Let Me Be Blunt in Talking About Chest Trauma

Trauma to the chest/torso is first broken down broadly as to whether or not injuries are internal or external. 

Most external injuries, such as abrasions or contusions may be painful, but not too serious. At least not right away. Admittedly, it's also possible to get deep and large lacerations which can be complicated and clinically significant, but it's the internal injuries to the chest organs—heart and lungs—that can be life threatening. 

And for chest injuries that affect the inner organs, trauma is divided into blunt and penetrating. For the most part, blunt trauma is far more common--think of falling and landing on your chest on some rocks. Penetrating trauma could happen if someone fell on something pointy and hard--and while most sticks would break before penetrating the chest wall--most isn't all. Penetrating trauma is really something seen in gunshot wounds, so a hunting accident could be something to worry about while out and about in the woods, but blunt trauma will be the focus today.

One of the big problems with blunt chest trauma is that there's no real way to accurately identify some of the more dangerous injuries while on the trail.  That, and there's not much that can be done about them outside of a hospital or for a lay-person.

That being said, let's cover some quick anatomy. And, for the purposes of this discussion, your "chest" includes your sides and your back--think rib cage, also known as "the bony thorax."

Most people have 12 paired ribs (more or less have been seen in up to 8% of the population) all of which connect to thoracic vertebrae in the back. These back bones protect the spinal cord, and I discussed some spinal cord injuries here. The ribs are responsible for protecting the heart, lungs, and some other anatomic structures.

The rib cage expands when you inhale and contracts when you exhale. This constant motion is one of the reasons that rib injuries can hurt so much. Anyway, while the rib cage can expand and contract, direct forces can damage the ribs (or sternum), when you land on your chest. 

Ribs are thinnest at the sides and towards the back, so while you may land on your chest, a rib could break in a different, weaker area. An interesting fact about bones is that the more forces that a bone is expected to support, the stronger it becomes. It's called Wolff's Law and it's why weight-bearing exercises are so important. Anyway, the reason I mention this is that even minor trauma can cause a rib injury--it can even happen from coughing or sneezing! 

Back to the trails, these are some of the injuries, from mild to serious, that can happen from falling on your chest:

• Rib contusion(s) [bruised rib(s)]
• Cracked rib(s)
• Broken rib(s) [fractures and breaks are the same thing]
• Flail chest
• Pneumothorax
• Hemothorax
• Cardiac contusion

Certainly, more internal chest injuries can occur, from traumatic aortic dissections (biggest blood vessel tearing), to diaphragm rupture (muscle that separates the chest cavity from the abdominal cavity tearing), and more, but these tend to happen from the forces seen in high speed motor vehicle crashes, not hiking or biking unless someone falls from a significant height. 

Looking at the first three injuries on that list--rib contusion through broken rib(s), the only way you'd be able to distinguish between these is that broken bones will hurt more than bruised or cracked bones, and with more ribs injured, pain with breathing will increase. So, if someone falls and hurts their ribs, and the pain isn't too bad, and breathing is easy, you're probably looking at a minor rib injury. Hurts to move at all? Hurts to breathe? Can you feel a "cracking" in the ribs? All pointing towards a broken rib or ribs. 

Most (and I'm making a generalization here) people with minor rib injuries should be able to get out of the woods under his or her own power. Of course, that all depends on if there are other injuries, if you've got a gnarly trail between you and the trail head, or many other factors, 

In the emergency department (if that's where you go), we don't put too much effort into finding broken ribs. Our main concern is making sure that the underlying lung is okay, and regular X-rays are decent at picking up those lung injuries. What regular X-rays are not great at is finding broken ribs, missing up to 50% in some cases. Some patient variables will have us use other imaging tests (such as CT scans, which have 10x the radiation of an X-ray), but for many otherwise healthy patients, rib contusions, cracked ribs and broken ribs are all treated the same--pain medication and time. Pain medication could mean Tylenol/acetaminophen, Advil/Motrin/ibuprofen or stronger stuff. 

Moving on to some of the more serious injuries, a "flail chest," happens when 3 ore more ribs break in more than one spot. These are pretty serious because significant forces were involved to break a rib in multiple places, and these cause severe problems with breathing. Called "paradoxical" movements, when the rest of the ribs are expanding to inhale, that broken segment goes inward. Flail chest injuries are also more likely to damage the underlying lung; with either pulmonary contusions (bruised lung) or pneumothorax--a collapsed lung.

Collapsed lungs, can happen spontaneously, but trauma is more likely cause. A pneumothorax can be small and managed without any specific intervention (other than probably a night in the hospital), but larger ones can be life threatening and require tubes to be inserted into the chest to get the air out. No, these chest tubes aren't something I'd be advocating to carry in your first aid kit, but being able to identify when someone might need one IS something you can learn. Essentially, the harder time a person is having to breathe, and the more pain someone is in, the more you should consider the possibility of a pneumothorax. Another sign of impending doom is called "tracheal deviation," and that's when the air outside the lung is expanding and squishing the lungs over to the point that they can perform their vital functions--getting oxygen in and carbon dioxide out, called a "tension pneumothorax." Paramedics could perform a "needle thoracostomy" which is stabbing a big needle into the chest to relieve the pressure. 

I bring up pneumothorax, tension pneumothorax, and also hemothorax--which is very similar to pneumothorax, except instead of air compressing the lung, it's blood, only for the sake of completeness.

Most trailside blunt chest trauma will be of the "is this a bruised rib or broken rib?" variety. But, if someone is really struggling to breathe and in significant pain, some of these other more serious injuries could be the cause.

One other serious injury, cardiac contusion, I'm saving for another day... but for now, we've covered rib and lung injuries, and it's time to get back outside!

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