CAQ REVIEW

Chest Trauma in Athletes

Rei Dallin Thomas, DO and Arthur Jason De Luigi, DO

Background the rapid diagnosis of serious sideline conditions, like pneu-

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While emergent chest trauma in athletes is concerning, it
is relatively uncommon (1). As extreme sports become more
mainstream, the incidence of life-threatening chest trauma
requiring immediate clinical care will likely rise. Non-
life-threatening chest trauma, a much more common occur-
rence, significantly influences the return to play (RTP) (~42%
of athletes return to sport within 1 wk) (2).
Risk Factors
The predominant risk factors for chest trauma remain
rapid deceleration and direct impact to the chest wall, usually
due to impact with another competitor, fixated sporting
equipment (goal post, etc.), or projectile (baseball, lacrosse
ball, etc.). Frequently, athletes that experience chest injuries
lack sufficient external protection. Injuries ranging from
runner’s nipples to pericardial effusion can, in some cases, be
prevented by better protection.
Treatment
More than other musculoskeletal injuries suffered during
sport, traumatic chest injuries represent a significant mortality
risk. All of the injuries discussed in this article, with the ex-
ception of commotio cordis, respond well to principles discussed
in Advanced Cardiac Life Support (ACLS). If a traumatic
chest injury is suspected on the field of play, these ACLS
principles should be employed immediately along with the
application of an automated external defibrillator (AED).
Prompt transfer to an advanced center of care should ensue.
With advancement in technology and transportability, ultra-
sound is emerging as a reliable diagnostic tool that can aid in
mothorax and pericardial effusions, along with less urgent
injuries, like rib and clavicular fractures (3). Most conditions
have the ability to be monitored and, if needed, addressed with
surgical correction.
Return to Play
The overall goal for managing athletes with chest trauma
is to return them to play. Once treatment is completed, RTP
decisions are heavily dependent on the severity and stability
of each athlete (see Tables 1 and 2).
Conclusions
Chest trauma suffered during athletic play provides the full
spectrum of consequences because they may vary from minor
to emergent to fatal injuries. It is imperative that the team
physician be able to provide appropriate evaluation and
treatment. The management of each athlete’s condition must
be driven by his/her stability.
The authors declare no conflict of interest and do not
have any financial disclosures.
References
1. Nathens AB, Fantus RJ. National Trauma Data Bank: annual report. Chicago,
IL; American College of Surgeons; 2009.
2. Johnson BK, Comstock RD. Epidemiology of chest, rib, thoracic spine, and
abdomen injuries among United States high school athletes, 2005/06 to
2013/14. Clin. J. Sport Med. 2017; 27:388Y93.
3. Feden JP. Closed lung trauma. Clin. Sports Med. 2013; 32:255Y65.

Department of Physical Medicine and Rehabilitation, MedStar Georgetown

University Hospital/National Rehabilitation Hospital, Washington, DC

Address for correspondence: Rei Dallin Thomas, DO, Department of

Physical Medicine and Rehabilitation, MedStar Georgetown University
Hospital/National Rehabilitation Hospital, 37th and O St, N.W.,
Washington, DC 20057; E-mail: dal.boricua@gmail.com.
Column Editor: Nailah Coleman, MD, FAAP, FACSM; E-mail:
ncoleman@childrensnational.org.

1537-890X/1708/251Y253
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Table 1.
Emergent chest injuries.
Emergent Injury Mechanism Diagnosis Treatment RTP

Pneumothorax Spontaneous or Clinical Stable Resolution on CXR

Posttraumatic where Chest pain, SOB, and Observation if Avoid flying for 2 wk
air is trapped between decreased breath G20% & Serial CXR after resolution
visceral pleura of lung sounds or hyper-resonant Unstable
and parietal pleura lung fields with percussion Needle decompression
of chest wall may be present. (if tension) at 2nd
Tension: deviated trachea Intercostal space,
away from injury, mid-clavicular line,
distended neck veins side of injury
Imaging Chest Tube
CXR, US, or *CT
Pericardial Effusion/ Increased accumulation Clinical Stable ECHO shows no
Cardiac Tamponade of fluid in the Chest pain and dyspnea Observation signs of active
pericardial sac that worsen while Unstable disease process
lying flat but improve Emergent drainage
when upright,
hypotension, JVD, and
muffled heart sounds.
ECG V electrical alternans
Imaging
CXR V boot/water
bottle shaped heart
*ECHO V Collapse
of R. Ventricle
CT/MRI
Commotio cordis Initiation of an Collapse of athlete ACLS guidelines for Full cardiac evaluation to r/o
arrhythmia following following direct cardiac arrest other possible causes
blunt trauma to the trauma to chest Use of improved
precordium before Arrhythmia noted on chest protection
peak of T wave AED (predominantly V-fib)
Autopsy needed to
exclude other
potential causes
Flail chest Segmental rib fractures Clinical Aggressive pain control Healed fractures w/o
(at least 2 locations Paradoxical May require ventilation any respiratory
on same rib) of at breathing Surgery is considered compromise
least 3 ribs Imaging
CXR
Sternoclavicular Dislocation of SC Clinical Anterior Full course of
(SC) dislocation joint in an anterior Localized pain Reduction immobilization and no
or posterior direction and swelling Immobilization  4Y6 wk continued evidence
following blunt force Imaging w/clavicular strap of instability
CXR *CT Posterior
Reduction under general
anesthesia ASAP
Immobilization w/figure
of 8 strap  4Y6 wk

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Table 2.
Urgent/subacute chest injuries.

Urgent/Subacute
Injury Mechanism Diagnosis Treatment RTP
Pulmonary Injury to lung parenchyma Clinical Supportive care with No specific guidelines.
contusion leading to accumulation Normal examination OR analgesia and Decision is based on
of fluid in alveolar spaces SOB, chest pain, supplemental oxygen symptom resolution
following blunt trauma tachypnea, decreased if needed that generally resolves
breath sounds, within 7 d3
or crackles
Imaging
CXR
*CT
Cardiac contusion Bruising of the Clinical Expectant management, No specific guidelines.
cardiac muscle Vague chest arrhythmias and heart Decision is based on
following high-velocity pain and/or palpitations failure can be seen symptom resolution
trauma leading Elevated troponins and absence of
to structural changes Imaging complications
ECG, Echo, MRI
Rib fracture Fracture of one of Clinical Rule out emergent 3 wk of noncontact
the 12 ribs Focal tenderness, associated conditions activity
bony crepitus, or Pain management (oral 6Y8 wk wearing
mobile rib segments and nerve blocks) rib protector
Imaging during contact
CXR, US, bone scan
Clavicle fracture Fracture of the clavicle Clinical Nonoperative 8Y12 wk if managed
in distal, middle (MC), Athlete holding Sling immobilization non-operatively
or proximal thirds arm against chest, w/ROM for 1Y3 wk Operative management
tenting, crepitus, Operative is on case-by-case basis
palpable segmental Neurovascular compromise,
movement open fracture, or
Imaging complete displacement
CXR
Runner’s nipples Repetitive Friction Raw or bloody nipples Supportive care with As tolerated by athlete
Injuries to the petroleum jelly,
exposed nipples bandage, or tape layer
Consider topical
ABX if infected
Costochondritis Inflammation to the Pain with respiration Supportive care with As tolerated by athlete
connecting cartilage and palpation analgesics (NSAIDs)
between ribs as needed
and sternum

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