Chapter 21: The Thorax and Abdomen

Chapter 21: The Thorax and Abdomen

Preventing Injuries to the Thorax and Abdomen • Utilize appropriate protective equipment • Imperative in collision sports • Abdominal musculature strengthening to protect underlying viscera • Be sure hollow organs are empty prior to competition • Reduces chance of injury to them

Assessment of the Thorax Abdomen • Injuries to this region can produce life-threatening situations • ATC’s evaluation should focus on signs and symptoms that indicate potentially life-threatening conditions • Continually monitor breathing, circulation and any indication of internal bleeding or shock

History • What happened to cause this injury? • Was there direct contact or a direct blow? • What position were you in? • What type of pain, was it immediate or gradual, location(s)? • Difficulty breathing? • What positions are most comfortable? • Do you feel faint, light-headed or nauseous? • Chest pain?

Hear or feel snap, crack or pop in your chest? • Muscle spasms? • Blood or pain during urination? • Was the bladder full or empty? • How long has it been since you last ate? • Is there a personal or family history of any heart, abdominal problems or other diseases involving the abdomen and thorax?

Observations • Is the athlete breathing? Are they having difficulty breathing? Does breathing cause pain? • Is the athlete holding the chest wall? • Is there symmetry of the chest during breathing? • If the athlete’s wind was knocked out, is normal breathing returning? How rapidly? • Body position

Check for areas of discoloration, swelling or deformities • Around umbilicus = intra-abdominal bleed • Flanks = swelling outside the abdomen • Protrusion or swelling in any portion of abdomen (internal bleeding) • Does the thorax appear to be symmetrical? • Are the abdominal muscles tight and guarding? • Is the athlete holding or splinting a particular part? • Monitor vital signs (pulse, respiration, BP) • Rapid weak pulse or drop in BP is an indication of a serious internal injury (involves blood loss)

Palpation • Thorax • Check for symmetry of chest wall movement and search for areas of tenderness • Palpate along ribs and intercostal spaces as well as costochondral junctions – locate points of tenderness • Abdomen • Patient should have arms at side, knees and hips flexed to relax abdomen • Feel for guarding and tenderness, rigidity (internal bleeding) • Be aware of possibility of referred pain

Referred Pain Patterns

Recognition and Management of Specific Injuries • Rib Contusion • Cause of Injury • Blow to the rib cage can bruise ribs, musculature or result in fracture • Signs of Injury • Painful breathing (particularly if muscles are involved) • Point tenderness; pain with rib compression • Care • RICE and NSAID’s • Rest and decrease in activity

Rib Fractures • Cause of Injury • Caused by a direct blow or the result of a violent muscular contraction • Can be caused by violent coughing and sneezing • Signs of Injury • History is critically important • Pain with inspiration, point tenderness and possible deformity with palpation • Care • Refer for X-rays • Support and rest; brace • Generally heals in 3-4 weeks

Costal Cartilage Injury • Cause of Injury • Result of a direct blow to the anterolateral aspect of the rib cage • Signs of Injury • Localized pain in region of costochondral junctions • Pain with movement; difficulty with breathing • Point tenderness and possible deformity • Care • Rest and immobilization • Healing may take 1-2 months

Intercostal Muscle Injuries • Cause of Injury • Muscles are subject to contusions and strains • Occur most often from direct blows or sudden torsion of the trunk • Signs of Injury • Pain occurs on active motions; pain with inspiration and expiration, coughing, sneezing and laughing • Care • Immediate pressure and application of cold for approximately 20 minutes • After hemorrhaging is controlled, immobilize the injury to make the athlete comfortable

Lung Injuries • Cause of Injury • Pneumothorax - • pleural cavity becomes filled with air, negatively pressurizing the cavity, causing a lung to collapse • Tension Pneumothorax • Pleural sac on one side fills with air displacing lung and heart, compressing the opposite lung • Hemothorax • Blood in pleural cavity causes tearing or puncturing of the lungs or pleural tissue • Traumatic Asphyxia • Result of a violent blow or compression of rib cage • Causes cessation of breathing and immediate medical attention

Signs of Injury • Breathing difficulty, shortness of breath, chest pain on side of injury • Coughed up blood, cyanosis, and potentially shock • With collapse of lung medical attention is required immediately • Care • Each of these conditions are medical emergencies and require immediate attention • Transport athlete to hospital immediately

Sudden Death Syndrome in Athletes • Cause of Condition • Hypertrophic cardiomyopathy - thickening of cardiac muscle w/ no increase in chamber size • Anomalous origin of coronary arteries • Marfan’s syndrome- abnormality in connective tissue results in weakening of aorta and cardiac vessels • Series of additional cardiac causes • Non-cardiac causes include drugs and alcohol, intracranial bleeding, obstructive respiratory disease • Signs of Condition • Most do not exhibit any signs prior to death • May exhibit chest pain, heart palpitations, syncope, nausea, profuse sweating, shortness of breath, malaise and/or fever

Care • Immediate medical attention is necessary – life threatening condition • Prevention • Counseling and screening are critical in early identification and prevention of sudden death • Screening questions should address the following • History of heart murmurs • Chest pain during activity • Periods of fainting during exercise • Family history • Thickening of heart or history of Marfan’s syndrome • Cardiac screening - electrocardiograms and echocardiograms may be needed to determine existing pathology

Breast Problems • Cause of Injury • Constant uncontrolled movement (particularly in large breasted women) • Stretching of Cooper’s ligament • Runner’s and cyclist’s nipple • Management • Females should wear well-designed bra that has minimum elasticity and allows for little movement • Special plastic cup-type brassieres may be required in sports with high levels of physical contact • Use of an adhesive bandage can be used to prevent runner’s nipple • Wearing a windbreaker can prevent cyclist nipple

Injuries to the Abdominal Wall • Abdominal Muscle Strain • Cause of Injury • Result of sudden twisting or reaching of trunk, tearing abdominal musculature • Contusions of Abdominal Wall • Cause of Injury • Caused by a compressive force - generally occurring in collision sports • Extent of injury depends on whether force is blunt or penetrating

Signs of Injury • May cause a hematoma to develop under fascia of surrounding muscle tissue • Swelling may cause pain and tightness w/in the region • Care • Cold pack and compression • Be sure to check for signs of internal injuries • Conservative management • Exercise should be kept pain free

Hernia (sports hernia) • Cause of Injury • Protrusion of abdominal viscera through portion of abdominal wall (congenital or acquired) • Inguinal vs. femoral hernias • Complications and strangulated hernias • Signs of Injury • Acquired hernia occur when natural weakness is further aggravated by a direct blow or strain • History of direct blow to groin area, pain and prolonged discomfort, superficial protrusion with pain increasing with coughing & reported pulling sensation in groin area

Care • Most physicians prefer athlete to refrain from hard physical activity until surgically repaired • Mechanical devices are not suitable for athletics due to friction and irritation they produce • While exercise is thought to be beneficial with regards to strengthening that is not the case

Blow to Solar Plexus • Cause of Injury • Transitory paralysis of the diaphragm due to blow to the middle portion of the abdomen • Signs of Injury • Stops respiration and leads to anoxia • Generally transitory • Care • Must help athlete overcome apprehension • Use short inspirations and long expirations • Calm athlete, prevent hyperventilation, blow into a paper bag • ATC should question possibility of internal injury

Stitch in the Side • Cause of Injury • Idiopathic condition with obscure cause and several hypotheses • Constipation, intestinal gas, overeating, diaphragmatic spasm, poor conditioning, lack of visceral support and weak abdominals, distended spleen, breathing techniques resulting in lack of oxygen, ischemia of diaphragm or intercostal muscles • Signs of Injury • Cramp-like pain that develops on either the right or left costal angle during hard physical activity • Management • Relaxation of the spasm • Stretch arm on affected side as high as possible • Flex trunk forward on the thighs • Additional problems may warrant further study

Injury of the Spleen • Cause of Injury • Result of a direct blow • Infectious mononucleosis (causing an enlarged spleen) • Signs of Injury • Indications of a ruptured spleen involve history of a direct blow, signs of shock, abdominal rigidity, nausea, vomiting • Kehr’s sign • Ability to splint self may produce delayed hemorrhaging - easily disrupted resulting in internal bleeding

Care • Conservative treatment involves 1 wk of hospitalization and a gradual return to activity • Surgery will result in three months of recovery while removal of spleen will result in a 6 month removal from activity • In cases of mononucleosis athlete may resume training in 3 weeks if spleen not enlarged and if there is no fever

Kidney Contusion • Cause of Injury • Result of an external force (force and angle dependent) • Susceptible to injury due to normal distention of blood • Signs of Injury • May display signs of shock, nausea, vomiting, rigidity of back muscles and hematuria (blood in urine) • Referred pain (costovertebral angle posteriorly radiating forward around the trunk) • Care • Monitor status of urine (hematuria) - refer if necessary • 24 hour hospitalization and observation with a gradual increase in fluid intake • Surgery may be required if hemorrhaging continues • 2 weeks of rest and close surveillance following initial return to activity is necessary

Liver Contusion • Cause of Injury • Blunt trauma - right side of rib cage • More susceptible if enlarged due to illness (hepatitis) • Signs of Injury • Hemorrhaging and shock may present • May require immediate surgery • Presents with referred pain in right scapula, shoulder and substernal area and occasionally in left anterior side of chest • Care • Referral to a physician for diagnosis and treatment

Appendicitis • Cause of Injury • Inflammation of the vermiform appendix (chronic or acute) • Result of blockage, lymph swelling, or carcinoid tumor • Early stages it presents as a gastric complaint, that gradually develops from red swollen vessel to a gangrenous structure that can rupture into bowels causing peritonitis • Signs of Injury • Mild to severe pain in lower abdomen, associated with nausea, vomiting and low grade fever • Pain may localize in lower right abdomen (McBurney’s point) • Care • Surgical intervention is often necessary (particularly if it is resulting in an obstructed bowel = life threatening)

Injuries to the Bladder • Cause of Injury • Blunt force to the lower abdomen may cause injury to urinary bladder if distended with urine • Hematuria is often associated with contusion of bladder during running (runner’s bladder) • Signs of Injury • Pain, discomfort of lower abdominal region, abdominal rigidity, nausea, vomiting, shock, bleeding from the urethra, increased quantity of bloody urine • Athlete should be instructed to monitor urine • Inability to urinate will present in case of ruptured bladder

Scrotal/Testicular Contusion • Cause of Injury • Result of blunt trauma and contusion to the vulnerable and sensitive scrotum • Signs and Symptoms • Hemorrhaging, fluid effusion, muscle spasm, severe pain (disabling) • May cause nauseating, disabling and painful condition • Care • Place athlete on side with knees to chest • Apply cold pack as pain subsides • If pain persist after 15-20 minutes referral will be necessary

Gynecological Injuries • Low incidence of injury in sports • Most common occurrence involve contusion of external genitalia (vulva - including the labia, clitoris and the vaginal vestibule) • Signs and Symptoms • Hematoma results from contusion - may also involve pubic symphysis resulting in osteitis pubis

Chapter 21: The Thorax and Abdomen