1. Blunt Chest Wall Injuries Yury Rabotnikov, M.D. PGY 1 ADVANCING SCIENCE, ENHANCING LIFE Weill Cornell Medical College

2. EPIDEMIOLOGY Rib Fx: 2/3 of admitted pts Sternal Fx: 8% of blunt chest trauma, 18 of multiple trauma Scapular Fx about 1-2%

3. Initial Assesment Hx: mechanism, PMH, presentation Physical: flail chest, Hypoxia, HD, Seat belt sign, pain, deformities, abd tenderness Imaging: CXR, EKG, CT (if stable enough).

4. High Risk Chest Wall Injuries Scapula fracture Flail chest Multiple rib fractures (≥3) and displaced rib fractures Sternal fracture Posterior sternoclavicular dislocation

5. Asymptomatic PTX: less then 8mm – observe Hemothorax: 300 cc needed to diagnose  36Fr chest tube. >1500cc  surgery Pulmonary contusion develop in 24 hours, resolve in 1 week. (Irregular, nonlobular opacification ). Intubation only if hypoxic. Tracheobronchial injury 1%. Most diet at the sceene (R main Bronchus> L main )

6. Associated complication Pneumonia - ~6% of all hospitalized pt’s w rib fx – Elderly pts( >65 y.o.) => 30% incidence, 22% mortality Retained hemothorax – dx CT, tx VATS Empyema :3-10% of pt’s w CT placed Fracture nonunion Respiratory failure

7. Associated Internal Injuries Blunt aortic and other mediastinal injury Pneumothorax Pulmonary contusion Cardiac contusion Myocardial rupture

8. Blunt Aortic Injury (BAI) Radiologic Findings: Wide mediastinum (supine CXR >8 cm; upright CXR >6 cm) Obscured aortic knob; abnormal aortic contour Left "apical cap" (ie, pleural blood above apex of left lung) Large left hemothorax Deviation of nasogastric tube rightward Deviation of trachea rightward and/or right mainstem bronchus downward Wide left paravertebral stripe

9. Isolated Chest wall injury: Main goals = (1) Pain control (2) Expansion of pulmonary volume Hospitalization = any pt w 3 or more rib fx ICU = elderly pt w 6 or more rib fx

10. Pain Control Regional anesthesia – Continuous epidural infusion => shorter duration of mechanical ventilation and dec risk pneumonia – Paravertebral block = unilateral rib fx – Intercostal nerve blocks – Intrapleural infusion IV narcotics IV NSAIDs (ex toradol)

11. Surgical Management – Flail chest + failure to wean from ventilator – Painful, movable ribs refractory to pain management strategies – Significant chest wall deformity – Chest wall instability due to fracture nonunion – Displaced rib fx found at thoracotomy – Internal Injuries.