1. Chapter 9
Thorax and Abdomen

2. Evaluation of Thorax and Abdomen
Injuries are less common than extremity Injuries
Can be Life Threatening
These Injuries demand immediate evaluation and subsequent activation of the emergency medical system

3. Evaluation of Thorax and Abdomen
Evaluation of the thorax and abdomen must follow a precise assessment process:
Primary Survey
Secondary Survey
This helps the examiner distinguish between acute trauma and non-traumatic conditions

4. Primary Survey First Survey the scene Looking for indication of injury
Approach in a calm reassuring manner
If the athlete is conscious this enhances relaxation and maintenance of the respiratory and circulatory systems
Be prepared to clear and maintain airway
Potential obstructions such as blood, vomitus, and foreign matter

5. Primary Survey
Once Cervical Spine injury is not suspected assist the patient in finding the most comfortable position for breathing.
Be prepared to give Artificial Ventilation or Cardiopulmonary Resuscitation and activate EMS.

6. Secondary Survey Once the primary survey is completed
Injury not life threatening
Consist of two elements:
History – The part of the evaluation in which the examiner questions the athlete to determine:

7. Secondary Survey - History
Mechanism of Injury
Onset of Symptoms
Location of Injury
Quantity and Quality of Pain
Type and location of any abnormal sensations
Progression of signs and symptoms
Nausea - The Feeling of Sickness
Weakness
Dyspnea – Difficulty breathing

8. Secondary Survey The physical examination is the next step
Can vary from athlete to athlete
But stay within normal limits
Physical activity can add to variance
Variances Include:
Respiratory Rate
Moistness
Color
Temperature of Skin
Pulse Rate

9. Secondary Survey – Vital Signs
These are Essential to Monitor During Evaluation
Abnormal Nerve Response
Blood Pressure
Movement
Pulse
Respiration
Skin Color
State of Consciousness
Temperature

10. Secondary Survey Following Vital Signs
Inspection
Auscultation – The process of listening to the
sounds of the chest and abdomen
Determines: Normal vs. Abnormal breathing Chest Sounds
Breathing Equality
Depth of Breaths
Percussion – Tapping (Listening for sounds such as
tympany, dullness, or hyperresonance)
Palpation – the use of the hands to examine a body part
Special Test

11. Secondary Survey Inspection Stage
Level of Consciousness
Skin Color
The Athlete’s positions, movements and signs of guarding or apprehension
Respiratory rate and rhythm for dyspnea (shortness of breath)
Symmetry of chest appearance and chest movements

12. Secondary Survey Signs of Trauma
Hemoptysis – coughing up blood Hematemesis – vomiting up blood Ecchymosis – escaping of blood into tissue

13. Secondary Survey Signs of Trauma
Signs of Respiratory Distress
Cyanosis – pale bluish skin color of the lips, finger tips,
or fingernails, from poor oxygenation of
the blood
Flail Chest
Tracheal Deviation
Jugular Vein Distension (JVD)
Pupil equality and responsiveness
Evidence of penetrating trauma
Vomiting
Bat

14. Secondary Survey Signs of Trauma – Abdominal Cavity
When examining the abdomen, each quadrant should be auscultated, percussed, and palpated

15. Secondary Survey Signs of Trauma – Abdominal Cavity
Abdominal palpation determines signs and symptoms of an acute abdomen
Symptoms Include:
Leakage of blood
Puss
Bowl contents into abdominal cavity causing peritoneal irritation
Signs of an Acute Abdomen:
Rebound Tenderness
Rigidity
Guarding

16. Secondary Survey Signs of Trauma – Abdominal Cavity
Rebound Tenderness – is identified by the examiner
pressing deeply into the abdominal
cavity and then quick
If it is painful peritoneal irritation may be present
Rigidity of the abdominal wall muscles occurs when peritoneal irritation causes reflex spasm of the abdominal muscles
Producing a board like-harness
Prevents the examiner from palpating the abdomen

17. Secondary Survey Signs of Trauma – Abdominal Cavity
Valsalva Maneuver
Used to provoke an increase in pain or mass protrusion if significant intra-abdominal trauma has occurred
To perform the Valsalva Maneuver:
the athlete takes a deep breath
hold their breath
strain as if a bowel movement
Pain could indicate protrusion through the abdominal wall

18. Secondary Survey Signs of Trauma – Abdominal Cavity
Evaluating Range of Motion
The assessment is divided into active, passive, and resistive motions
Motions are assessed in the three anatomical planes:
Sagittal Plane
Frontal Plane
Transverse Plane

19. Secondary Survey Signs of Trauma – Abdominal Cavity
Anatomical Plane Motions
Visually Note:
Apprehension
Limited Range of Motion
Painful Arcs

20. Secondary Survey Signs of Trauma – Abdominal Cavity
The Sagittal Plane
To evaluate:
The athlete stands and slowly flexes the truck to the point where the hands touch the toes or the floor.
Then the athlete is to return from flexion to standing upright and progress to trunk expression

21. Secondary Survey Signs of Trauma – Abdominal Cavity
The Frontal Plane
To evaluate:
The athlete stands and slowly flexes the trunk laterally to the Right as far as possible
Slowly returns to neutral
Repeat the motion to the left

22. Secondary Survey Signs of Trauma – Abdominal Cavity
The Transverse Plane
To evaluate:
The athlete stands and slowly rotates the trunk to the Right as far as possible
The Position is held
Repeat the motion to the left

23. Secondary Survey Signs of Trauma – Thoracic Cavity
Inspiration and expiration test inspiratory and expiratory function and elicit signs and symptoms of thoracic injury.

24. Secondary Survey Signs of Trauma – Thoracic Cavity
Evaluate inspiration and expiration by having athlete breathe in as much as possible and hold for a few seconds.
Ask the athlete to breath out slowly and fully to expire all air from the lungs
Instruct the athlete to breathe to hold that maximally expired position for a few seconds.
During activity observe the athlete for apprehension or limitations in the inspiratory movement as well as pain

25. Secondary Survey Signs of Trauma – Thoracic Cavity
Specific Signs and symptoms:
Inability to fully inspire
Pain during breathing
Guarding or apprehension with respirations

26. Secondary Survey Signs of Trauma – Thoracic Cavity
Fractures and Separations
May occur in bones and costal cartilages of the rib cage.
Complete separation or fracture, crepitius, grating, and popping sensations may be present with active and passive chest movements
In some cases passive stress can be applied to elicit further signs or symptoms

27. Secondary Survey Signs of Trauma – Thoracic Cavity
Rib Cage Fracture/Separation Test
Two Test Should be Performed:
Anterior/Posterior chest compression test
Test Lateral Ribs
Lateral chest compression test
Test posterior anterior chest
These test will help determine the extent of the injury.
Contusion vs. Fracture

28. Thorax & Abdomen Anatomy
Sternum
Ribs 12
Lumbar Vertabrae
Sacral Vertabrae
Coccyx

29. Muscles & Functions
Pectoralis Major – Pulls rib cage up; adducts arms; rotates arms medially; prime mover for arm flexion Pectoralis Minor – Draws scapula forward and downward; draws rib cage superiorly

30. Muscles & Functions
Latissimus Dorsi – extends the upper arm, adducts upper arm posteriorly.

31. Muscles & Functions
External Intercostals – Lifts the rib cage Rectus Abdominis – Flexes and rotates lumbar region

32. Muscles & Functions
Internal Abdominis Oblique – aids rectus abdominis; aids the back muscles in truck flexion and lateral flexion. External Abdominis Oblique - aids rectus abdominis; in truck rotation and lateral flexion

33. Muscles & Functions
Transverse Abdominis – Compresses abdominal contents

34. Internal Organs

35. Abdominal Quadrants
Right Upper (Superior) Quadrant
Liver and Adrenal Gland
Gallbladder Pylorus of the Stomach
Left Upper (Superior) Quadrant
Stomach
Spleen and Adrenal Gland
Portion of the Pancreas
Portions of the Colon and Small Intestine
Posterior - Left Kidney

36. Right Lower (Inferior) Quadrant
Abdominal Quadrants
Right Lower (Inferior) Quadrant
Appendix
Portions of the Large and Small Intestines
Portion of the Colon
Structures of the Urinary and Reproductive systems
Left Lower (Inferior) Quadrant

37. Hollow Organs Stomach Urinary Bladder Large an small Intestines
Vessels

38. Solid Organs
Kidneys
Pancreas
Liver

39. Assessment Test
Test for Bony Integrity Palpation: Physical Inspection Compression: Inward force applied to thorax and ribs through inspiration and manual pressure Distraction: Outward force applied to thorax and ribs through expiration

40. Compression Test: Thorax/Ribs Anterior/Posterior and Lateral:
Assessment Test
Compression Test: Thorax/Ribs
Anterior/Posterior and Lateral:
compression force applied to thorax and ribs through manual pressure
Compression Test: Pelvis
Anterior/Posterior and Medial / Lateral:
compression force applied to pelvis through manual pressure

41. Assessment Test Breathing
Inspiration: Action of taking a breath (inhalation)
Expiration: Action of releasing a breath (exhaling)

42. Assessment Test Signs of Acute Abdomen
Rebound Tenderness – Pain in the abdomen
upon the release of
pressure from the abdomen
Rigidity – Upon palpation, abdomen is rigid or hard
and not fully palpable
Guarding – Patient contract muscles while
palpation so that the palpation does
not hurt

43. Test to Detect Possible Peritoneal Irritation
Assessment Test
Test to Detect Possible Peritoneal Irritation
(intra-abdominal Pressure)
Iliopsoas Test – Moving leg into hip flexion,
which causes abdomen pain

44. Assessment Test - Possible Peritoneal Irritation
Obturator Test – With hip and knee in 90° flexion,
internal and external rotation of
hip will cause abdomen pain.

45. Assessment Test - Possible Peritoneal Irritation
Heel Pound Test – With hip and knee in full
extension, tap heel to increase
pain in the abdomen
Valsalva Maneuver – Athlete takes a deep breath,
hold their breath, and strain as
if having a bowel movement.

46. Immediate Referral Difficulty Breathing
Shortness of breath
Severe increasing pain in chest
Vomiting or coughing blood
Diminished chest movement on the affected side
Shifting or moving of trachea with each breath
Suspected rib fracture
Signs of acute abdominal pain
Rebound tenderness
Rigidity
Guarding
Blood in urine or stool
Prolonged discomfort, sensation of weakness, or pulling in groin
Superficial protrusion or palpable mass
Circulation or neurological impairment

47. Immediate Referral – cont.
Increasing Nausea
Vomiting
Presence of Fever
Presence of radiating or referred pain
Signs of shock
Doubt regarding the nature and severity of the thorax or abdomen injury

48. Common Injuries and Problems: Thorax
Acute traumatic injuries occurring to the thorax may involve the heart, lungs, and rib cage.
Myocardial Infarction – is ischemia to cardiac tissue,
which may result in a
disturbance of normal heart
function characterized by
arrhythmia
Ischemia – decrease in oxygenated blood flow
Arrhythmia – irregular heart beat

49. Signs and Symptoms of Myocardial Infarction
Persistent chest pain or pressure unrelieved by rest, position changes or medication
Breathing difficulty: noisier, shorter, faster than normal
Cyanosis
Moist face or profuse sweating
Radiation of pain to the left side (neck, shoulder, arm)
Levine’s Sign (clenched fist over the chest)
Hypotension or shock

50. Common Injuries and Problems: Thorax
Pericardial Tamponade – Compression of the heart
Caused by blunt trauma to the anterior chest wall
Bleeding accumulates inside the pericardial sac and will gradually increase
Causes external pressure on the heart
Preventing proper contraction

51. Common Injuries and Problems: Thorax
Cardiac Contusion – results from a direct blow to the
anterior chest wall in the heart
region
May cause Pericardial Tamponade

52. Common Injuries and Problems: Thorax
Lungs
Located in the thorasic cavity
Protected by the rib cage
Pneumothorax – characterized by air accumulation in
the pleural space
Occurs either spontaneously or traumatically from a blunt or sharp trauma to the chest wall
Air escapes from the lung upon each inspiration, collects in the pleural space and leads to collapse of lung

53. Common Injuries and Problems: Thorax
Thoracic related boney and joint injuries can occur to the rib cage structure.
The rib cage outlines the thoracic borders and provides protection to the heart, lungs, great vessels (aorta and vena cava), liver, and spleen
The ability to expand and relax is essential in assisting the lungs’ reparatory function

54. Common Injuries and Problems: Thorax
Rib Fractures
Nondisplaced fractures are usually benign
Most common rib fracture
Displaced fractures may result in lacerations to the lung and associated intercostal vessels.
Usually involve the 5th to 9th ribs
1st and 2nd are not common because the tremendous force required
Fractures in ribs 7 – 12 may be associated with liver, spleen, or kidney injuries

55. Common Injuries and Problems: Thorax
Signs and Symptoms of Rib Fractures
Pain at fracture site aggravated by coughing, breathing, movement, and compression test
Dyspnea (shortness of breath)
Localized tenderness
Bony or air crepitation
Contusion
Ecchymosis (escaping of blood into tissue)

56. Respiratory Conditions: Thoracic Cavity
Asthma – an inflammatory condition characterized by
bronchospasm, resulting in wheezing, and
shortness of breath (dyspnea)
Asthma can be exercise induced
Bronchitis – Inflammation of the bronchial tubes
Usually characterized by a progressive cough.
Hemoptysis – expectoration of blood arising from
lungs
Patient coughs up blood

57. Respiratory Conditions: Thoracic Cavity
Hyperventilation – increase in respiratory rate
usually associated with anxiety,
which causes a change in the
acid-base balance of the blood.
Symptoms include:
Dyspnea
Numbness
Tingling in the hands, fingers, and around the mouth

58. Respiratory Conditions: Thoracic Cavity
Influenza – a viral illness characterized as an acute,
rapid onset of fever, muscle ache,
headache, and fatigue; usually one to
two weeks
Pleuritis Chest Wall Pain – Inflammation of serous
membrane lining, which
lies between the lung
and the chest wall
Causes pain with inspiration and expiration or cough

59. Respiratory Conditions: Thoracic Cavity
Pneumonia – inflammation of the lungs caused primarily by
bacteria, viruses, chemical irritants, vegetable
dust, and allergy
Symptoms:
Fever
Cough
Chest pain

60. Common Injuries & Problems: Abdomen
When examining the abdomen, each quadrant should be auscultated, percussed, and palpated.
The most important function of palpation is to determine signs and symptoms of acute abdomen, which are rebound:
Tenderness
Rigidity
Guarding

61. Common Injuries & Problems: Abdomen
The spleen is the largest lymphatic organ and it is located in the upper left quadrant.
Directly below the diaphragm
Behind 9th, 10th, 11th ribs
Reservoir of red blood cells
Regulates the number of red blood cells in circulation
Destroys old or defective red blood cells and produces white blood cells

62. Common Injuries & Problems: Abdomen
Signs and Symptoms of Spleen Injury
Acute abdominal pain(rebound tenderness, rigidity, guarding)
Abdominal pain in the upper left quadrant
Pain radiating to the left shoulder and one third of the way down the arm or neck pain (Kehr’s Sign)
Shock
Possible left, lower rib fracture

63. Common Injuries & Problems: Abdomen

64. Common Injuries & Problems: Abdomen
Liver
Upper Right Quadrant
Small portion on the Left Upper Quadrant
Solid organ
Functions:
Manufacturing plasma proteins
Manufacturing and storage of blood cells
Removal of old or defective red blood cells
Breakdown of toxic substance
Glucose and fat metabolism
Mineral and vitamin storage
Bile production

65. Common Injuries & Problems: Abdomen
Signs & Symptoms of Acute Liver Injury
Acute or gradual onset of abdominal pain
Palpable tenderness
Rebound tenderness
Rigidity
Guarding
Abdominal pain in the right upper quadrant
Right shoulder or neck pain
Possible right, lower rib fracture

66. Common Injuries & Problems: Abdomen
Kidneys
Kidneys are paired solid, bean-shaped organs located in both the right and left upper quadrants near the spine.
Kidney’s function to help control blood volume
Remove waste from the blood

67. Common Injuries & Problems: Abdomen
Kidneys
Acute or gradual onset of abdominal pain, palpable tenderness, rebound tenderness, rigidity, guarding.
Hematuria (passing of blood in urine)
Bloody discharge or inability to void
Flank or low back pain
Positive Grey-Turner sign – ecchymosis in flank
Possible bony crepitus due to rib fracture

68. Non-Traumatic Injuries/Conditions: Abdomen
Appendicitis – Inflammation of the appendix.
Generally affect the young and more common in males
Characterized by low grade fever, signs of acute abdominal pain (lower right quadrant)
Nausea / Vomiting

69. Non-Traumatic Injuries/Conditions: Abdomen
Indigestion (heartburn) – Incomplete or imperfect digestion, usually accompanied by one or more of the following symptoms: pain, nausea, vomiting Stitch in the Side – Sharp pain in the side usually associated with strenuous physical activity, caused by muscle spasms and/or trapped gas

70. Musculoskeletal Conditions/Disorders
Arrhythmia -  is a problem with the rate or rhythm of the heartbeat.
The heart can beat too fast, too slow, or with an irregular rhythm.
Bradycardia – Arrhythmia with a slow heart beat
Flail Chest -  occurs when a segment of the
thoracic wall becomes unattached
from the rest of the chest wall. 

71. Musculoskeletal Conditions/Disorders
Hemopneumothorax - The presence of air or gas
and blood in the thoracic
cavity.
Hemothorax -  a collection of blood in the space
between the chest wall and the
lung (the pleural cavity).
Spontaneous Pneumothorax
collapsed lung, or pneumothorax, the collection of air in the space around the lungs. This buildup of air puts pressure on the lung, so it cannot expand as much as it normally does when you take a breath

72. Musculoskeletal Conditions/Disorders
Tachycardia - A heart rate of more than 100 beats per minute (BPM) in adults Dysmenorrhea - defined as difficult menstrual flow or painful menstruation. Ectopic Pregnancy - an abnormal pregnancy that occurs outside the womb (uterus). The baby (fetus) cannot survive, and often does not develop at all in this type of pregnancy

73. Musculoskeletal Conditions/Disorders
Gastroenteritis - a condition that causes irritation and
inflammation of the stomach and intestines
Hernia - a sac formed by the lining of the abdominal cavity
(peritoneum).
The sac comes through a hole or weak area in the fascia, the strong layer of the abdominal wall that surrounds the muscle.

74. Musculoskeletal Conditions/Disorders
Muscular Strains - when the muscle is stretched too far.

75. Rehabilitation
Before sending an athlete back to competition, the following rehabilitation guidelines must met:
Full Range of Motion
Strength, power, and endurance are proportional to the athletes size and sport
No pain during running, jumping, or cutting

76. Rehabilitation Program
Range of Motion Exercises
Torso
Flexion
Extension
Lateral Flexion
Rotation
Anatomical Plane Movement
Sagittal
Frontal
Transverse

77. Rehabilitation Program
Range of Motion Exercises
Thorax and Abdomen Exercise
Abdominal Crunches
Abdominal Lift
Abdominal Sit – ups
Arm Extensions
Arm Flexion
Bench Press
Incline Press
Pelvic Tilts
Prone Extensions
Prone Push -up