Chapter 21: The Thorax and Abdomen

Preventing Injuries to the Thorax and Abdomen Utilize appropriate protective equipment Imperative in collision sports Abdominal musculature strengthening to protect underlying viscera Be sure hollow organs are empty prior to competition Reduces chance of injury to them

Assessment of the Thorax Abdomen Injuries to this region can produce life-threatening situations ATC’s evaluation should focus on signs and symptoms that indicate potentially life-threatening conditions Continually monitor breathing, circulation and any indication of internal bleeding or shock

History What happened to cause this injury? Was there direct contact or a direct blow? What position were you in? What type of pain, was it immediate or gradual, location(s)? Difficulty breathing? What positions are most comfortable? Do you feel faint, light-headed or nauseous? Chest pain?

Hear or feel snap, crack or pop in your chest? Muscle spasms? Blood or pain during urination? Was the bladder full or empty? How long has it been since you last ate? Is there a personal or family history of any heart, abdominal problems or other diseases involving the abdomen and thorax?

Observations Is the athlete breathing? Are they having difficulty breathing? Does breathing cause pain? Is the athlete holding the chest wall? Is there symmetry of the chest during breathing? If the athlete’s wind was knocked out, is normal breathing returning? How rapidly? Body position

Check for areas of discoloration, swelling or deformities Around umbilicus = intra-abdominal bleed Flanks = swelling outside the abdomen Protrusion or swelling in any portion of abdomen (internal bleeding) Does the thorax appear to be symmetrical? Are the abdominal muscles tight and guarding? Is the athlete holding or splinting a particular part? Monitor vital signs (pulse, respiration, BP) Rapid weak pulse or drop in BP is an indication of a serious internal injury (involves blood loss)

Palpation Thorax Abdomen Check for symmetry of chest wall movement and search for areas of tenderness Palpate along ribs and intercostal spaces as well as costochondral junctions – locate points of tenderness Abdomen Patient should have arms at side, knees and hips flexed to relax abdomen Feel for guarding and tenderness, rigidity (internal bleeding) Be aware of possibility of referred pain

Recognition and Management of Specific Injuries Rib Contusion Cause of Injury Blow to the rib cage can bruise ribs, musculature or result in fracture Signs of Injury Painful breathing (particularly if muscles are involved) Point tenderness; pain with rib compression Care RICE and NSAID’s Rest and decrease in activity

Rib Fractures Cause of Injury Signs of Injury Care Caused by a direct blow or the result of a violent muscular contraction Can be caused by violent coughing and sneezing Signs of Injury History is critically important Pain with inspiration, point tenderness and possible deformity with palpation Care Refer for X-rays Support and rest; brace Generally heals in 3-4 weeks

Costal Cartilage Injury Cause of Injury Result of a direct blow to the anterolateral aspect of the rib cage Signs of Injury Localized pain in region of costochondral junctions Pain with movement; difficulty with breathing Point tenderness and possible deformity Care Rest and immobilization Healing may take 1-2 months

Intercostal Muscle Injuries Cause of Injury Muscles are subject to contusions and strains Occur most often from direct blows or sudden torsion of the trunk Signs of Injury Pain occurs on active motions; pain with inspiration and expiration, coughing, sneezing and laughing Care Immediate pressure and application of cold for approximately 20 minutes After hemorrhaging is controlled, immobilize the injury to make the athlete comfortable

Lung Injuries Cause of Injury Pneumothorax - Tension Pneumothorax pleural cavity becomes filled with air, negatively pressurizing the cavity, causing a lung to collapse http://www.youtube.com/watch?v=R-l1nzOezIw Tension Pneumothorax Pleural sac on one side fills with air displacing lung and heart, compressing the opposite lung Hemothorax Blood in pleural cavity causes tearing or puncturing of the lungs or pleural tissue Traumatic Asphyxia Result of a violent blow or compression of rib cage Causes cessation of breathing and immediate medical attention

Signs of Injury Breathing difficulty, shortness of breath, chest pain on side of injury Coughed up blood, cyanosis, and potentially shock With collapse of lung medical attention is required immediately Care Each of these conditions are medical emergencies and require immediate attention Transport athlete to hospital immediately

Pneumothorax

Sudden Death Syndrome in Athletes Cause of Condition Hypertrophic cardiomyopathy- thickening of cardiac muscle w/ no increase in chamber size Anomalous origin of coronary arteries Marfan’s syndrome- abnormality in connective tissue results in weakening of aorta and cardiac vessels Series of additional cardiac causes Non-cardiac causes include drugs and alcohol, intracranial bleeding, obstructive respiratory disease Signs of Condition Most do not exhibit any signs prior to death May exhibit chest pain, heart palpitations, syncope, nausea, profuse sweating, shortness of breath, malaise and/or fever

Hypertrophic cardiomyopathy Marfan’s

Care Immediate medical attention is necessary – life threatening condition Prevention Counseling and screening are critical in early identification and prevention of sudden death Screening questions should address the following History of heart murmurs Chest pain during activity Periods of fainting during exercise Family history Thickening of heart or history of Marfan’s syndrome Cardiac screening - electrocardiograms and echocardiograms may be needed to determine existing pathology

Breast Problems Cause of Injury Management Constant uncontrolled movement (particularly in large breasted women) Stretching of Cooper’s ligament Runner’s and cyclist’s nipple Management Females should wear well-designed bra that has minimum elasticity and allows for little movement Special plastic cup-type brassieres may be required in sports with high levels of physical contact Use of an adhesive bandage can be used to prevent runner’s nipple Wearing a windbreaker can prevent cyclist nipple

Injuries to the Abdominal Wall Abdominal Muscle Strain Cause of Injury Result of sudden twisting or reaching of trunk, tearing abdominal musculature Contusions of Abdominal Wall Caused by a compressive force - generally occurring in collision sports Extent of injury depends on whether force is blunt or penetrating

Signs of Injury May cause a hematoma to develop under fascia of surrounding muscle tissue Swelling may cause pain and tightness w/in the region Care Cold pack and compression Be sure to check for signs of internal injuries Conservative management Exercise should be kept pain free

Hernia Cause of Injury Signs of Injury Protrusion of abdominal viscera through portion of abdominal wall (congenital or acquired) Inguinal vs. femoral hernias Complications and strangulated hernias Signs of Injury Acquired hernia occur when natural weakness is further aggravated by a direct blow or strain History of direct blow to groin area, pain and prolonged discomfort, superficial protrusion with pain increasing with coughing & reported pulling sensation in groin area

Care Most physicians prefer athlete to refrain from hard physical activity until surgically repaired Mechanical devices are not suitable for athletics due to friction and irritation they produce While exercise is thought to be beneficial with regards to strengthening that is not the case

Blow to Solar Plexus Cause of Injury Signs of Injury Care Transitory paralysis of the diaphragm due to blow to the middle portion of the abdomen Signs of Injury Stops respiration and leads to anoxia Generally transitory Care Must help athlete overcome apprehension Use short inspirations and long expirations Calm athlete, prevent hyperventilation, blow into a paper bag ATC should question possibility of internal injury

Stitch in the Side Cause of Injury Signs of Injury Management Idiopathic condition with obscure cause and several hypotheses Constipation, intestinal gas, overeating, diaphragmatic spasm, poor conditioning, lack of visceral support and weak abdominals, distended spleen, breathing techniques resulting in lack of oxygen, ischemia of diaphragm or intercostal muscles Signs of Injury Cramp-like pain that develops on either the right or left costal angle during hard physical activity Management Relaxation of the spasm Stretch arm on affected side as high as possible Flex trunk forward on the thighs Additional problems may warrant further study

Injury of the Spleen Cause of Injury Signs of Injury Result of a direct blow Infectious mononucleosis (causing an enlarged spleen) Signs of Injury Indications of a ruptured spleen involve history of a direct blow, signs of shock, abdominal rigidity, nausea, vomiting Kehr’s sign Ability to splint self may produce delayed hemorrhaging - easily disrupted resulting in internal bleeding

Care Conservative treatment involves 1 wk of hospitalization and a gradual return to activity Surgery will result in three months of recovery while removal of spleen will result in a 6 month removal from activity In cases of mononucleosis athlete may resume training in 3 weeks if spleen not enlarged and if there is no fever

Kidney Contusion Cause of Injury Signs of Injury Care Result of an external force (force and angle dependent) Susceptible to injury due to normal distention of blood Signs of Injury May display signs of shock, nausea, vomiting, rigidity of back muscles and hematuria (blood in urine) Referred pain (costovertebral angle posteriorly radiating forward around the trunk) Care Monitor status of urine (hematuria) - refer if necessary 24 hour hospitalization and observation with a gradual increase in fluid intake Surgery may be required if hemorrhaging continues 2 weeks of rest and close surveillance following initial return to activity is necessary

Liver Contusion Cause of Injury Signs of Injury Care Blunt trauma - right side of rib cage More susceptible if enlarged due to illness (hepatitis) Signs of Injury Hemorrhaging and shock may present May require immediate surgery Presents with referred pain in right scapula, shoulder and substernal area and occasionally in left anterior side of chest Care Referral to a physician for diagnosis and treatment

Appendicitis Cause of Injury Signs of Injury Care Inflammation of the vermiform appendix (chronic or acute) Result of blockage, lymph swelling, or carcinoid tumor Early stages it presents as a gastric complaint, that gradually develops from red swollen vessel to a gangrenous structure that can rupture into bowels causing peritonitis Signs of Injury Mild to severe pain in lower abdomen, associated with nausea, vomiting and low grade fever Pain may localize in lower right abdomen (McBurney’s point) Care Surgical intervention is often necessary (particularly if it is resulting in an obstructed bowel = life threatening)

Injuries to the Bladder Cause of Injury Blunt force to the lower abdomen may cause injury to urinary bladder if distended with urine Hematuria is often associated with contusion of bladder during running (runner’s bladder) Signs of Injury Pain, discomfort of lower abdominal region, abdominal rigidity, nausea, vomiting, shock, bleeding from the urethra, increased quantity of bloody urine Athlete should be instructed to monitor urine Inability to urinate will present in case of ruptured bladder

Scrotal/Testicular Contusion Cause of Injury Result of blunt trauma and contusion to the vulnerable and sensitive scrotum Signs and Symptoms Hemorrhaging, fluid effusion, muscle spasm, severe pain (disabling) May cause nauseating, disabling and painful condition Care Place athlete on side with knees to chest Apply cold pack as pain subsides If pain persist after 15-20 minutes referral will be necessary

Gynecological Injuries Low incidence of injury in sports