1. Chapter 21: The Thorax and Abdomen

5. 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

6. 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

7. 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?

8. History (cont’d.) 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?

9. 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

10. Observations (cont’d.)
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)

11. 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

13. Referred Pain Patterns

14. Rib Contusion Cause of Injury Signs of Injury Care
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

15. 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

16. 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

18. 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

19. Lung Injuries Pneumothorax - Tension Pneumothorax Hemothorax
pleural cavity becomes filled with air, negatively pressurizing the cavity, causing a lung to collapse
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

20. Lung Injuries (cont’d.)
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

21. 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

22. Sudden Death Syndrome in Athletes
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

23. 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

24. Abdominal Injuries 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

25. Abdominal Injuries (cont’d.)
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

26. Hernia (Sports Hernia)
Cause 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

27. Hernia (cont’d.)
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

28. Solar Plexus Injury 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

29. 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

30. Splenic Injuries 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

31. Splenic Injuries (cont’d.)
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

32. 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

33. 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

34. 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)

35. Bladder Injuries Cause of Injury Signs 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

36. 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 minutes referral will be necessary

38. Gynecological Injuries
Low incidence of injury in sports
Most common occurrence involve contusion of external genitalia
Signs and Symptoms
Hematoma results from contusion - may also involve pubic symphysis resulting in osteitis pubis