Non-Orthopedic Injuries of the Torso…Dial 911!
Non-Orthopedic Injuries of the Torso…Dial 911!
JEFFREY H BOHMER, MD, FACEP EMERGENCY DEPARTMENT, NORTHWESTERN CENTRAL DUPAGE HOSPITAL My background
Worked in community ED for 15 years
I have seen many non-orthopedic, non-head injured patients in my career and my vantage is skewed given the select population I see
Although relatively rare, blunt injuries Introduction to the torso can be catastrophic
Early identification/suspicion of these injuries is key!
Take home message: Have a low threshold for ER referrals with these athletes Disclosures
I DO NOT have a financial/arrangement or affiliation with one or more organizations that may be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Trauma to the torso (chest, abdomen and Introduction pelvis) far less common than orthopedic injuries and head trauma The nature of blunt sports-related injuries can make them difficult to assess The relative rarity of such injuries and the often occult nature of them can make them difficult to suspect in an athlete These injuries can be life threatening and delay of diagnosis can be catastrophic Goals of this is review
1. Understand what injuries can occur to torso
Based on mechanism
Based on athlete complaint
2. Be able to decide whom needs Introduction immediate referral and what setting 3. Understand the emergent diagnostic workup and treatment of injuries
4. Be aware of complaints/pathology athletes may have that mimic injuries Chest Injuries
Case:
22 y/o previously healthy man presents via EMS for chest injury and difficulty breathing
Medics report patient was playing in a soccer match and took a knee to his right chest.
Patient nearly lost consciousness, but was awake upon EMS arrival
Vital signs normal except for respiratory rate of 28 and pulse ox of 91%
Lung and chest examination reveal diminished breath sounds on right, crepitus diffusely on the lateral chest wall, and looked something like this… Chest Injuries Chest Injuries
Flail chest is a high-energy, relatively narrow, blunt injury to chest causing a segment of multiple rib fractures.
The segment of fractured ribs moves in and out paradoxically from the rest of the chest.
Almost always associated with a collapsed lung (pneumothorax)
Treatment is chest tube thoracostomy Case:
Eleven y/o male playing shortstop and line drive is hit at him, he misjudges the ball and hit hits him square in the middle of chest
He becomes unresponsive immediately, and bystanders realize shortly he is not breathing, call 911 Chest Injuries and initiate CPR
Brought to ED in cardiac arrest, found to have an abnormal heart rhythm (ventricular fibrillation) and is defibrillated to a sinus rhythm
He is hospitalized in critical condition but recovers and walks out of the hospital 4 days later Chest Injuries
Commotio cordis and cardiac contusions are relatively unusual chest injuries.
Commotio cordis is theorized to occur due to blunt injury to the anterior heart at the exact moment of ventricular repolarization (T wave on the EKG), causing electrical havoc on the heart
Only treatment for this condition is defibrillation
Cardiac contusion (bruised heart) usually associated with significant sternal and/or left parasternal chest wall injury. Rib fractures
Blunt, relatively high-energy impact to chest wall
Athlete will localize pain, have difficulty with deep breaths, will often “splint” with breathing. Position change (sitting to standing especially) is difficult.
May feel crepitus at the site, or even a step-off of the fractured rib. Bruising usually takes several minutes to hours to show.
If rib fracture is suspected, x-rays are indicated. Patient should be seen by healthcare provider in next 24 hours as long as there is:
No suspicion of a collapsed lung Chest injuries Pain is relatively controlled at rest. No signs or respiratory distress/difficulty breathing
X-rays can identify displaced fractures but can miss non-displaced fractures 50% of the time
Whether or not a fracture is identified, athlete can return once pain-free with breathing/moving. Generally at least 3 weeks with a fracture identified. Chest wall contusions:
Often a diagnosis of exclusion
Blunt injury to the chest wall resulting in soft tissue and/or bony injury to the ribs/intercostal musculature, etc.
If rib fracture is not seen on x-ray, typically give this diagnosis, explaining Chest Injuries that a “hairline fracture” may not be visible
Guidelines are the same…athlete must be without pain with movement and breathing. Generally much quicker recovery Chest Injuries
Pneumothorax and Hemothorax: High energy impact to the thorax resulting in a collapse of the lung causing air to leak between lung and chest wall (pneumo) or bleeding between the lung and chest wall (hemo) Chest Injuries
Most infamous hemothorax in sports history occurred in September 2001
Drew Bledsoe took a hit in second game of season from Jets’ Mo Lewis.
Went to sidelines, starting feeling faint.
Athletic trainers thought he had suffered a concussion which made injury difficult to assess
He was in hemorrhagic shock by time he arrived at ED
Bledsoe was replaced by… The G.O.A.T. Chest Injuries
Treatment for Pneumo/hemothorax:
Generally chest tube placement (chest tube thoracostomy) is the definitive treatment
Tube is connected to a pleurevac which is connected to wall suction
Rarely patients require surgery. Indications for surgery include:
Massive hemorrhage (like Bledsoe)
Air leaks that do not improve with chest tube As in case of Bledsoe, Hemo and Pneumothorax can there may be a pneumothoracies can be spontaneous and concomitant injury be occult, especially tends to occur in thin, such as a concussion immediately after tall males that may delay diagnosis Chest Be suspicious for PTX if: •Mechanism is direct and Returning to a sport is Injuries high velocity highly variable and •Diminished lung sounds, dependent on size of chest wall crepitus, PTX and treatment, decreased chest rise but probably •Significant pain with anywhere from 2 respirations that often weeks (small, no radiate or are referred hospitalization) to 10 elsewhere from the point weeks (larger, of impact (often requiring chest tube shoulder or upper back) and hospitalization Abdominal Injuries
Abdominal injuries easier to classify by quadrant of injury or pain
Serious injuries are rare but are life threatening
Typically blunt injury to the abdomen is relatively well tolerated due to many layers of protection as well as the bony thorax that covers most of the liver and spleen
Liver and spleen are most vulnerable due to size and vascularity Abdominal Injuries
Case: 17 y/o male is tackled and takes a helmet to his exposed abdomen.
He experiences a brief syncopal episode and there was no sign of a head injury on the play
He complains of pain in his upper abdomen, and pain worsens with inspirations
He also notes his left shoulder seems to hurt but he did not have any apparent injury to it on the play
He is assessed on the field and has significant tenderness in his LUQ
Medics called, vital signs: b/p 90/50, HR 115 bpm. They start 2 IVs and transfer him to ED Abominal Injuries
Case (cont)
Upon arrival, a bedside ultrasound is performed
Trauma surgeon is notified and a CT is recommended which confirms splenic laceration Abdominal Injuries
Splenic injuries Most common major blunt injury of the abomen Result from blunt injury to the LUQ or left flank Patient will often localize pain in LUQ, often have pain with breathing and sometimes have referred pain the the left shoulder Can be low or high grade injuries Low grade injuries can be treated conservatively with close monitoring in the hospital Middle and Mid-high grade injuries may require treatment, often embolization is successful If bleeding is brisk (patient is in florid hemorrhagic shock), and/or patient has a high grade injury, surgical treatment is necessary (splenectomy) Abdominal Injuries
Liver injuries
Result from blunt force to the RUQ, R flank and/or right lower anterior chest
Patients will complain of pain in RUQ, may have respirophasic pain and referred pain to right shoulder
Although much larger than the spleen, tends not to cause catastrophic injury as often, likely due to its location (protected by ribs) and it is well encapsulated
Liver injuries can be low and high grade as well
These injuries rarely require intervention (embolization, almost never surgery), and tend to do well with conservative management Abdominal Injuries
Case: 21 y/o male football player presents with severe pain to his L flank after taking a hit from tackler
Pain is worse with breathing, and moving. Feels nauseated, no vomiting
On exam, he looks distressed from pain and has focal tenderness at his L costovertebral angle and just lateral to midline
His urine looks like… Abdominal Injuries
Renal injuries:
Much less common cause of major blunt abdominal trauma
Rarely severe enough to warrant surgery
Often result from direct blow to the flank region (very close anatomically to the spleen)
Patients are typically hospitalized for monitoring for blood loss as well as the hematuria Abdominal Injuries
Return to play: Liver injuries: Spleen injuries: Typically much longer recovery than splenic.
Highly variable on severity and clinical Typically, CT scans show resolution of injury in judgement 3-6 months Mild injury (one night stay in hospital, no significant blood loss, no intervention): 2 weeks CT follow up not the standard of care complete activity restriction, no restrictions by 6 anymore, but is suggested for some athletes weeks before at-risk activity is initiated again
Moderate/moderate-severe injury: If no Renal Injuries: splenectomy, probably 8-10 weeks until full return. Similar to liver injuries time-wise If athlete elects to have splenectomy, can Athlete should be asymptomatic and have return to sport in 3-4 weeks in some cases no blood in urine Athlete should be completely asymptomatic before returning. Decision is a case-by-case decision Abdominal Injuries
The mechanism of injury should increase suspicion for these injuries
Again, beware of concomitant head injury/concussion
Localization of pain, point tenderness, abdominal rigidity, pain with breathing, pain with movement referred pain increase suspicion Abdominal Injury Mimics Important to be aware of abdominal pains athletes may complain about that may not be injuries but signs of medical disease
Discuss by again dividing the abdomen into quadrants:
RUQ: Hapatobiliary
LUQ: Pancreas, gastric, renal
RLQ: Appendix, gynecological, testicular
LLQ: Gynecological, testicular, colonic Abdominal Mimics
Right Upper Quadrant:
Most common will be gallbladder disease
Classically, colicky, postprandial pain after heavier meal
Pain radiates to back (R subscapular)
Often with nausea/vomiting
If gallbladder becomes inflamed, pain more constant, and pain reproduced with palpation of RUQ and with deep breaths (Murphy’s sign) Abdominal Mimics
Left Upper Quadrant In Emergency Medicine, probably the quadrant least worried about Less likely in younger age group to have serious medical illness causing significant pain
Consider kidney infection (pyelonephritis)
Typically aching pain, often more in the back/flank with tenderness in CVA and/or LUQ
Usually febrile and nauseated, may have had urinary symptoms
Much more common in females
Kidney stones: Acute, severe, colicky pain usually in flank/back with N/V
Gastric issues: Typically will not cause an acute painful condition
Pancreatitis: Very rare in young age group…typically acute gnawing pain in epigastrum/LUQ radiating to back with N/V Abdominal Mimics
Right Lower Quadrant
Appendicitis is biggest concern
Typical history is vague central pain with anorexia that migrates to RLQ, perhaps with a fever, N/V, with focal tenderness and referred tenderness in LLQ (Rovsig sign)
Commonly known to be “the easiest and the hardest diagnosis to make”
Many patients don’t present typically
Biggest red flags with any abdominal pain patients:
Pain worsens with position change or suddent movements (bumps on the road cause pain)
Systemic complaints associated (nausea, fever, chills, anorexia)
“Gut instinct:” Athlete doesn’t appear well, not a “complainer”, etc. Abdominal Injury Mimics
Left Lower Quadrant (and RLQ) Ovarian cysts
If this is causing acute pain, typically due to a torsion (cyst causes the ovary to twist on its stalk and lose blood supply) or rupture
Torsion pain typically will radiate to the flank and the woman will usually have N/V and appear uncomfortable. May or may not have significant tenderness
Cyst rupture typically will not radiate, will likely have significant tenderness and peritoneal signs (pain with movement of the abdominal cavity) Testicular torsion
Young male athletes are prime suspects for this
Often will complain of pain in the L or RLQ because referred pain or they don’t want to tell you where it really hurts
Typically appear very uncomfortable, may be vomiting Emergency Department Evaluation
Before (EMS) or upon arrival, RN will classify as Level I, II, or III trauma based on history and severity
Initial assessment:
ABCDE, primary and secondary surveys
Uniform, consistent approach is key for all trauma victims
Airway, Breathing, Circulation, Disability, Exposure Identify and address initial life threats in this order
Primary and secondary surveys:
Primary is the evaluation of initial potential life threats (ABCD)
U/S (FAST scan) used in this process
ET intubation, tube thoracostomy, pelvic binder, tourniquet placement, thoracotomy
Secondary survey (head to toe exam) is performed after initial life threats are identified and treated
Looking for fractures, skin changes, neurological deficits, etc
Imaging (x-ray, CT) done once surveys are completed and patient is stabilized Conclusion
Be aware of the variable severity of injuries of the chest and abdomen Have a low threshold for sending these athletes in for an ER evaluation (or urgent care evaluation if not concerned about life threat) Red flags for chest injury: Shortness of breath, severe pain with breathing, diminished breath sounds, palpable crepitus or step-off, deformity (flail chest), or just mechanism Red flags for abdominal injury: Shocky, syncope, pain with position change, peritonitis, pain with breathing, significant tenderness Abdominal Mimics: Be aware of medical disease in these athletes that may cause abdominal pain, and have low threshold to refer these athletes for immediate evaluation