A chest injury is any form of physical injury to the chest including the ribs, heart and lungs.

Chest
injuries account for 25% of all deaths from traumatic injury.[1] Typically chest injuries are caused by
blunt mechanisms such as motor vehicle collisions or penetrating mechanisms such as stabbings.[2]

Contents
[hide]

1Classification
2Diagnosis
3See also
4References
5Bibliography

Classification[edit]
Chest injuries can be classified as blunt or penetrating. Blunt and penetrating injuries have
different pathophysiologies and clinical courses.
Specific types of injuries include:

Injuries to the chest wall

Chest wall contusions or hematomas.
Rib fractures
Flail chest
Sternal fractures
Fractures of the shoulder girdle
Pulmonary injury (injury to the lung) and injuries involving the pleural space
Pulmonary contusion
Pulmonary laceration
Pneumothorax
Hemothorax
Hemopneumothorax
Injury to the airways
Tracheobronchial tear
Cardiac injury
Pericardial tamponade
Myocardial contusion
Traumatic arrest
Hemopericardium
Blood vessel injuries
Traumatic aortic rupture
Thoracic aorta injury
Aortic dissection
And injuries to other structures within the torso
Esophageal injury (Boerhaave syndrome)
Diaphragm injury
 Chest Trauma
Pneumothorax - Tension CHEST TRAUMA

Tension pneumothorax INITIAL EVALUATION

PNEUMOTHORAX
TENSION PNEUMO
Tension pneumothorax is the progressive build-up of air within the OPEN PNEUMO
pleural space, usually due to a lung laceration which allows air to escape HAEMOTHORAX
into the pleural space but not to return. Positive pressure ventilation CONTUSION
may exacerbate this 'one-way-valve' effect. RIB FRACTURE / FLAIL
AORTIC INJURY
Progressive build-up of pressure in the pleural space pushes the CHEST DRAINS
mediastinum to the opposite hemithorax, and obstructs venous return
to the heart. This leads to circulatory instability and may result in
traumatic arrest. The classic signs of a tension pneumothorax are Classic signs of
deviation of the trachea away from the side with the tension, a hyper- tension pneumothorax
expanded chest, an increased percussion note and a hyper-expanded
chest that moves little with respiration. The central venous pressure is
usually raised, but will be normal or low in hypovolaemic states. Trachea
Expansion
However these classic signs are usually absent and more commonly the
patient is tachycardic and tachypnoeic, and may be hypoxic. These signs Percussion Note
are followed by circulatory collapse with hypotension and subsequent Breath sounds
traumatic arrest with pulseless electrical activity (PEA). Breath sounds
and percussion note may be very difficult to appreciate and misleading Neck veins
in the trauma room.

Tension pneumothorax may develop insidiously, especially in patients

with positive pressure ventilation. This may happen immediately or
PNEUMOTHORAX
some hours down the line. An unexplained tachycardia, hypotension and (TENSION)
rise in airway pressure are strongly suggestive of a developing tension.
PRIMARY SURVEY
AIRWAY
The X-ray on the right is a post-mortem film taken in a patient with
BREATHING
severe blunt trauma to the chest and a left tension pneumothorax. It
CIRCULATION
illustrates the classic features of a tension:
DISABILITY
EXPOSURE
Deviation of the trachea away from the side of the tension.
Shift of the mediastinum ADJUNCTS
Depression of the hemi-diaphragm (CXR)

With this degree of tension pneumothorax, it is not difficult to SECONDARY

appreciate how cardiovascular function may be compromised by the
tension, due to obstruction of venous return to the heart. This massive
tension pneumothorax should indeed have been detectable clinically
and, in the face of haemodynamic collapse, been treated with emergent
thoracostomy - needle or otherwise.

A tension pneumothorax may develop while the patient is undergoing

investigations, such as CT scanning (image at right) or operation.
Whenever there is deterioration in the patient's oxygenation or
ventilatory status, the chest should be re-examined and tension
pneumothorax excluded.

The presence of chest tubes does not mean a patient cannot develop a
tension pneumothorax. The patient below had a right sided tension
despite the presence of a chest tube. It is easy to appreciate how this
may happen on the CT image showing the chest tubes in the oblique
fissure. Chest tubes here, or placed posteriorly, will be blocked as the
overlying lung is compressed backwards. Chest tubes in supine trauma
patients should be placed anteriorly to avoid this complication.
Haemothoraces will still be drained provided the lung expands fully.

The CT scan also shows why the tension is not visible on the plain chest
X-ray - the lung is compressed posteriorly but extends out to the edge
of the chest wall, so lung markings are seen throughout the lung fields.
However there is midline shift compared to the previous film.

Post-mortem
chest X-ray of left
tension pneumothorax

After chest tube insertion

Initial chest film
mediastinal shift

Tension pneumothorax
identified on CT scan

Upper thorax showing Right tension

position of chest tubes pneumothorax

Tension pneumothorax may also persist if there is an injury to a major

airway, resulting in a bronchopleural fistula. In this case a single chest
tube is cannot cope with the major air leak. Two, three or occasionally Tension extends
more tubes may be needed to manage the air leak. In these cases behind liver
thoracotom is usually indicated to repair the airway and resect damaged
lung.

Beware also the patient with bilateral tension pneumothoraces. The

trachea is central, while percussion and breath sounds are equal on both
sides. These patients are usually haemodynamically compromised or in
traumatic arrest. Emergent bilateral chest decompression should be part
of the procedure for traumatic arrest where this is a possibility.

This (rare) chest X-ray shows the characteristic apparent 'disappearance

of the heart' with bilateral tension pneumothoraces.
 Chest Trauma
Pneumothorax - Open

Introduction

An open pneumothorax occurs when there is a pneumothorax associated with a chest wall defect, such
that the pneumothorax communicates with the exterior.

Pathophysiology

During inspiration, when a negative intra-thoracic pressure is generated, air is entrained into the chest
cavity not through the trachea but through the hole in the chest wall. This is because the chest wall
defect is much shorter than the trachea, and hence provides less resistance to flow. Once the size of
the hole is more than 0.75 times the size of the trachea, air preferentially enters through the thoracic
cavity.

This results in inadequate oxygenation and ventilation, and a progressive build-up of air in the pleural
space. The pneumothorax may tension if a flap has been created that allows air in, but not out.

Diagnosis

Diagnosis should be made clinically during the primary survey. A wound in the chest wall is identified
that appears to be 'sucking air' into the chest and may be visibly bubbling - this is diagnostic.

Breathing is rapid, shallow and laboured. There is reduced expansion of the hemithorax, accompanied
by reduced breath sounds and an increased percussion note. One or all of these signs may not be
appreciated in the noisy trauma room.

Stab wounds to back Video: Sucking wound

Management

100% oxygen should be delivered via a facemask. Consideration should be given to intubation where
oxygenation or ventilation is inadequate. Intubation should not delay placement of a chest tube and
closure of the wound.

The definitive management of the open pneumothorax is to place an occlusive dressing over the
wound and immediately place an intercostal chest drain.

Rarely, if a chest drain is not available and the patient is far from a definitive care facility, a bandage
may be applied over the wound and taped on 3 sides. This, in theory, acts as a flap-valve to allow air
to escape from the pneumothorax during expiration, but not to enter during inspiration. This dressing
may be difficult to apply to a large wound and it's effect is very variable. As soon as possible a chest
drain should be placed and the wound closed.

Chest Trauma
Haemothorax

Haemothorax

Haemothorax is a collection of blood in the pleural space and may be caused by blunt or penetrating
trauma. Most haemothoraces are the result of rib fractures, lung parenchymal and minor venous
injuries, and as such are self-limiting. Less commonly there is an arterial injury, which is more likely
to require surgical repair.

Diagnosis

Most small-moderate haemothoraces are not detectable by physical examination and will be identified
only on Chest X-ray, FAST or CT scan. However, larger and more clinically significant haemothoraces
may be identified clinically. If a large haemothorax is detected clinically it should be treated promptly.

Physical examination

Chest examination may indicate the presence of significant thoracic trauma with external bruising or
lacerations, or palpable crepitus indicating the presence of rib fractures. There may be evidence of a
penetrating injury over the affected hemithorax. Don't forget to examine the back!

Multiple stabbing: front Don't forget the back!

The classic signs of a haemothorax are decreased chest expansion, dullness to percussion and reduced
breath sounds in the affected hemithorax. There is no mediastinal or tracheal deviation unless there is
a massive haemothorax. All these clinical signs may be subtle or absent in the supine trauma patient
in the emergency department, and most haemothoraces will only be diagnosed after imaging studies.

Chest X-ray

Chest X-ray remains the standard test for diagnosis of thoracic trauma in the emergency department.
In the erect patient (penetrating injury), the classical picture of a fluid level with a meniscus is seen.
Although the erect film is more sensitive, it takes approximately 400-500mls of blood to obliterate the
costo-phrenic angle on a chest radiograph.

In the supine position (most blunt trauma patients) no fluid level is visible as the blood lies posteriorly
along the posterior chest. The chest X-ray shows a diffuse opacification of the hemithorax, through
which lung markings can be seen. It may be difficult to differentiate a unilateral haemothorax from a
pneumothorax on the opposite side.

FAST Ultrasound

It may be difficult to detect small amounts of blood (< 200mls) on the plain chest radiograph.
Emergency room ultrasound examination can detect smaller haemothoraces, although in the presence
of a pneumothorax or subcutaneous air ultrasound may be difficult or inaccurrate. When examining
the right and left upper quadrants, the examiner can usually view above the diaphragms to identify
any fluid collections. The significance of small haemothoraces that are not visible on plain films is not
entirely clear.

FAST Haemothorax,
Right Upper Quadrant diaphragm & liver
Examination (Left to Right)

Computed Tomography

Most cases of thoracic trauma do not require computed tomography (CT). CT is more sensitive than
the plain chest radiograph in diagnosing haemothoraces. However, CT can be invaluable in
determining the presence and significance of a haemothorax, especially in the blunt, supine trauma
patient who may have multiple thoracic injuries. Small amounts of blood are detectable and can be
localised to specific areas of the thoracic cavity. The significance of CT-only detectable haemothoraces
is not entirely clear, and certainly some of these will require no treatment. CT may also be useful in
differentiating haemothorax from other thoracic pathology such as pulmonary contusion or aspiration.

Chest Trauma
Rib fractures & Flail Chest CHEST TRAUMA

Chest wall injury is a extremely common following blunt trauma. It INITIAL EVALUATION
varies in severity from minor bruising or an isolated rib fracture to PNEUMOTHORAX
servere crush injuries of both hemithoraces leading to respiratory TENSION PNEUMO
compromise. OPEN PNEUMO
HAEMOTHORAX
CONTUSION
While many chest injuries will require no specific therapy, they may be RIB FRACTURE / FLAIL
indicators of more significant underlying trauma. Multiple rib fractures AORTIC INJURY
will often be associated with an underlying pulmonary contusion, which CHEST DRAINS
may not be immediately apparent on an initial chest X-ray. Fractures of
the lower ribs may be associated with diaphragmatic tears and spleen or
liver injuries. Injuries to upper ribs are less commonly associated with
injuries to adjacent great vessels. This is especially true of a first rib
fracture, which requires a significant amount of force to break and CHEST WALL
indicates a major energy transfer. A fracture of the first rib should INJURY
prompt a careful search for other injuries. Note also that the rib cage
and sternum provide a significant amount of stability to the thoracic
PRIMARY SURVEY
spine. Severe disruption of this 'fourth column' may convert what would AIRWAY
otherwise be a stable thoracic spine fracture into an unstable one. BREATHING
CIRCULATION
Flail Chest DISABILITY
EXPOSURE
A flail chest occurs when a segment of the thoracic cage is separated
from the rest of the chest wall. This is usually defined as at least two ADJUNCTS
fractures per rib (producing a free segment), in at least two ribs. A CXR
segment of the chest wall that is flail is unable to contribute to lung
expansion. Large flail segments will involve a much greater proportion SECONDARY SURVEY
of the chest wall and may extend bilaterally or involve the sternum. In
these cases the disruption of normal pulmonary mechanics may be large
enough to require mechanical ventilation.

R chest injury
clinical deformity

R flail chest Video

The main significance of a flail chest however is that it indicates the

presence of an underlying pulmonary contusion. In most cases it is the
severity and extent of the lung injury that determines the clinical course
and requirement for mechanical ventilation. Thus the management of
flail chest consists of standard management of the rib fractures and of
the pulmonay contusions underneath.
R chest injury
R rib fractures
Diagnosis

Most significant chest wall injuries will be identified by physical

examination. Bruising, grazes or seat-belt signs are visible on
inspection, and palpation may reveal the crepitus associated with
broken ribs. Awake patients will complain of pain on palpation of the
chest wall or on inspiration.

A flail chest is identified as paradoxical movement of a segment of the

chest wall - ie indrawing on inspiration and moving outwards on
expiration. This is often better appreciated by palpation than by
inspection.

Chest X-ray

The antero-posterior chest radiograph will identify most significant chest

wall injuries, but will not identify all rib fractures. Lateral or anterior rib
fractures will often be missed on the initial plain film. However, since
the management of rib fractures is determined by their clinical
significance rather than by their number or position, dedicated rib views
are never indicated.

For adult blunt trauma patients, a haemothorax, pneumothorax or

pulmonary contusion seen on chest X-ray will almost always be
associated with a rib fractures, whether or not identified clinically or by
X-ray. In paediatric patients the ribs are more pliable and less likely to
fracture, although there will still be significant contusion of chest wall
structures.

R flail segment R flail segment

L rib fractures close-up

Computed Tomography

Computed tomography provides very little further clinical information

and is not indicated for the initial evaluation of chest wall injuries.

Management

Management of chest wall injury is directed towards protecting the

underlying lung and allowing adequate oxygenation, ventilation and
pulmonary toilet. This strategy is aimed at preventing the development
of pneumonia, which is the most common complication of chest wall
injury. Note that while a young fit patient will easily manage one or two
rib fractures with simple analgesia, the same injury in an elderly patient
is regarded as major and will frequently lead to pneumonia and
respiratory failure if not appropriately managed (and even then).

All patients should initially be placed on 100% oxygen via a non-

rebreathing facemask.

Analgesia

Analgesia is the mainstay of therapy for rib fractures. While strapping

the chest to splint rib fractures may seem like a good idea, it impedes
chest wall movement and prevents adequate inspiration and clearance
of secretions. Opioid analgesics are useful, but when used as the sole
analgesic agent may require such high doses that they produce
respiratory depression - especially in the elderly. Patient controlled
administration of an opioid infusion (PCA) is the best method for
cooperative patients. The addition of a non-steroidal anti-inflammatory
agent may provide adequate relief, but these should be withheld until
other injuries have been excluded (eg. traumatic brain injury) and used
with caution in the elderly.

Undoubtedly the best analgesia for a severe chest wall injury is a

continuous epidural infusion of a local anaesthetic agent (+/- an opioid).
This provides complete analgesia allowing normal inspiration and
coughing without the risks of respiratory depression. Epidurals may be
placed in the thoracic or high-lumbar positions.

Other methods of local anaesthetic administration are available, but are

poor in comparison to an epidural. For one or two isolated rib fractures,
posterior rib blocks may be appropriate. Local anaesthetic is infiltrated
around the intercostal nerve posteriorly. These blocks will last 4-24
hours and will then have to be repeated. Where a chest tube is present,
some practitioners advocate instilling a local anaesthetic solution into
the pleural splace. However the volume needed is large, the results very
variable, and local anaesthetic toxicity due to rapid pleural absorbtion a
possibility.

Intubation & Ventilation

Intubation and mechanical ventilation is rarely indicated for chest wall

injury alone. Where ventilation is necessary it is usually for hypoxia due
to underlying pulmonary contusions. Positive pressure ventilation may
be required for severe chest wall instability resulting in inadequate
spontaneous ventilation. Intubation and ventilation may be required
when anaesthesia is necessary to provide immediate and adequate
analgesia and allow further assessment and management.

Ventilation is usually necessary only until the resolution of the

pulmonary contusion. Healing and stabilisation of rib fractures is rarely
the limiting step in weaning from mechanical ventilation, except in the
most severe chest injuries.

Chest tube insertion

Patients with rib fractures who receive positive pressure ventilation are
at an increased risk of developing a pneumothorax or tension
pneumothorax due to laceration of the lung by the sharp fracture end.
Many authors recommend placement of a prophylactic chest tube for all
patients with rib fractures who receive mechanical ventilation. This
practice varies depending on the presence of other injuries, monitoring
environent and available resources. For example, the patient with
isolated chest injuries with continuous cardiorepiratory monitoring in an
intensive care unit can probably be observed without a chest tube. In
contrast, in a patient anaesthetised for prolonged surgery, placement of
a prophylactic chst tube may be more appropriate. Especially where the
signs of a tension pneumothorax may be mistaken for signs of
haemorrhagic shock.

Rib fracture fixation

The popularity of rib fracture fixation has waxed and waned over the
past 5 decades. External fixation and stabilisation was common for large
chest wall injuries prior to the development of tracheal intubation and
mechanical ventilation.

External stabilisation External stabilisation

c1960 c1960

Positive pressure ventilation essentially provides an 'internal

stabilisation' to the thoracic cage as well as improving oxygenation and
ventilation for the management of pulmonary contusion. Hence it has
essentially replaced fracture fixation over the past twenty years. In the
last few years however a few studies have suggested that some groups
of patients (as yet unidentified) may benefit from early fracture fixation,
allowing earlier weaning from mechanical ventilation and reducing acute
complications and chronic chest wall pain.

Cardiac tamponade, also known as pericardial tamponade, is when fluid in the pericardium (the
sac around the heart) builds up and results in compression of the heart.[2] Onset may be rapid or
more gradual.[2] Symptoms typically include those of cardiogenic shock including shortness of breath,
weakness, lightheadedness, and cough.[1] Other symptoms may relate to the underlying cause.[1]
Common causes include cancer, kidney failure, chest trauma, and pericarditis.[2] Other causes
include connective tissue diseases, hypothyroidism, aortic rupture, and following cardiac surgery.[4] In
Africa, tuberculosis is a relatively common cause.[1]
Diagnosis may be suspected based on low blood pressure, jugular venous distension, pericardial
rub, or quiet heart sounds.[2][1]The diagnosis may be further supported by
specific electrocardiogram (ECG) changes, chest X-ray, or an ultrasound of the heart.[2] If fluid
increases slowly the pericardial sac can expand to contain more than 2 liters; however, if the
increase is rapid as little as 200 mL can result in tamponade.[2]
When tamponade results in symptoms, drainage is necessary.[5] This can be done
by pericardiocentesis, surgery to create a pericardial window, or a pericardiectomy.[2] Drainage may
also be necessary to rule out infection or cancer.[5] Other treatments may include the use
of dobutamine or in those with low blood volume, intravenous fluids.[1] Those with few symptoms and
no worrisome features can often be closely followed.[2] The frequency of tamponade is unclear.[6] One
estimate from the United States places it at 2 per 10,000 per year.[3]

B.

B.1
 Chest Trauma
Pulmonary Contusion CHEST TRAUMA

Pulmonary contusion is an injury to lung parenchyma, leading to INITIAL EVALUATION

oedema and blood collecting in alveolar spaces and loss of normal lung PNEUMOTHORAX
structure & function. This blunt lung injury develops over the course of TENSION PNEUMO
24 hours, leading to poor gas exchange, increased pulmonary vascular OPEN PNEUMO
resistance and decreased lung compliance. There is also a significant HAEMOTHORAX
inflammatory reaction to blood components in the lung, and 50-60% of CONTUSION
RIB FRACTURE / FLAIL
patients with significant pulmonary contusions will develop bilateral
AORTIC INJURY
Acute Respiratory Distress Syndrome (ARDS).
CHEST DRAINS

Pulmonary contusions occur in approximately 20% of blunt trauma

patients with an Injury Severity Score over 15, and it is the most
common chest injury in children. The reported mortality ranges from 10
to 25%, and 40-60% of patients will require mechanical ventilation. The PULMONARY
complications of pulmonary contusion are ARDS, as mentioned, and CONTUSION
respiratory failure, atelectasis and pneumonia.
PRIMARY SURVEY
Diagnosis AIRWAY
BREATHING
Pulmonary contusions are rarely diagnosed on physical examination. CIRCULATION
The mechanism of injury may suggest blunt chest trauma, and there DISABILITY
may be obvious signs of chest wall trauma such as bruising, rib EXPOSURE
fractures or flail chest. These suggest the presence of an underlying
pulmonary contusion. Crackles may be heard on auscultation but are ADJUNCTS
rarely heard in the emergency room and are non-specific. CXR

Severe bilateral pulmonary contusions may present with hypoxia - but SECONDARY SURVEY
more usually hypoxia develops as the pulmonary contusions blossom or
as a result of subsequent ARDS.

Chest X-ray

Most significant pulmonary contusions are diagnosed on plain chest X-

ray. However the chest X-ray will often under-estimate the size of the
contusion and tends to lag behind the clinical picture. Often the true
extent of injury is not apparent on plain films until 24-48 hours following
injury.

L pulmonary contusion
L pneumothorax

Pulmonary Contusion Pulmonary Contusion

Admission CXR 24 Hours lung contusion at
thoracotomy
Computed Tomography

Computed tomography (CT) is very sensitive for identification of

pulmonary contusion, and may allow differentiation from areas of
atelectasis or aspiration. CT also allows for 3-dimensional assessment
and calculation of the size of contusions. However, most contusions that
are visible only on a CT scan are not clinically relevant, in that they are
not large enough to impair gas exchange and do not worsen outcome.
Nevertheless, CT will accurately reflect the extent of lung injury when
pulmonary contusion is present.

Management

Managment of pulmonary contusion is supportive while the pulmonary

contusion resolves. Most contusions will require no specific therapy.
However large contusions may affect gas exchange and result in
hypoxaemia. As the physiological impact of the ocntusions tends to
develop over 24-48 hours, close monitoring is required and
supplemental oxygen should be administered.

Many of these patients will also have a significant chest wall injury, pain R pulmonary contusion
from which will affect their ability to ventilate and to clear secretions. (Chest wall injury)
Management of a blunt chest injury therefore includes adequate and
appropriate analgesia. Tracheal intubation and mechanical ventilation
may be necessary if there is difficulty in oxygenation or ventilation.
Usually ventilatory support can be discontinued once the pulmonary
contusion has resolved, irrespective of the chest wall injury.

The classic management of pulmonary contusion includes fluid

restriction. Much of the data to support this comes from animal models
of isolated pulmonary contusion. However, while relative fluid excess
and pulmonary oedema will augment any respiratory insufficience, the
consequences of the opposite - hypovolaemia are more severe and ARDS after
long-lasting. Prolonged episode of hypoperfusion in trauma patients will R pulmonary contusions
result in inflammatory activation and acute lung injury, and may result
in ARDS and multiple organ failure. Hence the goal for management of
patients with pulmonary contusion should be euvolaemia.

Complications

Pulmonary contusions will usually resolve in 3 to 5 days, provided no

secondary insult occurs. The main complications of pulmonary contusion
are ARDS and pneumonia. Approximately 50% of patients with
pulmonary contusion develop ARDS, and 80% of patients with
pulmonary contusions involving over 20% of lung volume. Direct lung
trauma, alveolar hypoxia and blood in the alveolar spaces are all major
activators of the inflammatory pathways that result in acute lung injury.

Pneumonia is also a common complication of pulmonary contusion,

blood in the alveolar spaces providing an excellent culture medium for
bacteria. Clearance of secretions is decreased with pulmonary
contusion, and this is augmented by any chest wall injury and
mechanical ventilation. Good tracheal toilet and pulmonary care is
essential to minimise the incidence of pneumonia in this susceptible
group.
Traumatic aortic rupture
From Wikipedia, the free encyclopedia

Traumatic aortic rupture

The aorta, shown in red

Classification and external resources

Specialty emergency medicine

ICD-10 S25.0, S35.0

ICD-9-CM 901.0, 902.0

 MeSH D001019

[edit on Wikidata]

Traumatic aortic rupture, also called traumatic aortic

disruption or transection, is a condition in which the aorta, the
largest artery in the body, is torn or ruptured as a result of trauma to
the body. The condition is frequently fatal due to the
profuse bleeding that results from the rupture. Since the aorta
branches directly from the heart to supply blood to the rest of the body,
the pressure within it is very great, and blood may be pumped out of a
tear in the blood vessel very rapidly. This can quickly result
in shock and death. Thus traumatic aortic rupture is a common killer
in automotive accidents and other traumas,[1] with up to 18% of deaths
that occur in automobile collisions being related to the injury.[2] In fact,
aortic disruption due to blunt chest trauma is the second leading cause
of injury death behind traumatic brain injury.[3][4]
Aortic rupture can also be caused by non-traumatic mechanisms,
particularly abdominal aortic aneurysm rupture.

Tracheobronchial injury
From Wikipedia, the free encyclopedia

Tracheobronchial injury
 Reconstruction of the trachea and bronchi with x-ray computed

tomography showing disruption of the right main bronchus with

abnormal lucency (arrow)[1]

Classification and external resources

Specialty emergency medicine

ICD-10 S27.4, S27.5

ICD-9-CM 862.21

eMedicine radio/706

[edit on Wikidata]

Tracheobronchial injury (TBI) is damage to the tracheobronchial

tree (the airway structure involving the trachea and bronchi).[2] It can
result from blunt or penetrating trauma to the neck or chest,[3] inhalation
of harmful fumes or smoke, or aspiration of liquids or objects.[4]
 Though rare, TBI is a serious condition; it may cause obstruction of the
airway with resulting life-threatening respiratory insufficiency.[2]Other
injuries accompany TBI in about half of cases.[5] Of those people with
TBI who die, most do so before receiving emergency care, either from
airway obstruction, exsanguination, or from injuries to other vital
organs. Of those who do reach a hospital, the mortality ratemay be as
high as 30%.[6]
TBI is frequently difficult to diagnose and treat.[7] Early diagnosis is
important to prevent complications, which include stenosis(narrowing)
of the airway, respiratory tract infection, and damage to the lung tissue.
Diagnosis involves procedures such as bronchoscopy, radiography,
and x-ray computed tomography to visualize the tracheobronchial
tree. Signs and symptoms vary based on the location and severity of
the injury; they commonly include dyspnea (difficulty
breathing), dysphonia (a condition where the voice can be hoarse,
weak, or excessively breathy), coughing, and abnormal breath sounds.
In the emergency setting, tracheal intubation can be used to ensure
that the airway remains open. In severe cases, surgery may be
necessary to repair a TBI.[3]

Contents
[hide]

1Anatomy
2Classification
3Signs and symptoms
4Causes
5Mechanism
6Diagnosis
7Prevention
8Treatment
9Prognosis and complications
10Epidemiology
11History
12Notes
13References

Anatomy[edit]
Diagram of the larynx, trachea and bronchi.

The trachea and bronchi form the tracheobronchial tree. The trachea is
situated between the lower end of the larynx and the center of the
chest, where it splits into the two bronchi at a ridge called the carina.
The trachea is stabilized and kept open by rings made of cartilage that
surround the front and sides of the structure; these rings are not closed
and do not surround the back, which is made of membrane.[8] The
bronchi split into smaller branches and then to bronchioles that supply
air to the alveoli, the tiny air-filled sacs in the lungs responsible for
absorbing oxygen. An arbitrary division can be made between
the intrathoracic and cervical trachea at the thoracic inlet, an opening
at the top of the thoracic cavity.[9] Anatomical structures that surround
and protect the tracheobronchial tree include the lungs,
the esophagus, large blood vessels, the rib cage, the thoracic spine,
and the sternum.[9] Children have softer tracheas and a more elastic
tracheobronchial trees than adults; this elasticity, which helps protect
the structures from injury when they are compressed, may contribute
to the lower incidence of TBI in children.[8]

Classification[edit]
Lesions can be transverse, occurring between the rings of the trachea,
longitudinal or spiral. They may occur along the membranous part of
the trachea, the main bronchi, or both.[2] In 8% of ruptures, lesions are
complex, occurring in more than one location, with more than one type
of lesion, or on both of the main bronchi and the trachea.[2] Transverse
tears are more common than longitudinal or complex ones.[9]The
laceration may completely transect the airway or it may go only
partway around. Partial tears that do not go all the way around the
circumference of the airway do not allow a

The Injured Esophagus

Kenneth L. Mattox, MD, FACS

Joseph S. Coselli, MD, Section Editor

 Author information Copyright and License information

This article has been cited by other articles in PMC.

Injury to the esophagus, although not often seen, is an intolerable

condition in the absence of early detection and appropriate surgical
intervention. The cause can be penetrating or blunt injury, iatrogenic
injury, laceration from ingestion of a sharp object, or tissue
destruction secondary to swallowing a caustic substance. Ingestion
of alkaline or acid liquids can be accidental or purposeful. In
Southeast Asia, this method of attempting suicide is more common
than in North America. Iatrogenic injuryespecially during
endoscopy, tube insertion, forceful dilation, and balloon insertion or
inflationis the most common cause. Spontaneous rupture of the
esophagus is relatively rare but can be as devastating as any of the
causes described above

Diaphragmatic rupture (also called diaphragmatic injury or tear) is

a tear of the diaphragm, the muscle across the bottom of the ribcage
that plays a crucial role in respiration. Most commonly, acquired
diaphragmatic tears result from physical trauma. Diaphragmatic
rupture can result from blunt or penetrating trauma[2] and occurs in
about 5% of cases of severe blunt trauma to the trunk.[3]
Diagnostic techniques include X-ray, computed tomography, and
surgical techniques such as laparotomy. Diagnosis is often difficult
because signs may not show up on X-ray, or signs that do show up
appear similar to other conditions. Signs and symptoms included chest
and abdominal pain, difficulty breathing, and decreased lung sounds.
When a tear is discovered, surgery is needed to repair it.
Injuries to the diaphragm are usually accompanied by other injuries,
and they indicate that more severe injury may have occurred. The
outcome often depends more on associated injuries than on the
diaphragmatic injury itself.[4] Since the pressure is higher in
the abdominal cavity than the chest cavity, rupture of the diaphragm is
almost always associated with herniation of abdominal organs into the
chest cavity, which is called a traumatic diaphragmatic hernia.[5] This
herniation can interfere with breathing, and blood supply can be cut off
to organs that herniate through the diaphragm,[6] damaging them.

Contents
[hide]

1Signs and symptoms

2Causes
3Mechanism
4Diagnosis
o 4.1Location
 5Treatment
6Prognosis
o 6.1Complications
7Epidemiology
8History
9References

Signs and symptoms[edit]

Breath sounds on the side of the rupture may be
diminished, respiratory distress may be present, and the chest or
abdomen may be painful.[3] Orthopnea, dyspnea which occurs when
lying flat, may also occur,[7] and coughing is another sign.[5] In people
with herniation of abdominal organs, signs of intestinal blockage
or sepsis in the abdomen may be present.[5] Bowel sounds may be
heard in the chest, and shoulder or epigastric pain may be
present.[4] When the injury is not noticed right away, the main
symptoms are those that indicate bowel obstruction.[4]

Causes[edit]
The injury may be caused by blunt trauma, penetrating trauma, and
by iatrogenic causes (as a result of medical intervention), for example
during surgery to the abdomen or chest.[4]Injury to the diaphragm is
reported to be present in 8% of cases of blunt chest trauma.[8] In cases
of blunt trauma, vehicle accidents and falls are the most common
causes.[4]Penetrating trauma has been reported to cause 12.320% of
cases, but it has also been proposed as a more common cause than
blunt trauma; discrepancies could be due to varying regional, social,
and economic factors in the areas studied.[2] Stab and gunshot
wounds can cause diaphragmatic injuries.[4] Clinicians are trained to
suspect diaphragmatic rupture particularly if penetrating trauma has
occurred to the lower chest or upper abdomen.[9] With penetrating
trauma, the contents of the abdomen may not herniate into the chest
cavity right away, but they may do so later, causing the presentation to
be delayed.[4] Since the diaphragm moves up and down during
breathing, penetrating trauma to various parts of the torso may injure
the diaphragm; penetrating injuries as high as the third rib and as low
as the twelfth have been found to injure the diaphragm.[10]

What Is a Myocardial
Contusion?
A myocardial contusion is a bruise of the heart muscle,
which can occur with serious bodily injury. This is most
commonly caused:
 by a car accident
by falling from heights greater than 20 feet
by receiving chest compressions during
cardiopulmonary resuscitation (CPR)

Myocardial contusion shouldnt be confused with

infarction. Myocardial infarction, or a heart attack,
occurs when the heart is severely damaged as a result
of a lack of blood flow to the muscle.

Cases of myocardial contusion can vary from mild to

severe. A medical professional must evaluate each
contusion. This condition can lead to complications,
particularly if its severe and left untreated. See your
doctor immediately if youre in a serious accident.

SYMPTOMS

What Are the Symptoms

of a Myocardial
Contusion?
The symptoms of myocardial contusion can vary
depending on when your accident occurred and the
severity of your injury. You may experience:

extreme pain above the ribs

an increased heart rate
 weakness
excessive fatigue
lightheadedness
nausea
vomiting
shortness of breath

Any of these symptoms should be evaluated

immediately. The symptoms of severe heart contusions
may mimic those of a heart attack.

CAUSES

What Are the Causes of

a Myocardial Contusion?
Bodily injuries and accidents cause contusions of the
heart. The heart muscle can be bruised if blunt force or
pressure impacts the chest.

The most common causes of this condition include:

falls
car accidents
being struck by a car
CPR injuries

Subcutaneous emphysema
From Wikipedia, the free encyclopedia

Subcutaneous emphysema

An abdominal CT scan of a patient with subcutaneous emphysema

(arrows)

Classification and external resources

Specialty emergency medicine

ICD-10 T79.7, T81.8

ICD-9-CM 958.7, 998.81

DiseasesDB 29756

MedlinePlus 003286

MeSH D013352

[edit on Wikidata]

Subcutaneous emphysema is when gas or air is in the layer under

the skin. Subcutaneous refers to the tissue beneath the skin,
 and emphysema refers to trapped air. It is sometimes
abbreviated SCE or SE and also called tissue emphysema, or Sub Q
air. Since the air generally comes from the chest cavity, subcutaneous
emphysema usually occurs on the chest, neck and face, where it is
able to travel from the chest cavity along the fascia.[1] Subcutaneous
emphysema has a characteristic crackling feel to the touch, a
sensation that has been described as similar to touching Rice
Krispies;[2] this sensation of air under the skin is known
as subcutaneous crepitation.
Numerous etiologies of subcutaneous emphysema have been
described. Pneumomediastinum was first recognized as a medical
entity by Laennec, who reported it as a consequence of trauma in
1819. Later, in 1939, at The Johns Hopkins Hospital, Dr. Louis
Hamman described it in postpartum woman; indeed, subcutaneous
emphysema is sometimes known as Hamman's syndrome. However,
in some medical circles, it can instead be more commonly known
as Macklin's Syndrome after L. Macklin, in 1939, and M.T. and C.C.
Macklin, in 1944, who cumulatively went on to describe the
pathophysiology in more detail.[3]
Subcutaneous emphysema can result from puncture of parts of
the respiratory or gastrointestinal systems. Particularly in the chest and
neck, air may become trapped as a result of penetrating
trauma (e.g., gunshot wounds or stab wounds) or blunt
trauma. Infection (e.g., gas gangrene) can cause gas to be trapped in
the subcutaneous tissues. Subcutaneous emphysema can be caused
by medical procedures and medical conditions that cause the pressure
in the alveoli of the lung to be higher than that in the tissues outside of
them.[4] Its most common causes are pneumothorax and a chest
tube that has become occluded by a blood clot or fibrinous material. It
can also occur spontaneously due to rupture of the alveoli with
dramatic presentation.[5] When the condition is caused by surgery it is
called surgical emphysema.[6] The term spontaneous subcutaneous
emphysema is used when the cause is not clear.[5] Subcutaneous
emphysema is not typically dangerous in and of itself, however it can
be a symptom of very dangerous underlying conditions, such as
pneumothorax.[7] Although the underlying conditions require treatment,
subcutaneous emphysema usually does not; small amounts of air are
reabsorbed by the body. However, subcutaneous emphysema can be
uncomfortable and may interfere with breathing, and is often treated by
removing air from the tissues, for example by using large bore needles,
skin incisions or subcutaneous catheterization.

Contents
[hide]

1Symptoms and signs

2Causes
o 2.1Trauma
o 2.2Medical treatment
o 2.3Infection
3Pathophysiology
 4Diagnosis
5Treatment
6Prognosis
7History
8References

Symptoms and signs[edit]

Signs and symptoms of spontaneous subcutaneous emphysema vary
based on the cause, but it is often associated with swelling of the neck
and chest pain, and may also involve sore throat, neck pain, difficulty
swallowing, wheezing and difficulty breathing.[5] Chest X-rays may
show air in the mediastinum, the middle of the chest cavity.[5] A
significant case of subcutaneous emphysema is easy to detect
by touching the overlying skin; it feels like tissue paper or Rice
Krispies.[8] Touching the bubbles causes them to move and sometimes
make a crackling noise.[9] The air bubbles, which are painless and feel
like small nodules to the touch, may burst when the skin above them is
palpated.[9] The tissues surrounding SCE are usually swollen. When
large amounts of air leak into the tissues, the face can swell
considerably.[8] In cases of subcutaneous emphysema around the
neck, there may be a feeling of fullness in the neck, and the sound of
the voice may change.[10] If SCE is particularly extreme around the neck
and chest, the swelling can interfere with breathing. The air can travel
to many parts of the body, including the abdomen and limbs, because
there are no separations in the fatty tissue in the skin to prevent the air
from moving.[11]

Causes[edit]
Trauma[edit]
Conditions that cause subcutaneous emphysema may result from both
blunt and penetrating trauma;[5] SCE is often the result of a stabbing or
gunshot wound.[12] Subcutaneous emphysema is often found in car
accident victims because of the force of the crash.
Chest trauma, a major cause of subcutaneous emphysema, can cause
air to enter the skin of the chest wall from the neck or lung.[9] When
the pleural membranes are punctured, as occurs in penetrating trauma
of the chest, air may travel from the lung to the muscles and
subcutaneous tissue of the chest wall.[9] When the alveoli of the lung
are ruptured, as occurs in pulmonary laceration, air may travel beneath
the visceral pleura (the membrane lining the lung), to the hilum of the
lung, up to the trachea, to the neck and then to the chest wall.[9] The
condition may also occur when a fractured rib punctures a lung;[9] in
fact, 27% of patients who have rib fractures also have subcutaneous
emphysema.[11] Rib fractures may tear the parietal pleura, the
membrane lining the inside of chest wall, allowing air to escape into the
subcutaneous tissues.[13]
Subcutaneous emphysema is frequently found in pneumothorax (air
outside of the lung in the chest cavity)[14][15] and may also result from air
in the mediastinum, pneumopericardium (air in the pericardial
cavity around the heart).[16] A tension pneumothorax, in which air builds
up in the pleural cavity and exerts pressure on the organs within the
chest, makes it more likely that air will enter the subcutaneous tissues
through pleura torn by a broken rib.[13] When subcutaneous
emphysema results from pneumothorax, air may enter tissues
including those of the face, neck, chest, armpits, or abdomen.[1]
When subcutaneous emphysema occurs with pneumomediastinum,
the condition is known as Hamman's
syndrome.[17] Pneumomediastinum can result from a number of events.
For example, foreign body aspiration, in which someone inhales an
object, can cause pneumomediastinum (and lead to subcutaneous
emphysema) by puncturing the airways or by increasing the pressure
in the affected lung(s) enough to cause them to burst.[18]
Subcutaneous emphysema of the chest wall is commonly among the
first signs to appear that barotrauma, damage caused by excessive
pressure, has occurred,[1][19] and it is an indication that the lung was
subjected to significant barotrauma.[20] Thus the phenomenon may
occur in diving injuries.[5][21]
Trauma to parts of the respiratory system other than the lungs, such as
rupture of a bronchial tube, may also cause subcutaneous
emphysema.[13] Air may travel upward to the neck from a
pneumomediastinum that results from a bronchial rupture, or
downward from a torn trachea or larynx into the soft tissues of the
chest.[13] It may also occur with fractures of the facial
bones, neoplasms, during asthma attacks, when the Heimlich
maneuver is used, and during childbirth.[5] It is estimated to occur with
pneumomediastinum in one in every 2000100,000 deliveries.[17] Injury
with pneumatic tools, those that are driven by air, is also known to
cause subcutaneous emphysema, even in extremities (the arms and
legs).[22] It can also occur as a result of rupture of the esophagus; when
it does, it is usually as a late sign.[23]

Traumatic pneumothorax is air in the pleural space resulting

from trauma and causing partial or complete lung collapse.
Symptoms include chest pain from the causative injury and
sometimes dyspnea. Diagnosis is made by chest x-ray.
Treatment is usually with tube thoracostomy

Hemothorax is the presence of blood in the pleural space.

The source of blood may be the chest wall, lung parenchyma,
heart, or great vessels. Although some authors state that a
hematocrit value of at least 50% is necessary to differentiate a
hemothorax from a bloody pleural effusion, most do not agree
on any specific distinction.
Hemothorax is usually a consequence of blunt or penetrating
trauma. Much less commonly, it may be a complication of
disease, may be iatrogenically induced, [1] or may develop
spontaneously.
 Fractured Rib - Topic
Overview
ARTICLES ONFRACTURED RIB

Topic Overview
Other Places To Get Help
Related Information
References
Credits
A rib fracture is a break in a rib bone.[1] This typically results in chest
pain that is worse with breathing in.[1] Bruising may occur at the site of
the break.[3] When several ribs are broken in several places a flail
chest results.[4] Potential complications include
a pneumothorax, pulmonary contusion, and pneumonia.[2][1]
Rib fractures usually occur from a direct blows to the chest such as
during a motor vehicle collision or from a crush injury.[2][1]Coughing
or metastatic cancer may also result in a broken rib.[1] The middle ribs
are most commonly fractured.[5][1] Fractures of the first or second ribs
are more likely to be associated with complications.[6] Diagnosis can be
made based on symptoms and supported by medical imaging.[3]
Pain control is an important part of treatment.[7] This may include the
use of paracetamol (acetaminophen), NSAIDs, or opioids.[2] A nerve
block may be another option.[1] While fractured ribs have been
wrapped, this may increase complications.[1] In those with a flail chest,
surgery may improve outcomes.[8][9] They are a common injury following
trauma.

Causes[edit]
Rib fractures can occur with or without direct trauma during
recreational activity. Cardiopulmonary resuscitation (CPR) has also
been known to cause thoracic injury, including but not limited to rib
and sternum fractures. They can also occur as a consequence of
diseases such as cancer or rheumatoid arthritis. While for elderly
individuals a fall can cause a rib fracture, in adults automobile
accidents are a common event for such an injury.[11]

ABDOMEN. Classification based on types of injuries

Practice Essentials
Penetrating abdominal trauma typically involves the
violation of the abdominal cavity by a gunshot wound
or stab wound.

Penetrating abdominal trauma. Tangential gunshot

wound to the liver.

View Media Gallery

Signs and symptoms

Signs and symptoms of penetrating abdominal trauma

depends on various factors, including the type of
penetrating weapon or object, the range from which the
injury occurred, which organs may be injured, and the
location and number of wounds.
Close-range injuries transfer more kinetic energy than
those sustained at a distance, although range is often
difficult to ascertain when assessing gunshot wounds.
A gunshot wound is caused by a missile propelled by
combustion of powder. These wounds involve high-
energy transfer and, consequently, can involve an
unpredictable pattern of injuries. Secondary missiles,
such as bullet and bone fragments, can inflict
additional damage. Stab wounds are caused by
penetration of the abdominal wall by a sharp object.
This type of wound generally has a more predictable
pattern of organ injury. However, occult injuries can be
overlooked, resulting in devastating complications
Abdominal trauma is an injury to the abdomen. It may be blunt or penetrating and may involve
damage to the abdominal organs.[1] Signs and symptoms include abdominal pain, tenderness,
 rigidity, and bruising of the external abdomen. Abdominal trauma presents a risk of severe blood
loss and infection. Diagnosis may involve ultrasonography, computed tomography, and peritoneal
lavage, and treatment may involve surgery.[2] Injury to the lower chest may cause splenic or liver
injuries.

Blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma is a physical trauma to
a body part, either by impact, injury or physical attack. The latter is usually referred to as blunt force
trauma. Blunt trauma is the initial trauma, from which develops more specific types such
as contusions, abrasions, lacerations, and/or bone fractures. Blunt trauma is contrasted
with penetrating trauma, in which an object such as a bullet enters the body.

Bones may break (called fractures), bones in joints may become separated from
each other (called dislocations)

Fractures: Types and Treatment

The word Fracture implies to broken bone. A bone may get fractured completely or partially and it is
caused commonly from trauma due to fall, motor vehicle accident or sports. Thinning of the bone due
to osteoporosis in the elderly can cause the bone to break easily. Overuse injuries are common cause
of stress fractures in athletes.
Types of fractures include:

Simple fractures in which the fractured pieces of bone are well aligned and stable.
Unstable fractures are those in which fragments of the broken bone are misaligned and displaced.
Open (compound) fractures are severe fractures in which the broken bones cut through the skin. This
type of fracture is more prone to infection and requires immediate medical attention.
Greenstick fractures: This is a unique fracture in children that involves bending of one side of the bone
without any break in the bone.

An open fracture, also called a compound fracture, is a fracture in which there is an

open wound or break in the skin near the site of the broken bone. Most often, this
wound is caused by a fragment of bone breaking through the skin at the moment of the
injury.

An open fracture requires different treatment than a closed fracture, in which there is no
open wound. This is because, once the skin is broken, bacteria from dirt and other
contaminants can enter the wound and cause infection. For this reason, early treatment
for an open fracture focuses on preventing infection at the site of the injury. The wound,
tissues, and bone must be cleaned out in a surgical procedure as soon as possible. The
fractured bone must also be stabilized to allow the wound to heal.

Illustration and x-ray show an open fracture. The broken end of the tibia (shinbone) has torn
through the soft tissues and is protruding through the skin.
(Right) Reproduced from Egol KA, Gardner MJ, eds: Let's Discuss Management of Common Fractures. Rosemont,
IL, American Academy of Orthopaedic Surgeons, 2016, pp. 135-152.

Cause
Most open fractures are caused by some type of high-energy eventsuch as a gunshot or
motor vehicle accident. These patients will often have additional injuries to other parts
of the body.

An open fracture can also result from a lower-energy incident, such as a simple fall at
home or an injury playing sports.

Description
Open fractures vary greatly in severity. In many high-energy injuries, there is obvious
skin loss and the bone can be seen protruding through the wound. In other cases, the
wound may be no larger than a puncture.

In either situation, the damage to the soft tissues around the boneincluding muscles,
tendons, nerves, veins, and arteriescan be extensive. For this reason, any acute
fracture with an open wound in the area is considered to be an open fracture.

In this injury to the lower leg, the broken bones are not visible, but there is a small open wound
over the fractures. Special care must be taken to prevent infection.

Reproduced and adapted from Zalavras CG, Marcus RE, Levin LS, Patzakis MJ: Management of open
fractures and subsequent complications. Instructional Course Lecture 57. Rosemont, IL, American
Academy of Orthopaedic Surgeons, 2008: pp. 51-63.

The severity of an open fracture depends upon several factors, including:

The size and number of the fracture fragments
The damage to surrounding soft tissues
The location of the wound and whether the soft tissues in the area have good blood
supply
Contamination
To some extent, the setting in which an open fracture occurs will affect the degree of
contamination. Objects such as dirt, broken glass, grass, mud, and even the patient's
own clothing can be driven into an open wound. Knowing the setting where your injury
occurred can help your doctor determine the best course of treatment
A closed fracture is a broken bone that does not penetrate the skin. This is an important
distinction because when a broken bone penetrates the skin (an open fracture) there is a
need for immediate treatment, and an operation is often required to clean the area of the
fracture. Furthermore, because of the risk of infection, there are more often problems
associated with healing when a fracture is open to the skin.

Closed fractures may still require surgery from proper treatment, but most often this
surgery is not an emergency and can be performed in the days or weeks following the
injury. While a closed fracture does not penetrate the skin, there can still be severe soft-
tissue injury associated with closed fractures. The condition of soft-tissues can still alter
treatment recommendations, as closed fractures with severe soft-tissue injury may cause
concern for surgical intervention.
Examples of the most common closed fractures include:

Broken Wrist: A wrist fracture is the most common type of fracture that requires
medical treatment. Often closed wrist fractures can be treated with a cast to
hold the healing bones in proper position. More severe wrist fractures may
require surgery, even when the injury is closed. In these cases, pins, plates, and
screws are commonly used for treatment.
Hip Fractures: A broken hip is the most common type of closed fracture in the
elderly population. Almost always these are closed fractures, as open hip
fractures are exceedingly rare injuries. Despite being a closed fracture, broken
hips almost always require surgical treatment.

Ankle Fractures: A broken ankle occurs when the ankle joint is severely twisted in
the bone is injured. While in younger patients a sprain is often the result, as
people get older bone is often the injured structure. Depending on the severity
of the injury, surgery may be needed

Compartment Syndrome
Compartment syndrome is a painful condition that occurs when pressure within the
muscles builds to dangerous levels. This pressure can decrease blood flow, which
prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a severe

injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment syndrome, is

usually not a medical emergency. It is most often caused by athletic exertion.

Anatomy
Compartments are groupings of muscles, nerves, and blood vessels in your arms and
legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is
to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.

The area between the knee and ankle has four major muscle compartments: anterior, lateral, superficial
posterior, deep posterior.
Figure A: Reproduced and adapted with permission from Gruel CR: Lower Leg, in Sullivan JA, Anderson SJ
(eds): Care of the Young Athlete. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000. Figure B:
Reproduced and adapted from The Body Almanac. American Academy of Orthopaedic Surgeons, 2003.

Description
Compartment syndrome develops when swelling or bleeding occurs within a
compartment. Because the fascia does not stretch, this can cause increased pressure on
the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve
cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle
cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent

disability and tissue death may result. This does not usually happen in chronic
(exertional) compartment syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the
lower leg (calf). It can also occur in other compartments in the leg, as well as in the
arms, hands, feet, and buttocks.

Cause
Acute Compartment Syndrome
Acute compartment syndrome usually develops after a severe injury, such as a car
accident or a broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

A fracture.
A badly bruised muscle. This type of injury can occur when a motorcycle falls on
the leg of the rider, or a football player is hit in the leg with another player's
helmet.
Reestablished blood flow after blocked circulation. This may occur after a surgeon
repairs a damaged blood vessel that has been blocked for several hours. A blood
vessel can also be blocked during sleep. Lying for too long in a position that blocks
a blood vessel, then moving or waking up can cause this condition. Most healthy
people will naturally move when blood flow to a limb is blocked during sleep. The
development of compartment syndrome in this manner usually occurs in people
who are neurologically compromised. This can happen after severe intoxication
with alcohol or other drugs.
Crush injuries.
Anabolic steroid use. Taking steroids is a possible factor in compartment
syndrome.
Constricting bandages. Casts and tight bandages may lead to compartment
syndrome. If symptoms of compartment syndrome develop, remove or loosen any
constricting bandages. If you have a cast, contact your doctor immediately.
Dislocations are joint injuries that force the ends of your bones out of position. The cause is often a
fall or a blow, sometimes from playing a contact sport. You can dislocate your ankles, knees,
shoulders, hips, elbows and jaw. You can also dislocate your finger and toe joints. Dislocated joints
often are swollen, very painful and visibly out of place. You may not be able to move it.
A dislocated joint is an emergency. If you have one, seek medical attention. Treatment depends on
which joint you dislocate and the severity of the injury. It might include manipulations to reposition
your bones, medicine, a splint or sling, and rehabilitation. When properly repositioned, a joint will
usually function and move normally again in a few weeks. Once you dislocate a shoulder or
kneecap, you are more likely to dislocate it again. Wearing protective gear during sports may help
prevent dislocations.

E. and F. encode

OVERVIEW
Traumatic injuries that affect the urinary tract and its organs or the male genitalia can be treated
very effectively by our reconstructive urologists. If you have experienced a traumatic accident or
injury that needs to be taken care of, contact our reconstructive urology clinic for an immediate
consultation.
 WHAT ORGANS CAN BE INJURED WITH TRAUMA?
The genito-urinary system encompasses many organs:

Kidneys
Ureters
Bladder
Urethra
Testis
External genitalia
These organs can be damaged along with other internal organs when patients have suffer massive
multi-systems trauma from incidents like auto accidents, industrial accidents or when patients are
victims of gunshot wounds or other violent crimes.

The external genitalia and the urethra (urinary channel from the bladder) can also be damaged
with site-specific trauma that can be fairly minor. Some genito-urinary injuries are managed with
immediate surgery to save the life of the patients that have been the victims of trauma; other
injuries are managed with observation and delayed surgery if needed in the future after healing
has had time to occur.

FIND A RECONSTRUCTIVE UROLOGIST

BY NAME

BY LOCATION

KIDNEY INJURY
In areas other than urban centers, most kidney injuries occur from a blunt force trauma, such as a
high-speed auto accident. In these injuries other organ injuries and broken bones are very
common. Most of these kidney injuries can be managed with careful observation.

On occasion an injury is so severe that patients require immediate life saving operations to either
repair or remove the kidney. Occasional patients need other procedures like insertion of drains
around the kidney or a temporary drainage tube (urinary stent) to help the kidney heal. In rare
cases the kidney may need to be removed in the future because of chronic infection or loss of
function. Usually the loss of one kidney does not increase the chance of kidney failure in the
future.

URETHRAL TRAUMA
The urethra is usually injured in one of two ways:

1. Pelvic fracture - The sheering forces of the pelvic fracture tear the urethra into two somewhere around the
location of the prostate as the urethra travels towards the bladder. This is called a posterior urethral
 disruption. Often a procedure is done to try to realign the urethra so that it can heal together over a
catheter. Other times the damage is too severe and a catheter is left in the bladder and a plan is made for
subsequent surgery in the future. Scarring occurs in the area where the urethra was ripped apart and
usually a surgery needs to be done where this scar is removed and the healthy urethra is brought to the tip
of the prostate and sewn to the other uninjured portion of the urethra. This surgery is called a posterior
urethroplasty.
2. Straddle injury - In this injury a male patient falls forcefully with the legs apart on something hard. Some
examples of this are falling upon the crossbar of a bicycle, a railing, or being bucked onto the horn of a
saddle. In this injury, the urethra is squeezed against the underside of the pubic bone and forcefully
divided in two. Usually patients have a lot of bleeding from the penis and a large bruise forms in the groin
and perineum (the area between the anus and the scrotum). The initial management of these injuries
involves a similar strategy to pelvic fracture injuries. A catheter can be placed across the gap in hopes that
the urethra will heal together or a catheter can be placed through the abdomen into the bladder
(suprapubic tube) and a surgery can be done some time later to fix the scarring that develops.

TREATMENT
Most of these traumatic injuries to the urethra can be fixed about three to six months after they
occur. We know that fixing the injuries immediately after they occur increases the chance of
recurrent scarring and also can harm erections. This is the reason for the delay for three to six
months.

During this time patients are treated with a suprapubic catheter, which is changed every four to
six weeks in our clinic. In some cases it is important to wait for complete healing of pelvic
fractures and the pelvis to stabilize before surgery is performed.

BLADDER TRAUMA
The bladder can be injured either during a pelvic fracture or secondary to a forceful blow to the
abdomen when the bladder is full. This very commonly can occur due to a seatbelt or a steering
wheal injury during a automobile accident. Bladder injuries that open into the abdomen are
closed immediately, those that spill urine into the tissues surrounding the bladder but do not
communicated with the abdominal cavity can be treated with a urinary catheter for
approximately two weeks.

Chronic problems with urinary leakage outside of the bladder into the pelvic area or the skin can
occasionally occur after severe injuries. In these cases patients may need reconstructive surgery.

PENILE TRAUMA
One of the main causes of penile trauma is intercourse. When an injury occurs during intercourse
the penile trauma is called a penile fracture. The mechanism of this injury is the erect penis
comes out of the vagina and forcefully impacts the pubic bone of the partner. This force buckles
the erect penis and a tear occurs in the tough outer lining (tunica albuginea) of the natural piston
 of the penis (corporal body). The penis rapidly loses its rigidity and a large bruise develops from
the base of the penis to the head of the penis.

A moderate amount of pain is associated with this. Occasionally the tear is so severe that the
urethra (urinary channel) is also injured. Penile fractures should be repaired as soon as is
practical after they occur. If they are not repaired, most urologists feel there is an increased
likliehood of erectile problems and scarring in the future.

TREATMENT
To repair a penile fracture, an incision is made over the area and strong stiches are used to
reapproximate the torn portions of the tough outer lining of the penile shaft. The urethra is
repaired at the same time.

TESTICULAR TRAUMA
Trauma to the testis can cause the testicle to rupture. The types of trauma that can cause these
injuries include:

Sports related accidents,

Penetrating injuries like a gunshot wound, or
Any forceful blow to the testicle.
The testicle contains seminiferous tubules, which are responsible for the production of
testosterone and sperm. Prompt repair of these ruptures can preserve the function of the testicle
and minimize pain and scarring from the injuries. This is done through a small incision within
the scrotal wall.

Occasionally testicles are not salvageable with surgery and must be removed at the time of
surgery. It is infrequent that this is the case, usually some testicular function can be preserved

URETERAL INJURIES
The ureter runs from the kidney to the bladder and transports urine from the kidney to the
bladder. The most common cause of injury to the ureter is during some type of surgery. The
ureter can be injured particularly during hysterectomy or other gynecologic procedures. This is
because of the proximity of the ureter to the uterus and gynecologic structures of the pelvis. The
management of these injuries usually involves surgery to reconnect the ureter to the bladder.
There are a variety of ways of accomplishing this depending upon the length of the scarring or
ureteral injury.

Encode arterial trauma

 URMC / Encyclopedia / Classification of Burns

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Classification of Burns
What are the classifications of burns?
Burns are classified as first-, second-, or third-degree, depending on how deep and severe
they penetrate the skin's surface.

First-degree (superficial) burns. First-degree burns affect only the epidermis, or outer
layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an
example. Long-term tissue damage is rare and usually consists of an increase or decrease
in the skin color.
Second-degree (partial thickness) burns. Second-degree burns involve the epidermis
and part of the dermis layer of skin. The burn site appears red, blistered, and may be
swollen and painful.
Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis
and may go into the subcutaneous tissue. The burn site may appear white or charred
Fourth degree burns. Fourth degree burns also damage the underlying bones, muscles,
and tendons. There is no sensation in the area since the nerve endings are destroyed.