The volume of people involved in sports in the United States continues to occur at a very high level throughout various age groups. Each year greater than 7.8 million high school students and 60 million youth older than 6 yr participate in organized athletics (1,2). Meanwhile, adults are showing increased participation in higher risk activities with extreme action and adventure sports totaling 22 million participants and obstacle racing adding 4.5 million annually (3,4). With the large overall numbers and increasing adult participation in riskier activity, it is likely that the sideline physician will be increasingly exposed to chest trauma.
In general, chest and torso trauma related to sports is relatively rare. It can be caused by rapid deceleration or direct impact to the thorax. While infrequent, however, these injuries run the risk of being extremely serious and even life-threatening. In overall trauma mortality, thoracic injuries account for about 25% of all early-trauma related deaths, but some studies have shown sports causing only about 2% of those chest injuries requiring treatment (5,6). A recent analysis of high school athletics found only 4.9 injuries to the torso — including chest, thoracic spine, and abdomen — per 100,000 athletic exposures. Most of these injuries were benign and related to contusion or muscle strain, but around half of all torso injuries still required further diagnostic workup. Additionally, only 42.3% of all athletes returned to sport within a week after a torso injury (7). Prompt identification and treatment can mean a significant difference in outcome. Sports medicine providers must be aware of the spectrum of injuries that can occur, from the mundane to the deadly, and be ready to act appropriately.
Evaluation should begin with the basic principles of any initial injury encounter. While Advanced Traumatic Life Support (ATLS) cannot fully be performed field-side, its guidelines provide an appropriate outline for action. The common acronym of “ABC” — indicating airway, breathing, and circulation — is often used. Patient assessment should begin with an evaluation of airway patency. Any cause of obstruction should be addressed immediately, with a jaw thrust being appropriate in most instances. Breathing status is evaluated by inspection and auscultation. If deficient, the primary cause should be treated per the specific interventions indicated below, along with supplemental oxygen and positive pressure ventilation with bag valve mask. Circulation is assessed with evaluation of pulse presence/quality, heart rate, and blood pressure. Circulatory collapse can occur through hemorrhagic shock related to intrathoracic blood loss. Additionally, obstructive shock can be related to impeded venous return due to elevated intrathoracic pressure (as in tension pneumothorax) or inadequate cardiac filling (as in cardiac tamponade). Any life-threatening abnormality of airway, breathing, or circulation failure must be treated as it is discovered. Less severe conditions are more thoroughly evaluated/treated on a less emergent basis once the athlete is confirmed as stable.
The primary survey is often expanded to “ABCDE” to include disability and exposure. Disability evaluation constitutes a basic assessment of neurologic status, while exposure serves as a reminder to examine the patient fully from head to toe to ensure that no injuries are missed.
While this focus resides on chest trauma, one must also consider associated injury, specifically intra-abdominal trauma. Although specific abdominal conditions and treatments are beyond the scope of this article, basic trauma assessment and appropriate triage protocols apply.
The increased utilization of bedside and field-side ultrasound provides an evolving aspect of this topic. Bedside ultrasound has been used in emergency medicine and trauma surgery for some time with good accuracy in diagnosis of chest trauma (8–11). This modality provides added benefit of portability, relatively low cost, and avoidance of ionizing radiation. As sports medicine providers become more adept at the use of ultrasound within the musculoskeletal realm, expansion to more nonmusculoskeletal applications is a natural step. Opportunities for expedited diagnosis using portable ultrasonography will be highlighted throughout this overview.
Acute Life-Threatening Emergencies
A pneumothorax occurs when air becomes trapped between the visceral pleura of the lung and the parietal pleura of the chest wall. This can occur spontaneously or with trauma. Spontaneous pneumothorax most often occurs in young, tall males (12). It has been described as occurring in noncontact sports such as scuba diving, weight lifting, and running (6). Additionally, it can occur in older people with underlying pulmonary disease. Pneumothorax in trauma typically results from rib fracture that leads to direct injury of the pleura; however, sports-related traumatic pneumothorax in the absence of rib fracture has been reported (13). Simple pneumothorax itself is rarely life-threatening, but it can develop into and must be distinguished from tension pneumothorax, which can quickly lead to death.
Diagnosis of pneumothorax is based initially on clinical signs and symptoms. Patients usually complain of a pleuritic chest pain and shortness of breath. Breath sounds may be decreased, and lung fields may be hyper-resonant with percussion. Subcutaneous emphysema also may be appreciated. Hypoxia can be seen in more severe cases. However, even in the absence of physical exam signs, suspicion must remain high, as clinical diagnosis can be difficult.
While chest X-ray has historically been the first line in evaluation for the condition, ultrasound has gained popularity in the acute setting for an expedient diagnosis of pneumothorax. This modality has been found to be extremely accurate and is now being considered the preferred first-line tool for diagnosis in critical care settings (14). Studies have demonstrated better sensitivity and similar specificity when comparing ultrasound to standard chest X-ray (8). Specificities have been found to be greater than 99% (9). Pneumothorax on ultrasound demonstrates lack of normal lung sliding, absence of B-lines (also known as comet tail artifacts), and possible presence of a lung point/transition point. M-mode utilization allows for visualization of lung sliding using a static image (Fig. 1A, B). Further workup with formal chest X-ray is still indicated when appropriately removed from the athletic venue. This can quantify the size of the pneumothorax and evaluate for associated bony injury. If the diagnosis is in question, computerized tomography (CT) scanning of the chest can be used, which is still considered the gold standard.
Tension pneumothorax is a clinical diagnosis that should be made before the attempt at any diagnostic imaging, as the delay in management can prove fatal. This condition leads to a severe increase in intrathoracic pressure that impedes venous return and ultimately decreases cardiac output. The patient usually appears to be in distress, and signs typically involve hypotension, a deviated trachea away from the side of injury, distended neck veins, and decreased or absent breath sounds.
Management of pneumothorax depends on the extent of the ailment and the condition of the patient. For a small, simple pneumothorax with stable vital signs and no distress, observation alone is usually sufficient. Depending upon provider and patient comfort, this can be performed in the inpatient or outpatient setting. Serial imaging will confirm the resolution and return to play timeline. Air travel should be avoided when pneumothorax is suspected or confirmed. Though no strict guidelines exist for timeline on resuming air travel after resolution of pneumothorax, it is felt that flying should be avoided for at least the first 2 wk after confirmed resolution (15).
With more notable pneumothoracies, tube thoracostomy is often performed to aid in resolution and healing. For tension pneumothorax, immediate needle decompression is critical. Though it is anxiety-inducing, this procedure should be within the scope of all sports medicine practitioners who provide care on the sidelines. Using a large bore catheter, the second intercostal space in the midclavicular line on the side of injury should be punctured. Typically a large release of air is appreciated when the pleural space is entered. The needle should then be removed and the catheter secured in place while transport for definitive care is arranged.
Pericardial Effusion, Cardiac Tamponade
A pericardial effusion occurs when there is an increased accumulation of fluid in the pericardial sac surrounding the heart. There are numerous causes of pericardial effusions occurring under conditions that are infectious, inflammatory (e.g., rheumatoid arthritis, Sjogren syndrome, systemic lupus erythematosus), neoplastic, cardiac, idiopathic, or traumatic. Under normal physiologic conditions, the pericardial sac contains 15 to 50 milliliters of serous fluid (16). Cardiac tamponade occurs when fluid accumulation reaches a point at which ventricular filling is reduced and hemodynamic compromise is observed. In the acute setting with pericardial effusion occurring due to trauma, cardiac tamponade can be seen with as little as 200 to 300 ml of fluid accumulated in the pericardial space (17). Any athlete sustaining chest trauma could potentially develop a pericardial effusion/cardiac tamponade. However, given the wide variety of other causes, athletes with any of the underlying medical conditions known to be a risk factor could develop a pericardial effusion/cardiac tamponade spontaneously.
The diagnosis of pericardial effusion should be based on clinic presentation and diagnostic imaging. Some patients with pericardial effusion may be asymptomatic, but those with symptoms may report chest pain and dyspnea that worsen when lying flat and improve while in an upright position. On physical exam, the athlete may have findings described as Beck's Triad, which includes hypotension, jugular venous distention, and muffled heart sounds. Beck's Triad is seen in a minority of individuals with pericardial effusion/cardiac tamponade, but more commonly in the setting of acute chest trauma (18). Electrocardiogram findings may include electrical alternans, which describes consecutive, normally conducted QRS complexes alternating in height. Chest X-ray findings may include the heart appearing boot- or water bottle-shaped.
Pericardial effusions can certainly be seen on a CT/MRI, but echocardiography is the diagnostic modality of choice (16). Echocardiography can dynamically assess the pericardial effusion, providing the size of the effusion and evaluation of abnormal filling patterns suggestive of cardiac tamponade. A pericardial effusion appears as an anechoic fluid collection within the pericardial sac surrounding the heart (Fig. 2). On dynamic ultrasound, cardiac tamponade appears as pathologic collapse of the right ventricle during diastole. Certainly with ultrasound becoming an increasingly common practice in sports medicine, the ability to quickly assess the pericardial space with bedside ultrasound could be a valuable diagnostic tool when suspicion for pericardial effusion/cardiac tamponade is high.
The treatment of pericardial effusions ranges from observation to emergent intervention and is dependent on the clinical status of the patient, underlying etiology, and expected clinical course. Small effusions, if not causing symptoms, can often be observed. If signs of cardiac tamponade are present, emergent treatment with drainage is needed. These techniques include needle pericardiocentesis, percutaneous ballon pericardiotomy, video-assisted thoracoscopic surgery (VATS) approach, surgical pericardial window, and emergent thoracotomy (19). Though needle pericardiocentesis would rarely be required in the acute athletic setting, one should be aware of this procedure, as it could prove to be lifesaving.
Though it is initiated by trauma, this condition does not involve any traumatic structural damage, but instead relates to an initiation of abnormal function of the heart. Commotio cordis occurs after acute direct trauma to the precordium. It is thought that the likely precipitating factor is impact during an extremely narrow segment of the T-wave upstroke portion of the cardiac cycles, which initiates arryhthmogenic changes, leading to ventricular fibrillation (20). Diagnosis relates to the recognition of typical signs of arrhythmia leading to cardiac arrest after an appropriate traumatic event. The specifics of the traumatic impact can vary quite widely, but most frequently involves direct anterior chest wall impact from a firm, small ball (such as baseball or lacrosse ball) in a child or adolescent (21). Treatment should follow usual ACLS guidelines and sideline management of cardiac arrest. Use of early defibrillation in this condition has been shown to be the most critical component of treatment. Though survival rate has been improving over recent years, it is still extremely low overall at 15% and drops to 3% if initial attempt at resuscitation is delayed beyond 3 min (22).
Flail chest occurs when there is an unstable portion of the chest wall secondary to multiple rib fractures. This condition requires segmental rib fractures—at least two locations of the same rib—of at least three consecutive ribs. This condition is unlikely to be encountered in sport-related injury, but it should be present among the differential diagnoses of chest trauma.
Flail chest is characterized by paradoxical breathing wherein the flail segment of the chest falls during the expected chest expansion of inhalation and rises during the anticipated depression of exhalation. Management requires aggressive pain control to allow for full expansion of the lungs and can require mechanical ventilation. There has been some increasing interest regarding surgical fixation of rib fracture to allow for earlier recovery (23,24).
The overall rate of sternoclavicular dislocation is low. Historical studies reported the condition to be involved in less than 5% of all shoulder girdle injuries, though some authors feel this may have underreported the condition (25,26). Anterior instability is much more common than its posterior counterpart, but posterior dislocation carries the risk of increased injury to associated mediastinal structures (27). Injury usually occurs with indirect contact after lateral compression to the shoulder. Direction of the instability will be related to the point of impact and the position of the shoulder at the time of impact. Direct injury can occur after impact being placed to the medial clavicle, usually resulting in a posterior dislocation (28).
Diagnosis can be suspected by clinical palpation of the area, though subtle depression of posterior dislocation can be difficult to discern. Plain film radiography lacks adequate sensitivity due to the overlapping anatomic structures seen on imaging, including medial clavicle, ribs, sternum, and vertebrae. Serendipity view, with the X-ray beam directed 40 degrees cranially, can enhance visualization of isolated sternoclavicular dislocation. Definitive confirmation often requires CT and this allows for assessment of associated injuries.
Early management consists of primary identification and transfer for definitive care in severe cases. Anterior dislocations can be managed conservatively, but typically warrant an attempt at reduction. Ideally, these should be reduced within 24 h and can often be achieved by closed reduction (29). Closed reduction of posterior dislocations should not be routinely considered, and current recommendations direct toward open reduction (26). This often uses an orthopedist comfortable in the management of the injury, with on-site availability of trauma and/or thoracic surgery. In the rare event of posterior dislocation with severe hemodynamic or airway compromise, emergent reduction can be considered. Several techniques have been described. One potential technique involves placing a bolster between the shoulder blades of the supine patient, with subsequent posteriorly directed pressure applied to the shoulder in order to lever the clavicle on the first rib. Alternatively from this position, traction can be pulled on the arm while moving it into abduction and extension. Manual traction on the medial clavicle with the provider’s fingers or a sterile towel clip also can be used (26,28).
Blunt aortic injury is an often fatal condition that is seen in the setting of severe chest trauma. For those individuals suffering blunt aortic injury, as many as 80% will die before arrival in the hospital (30). The majority of blunt aortic injuries occur in the setting of motor vehicle crashes. However, in the sport setting, blunt aortic injury could occur under any circumstance in which sudden deceleration occurs. Various research articles have described aortic injuries sustained from sporting events ranging from rugby to skiing (31,32). This injury occurs when sudden deceleration leads to significant forces being applied to the fixed and mobile portions of the aorta, potentially causing tears.
The diagnosis of blunt aortic injury is based on imaging (30). However, if an athlete suffers severe chest trauma and complains of chest pain and/or if hemodynamic compromise is present, aortic injury should certainly be on the differential diagnosis. Chest X-ray imaging may reveal indistinct mediastinal silhouette and loss of normal contour of the aorta. Although it is easy to complete, chest X-ray has an unacceptable rate of missed injury (30). For many years, aortography was considered the best diagnostic test, but given its requirement for special personnel and the fact that it is highly invasive, it has been replaced by CT as the diagnostic imaging test of choice for blunt aortic injury.
Treatment of blunt aortic injury depends on severity and ranges from medical therapy to operative repair. Medical management revolves around beta-blockers and antihypertensive medications to decrease shear force on the aortic wall. When intervention is deemed to be necessary, surgical options range from a clamp-and-sew to shunt-bypass technique. Over the past 50 yr, there has been a great deal of advancement in endovascular grafting for aortic injury repair. More and more, this mode of treatment is becoming the intervention of choice in the setting of blunt aortic injury (33).
Urgent and Subacute Issues
Chest wall contusion
Overall, contusion is the most common outcome of chest trauma and accounts for nearly 50% of all injuries to the torso (7). Diagnosis is primarily clinical by appropriate history and examination but can require further workup to evaluate for more severe associated conditions. Symptoms and examination findings can easily overlap those seen with rib fracture, pulmonary contusion, and pneumothorax. Once other conditions have been ruled out, treatment includes pain control modalities with ice, analgesics, and anti-inflammatories.
Rib fracture is one of the more common types of chest trauma (34). Though it is not acutely life-threatening by itself, rib fracture can be associated with several of the potentially fatal conditions listed above. Concomitant injuries must be considered, especially with extra vigilance for pneumothorax.
Diagnosis is typically made by chest X-ray and/or rib series X-ray, which can be supported by physical exam with focal rib tenderness, bony crepitus, or mobile rib segments. Ultrasound also can be used for diagnosis. A fracture appears as a cortical irregularity of the hyperechoic bony cortex of the rib (Fig. 3). Ultrasound has been found to be accurate and routinely more sensitive than standard radiography (10,11).
Once associated emergency conditions have been ruled out, acute management of rib fracture centers around pain management and pulmonary hygiene to prevent secondary complications. Inadequate initial treatment can lead to self-splinting and resultant atelectasis with the risk of subsequent pneumonia. Pain control often requires the use of narcotics, in addition to acetaminophen and nonsteroidal anti-inflammatories. Additionally, nerve blocks can be employed in the appropriate setting.
Isolated rib fractures in the young, healthy athlete can typically be treated as an outpatient after demonstration of adequate pain control and lack of respiratory distress. Hospital admission is often recommended in the elderly and those with significant comorbid illnesses. Hospitalization can be considered for a patient with 3 or more rib fractures and should be suggested if there are any signs of respiratory compromise. This can be indicated by oxygen saturation less than 92% on room air, failure to achieve incentive spirometry greater than 1000 cc or 15 cc·kg−1, and vital capacity less than 55% of predicted (35).
Pulmonary contusion is a relatively common finding in major blunt trauma such as motor vehicle accidents and severe falls, but reports have indicated that it can also occur in collegiate football players (36,37). Additionally, there have been case reports occurring in divers after direct chest wall impact to water (38).
Presenting signs and symptoms of the condition are vague and nonspecific. Patients usually complain of shortness of breath and chest pain. Physical exam can include tachypnea, wheezing, decreased breath sounds, or crackles, or exam may be completely normal (39). Hemoptysis may be present. Any of the signs and symptoms may develop immediately or can present in a delayed fashion.
Chest X-ray is typically normal immediately after injury, but appearance of infiltrates will often develop later, anywhere from 4 to 48 h after injury. CT scan is considered the gold standard for evaluation and will demonstrate pathologic changes immediately (40). Management consists of supportive care with analgesia and pulmonary hygiene. Hypoxia is treated with supplemental oxygen, and close vigilance must be maintained, as the condition can rarely evolve into Adult Respiratory Distress Syndrome (ARDS), which often requires mechanical ventilation.
Cardiac contusion is a relatively rare result of blunt chest impact in sports. It is more commonly seen in high-velocity trauma, such as in a motor vehicle accident, but it has been reported in various sporting activities, including professional soccer (41). In sports, this injury is most commonly caused by direct injury to the precordium.
Though the mechanism is similar to that of commotio cordis, this injury, in contrast, does lead to structural changes in the heart. These changes vary on a spectrum of severity but demonstrate indicators of myocardial damage. Symptoms can be mild and may consist of only vague chest pain and palpitations.
Initial evaluation includes electrocardiography and echocardiography, though these can be normal, and demonstrate only nonspecific findings when abnormal. Labs will demonstrate elevation in cardiac enzymes, and magnetic resonance imaging (MRI) is likely useful in confirming diagnosis. Expectant management is usually uneventful, though complications of arrhythmia and heart failure can be seen and must be monitored for (42).
Overall, chest injuries in sports are relatively rare, and the majority of injuries that do occur are largely benign and self-limiting. Thoracic injuries, however, have many similar overlapping signs and symptoms, and several conditions can often occur concomitantly. Additionally, the more significant injuries can have dire complications, especially if diagnosis is missed or delayed. Sports medicine providers must be aware of the conditions on the severe end of the spectrum that often necessitate further evaluation. As sports medicine providers become more comfortable with the use of field-side ultrasound, expanding its use beyond musculoskeletal pathology toward the ability to assess potential traumatic chest injuries could be extremely valuable. When the severe injuries do occur, providers must be comfortable in trauma protocol and aware of lifesaving procedures that may need to be performed.
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