Thorax and Abdominal Injuries

General Principles

Injuries to the thorax and abdomen are more often seen in sports involving sudden deceleration and impact (e.g., football, ice hockey, skiing, and snowboarding).
Early recognition and management of these potentially life-threatening injuries are imperative. Serial assessments and a high index of suspicion are essential for accurate evaluation. Once severe injury is recognized, emergency medicine fundamentals and stabilization should be initiated until transfer to a hospital occurs.
Torso injuries overlap with injuries to the skeletal system (e.g., traction apophysitis of iliac crest presenting as lower abdominal pain; shoulder conditions can radiate to the thorax; similarly, thoracic and abdominal conditions can radiate to the extremities, confusing the source of symptoms).

Combination of upper abdomen injuries can be divided into three regions:
- Midline region: Left lobe of liver, pancreas, duodenum, transverse colon, small bowel and mesentery, aorta, inferior vena cava, sternum, lower ribs, and heart.
- Right region: Liver, kidney, adrenal gland, hemidiaphragm, lung, pneumothorax or hemothorax, and ribs.
- Left region: Other paired organs, but spleen instead of liver.
In sports, organs can suffer damage usually resulting from compressive forces (e.g., tackle or bicycle handlebar) that push solid or viscus organ against the spine.
Deceleration forces and penetrating injuries are uncommon in athletics, although “almost penetrating” injuries are possible (e.g., hockey stick or ski pole) without causing a wound.
Abdominal organs in children are more susceptible to injury from trauma because of their relative position (more anterior and lower because of the more horizontal nature of the diaphragm), still developing abdominal musculature, and pliable nature of cartilaginous ribs.
“Getting the wind knocked out” is more common than significant trauma to visceral organs. An unguarded blow to the epigastric region causes temporary reflex spasm of the diaphragm. Loosening of restricting garments and flexion at the knees and hips usually restores normal respiration. Because of the risk of intra-abdominal injury, serial observation and follow-up are necessary.

Sport-specific data are limited.

Myocardial injury: Up to 76% of patients may sustain blunt chest trauma with direct compression of the heart between the anterior chest wall and vertebral column. Most common cardiac injury is cardiac contusion (60%) among pediatric patients. Most common causes are motor vehicle accident (MVA) (50%), sports injuries, and falls. Sudden cardiac death (36%) was the most common catastrophic injury in high school and intercollegiate athletes in 2019.
Abdominal injury: Second most common sport-related internal organ injury is the spleen, which can occur in 5.6 per 1,000,000 children, and in college it can occur in up to 57%. Most of these injuries were sustained during football, ice hockey, soccer, or horseback riding.
Thoracic and pulmonary injuries: Study assessing chest wall injuries in high school athletes demonstrated that only 2% required surgical intervention, with two-thirds of surgeries being from football or wrestling. Despite potential for catastrophic outcomes of chest wall injuries, most injuries were contusions/strains (63%), and nearly 60% of athletes were able to return to play in <1 week.

Accurate account of events leading to injury is important in establishing diagnosis.
History and physical examination (PE) are sometimes unreliable, particularly in children and if there is an altered level of consciousness.
Seemingly minor trauma can cause delayed splenic rupture or other injuries; careful history-taking, including past injuries, surgeries, and illnesses, is paramount.
Previously undiagnosed preexisting condition such as inflammatory bowel disease, liver hemangioma, and infectious mononucleosis can cause major clinical symptoms after trauma to affected organ.
Detailed history of patient’s pain and use of pain scale upon initial presentation and during serial evaluations are useful.

See Chapter 4: “Sideline Preparedness and Emergencies,” for discussion of initial evaluation of injuries to thorax and abdomen.

If thoracic and abdominal injuries are both present, thoracic injuries are usually more symptomatic and will distract attention from abdominal pain, which is usually less localized and specific.
Abdominal pain can be vague and diffuse or localized to a quadrant. Abdominal pain is sensitive but not specific to the presence of injury; 50% of individuals with pain have no significant injury. Always examine the chest and spine when evaluating an abdominal complaint; consider examining inguinal and pelvic regions.
Frequent monitoring of vital signs, including orthostatics, is important to gauge cardiovascular status; in addition, respiratory rate, rhythm, and use of accessory respiratory muscles should be observed. If difficult to obtain blood pressure by auscultation, deflate the cuff until palpable return of brachial or radial pulse; the systolic pressure obtained by auscultation is approximately 10 mmHg higher.

Observe effort of breathing; listen for abnormal breathing sounds.
Look for asymmetry, deformity, swelling, bruising, lacerations, and scars.
Confirm that trachea is in midline and chest has normal anteroposterior (AP) diameter.
Evaluate abdominal contour and signs of increasing abdominal girth; observe for peristaltic or pulsating movements.
Observe for splinting or guarding of torso and upper extremities (UEs) or any change in neck position.

Auscultate anteriorly and posteriorly, comparing for asymmetry. If breath sounds are decreased, normal lung has been displaced by air (suspect pneumothorax) or fluid (hemopneumothorax or pleural effusion).
Percuss anterior and posterior chest, comparing both sides, and for normal diaphragmatic excursion with inspiration (symmetrical 3–5 cm). If hyperresonant, suspect pneumothorax; if dull, suspect fluid. Percuss all four quadrants; percuss liver span (range 6–12 cm), check for splenic enlargement.
Auscultate before palpating, as bowel sounds can change with manipulation. Listen for bruits over aorta and renal and iliac arteries. Gently palpate to check for areas of tenderness, noting facial expression and guarding. Follow with deep palpation to further delineate areas of pain or presence of abdominal masses. Include a complete evaluation of the genitourinary system.
For bony and soft tissue injuries of the thorax, perform neck, thoracic spine, and shoulder range-of-motion (ROM) and strength tests and palpate for crepitus, deformities, or tenderness.

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