Injuries to the thorax and abdomen

Injuries to the thorax and abdomen Presented by coach derr

introduction • This chapter begins with a gross anatomy of the throax and abdomen. • It discusses the internal organs that can be injured through sports participation. • The internal organs and structures covered include the heart and lungs, liver, kidneys, spleen, stomach, and diaphragm.

Introduction • The chapter also discusses external injuries such as fractures to the ribs, various joint-related problems, and breast injuries and contusions. • Many of these injuries can be debilitating and even life-threatening.

Anatomy review • The thorax and abdominal cavities contain the majority of the vital organs of the body. • This area is enclosed by the spinal column, rib cage, and the clavicle , which provide bony protection for the area.

Anatomy review • The vertebrae in this area include the 12 thoracic vertebrae and the 5 lumbar vertebrae located posterior to the abdomen. • There are 12 pairs of ribs in both males and females. • The first 7 pairs of ribs are connected to the spinal column posteriorly and the sternum anteriorly.

Anatomy review • The anterior connection of the true ribs is made via a costal cartilage for each rib. • The remaining ribs, specifically ribs 8 through 10, connect via a common costal cartilage. • Ribs 11 and 12 do not connect to the sternum anteriorly; thus, they are called floating ribs. • The 8th to 12th pairs are sometimes referred to as false ribs.

Anatomy review • All of the joints between the ribs and the spinal column are reinforced with strong ligamentous support. • The area is further strengthened by the anterior longitudinal ligament, which runs on the anterior surface of the spinal column from the occipital bone of the skull to the pelvic surface of the sacrum.

Anatomy review • The main joints of the thorax include the intervertebral joints, the vertebral and rib joints, the sternocostal and costochondral joints, and the sternoclavicular joints. • The intervertebral joints are those between each of the vertebral bodies. • These joints are stabilized by ligaments and the intervertebral disks located between each vertebral body.

Anatomy review • The intervertebral disks are mostly fibrocartilaginous and play an important role in the weight-bearing ability of the spine. • The ribs articulate with the vertebrae in an interesting manner. • Each rib articulates with two adjacent vertebrae and the intervertebral disk. • These joints are strengthened by the ligaments that allow the gliding movements of the ribs at the vertebral column • Anteriorly, the first though the seventh ribs articulate wit the sternum directly from their costal cartilage. • Ribs 8 through 10 articulate with the sternum through a common cartilage. • These joints are known as the strenocostal joints. • The point at which the rib attaches to the costal cartilage is known as the costochondral joint. • Typically there is no movement at this joint.

Anatomy review • One of the main joints of the thorax is the sternoclavicular joint. • Articulation between the clavicle and the sternum • The only body articulation between the thorax and the arm, and it is supported by strong ligaments.

Anatomy review • Several muscles surround the thorax and abdomen. • the main thoracic muscles include the intercostal muscles, both internal and external, which function primarily to lift the rib cage and assist with breathing.

Anatomy review • More superficially, the pectoralis major and minor are located in the upper chest area and mainly control arm movement.

In the posterior thorax several muscles running the length of the spinal column are responsible for a variety of movements as well as stabilization of the spine. • Most of the deep muscles running the length of the back, including the spinalis, longissimus, iliocostals, and others are responsible for keeping the spine erect.

Anatomy review • More superficially, muscles such as the latissimus dorsi, rhomboids, trapezius, and deltoid are mainly responsible for movements of the upper extremity.

Anatomy review • In the abdominal region there are also several IMPORTANT MUSCLES. • THE MAIN MUSCLES OF THE ANTERIOR ABDOMINAL REGION ARE THE EXTERNAL AND INTERNAL OBLIQUES AND THE RECTUS ABDOMINIS. • THE OBLIQUE MUSCLES HELP TO FLEX AND ROTATE THE TRUNK. • THE RECTURS ABDOMINIS IS THE MAIN MUSCLE OF THE ANTERIOR ABDOMINAL WALL. • FLEXES THE TRUNK

Internal organs • Two main organs in the thorax are the lungs and heart • Each lung is encased in separate and closed space called the pleural sac • Helps to make respiration a smooth process • Oxygenate blood as it circulates • Normally light, soft, spongy, and pinkish in a healthy person • Right lung has three lobes; the left has two • Right is a little larger and heavier

Internal organs • Located directly between the two lungs is the heart • Heart is situated in an area called the mediastinum • Houses major blood vessels and parts of the respiratory and digestive systems • Trachea and esophagus • Also houses nerve and lymphatic tissues

Internal Organs • Inferior to the pleural cavities and the mediastinum is a muscle called the diaphragm. • Separates the thoracic and abdominal cavities • Main muscle of respiration • It is a circular muscle with a tendon In the middle which allows the muscle to contract and assist with breathing.

Internal organs • The abdominal region is divided into 4 quadrants: • Right upper quadrant • Right lower quadrant • Left upper quadrant • Left lower quadrant • Umbilicus serves as the center point.

Internal organs • Right upper quadrant • Liver, gallbladder, and right kidney • Right lower quadrant • Ascending colon • Appendix • Left upper quadrant • Stomach, spleen, pancreas, and left kidney • Left lower quadrant • Descending colon

Exercise… • With your note card, make four quadrants and fill in the organs for each. • This will be a study guide for you as we continue the power point.

Common sports injuries • Are relatively uncommon in children and adolescents. • If injuries do happen some require immediate attention to prevent long-term disability and possibly even death. • We will first focus on external injuries involving the skeletal, muscular, and other external components of the region.

External injuries…Fractures • Fractures can occur as a result of direct trauma • May fracture a rib, the sternum, clavicle, or another part of the vertebra. • If a fracture occurs it should be treated immediately • w/o proper care, complications can occur • May develop pneumothorax or hemothorax

External injuries..fractures • A pneumothorax is the presence of air in the pleural cavity. • A hemothorax is the presence of blood in the pleural cavity. • With a sternalfx, two complications may arise. • Manubrium if dislocated and moves posteriorly, could lead to an airway obstruction. • If the sternum and ribs are separated completely, a fail chest (loss of stability to the thoracic cage) can occur. • Can lead to pneumothorax or hemothorax

External injuries..fractures • A more common fracture in sports is to the ribs. • Most often, ribs are fractured in contact sports when two players collide and the rib cage is violently compressed. • The 5th through the 9th pairs of ribs are generally more susceptible to fracture. • The bones can be broken in varying degrees of severity, from greenstick to displaced fx.

External injuries..fractures • S&S: • Extreme localized pn at the site of injury that is aggravated by sneezing, coughing, forced inhalation, or sometimes movement. • May grasp the chest wall at the point of injury. • Mild swelling, there may be bony deformity. • May c/o breathing difficulties and take rapid, shallow breaths. • TX: • Monitor the athlete’s vital signs and watch for any respiratory distress. • Arrange for transport to a health care facility.

External Injuries..Fractures • May also experience subluxations and dislocations. • Mainly you will see costochondral separations, which involve some type of disunion of the sternum and ribs. • In a costochondral separation, the cartilage portion of the costosternal union is either separated from the sternum medially or from the rib laterally. • Typically , the athletes with a costochondral separation experiences a great deal of pain at the time of the injury and in many cases will c/o pain for weeks after the injury.

Costochondral separation • S&S: • Report a pop or a snap occurred • Palpable defect may be felt because deformity • Swelling in the area • Maximum or near maximum inhalation may be very difficult • Experiences localized pn and tenderness over the area • TX: • Immediately apply ice and light compression • Treat for shock if necessary • Arrange for transport to a medical facility

Internal injuries… • Many organs and structures can be injured from direct trauma in collision and contact sports. • If is not always easy to determine • Therefore, the coach or athletic trainer must be educated and knowledgeable about the signs and symptoms of possibly injury to an internal organ

Heart injuries… • Although considered a rare occurrence, sudden death among athletes has become a more publicized event in recent years. • Many times, sudden death in athletes is a result of a cardiac problem. • In a report from the U.s. national registry of sudden death in athletes (Minneapolis heart institute foundation) from 1980 – 2006, there were 1866 reported sudden death events in athletes.

Heart injuries… • Any time the heart is compressed between the sternum and the spinal column by a violent external force, such as might be caused by being hit by a baseball, lacrosse ball, or hockey puck, a cardiac contusion or other thoracic injuries can result. • When an athlete is hit In the chest and the impact is timed exactly with the repolarization phase of the contracting heart, it is possible for the athlete to experience ventricular fibrillation leading to death. • This injury is known as commotiocordis and appears to be more prevalent in male youth playing lacrosse, hockey, football, basketball and other sports .

Heart injuries… • Additionally, a blunt trauma to the chest may also cause aortic rupture, injure the pericardium or coronary arteries, or cause valvular damage. • Aortic injury is often fatal and must be given immediate attention if suspected. • A majority of people who suffer from aortic injury die before emergency care is instituted. • Watch any athlete with a chest injury for breathing problems, fainting, decreases in heart rate and blood pressure, and c/o severe chest pains.

Heart injuries… • Hypertrophic cardiomyopathy (HCM) is a genetic disorder most often discovered after the death of an athlete. • Ex) in glory road • HCM is generally described as an excessive thickening of the left ventricle wall, resulting in a ventricle that is less efficient in pumping the necessary volume of blood

Heart injuries… • the prevention of injuries to the heart, lungs, and chest is primarily a function of protective equipment as part of the sport or activity. • In baseball and softball, the catcher is equipped with a chest protector. • In football, hockey, lacrosse, and some other contact sports, part of the uniform is protective equipment designed to reduce possible impact to the heart and chest area. • ATC’s and other likely early care providers must be current in their CPR training and prepared with either an AED or an EAP that would provide immediate care for a player experiencing signs and symptoms of sudden cardiac arrest.

Lung injuries… • An athlete may experience a pulmonary contusion. • Can be a complication of a rib fx, contusion, or some other type of pulmonary injury and can go undetected. • Pulmonary contusion has been reported in up to 70% of people experiencing blunt chest trauma. • Ribs can puncture and fracture the pleural sac that surrounds the lung(s). • If air gets into the pleural cavity, there is a possibility of a lung collapse (pneumothorax).

Lung injuries… • Pneumothorax is the presence of air or a gas in the pleural cavity (space between the lungs and chest wall), which may cause a partial or complete collapse of the lung. • With air in the cavity, it inhibits the lung’s ability to expand for normal breathing to occur.

Lung Injuries… • There is also the possibility of spontaneous pneumothorax among athletes. • Occurs without a preceding traumatic event. • This injury is significant and must be attended to by a physician. • The progress of the athlete should be monitored over a period of days by the athlete’s health care provider because some injuries have a tendency to exhibit complications later.

Lung Injuries… S&S TX: • c/o severe pn in the chest area, sometimes radiating to the thoracic spine. • Experience breathing problems-either SOB or painful breathing exhibited by short, shallow breaths. • Loss of chest wall movement during breathing. • Nonproductive cough and may have a tachycardia heart rate. • Treat the athlete for possible shock • Monitor vital signs continuously • Arrange for transport to a medical facility

Liver Injuries… • Aids in the production of plasma proteins and the detoxification of alcohol and other substances. • Has digestive functions. • It is located in the upper right quadrant of the abdomen and can be susceptible to blunt trauma in collision sports such as football. • May be implicated if a rib fx occurs in the upper right abdominal quadrant. • The liver is fairly safe from injury associated with sports participation

Kidney injuries.. • Serve to maintain the proper levels of waste, gas, salt, water, and other chemicals in the bloodstream. • Located posteriorly and somewhat inferiorly on each side of the abdomen. • Are susceptible to injury from blunt trauma or heat (via extreme exercise in the heat). • Can experience acute renal failure, and the kidneys will cease to function.

Kidney injuries… • An athlete who has hematuria (blood in the urine) after being hit by an opponent in the lower back or after having experienced strenuously in the heat should be seen by a physician. • Both of these scenarios can lead to kidney problems or damage. • Many times, an athlete’s exercise regimen must be modified until the urine is once again clear of any blood.

Spleen injuries… • The main function of the spleen is to maintain a reserve of ready-to-use blood cells for the body. • It is located in the upper left quadrant of the abdomen and is somewhat protected by the ribs on the lower left side. • The spleen is susceptible to injury from both blunt trauma and internal disorders. • An athlete who gets hit hard In the abdomen over the spleen can suffer a lacerated spleen.

Spleen injuries… • Nevertheless, the spleen has the capacity to splint or patch itself at the site of the injury because of its reservoir of red blood cells. • If the spleen does patch itself completely and the athlete is allowed to continue participating, there remains the possibility that the patch may be disrupted by even a small amount of trauma. • This can allow internal bleeding to resume, and death can occur even as long as days afterward. • If an athlete is hit hard in the upper left quadrant and later c/o pain in the abdomen and/or left shoulder and upper third of the left arm this is known as kehr’s sign.

Spleen injuries… • Additionally, if the athlete is suffering from mononucleosis, the spleen will probably be enlarged and susceptible to injury not only from blunt trauma but from excessive movement during sports participation.

Bladder injuries… • The bladder acts as a reservoir for the urine produced by the kidneys. • It is located under the midline of the abdominal quadrants; this is a well protected area, and the bladder is rarely injured by participation in sports and athletics. • If the athlete receives a direct blow to the area of the bladder and injury does occur, the signs are pn in the localized area and possibly blood in the urine. • Avoiding injury to the bladder is best accomplished by emptying it before practice or competition.

Abdominal pain… • Various types of abdominal pn occur in athletes before, during, and after competition. • If an athlete is experiencing chronic pn in the same location, the athlete should see a physician as soon as possible. • Another reason for abdominal pn is referred pn, as noted with the spleen. • Stomach problems such as dodenal ulcer are typically localized to the stomach area but have been known to produce lower back pn complaints. • Similarly, low back pn can be referred to other regions of the pelvic area from problems in the low back or iliac crest regions.

Abdominal pain… • Exercise-related transient abdominal pain (ETAP) is a problem commonly called, “side ache” or “stich in the side” by athletes. • This problem typically occurs during running early in an exercise regimen of an unconditioned athlete. • The actual cause of this problem as not been exactly determined, but different hypotheses have been put forth to try to explain why this problem might occur in athletes. • Some possible explanations are ischemia in the diaphragm, stress on the visceral connective tissues, or a cramping of the local musculature.

Abdominal pain… • Preexisting conditions of the chest that may disqualify an athlete from participation can include but are not limited to problems such as HCM (abnormal left ventricle growth), heart murmurs and arrhythmias, significantly decreased lung function from disease or a disorder such as cystic fibrosis, or chronic obstructive pulmonary disease. • Disqualifying from sports participation based on these conditions is dependent on the type of sport being considered, the amount of stress the activity will place on the dependent structures or systems, and the ability to control potential problems during the activity.

Conclusion… • Athletes with what might be considered a severe cardiac or respiratory disorder may be able to participate in specific activities depending on the control of their disorder, the type of activity, and the willingness of the physician to help the athlete make the necessary adjustments for participation at some level.

Injuries to the thorax and abdomen