8.
38. Lively MW. Pulmonary contusion in a collegiate diver: a case report. J. Med.
Case Rep. 2001; 5:362.
39. Cohn SM. Pulmonary contusion: review of the clinical entity. J. Trauma.
1997; 42:973Y9.
40. Trupka A, Waydhas C, Hallfeldt KK, et al. Value of thoracic computed to-
mography in the first assessment of severely injured patients with blunt chest
trauma: results of a prospective study. J. Trauma. 1997; 43:405Y11.
41. Vago H, Toth A, Apor A, et al. Images in cardiovascular medicine. Cardiac
contusion in a professional soccer player: visualization of acute and late
pathological changes in the myocardium with magnetic resonance imaging.
Circulation. 2010; 121:2456Y61.
42. Sybrandy KC, Cramer MJ, Burgersdijk C. Diagnosing cardiac contusion: old
wisdom and new insights. Heart. 2003; 89:485Y9.
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