T r au m a a n d E me r g en c y C ar e 1151
Chest Wall,
Pneumothorax, and
Hemothorax
Scott M. Moore, MD, Fredric M. Pieracci, MD, MPH, FACS,
and Gregory J. Jurkovich, MD
A lthough Hippocrates was the first to describe chest tube inser-
tion for pleural drainage, this did not become the standard treat-
ment for hemothorax and pneumothorax until the nineteenth
century and was greatly facilitated by the development of the under-
water seal device by Playfair. The approach to the majority of chest
wall injuries in the modern era appropriately has emphasized non-
operative management. However, published reports of closed reduc-
tion and external fixation of flail chest appeared as early as the first
half of the twentieth century, with the first report of internal fixation
using wire suture occurring in 1950. Open reduction and plate sta-
bilization of complex rib fractures are becoming more common as
specialized plating systems have been developed.
Thoracic trauma is a major source of morbidity and mortality
and is second only to head injury as a cause of death in the injured
patient. Furthermore, this statistic likely underestimates the burden
of thoracic injuries, which are the cause for on-scene fatalities in an
estimated 50% of cases. Among those patients who reach medical
attention, thoracic trauma portends an overall mortality of 8.4%,
with complications from chest injuries contributing to another 25%
of trauma-related deaths. Injury mechanism is a critical determinant
of the pattern of thoracic injury, with chest wall injuries more often
resulting from blunt mechanisms that involve crushing forces, major
pulmonary and cardiac injuries resulting from penetrating trauma,
and aortic injuries associated with both types of mechanisms. This
chapter focuses on the management of the most commonly encoun-
tered thoracic injuries, which include chest wall injuries, pneumo-
thorax, and hemothorax. Operative repair of cardiac, pulmonary,
great vessel, and aerodigestive tract injuries are described elsewhere.
INITIAL APPROACH
Patients who sustain thoracic trauma are evaluated systematically
according to the tenets of the Advanced Trauma Life Support (ATLS)
protocol: a primary survey is conducted that prioritizes identification
and correction of airway problems, then breathing abnormalities,
and finally circulatory dysfunction. Endotracheal intubation or sur-
gical airway placement, chest tube insertion, establishment of ade-
quate intravenous access for resuscitation, and maneuvers to control
hemorrhage and temperature are instituted as soon as problems are
found. In addition, practitioners should assume the presence of a
spinal cord injury and vigilantly avoid hypothermia during this stage.
With specific regard to thoracic trauma, the conditions that are
immediately life threatening include tension and open pneumotho-
rax, massive hemothorax, flail chest, major pulmonary contusion, air
embolism, and cardiac tamponade. Vital sign abnormalities that are
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accompanied by examination findings of unilateral loss of breath
sounds, hyperresonance or dullness to percussion, tracheal deviation,
distended or flattened neck veins, and chest wall instability or
crepitus signal a life-threatening condition that requires immediate
attention.
After the primary survey, a secondary survey is performed to
uncover potentially life-threatening problems that were not identi-
fied initially. This is accomplished by more in-depth physical exami-
nation and diagnostic tests. In the patient with suspected thoracic
trauma, the latter should include a portable chest x-ray (CXR), which
has the advantage of rapidly diagnosing potentially life-threatening
injuries without the need to transport the patient away from resources
needed for resuscitation. It should be noted, however, that the por-
table supine CXR often misses intrathoracic pathology, with rela-
tively poor sensitivity for pneumothorax (28% to 75%), hemothorax
(75%), rib fractures (50%), sternal fractures (50%), pulmonary con-
tusion (44%), and aortic injuries (41% to 88%).
Bedside ultrasound has become standard practice in the initial
trauma evaluation (i.e., focused assessment with sonography for
trauma, or FAST), and more recently the extended version of the
FAST (i.e., eFAST) has augmented the standard pericardial, abdomi-
nal, and pelvic views with additional views of the bilateral pleural
spaces. In experienced hands the eFAST has a sensitivity that sur-
passes portable CXR for detection of pneumothorax (86% to 98%)
and can be used to identify other potentially life-threatening injuries
such as hemothorax and pulmonary contusion.
Routine chest computed tomography (CT) for evaluation of tho-
racic trauma is costly and exposes a large patient population to
harmful levels of ionizing radiation, whereas missed injuries have the
potential for significant morbidity and mortality. To help guide deci-
sion making for chest imaging, the NEXUS Chest screening tools
have been developed and shown to have a sensitivity greater than
99% for thoracic injuries of major clinical significance (Boxes 1
and 2). There has been recent debate about the clinical significance
of injuries not identified on CXR but later seen on CT imaging. In a
recent study, these so-called “occult” injuries were found to occur in
25% of all patients who undergo both CXR and CT imaging, and
among injured patients the rate of occult injury identification is
greater than 70%. As discussed later, many occult pneumothoraces
and hemothoraces can be managed expectantly, and most rib frac-
tures are managed nonoperatively based on their clinical sequelae
(i.e., severity of pain, strength of cough) rather than on their radio-
logic appearance. However, clinically significant occult injuries do
occur, with the aforementioned study finding that 66.2% of injuries
that required major interventions (i.e., mechanical ventilation, tube
thoracostomy, surgery) were occult, though it is unclear from the
observational nature of this study that the CT results actually changed
management. However, management of less clinically apparent inju-
ries probably is affected by CT imaging, with 25% of occult great
vessel injuries, 9.8% of occult spine fractures, and 100% of occult
diaphragm ruptures in this study requiring surgery. It is also clear
that CT-identified occult injuries lead to a high rate of admission,
with 9 in 10 patients with occult injuries being admitted. Ongoing
clinical investigations continue to try to identify the specific variants
of injuries that are seen only on chest CT (vs CXR) and warrant
treatment.
1152 Chest Wall, Pneumothorax, and Hemothorax
BOX 1:  NEXUS Chest: Indications for Chest
X-Ray*
Age >60 years
Rapid deceleration mechanism
Fall >20 ft
Motor vehicle collision >40 mph
Chest pain
Intoxication
Abnormal alertness or mental status
Distracting injury
Chest wall tenderness
*All criteria absent: very low risk for intrathoracic injury and chest imaging
not indicated.
BOX 2:  NEXUS Chest: Indications for Chest CT*
Abnormal chest x-ray
Distracting injury
Chest wall tenderness
Sternum tenderness
Thoracic spine tenderness
Scapula tenderness
Rapid deceleration injury
*All criteria absent: may forgo chest computed tomography.
SPECIFIC INJURIES
Rib Fractures and Flail Chest
Rib fractures are very common and have a prevalence of 10% in
trauma admissions overall, making them the most common injury
in patients with blunt chest trauma. The high frequency of these
injuries necessitates that all surgeons caring for trauma patients be
well versed in the potential complications and optimal management
strategies for rib fractures. The surprisingly high mortality rate asso-
ciated with chest wall injuries (10% to 20%) stems from pain-induced
splinting with resultant poor pulmonary hygiene, which can lead to
progressive atelectasis and pneumonia if pain is not managed aggres-
sively. Rib fractures also commonly result in a tremendous amount
of chronic pain, disability, and loss of productive life years; the major-
ity of patients with flail chest who survive to discharge are never able
to return to pre-injury levels of employment. The high incidence of
associated injuries (especially pulmonary contusion and head inju-
ries) undoubtedly contributes to the mortality rate as well. The most
commonly injured ribs after blunt chest trauma are the fourth
through tenth, and the specific location of rib fractures can implicate
other injuries; lower rib fractures (ninth to eleventh) should direct
attention to possible abdominal solid organ injury (left side spleen,
kidney; right side liver, kidney), whereas upper rib fractures (first to
third) are associated with injuries to the head, neck, spinal cord, and
great vessels. High rib fractures have been associated with blunt
cerebrovascular injury (BCVI). In addition to rib number, the total
number of fractures also dictates risk, with each additional rib frac-
ture increasing the risk of pulmonary complications and death. Frac-
ture location within the rib also affects patient outcome. In general,
lateral and subscapular fracture lines produce the most pain, whereas
very posterior or anterior fracture lines usually are better tolerated.
Finally, degree of displacement, overlap, and angulation of the frac-
ture itself all contribute to alterations of pulmonary mechanics, pain,
and injury to surrounding structures such as the intercostal bundle,
lung, and diaphragm.
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BOX 3:  RibScore*
≥6 ribs fractured
≥3 bicortically displaced fractures
≥1 fracture in each anatomic area†
Flail chest
Bilateral fractures
First rib fracture
*1 point is assigned for each variable; RibScore ≥4 may benefit from
surgical stabilization of rib fractures.
†Defined as anterior, lateral, and posterior.
The danger posed by chest wall injuries is compounded with
increasing age, as patients over 65 years old have an overall mortality
of 22% and a pneumonia rate of 33%, compared with 10% and 17%,
respectively, for younger patients. Furthermore, each additional rib
fracture in the older person increases the relative risk of death by
19% and that of pneumonia by 27%. The impact of age on mortality
from rib fractures was reinforced by a survey of the National Trauma
Data Bank (NTDB), which showed a dramatic increase in mortality
with greater than six rib fractures. Even lesser extremes of age impart
additional risk, as demonstrated by a study by Holcomb and col-
leagues that showed that patients older than 45 years have signifi-
cantly increased ventilator time, intensive care unit (ICU) length of
stay, and duration of hospitalization when compared with younger
patients.
Flail chest is a specific rib fracture pattern that is defined by three
or more adjacent ribs with fractures in two or more places. Although
the most common fracture pattern that results in a flail segment is
two unilateral fracture lines (lateral flail), a flail segment also can
result from bilateral fractures of three or more consecutive ribs (ante-
rior flail) or when three or more unilateral fractures are associated
with a sternal fracture. In a recent multicenter retrospective study,
flail chest was found in 1% of patients admitted to trauma centers
with a blunt injury mechanism. Flail chest represents the most severe
form of chest wall injury after blunt trauma, with more than 80% of
patients needing ICU admission, more than 50% requiring mechani-
cal ventilation, and an overall mortality of 16%. With spontaneous
breathing, a paradoxical outward movement of the flail segment will
be observed during expiration, followed by inward movement during
inspiration. It is important to note that such paradoxical motion is
eliminated during positive pressure ventilation (PPV), which may
lead to initial oversight of the injury, especially in patients who are
intubated before arrival in the trauma bay. Because of the large
amount of force required to cause a flail chest injury, additional
injuries are frequently present and can contribute greatly to patient
morbidity and mortality. The most commonly associated injuries are
pulmonary contusion (46% to 77%), pneumothorax and hemotho-
rax (44% to 70%), and head injury (15%). In addition to the pain
and splinting encountered with all rib fractures, flail chest imparts
mechanical instability that limits thoracic volume and has a high
incidence of pulmonary contusion that causes blood accumulation
within the alveolar spaces.
Several scoring systems have been developed to quantify the
severity of chest wall injury. We recently proposed the RibScore,
which involves several detailed radiographic parameters related to rib
fracture pattern (Box 3). This score has been found to be highly
predictive of adverse pulmonary outcomes and is useful for predict-
ing which patients may benefit from surgical stabilization of rib
fractures (Figure 1). Other scores that incorporate nonfracture
parameters (e.g., age, pulmonary contusion) include the Organ
Injury Scale (OIS) Chest Wall Grade, Rib Fracture Score, Chest
Trauma Score, and Pressley Score.
The treatment of rib fractures and flail chest is nonoperative in
the vast majority of cases, and patients usually can be managed suc-
cessfully with aggressive pain control, early and effective pulmonary

100%
Pneumonia
Respiratory failure
80%
Tracheostomy
60%
40%
20%
0%
0 1 2 3 4 5
RibScore
FIGURE 1  Morbidity associated with increasing RibScore. Based entirely
on radiographic appearance of rib fractures, RibScore provides a prompt
risk stratification for complications related to rib fractures.
BOX 4:  Admission Criteria for Rib Fractures
Admission if, after pain control with oral medication, ≥2 of the
following are present:
Respiratory rate >18
Incentive spirometry <75% predicted
Numeric pain score ≥6
Poor cough
Age ≥65 years
≥3 fractures
If admission criteria are met, intensive care unit (ICU) admission
if ≥1 of the following are present:
Age ≥65 years
≥6 fractures
Incentive spirometry <60% predicted
Flail chest
>4 L oxygen required to maintain arterial oxygen saturation
(SpO2) >90%
Associated injury requiring ICU admission
toilet, and supportive care. For simple unilateral fractures involving
no more than three ribs, young patients with adequate pain control
on oral analgesics and without comorbidities can be managed suc-
cessfully as outpatients. All other patients should be considered for
admission, and there should be a low threshold to admit patients
with high-risk features to the ICU (Box 4). Systemic analgesics with
narcotic and non-narcotic agents given both orally and parenterally
are necessary, as are early mobilization, aggressive use of incentive
spirometry, and chest physiotherapy (Box 5). Patient-controlled
analgesia (PCA) is a safe and effective method for delivering paren-
teral narcotics and should be implemented liberally. Whenever pos-
sible, non-narcotic analgesics such as nonsteroidal anti-inflammatory
drugs (NSAIDs) and gabapentin should be prescribed to patients
with rib fractures.
Epidural catheters are especially useful in patients with extensive
rib fractures or flail chest, as they avoid the respiratory depression,
somnolence, and gastrointestinal symptoms that accompany high-
dose parenteral narcotics while providing superior pain control.
Several studies have demonstrated convincingly that epidural anal-
gesia after chest wall injuries translates into decreased ventilator days,
fewer pulmonary complications, and shortened ICU and hospital
length of stay, especially when used in older patients with multiple
fractures. Current guidelines strongly recommend placement of an
epidural for patients older than 65 years with four or more rib
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T r au m a a n d E me r g en c y C ar e 1153
BOX 5:  Pain Management of Rib Fractures
Outpatient
Incentive spirometer
Ibuprofen 800 mg PO q6H
Gabapentin 100 mg PO TID
Diazepam 5-10 mg PO QD
Oxycodone PRN
Inpatient
Incentive spirometer
Ambulation
Ibuprofen 800 mg PO q6H
Gabapentin 100 mg PO TID
Diazepam 5-10 mg PO QD
Oxycodone PRN
Intravenous narcotics PRN
Consider epidural or paravertebral catheter
Consider surgical stabilization of rib fractures
PO, orally; PRN, as needed; q6H, every 6 hours; QD, daily; TID, three times
a day.
fractures and suggest consideration of epidural analgesia in younger
patients with four or more fractures and in older patients with lesser
injuries. The most common risks associated with epidural anesthesia
include hypotension and pruritus, with the more serious complica-
tions of epidural hematoma, infection, and spinal cord injury occur-
ring very rarely. Most patients are eligible for epidural analgesia;
however, some absolute contraindications that are especially relevant
to the trauma population include increased intracranial pressure,
localized infection or rash, and inability to maintain position for
catheter placement. Relative contraindications include a history of
spine surgery; spinal fracture; instability near the desired level of
epidural placement; severe aortic stenosis, mitral stenosis, or pulmo-
nary hypertension; uncorrectable coagulopathy (i.e., certain antico-
agulants, antiplatelet agents, or inherited coagulopathies), and
ongoing vasopressor requirement. Despite their efficacy, low compli-
cation rate, and availability at most trauma centers, recent reports
from the NTDB indicate that only 8% of patients with flail chest
receive epidural catheters, suggesting that this effective analgesic
modality is greatly underused.
Regional analgesia also can be achieved by intercostal, intrapleu-
ral, paravertebral, and paracostal delivery of anesthetic, with the
latter being an attractive option given the relative simplicity of cath-
eter placement and encouraging efficacy in preliminary studies. Para-
costal catheters (Figure 2) are placed by palpating the lower rib
margin approximately 5 cm lateral to the spinous processes and
passing a spinal needle to localize the rib with injection of local
anesthetic in the skin, subcutaneous tissue, and paravertebral muscles.
A small incision is made, and an obturator with tearaway sheath then
is passed bluntly to the level of the scapula in a plane parallel and
immediately superficial to the posterior rib cage. A long catheter then
is exchanged for the obturator, and the sheath is removed. The cath-
eter is secured and the incision is sealed with surgical adhesive to
prevent leakage of anesthetic. The typical anesthetic regimen is a
bolus dose of 0.25% bupivacaine (20 mL) followed by a continuous
infusion (0.125% at 12 mL/hr) by either a pump or an elastomer
reservoir.
Surgical Stabilization of Rib Fractures
Basic orthopedic principle dictates that the management of fractures
involves reduction and fixation. The ribs are unique in that they
move with each breath, rendering external fixation impossible. Fur-
thermore, in the case of long bone fractures, selective immobilization
1154 Chest Wall, Pneumothorax, and Hemothorax
FIGURE 2  Rib fracture pain management with local-regional anesthesia.
Anesthetic catheters typically are placed peri-incisional after surgical
stabilization of rib fractures (SSRF). Paracostal placement can be
performed at the bedside in patients not undergoing SSRF.
by patients secondary to pain is relatively inconsequential. By con-
trast, selective immobilization of the ribs due to pain results in atel-
ectasis, accumulation of pulmonary secretions, pneumonia, and
eventual respiratory failure. These hypothetical observations as well
as the high incidence of painful nonunions from severely displaced
fractures form the basis for recommending surgical stabilization of
rib fractures (SSRF) in select fracture patterns.
Rib fracture repair has been performed for more than 60 years
but until recently has been limited by nonspecific fixation systems,
lack of efficacy data, and lack of ownership by a surgical discipline.
Over the last 10 years, several prospective studies, including three
randomized controlled trials and two meta-analyses, have docu-
mented the efficacy of SSRF, primarily in patients with flail chest.
Specifically, reduced pneumonia rates, decreased duration of
mechanical ventilation, decreased length of ICU stay, decreased need
for tracheostomy, and lower medical costs have been observed. More
recently, evidence suggests that certain nonflail fracture patterns,
such as multiple contiguous severely displaced fractures, can progress
to long-term disability and chronic pain, and SSRF potentially may
abrogate this progression. We currently consider SSRF in all patients
with flail chest, patients with three or more severely (bicortical) dis-
placed fractures, and any patient who has failed maximal nonopera-
tive management after 24 hours.
The optimal timing for SSRF is not established. Some have advo-
cated SSRF after certain clinical variables become apparent (i.e.,
failed ventilator wean, intractable pain); however, earlier repair
has definite advantages. Inflammation around the fractures peaks
between 3 and 5 days postinjury, and pain from rib movement during
respiration can cause progressive splinting, atelectasis, and potential
respiratory failure. Therefore SSRF within 72 hours of patient pre-
sentation may provide the best window for technical success and
prevention of complications. Ideally the patient with severe rib frac-
tures is identified as a candidate for SSRF at the time of presentation
and, assuming hemodynamic stability and the absence of competing
operative priorities, is transported directly from the trauma bay to
the operating room for SSRF. Choice of positioning and incision are
dictated by the fracture patterns. In most cases, rib fracture repair
may be accomplished without any muscle division. Anterior fractures
are approached via a submammary incision in the supine position,
with elevation of a pectoralis flap. For isolated lateral fractures of 3
to 5 contiguous ribs, an 8- to 10-cm longitudinal incision after the
anterior border of the latissimus dorsi muscle and centered over the
middle fracture usually provides adequate exposure. The serratus
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anterior muscle fibers are split, thereby exposing the fractures. Alter-
natively, extensive lateral and posterior fractures involving five or
more contiguous ribs typically are best approached through a stan-
dard posterolateral thoracotomy incision (Figure 3). Whether all
fractures must be repaired is controversial, and some groups have
advocated fixing only one side of a flail segment or repairing every
other rib in the setting of multiple contiguous fractures. Dissection
of the rib periosteum should be minimized to ensure adequate blood
supply for fracture healing and is accomplished by a limited 3 to 5 cm
of exposure on both sides of the fracture (Figure 4). After exposure
of the fractured segments, right angle clamps and gentle traction are
used to align the fractured segments (“double right angle” tech-
nique). A variety of fixation systems are currently available. For
systems using plates and screws, depth gauges should be used to select
the proper screw length, and a specialized drill and drill guide assists
in ensuring that holes are perpendicular and at proper depth to
achieve bicortical penetration. Low clearance areas (i.e., upper pos-
terior ribs deep to the scapula) will require a specialized right angle
drill and screwdriver. Newer systems use self-tapping and locking
screws that eliminate the need for an additional drilling step and
prevent screws from backing out. The surgeon must ensure that
screws are placed perpendicular to the rib with bicortical purchase,
with at least three screws on both sides of the fracture. In addition,
plates should sit flush with the rib. Most commercially available
plating systems have precontoured plates for each rib; however, these
typically are designed for anterolateral fractures, and plate bending
is often necessary for posterior fractures. SSRF also affords an oppor-
tunity to evacuate blood and fluid from the pleural space under direct
visualization, perform pulmonary toilet via directed bronchoscopy,
and place local-regional anesthesia catheters under direct vision and
palpation. Finally, thoracoscopic SSRF has been described by our
group and is currently under development.
Sternal Fractures
Once considered a major risk factor for occult thoracic injuries such
as cardiac contusion or great vessel injury, the mechanism for sternal
fractures has shifted over the last few decades. Before widespread
implementation of three-point restraints, rapid deceleration and
steering wheel impact were the most common culprits of sternal
fractures; however, now they are caused most frequently by shoulder
belt impingement. A recent study by Odell and colleagues found
that 26.4% of sternal fractures were isolated, with the remainder
being associated most commonly with extremity fractures (42.2%),
head and neck injuries (39.3%), rib fractures (38.4%), spine injuries
(25.7%), and pulmonary contusions (25.6%). Cardiac contusion and
great vessel injury were present in only 2.3% and 1.1%, respectively.
History, physical examination, basic imaging, and electrocardiogra-
phy at the time of initial evaluation are adequate to rule out associ-
ated injuries. If such studies confirm that the injury is indeed isolated,
fit and nongeriatric patients often can be managed on an outpatient
basis. This is supported by the finding by Odell and colleagues that
none of the 492 patients with isolated sternal fracture required endo-
tracheal intubation, chest tube placement, or operative intervention.
For nonisolated cases, cardiac contusion should be suspected if the
electrocardiogram demonstrates unexplained tachycardia (the most
common dysrhythmia), frequent premature ventricular contractions
(PVCs), right bundle branch block, ST segment changes, or other
arrhythmias, and such patients require admission for continuous
cardiac monitoring and echocardiography. Persistent shock in the
thoracic trauma patient without ongoing hemorrhage and after
adequate volume resuscitation should receive echocardiography,
which can detect specific pathologies such as pericardial effusion,
wall motion abnormalities, septal rupture, or valvular dysfunction.
Because the right ventricle underlies the sternum, wall motion abnor-
malities most likely are seen in this location. Cardiac biomarkers
generally are not useful for the management of suspected cardiac
contusion. Operative repair of sternal fractures is sometimes
 T r au m a a n d E mer ge n c y C a re 1155

A C

FIGURE 3  Incisions for surgical stabilization of rib fractures. A, Extensive posterior and lateral fractures are best exposed through a standard
posterolateral thoracotomy incision. B, Isolated lateral fractures can be exposed through a more limited incision centered over the middle fracture
(arrow). C, Anterior rib fractures are best exposed by inframammary incisions (arrows).

A B

FIGURE 4  Operative technique for surgical stabilization of rib fractures. A, Double right angle technique aligns fracture ends before placement of rib
plates. B, Right angle drill and screwdriver are useful for plate fixation in low-clearance areas such as the subscapular space.

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1156 Chest Wall, Pneumothorax, and Hemothorax
indicated for significant displacement and overlap or when associated
with rib fractures deemed appropriate for SSRF and can be accom-
plished with similar principles of exposure and fixation as SSRF.
Scapular Fractures
The scapula is uncommonly injured because of its mobility on the
chest wall and protection by the rib cage anteriorly and well-
developed musculature posteriorly. For this reason, fractures of the
scapula typically involve high-energy transfer and are associated with
other injuries in 80% to 95% of cases. Scapula fractures are consid-
ered sentinel injuries because of the relatively high rate of associated
great vessel, major thoracic, abdominal, head, and spinal injuries in
historical reports. A more recent study of the NTDB, which included
more than 9000 scapular fractures, found that patients with scapular
injuries had significantly higher rates of rib fracture (53% vs 10%),
pneumothorax (33% vs 8%), spinal fracture (29% vs 12%), head
injury (39% vs 26%), abdominal injury (17% vs 10%), and pelvic
fracture (15 vs. 6.3%); however, there was not a significantly increased
association with heart, great vessel, or brachial plexus injury, and
mortality also was unaffected. After adjusting for injury severity score
(ISS), fractures to the ribs, spine, and pelvis all remained indepen-
dently associated with scapular fractures.
Fractures can involve the acromion, coracoid process, body, neck,
or glenoid portion of the scapula, and management often is influ-
enced by commonly encountered accompanying injuries such as
acromioclavicular separation, clavicle fractures, and humeral frac-
tures. For nondisplaced acromion, stable coracoid, and the majority
of scapular body and neck fractures, several weeks in a shoulder sling
followed by passive and active motion exercises usually suffice for
treatment. Operative treatment may be needed for significantly dis-
placed acromion fractures and unstable coracoid and glenoid frac-
tures that result in instability of the superior shoulder suspensory
complex. Combined fracture of the glenoid neck and clavicle can
result in a “floating shoulder,” which often benefits from operative
stabilization in order to provide fixation with the rest of the skeleton.
Especially high-energy mechanisms may result in scapulothoracic
dissociation, which is a devastating injury that is defined by lateral
displacement of the scapula and complete loss of the scapulothoracic
articulation. These injuries are associated with a high frequency of
severe brachial plexus and vascular injury (>80% to 90%), which may
mandate early above-elbow amputation if the extent of nerve injury
precludes a meaningful functional recovery.
Clavicle Fractures and Dislocations
The clavicle is involved in nearly half of shoulder girdle injuries,
which include fractures of the proximal, middle, and distal third as
well as dislocations of the acromioclavicular and sternoclavicular
joints. Although historically managed nonoperatively, there has been
renewed interest in operative management of distal clavicle fractures
because of the recognition of increased rates of nonunion and poten-
tial for functional disability if poor fracture healing occurs. Acromio-
clavicular dislocation (or “shoulder separation”) often is managed
nonoperatively, although higher-energy mechanisms can result in
concomitant coracoclavicular disruption and may require operative
reduction. Sternoclavicular dislocation requires considerable force
and should prompt a diligent search for associated injuries in the
neck, chest wall, and shoulder. Although anterior fractures are much
more common, posterior sternoclavicular dislocations can be espe-
cially troublesome if the displaced clavicular head causes injury to
the underlying trachea, lung, great vessels, or esophagus. For this
reason, reductions of these dislocations should be performed only
with appropriate surgical expertise immediately on hand.
Pneumothorax
Pneumothorax is defined by entry of air into the pleural space, which
is usually a result of parenchymal lung injury and occurs with both
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blunt and penetrating mechanisms. For blunt injuries, the most
common cause is lung lacerations caused by fractured ribs, although
increases in intrathoracic pressure and pulmonary contusions as a
result of sudden deceleration mechanisms can lead to pneumothorax
in the absence of rib fractures. Recent studies estimate the prevalence
of pneumothorax at 29% for blunt trauma, at 20% for penetrating
mechanisms, and as high as 64% in intubated patients who sustained
major chest trauma (ISS >30). Undoubtedly the frequency of detec-
tion has increased with the increased use of CT imaging of trauma
patients, with a recent study reporting that 67.8% of diagnosed
pneumothoraces were occult (i.e., not apparent on initial CXR but
later seen on CT). Although the clinical significance of occult pneu-
mothorax is controversial (discussed later), there is no debate con-
cerning the importance of early recognition and treatment of
clinically overt pneumothorax, as these injuries continue to be a
major source of preventable death in both adult and pediatric trauma
populations.
Pneumothorax should be suspected in all blunt trauma patients
and especially in those with evidence of thoracic trauma. As men-
tioned, penetrating trauma also carries a significant risk for pneu-
mothorax and often is suggested by the offending object’s trajectory.
On examination, pneumothorax can be seen with crepitus, unequal
chest rise, unilateral breath sounds, and hyperresonance, though the
last two may be difficult to ascertain in the noisy trauma bay. Indeed,
the sensitivity of physical examination for pneumothorax after
trauma is 50% to 58%, with a specificity of 97% to 98%, suggesting
that examination findings should be acted on when present but not
relied on to rule out the condition. The anteroposterior (AP) supine
CXR is used most commonly as the initial imaging test in trauma
patients, and any pneumothorax large enough to be visible on plain
x-ray or accompanied by respiratory compromise should be treated
by tube thoracostomy. As mentioned earlier, plain x-ray is notori-
ously inaccurate at diagnosing pneumothorax, which has prompted
interest in bedside ultrasound as an initial screening test for pneu-
mothorax. Normally, ultrasound of the pleural space will reveal char-
acteristic sliding between the parietal and visceral pleura as well as
comet tail artifacts and B-lines, all of which are absent in the setting
of pneumothorax. A recent meta-analysis comparing supine CXR
with bedside ultrasound found the latter to have superior sensitivity
(49.7% vs 85.3%) and equivalent specificity (99.3% vs 98.4%).
Despite the evidence for its superior accuracy, pleural ultrasound has
not been applied universally as a standard part of the initial trauma
evaluation, which is likely because of a lack of necessary equipment
and training, its high dependence on operator experience and skill,
and a scarcity of high-quality studies evaluating any advantage.
Tension pneumothorax is an immediately life-threatening condi-
tion that occurs when a one-way valve leads to progressive air trap-
ping in the pleural space. The high pressure that develops leads to
total collapse of the ipsilateral lung and shifting of the mediastinal
structures, which causes kinking of the superior and inferior vena
cava and loss of venous return to the heart. Examination findings
include the typical findings of pneumothorax (absent breath sounds,
hyperresonance) with the addition of distended neck veins, elevated
hemithorax on the affected side, hypotension, and cyanosis. Respira-
tory and cardiovascular collapse occurs rapidly, and pleural decom-
pression can be lifesaving. Diagnostic imaging delays treatment and
should be avoided. Needle decompression (second intercostal space
at the midclavicular line) is rapid and the recommended initial treat-
ment, especially for providers who are less experienced with tube
thoracostomy; however, individuals with thick chest walls may not
be decompressible by traditional length angiocatheters (5 cm) and
may be better served by initial tube thoracostomy. Alternatively,
needle decompression through the fifth intercostal space at the
midaxillary line offers a shorter distance to the pleural space and is
an option. Needle decompression only converts a tension pneumo-
thorax into a simple pneumothorax and always should be followed
by tube thoracostomy for definitive treatment.
Open pneumothorax results when a large chest wall defect leads
to direct communication between the pleural space and the

surrounding environment. If the wound is greater than two thirds
the diameter of the trachea, air will preferentially enter the wound
instead of the airway during inspiration. Such injuries require prompt
treatment to prevent respiratory decompensation and are treated
initially by placement of a three-sided occlusive dressing, which
creates a flap valve that occludes the wound on inspiration but allows
egress of air on expiration. Immediate tube thoracostomy should be
performed after placement of the dressing. The chest wall defect then
can be repaired primarily for smaller wounds or may require rota-
tional or free flaps for extensive injuries.
The management of occult pneumothorax has been a subject of
debate. Given that the majority of pneumothoraces diagnosed in
contemporary practice are occult and up to 22% of tube thoracosto-
mies have complications (i.e., lung injury, intercostal artery lacera-
tion, empyema, malpositioning, postremoval recurrence), the
decision of whether to perform tube thoracostomy for occult pneu-
mothoraces is not trivial. Historically, the chest tube insertion rate
for occult pneumothorax is widely variable (12% to 82%), which is
in contrast to the consistently high rate of tube thoracostomy for
overt pneumothoraces (65% to 95%). One possible explanation for
this variability is that occult pneumothoraces typically are assumed
to be smaller than overt ones, although several studies have found no
significant difference in the measured size of occult and overt pneu-
mothoraces. Because of this variability and uncertainty regarding
management, the American Association for the Surgery of Trauma
(AAST) sponsored a multi-institutional prospective study that exam-
ined the safety of an observation strategy for occult pneumothorax.
The authors followed 569 patients with occult pneumothorax, 21%
of whom had chest tubes placed; the remaining patients were
observed. Only 6% of patients failed observation, and none of the
patients that failed observation developed a tension pneumothorax
or any other adverse events related to delayed tube thoracostomy.
Average size of the pneumothorax greater than 7 mm, presence of
hemothorax, and PPV all were associated with higher rates of obser-
vation failure. In addition, respiratory distress was associated with 6
times higher risk for failure, and interval increase in size of the pneu-
mothorax was associated with 70 times the risk for failure; on mul-
tivariate analysis, these were the only factors that independently
predicted observation failure. The conclusion from this study was
that occult pneumothoraces can be observed safely with interval
CXRs, and that this strategy can be extended to patients who are
undergoing PPV. The safety of withholding chest tube placement for
occult pneumothoraces among ventilated patients was reproduced in
a recent study of pediatric patients that reported findings similar to
those of the AAST study.
Hemothorax
Accumulation of blood within the pleural space is a common occur-
rence in both blunt and penetrating trauma patients. For blunt inju-
ries, the source of blood is most commonly fractured ribs and
adjacent lung laceration, though intercostal artery, great vessel, pul-
monary hilar, and cardiac injuries also may be implicated. In rare
instances, a combination of abdominal hemorrhage and diaphragm
injury can cause hemothorax. For penetrating injuries, direct injury
to the lung, intercostal arteries, heart, or major intrathoracic vessels
is the most common source. Bleeding from fracture-associated lung
lacerations typically resolves spontaneously on re-expansion of the
lung; however, high pressure sources (i.e., intercostal artery) are less
likely to resolve on their own and may require operative or endovas-
cular control. Because pulmonary parenchymal injury is the usual
source for blood, air often accompanies blood within the pleural
space and is referred to as a hemopneumothorax. On examination,
hemothorax is signaled by absent or decreased breath sounds, dull-
ness to percussion (unless a hemopneumothorax, which may be
hyperresonant), and tracheal deviation away from the affected side.
Large quantities of blood within the pleural space can cause complete
lung collapse and mediastinal shift with kinking of the venous inflow
to the heart, resulting in tension physiology. However, in contrast to
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T r au m a a n d E mer ge n c y C a re 1157
tension pneumothorax, such cases usually are not seen with dis-
tended neck veins because of the accompanying hypovolemia.
Depending on the quantity of blood, upright AP CXR may reveal
blunting of the costophrenic angle or complete opacification of the
hemothorax. In general, the minimum amount of blood needed to
produce plain x-ray findings is 200 to 500 mL, although much larger
volumes may not be apparent if the film is taken in the semi-upright
or supine position, as is often the case with the blunt trauma patient.
Indeed, pleural volumes as high as 1000 mL may be missed with the
supine CXR and may produce just a subtle haziness that easily can
be overlooked. In general, CT imaging is much more sensitive than
CXR for hemothorax, which was demonstrated in a recent multi-
center study in which 80% of hemothoraces were visible on CT but
not on CXR.
The management of these occult hemothoraces is not clear, as the
size of hemothorax that warrants drainage has been a matter of
debate. Proponents of drainage for all hemothoraces cite the diffi-
culty in achieving adequate drainage if delayed and the subsequent
risk of developing fibrothorax when blood is left in the pleural space.
Advocates for selective drainage highlight the increased risk of infec-
tion and empyema by introducing a foreign body into the pleural
space as well as the overall 20% complication rate associated with
tube thoracostomy. Several small studies have attempted to provide
guidance on this question and, although they are limited by obser-
vational design and lack of long-term follow-up, generally show that
hemothoraces less than 1.5 cm in maximal cross-sectional diameter
on CT can be observed safely. Our practice has been to selectively
drain all hemothoraces that appear to be more than 500 mL.
Massive hemothorax is defined by more than 1500 mL of blood
within the pleural space and is an indication for operative explora-
tion. In contrast to smaller hemothoraces, massive hemothorax is
usually the result of a major pulmonary vascular or arterial source,
neither of which is likely to spontaneously stop bleeding without
operative control. Ongoing blood loss (more than 200 mL/hr for 2
to 4 hours) also should prompt operation. Because of the higher risk
of major vascular disruption, we have a lower threshold (>1000 mL
initial drainage) for operative exploration after penetrating trauma.
Though generally useful, these guidelines should be used with
caution under certain circumstances. Blunt trauma patients with a
delayed presentation (i.e., those in rural areas with long transport
times) may be better served by placing more emphasis on ongoing
losses than on initial output. Patients on anticoagulation therapy also
warrant careful clinical judgment before operative exploration, as
chest wall and pulmonary parenchymal injuries can cause substantial
bleeding in these patients that often responds well to correction of
coagulopathy rather than to immediate attempts at operative control.
Retained hemothorax is defined as a residual hemothorax despite
attempted evacuation by tube thoracostomy and is estimated to
occur in 10% to 20% of cases. The diagnosis should be suspected
when there is a persistent opacity on CXR after tube thoracostomy
and is best confirmed by noncontrast chest CT. In addition to its
deleterious effects on pulmonary function, retained hemothorax is a
major risk factor for development of empyema. A recent study
revealed a 26.8% risk of empyema with retained hemothorax, com-
pared with only 2% of patients who had complete evacuation. Other
independent risk factors for empyema identified by this study were
rib fractures (odds ratio [OR] 2.3), ISS of 25 or more (OR 2.4), and
the need for additional procedures to treat the hemothorax (OR
28.8). Overall, 50% of patients who developed empyema ultimately
required thoracotomy. Because of the morbidity associated with tho-
racotomy, there has been great interest in identifying management
strategies that avoid this outcome. Options include initial observa-
tion, placement of additional chest tubes, image-guided chest drain-
age, instillation of fibrinolytics through the existing chest tube, and
video-assisted thoracoscopic surgery (VATS). The AAST sponsored a
multicenter observational study to help elucidate which of these
approaches offers the most favorable patient outcomes. This study
found that observation alone was associated with an 83.2% success
rate (defined as not needing additional interventions) in selected
patients, especially if the residual hemothorax volume was estimated
to be less than 300 mL. For larger volumes (300 to 900 mL), VATS
was associated with a high success rate; however, it was less successful
when there was an associated diaphragm injury. Additional interven-
tions were required in 63.9% of patients who underwent a second
chest tube placement, in 41.2% who underwent image-guided chest
drainage, and in 66.6% who underwent fibrinolytic therapy. On the
basis of these outcomes, observation is recommended for retained
hemothoraces that are less than 300 mL, whereas VATS should be
performed for larger collections, with the understanding that retained
hemothoraces greater than 900 mL, especially when associated with
diaphragm injury, are at higher risk for needing eventual thoracot-
omy. Fibrinolytics, additional tube thoracostomies, and image-
guided procedures are often ineffective in this setting and therefore
are discouraged for treatment of retained hemothorax. In addition,
there are data to support VATS within the first 3 to 7 days of hospi-
talization to minimize risk for infection and need for thoracotomy.
Tube Thoracostomy
Preparation for tube thoracostomy should include skin preparation
with an alcohol-based 2% chlorhexidine solution and wide draping,
with the surgeon wearing sterile gloves, cap, gown, and face mask.
Unstable patients (i.e., those with tension pneumothorax) may
require abbreviated skin preparation and draping. Use of prophy-
lactic antibiotics before chest tube insertion is debated. This is
exemplified by guidelines from the Eastern Association for the
Surgery of Trauma (EAST), which initially recommended presump-
tive antibiotics when released in 2002; the updated guidelines in
2012 retracted this recommendation based on poor quality and
conflicting data.
The optimal site is typically at the fifth intercostal space (nipple
level in males) just anterior to the midaxillary line. Local anesthetic
should be infiltrated liberally into the skin, subcutaneous tissues,
intercostal muscles, and pleura. A 2- to 3-cm horizontal incision is
made, and a Kelly clamp is used to dissect through the tissues in the
direction of the intended interspace, taking care to dissect immedi-
ately on top of the rib. Once the pleura is reached, it should be bluntly
punctured forcefully but in a controlled fashion so as to avoid injury
to underlying lung. Generous spreading of the tract with the Kelly
clamp at this point will greatly facilitate tube placement. A gloved
finger then should be inserted into the pleural space. This maneuver
should be done carefully or not at all in patients with multiple rib
fractures, which can cause injury to the provider’s finger. However,
finger palpation can provide several pieces of useful information,
including confirmation of intrapleural placement, diagnosis of
cardiac tamponade (left side), diagnosis of diaphragmatic rupture,
and sweeping away of any adhesions. The chest tube then is clamped
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at its tip and directed through the tract and into the pleural space.
Because trauma patients often will have a combination of fluid and
air in the pleural space (i.e., hemopneumothorax), the tube should
be directed along the posterior chest wall toward the apex. Spinning
the tube during advancement helps to prevent lodgment into the
fissure, and fogging of the tube confirms intrapleural placement. The
tube then is secured with heavy suture, attached to a water seal drain-
age device, and covered with an occlusive and sterile dressing.
Authorities historically have recommended large bore chest tubes
(36F to 40F) for treatment of hemothorax, although no studies have
supported this assertion and studies have shown no difference
between small (28F to 32F) and large (36F to 40F) tubes for successful
evacuation of hemothorax.
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