Trunk Injuries

Pneumothorax

A pneumothorax may occur spontaneously during a sporting event or acutely after blunt or penetrating trauma in sports activity. It occurs when air is introduced between the lung and the pleura, the membrane that surrounds the lungs. Depending on the mechanism with which the contact between these two surfaces was compromised, air can accumulate and compress the lung, resulting in chest pain and shortness of breath. This can lead to respiratory failure. If enough air accumulates, the pressure from this trapped air can compress the heart and limit its ability to fill and then pump blood, leading to cardiovascular collapse and death.

Spontaneous pneumothorax is caused by a ruptured bleb at the surface of the lung and leads to escape of air from the lung into the space between the lung and the pleura. It is most common in tall, thin males but can occur in any age-group or gender. It can occur at rest and also during vigorous exercise and can be mistaken for a musculoskeletal chest pain. The athlete generally will complain of moderate to severe pleuritic sharp pain on the left or the right, associated with varying degrees of shortness of breath. Generally, a spontaneous pneumothorax is small and stable, but it can progress to the life-threatening complications described above. The patient needs to be transported to a medical facility where imaging can be done and a thoracostomy performed to relieve the pressure. In the event that immediate transport is unavailable and the patient is experiencing cardiovascular collapse, an emergent decompression needle thoracostomy can be performed by qualified medical professionals.

Traumatic pneumothorax can be caused by blunt or penetrating forces. The force required to cause a pneumothorax from blunt trauma is generally significant and has associated injury, such as rib fractures. Rib fractures require only pain medication as treatment, but all suspected rib fractures require a plain radiograph to rule out the diagnosis of pneumothorax. For penetrating trauma, such as skate-induced chest wall laceration in ice hockey, a plain radiograph should be ordered to rule out the diagnosis of pneumothorax even when suspicion is low for it. Any lacerations or punctures to the chest wall should not be explored, as this can cause a pneumothorax in some cases. Complications and treatment are the same as described above.

Cardiac Contusion

High-speed blunt trauma to the chest can result in injury to the heart, the most dramatic effect of which is sudden death, or commotio cordis. Cardiac contusion in sports is rare but occurs when forces are transmitted from the ballistic (as in baseball) or opposing player (as in American football) to the chest of the athlete. The myocardium is bruised, which causes pain and can affect cardiac output and in rare cases can lead to failure. The diagnosis should be considered in any athlete who complains of chest pain after a high-speed impact. Evidence of significant injury, as with sternal fracture/injury or multiple anterior rib fractures, should increase suspicion of cardiac injury. Emergency evaluation includes a chest radiograph, electrocardiogram, and cardiac enzymes. If there is a high suspicion of cardiac contusion, an echocardiogram may be taken and/or the patient may be kept under observation.

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