Surgical Unit 2009

The Thorax or Chest
Region of the body between the neck and the

abdomen The framework of the wall- thoracic cage: vertebral column, ribs, IC spaces, sternum, costal cartilages Communication with the neck- thotacic outlet Separated from the abdomen by the diaphragm

The thorax or Chest
The cavity of the thorax: mediastinum and

laterally, pleurae and lungs The lungs are covered-thin membranevisceral pleura The inner surface of the chest wall- parietal pleura Between lungs and thoracic wall- pleural cavity

Physical examination
Detect the evidence of disease: Inspection Palpation Percussion Auscultation



Pectum excavatum

Pectus carinatum




Bluish discoloration Lack of O2 in the blood

 Exaggerated

anteroposterior and longitudinal curvature of the nails  Loss of angle between nail and nail bed (demonstrated by "Lovidond's diamond sign")  "Drumstick" or "parrot beak" appearance of the nail

Thoracic cage

Surface landmarks

Surface landmarks

Surface landmarks Thorax- anterior aspect
Suprasternal notch Sternal angle Xiphisternal joint Subcostal angle Costal margin Clavicle Ribs Axillary folds

Lines of orientation
Midsternal line Midclavicular line Anterior axillary line Posterior axillary line Midaxillary line Scapular line

Lines of orientation

Lines of orientation

Lines of orientation


Surface landmarks Thorax-posterior aspect
Spinous processes of the thoracic vertebrae Scapula: superior angle, inferior angle







Surface landmarks

Surface landmarks










Thoracic outlet syndrome
Compression of the neurovascular bundle Causes: cervical rib or trauma arm/neck Cervical rib- enlarged transverse process-C7:  free anterior end or connected to rib 1  fibrous band/joint Pressure symptoms on lower trunk of BP- pain

forearm/hand , hand muscle wasting. Arterial/venous involvement is less common

Thoracic outlet obtruction
Diagnosis- history and physical examination Ulnar nerve conduction studies- confirm dg. Treatment- decompress the TO-resecting

cervical rib

Injuries to the thoracic cage
Rib fractures Sternal fractures Flail chest

Rib fractures
The most common injuries- blunt chest

trauma Old people- minor trauma- rib fracture Fracture of the 1st rib- mark for severe lesions Fracture of the lower ribs- hepatic and splenic injury- hemoperitoneum Treatment- IC nerve blocks/epidural anesthesia Complications: hemothorax, pneumothorax, atelectasis, pneumonia.

Sternal fracture
Rare fracture- car steering wheel- abrupt

deceleration Associated injuries: pseudoaneurism, ruptured esophagus, myocardial contusion, ruptured bronchus, flail chest Diagnosis- mechanism of injury, physical examination, CXR- lateral view Treatment- pain killers

Flail chest
20% of pts. with severe blunt chest injury Multiple segmental rib fractures The stability of the chest is lost The flail segment- sucked in – inspiration/

driven out-expiration= paradoxical respiratory movements Paradoxical respiration- movement of air between the lungs- poor ventilation-poor oxygenation Treatment- pain relief, OTI with +p. if needed.

Chest trauma- case report
 A 32-year-old female patient suffered an automobile accident

which resulted:
 in left hemopneumothorax,  left pulmonary contusion and  double fractures extending from the third to the eighth left costal


as seen on chest X-rays and computed tomography scans of the chest.
 Tomography of the skull, cervical spine, abdomen, and pelvis, were

normal  Electrocardiogram and echocardiogram-WNL,  Tests for muscle enzymes and markers of myocardial necrosisWNL
 Water-sealed thoracic drainage was performed,

Case report
Mechanical ventilation- not needed

Chest deformation- surgical repair

Case report
Reduction of the fractures and fixation of the ribs

with steel wires, perforating the extremities of the ribs with a drill, passing the steel wire from one rib segment to another, and tying it.  A chest tube was inserted and left in place until the third day. The patient evolved to excellent pain control and improved respiratory dynamics. Postoperative X rays and tomography scans confirmed the favorable result of the surgical treatment .

Fractures 2nd.and 6th left rib with callus formation

Flail chest

Flail chest

Multiple rib fractures Pneumothorax

Rib fractures, left hemopneumothorax

Disorders of the pleural space
Spontaneous pneumothorax Iatrogenic pneumothorax Traumatic pneumothorax Tension pneumothorax Sucking chest wound

Spontaneous pneumothorax Iatrogenic pneumothorax Traumatic pneumothorax Tension pneumothorax “Sucking chest wound”

Pleural effusion
Collection of pleural fluid Etiology:
infection secondary from intra abdo. sepsis heart failure cirrhosis malignancy:

primary mesothelial tumor,  bronchogenic carcinoma,  metastatic carcinoma

Pleural effusion
Symptoms: chest pain, cough, dyspnea Signs: dullness on percussion, absent BS. on

Diagnosis: CXR, thoracocentesis-

culture/Gram’s stain, Rivalta reaction, cytology, biochemistry.

Blood accumulating within pleural space 50%-70% of the pts. with blunt/penetrating

chest trauma Minimal bleeding- observation Extensive bleeding- prompt action Diagnosis- mechanism of injury, symtoms, signs, CXR/CT Symtoms: chest pain, dyspnea/polipnea cyanosis, Signs: trauma mark, BS absent, BP, PR, capillary refill

Pleural drainage tube, Oxygen Pain killers Exploratory thoracotomy

massive initial drainage> 1000ml.  bleeding> 200ml/h

Case report
 Horner’s syndrome - triad of symptoms (miosis, ptosis, and

anhydrosis) resulting from disruption of the cervical sympathetic pathways .
 In blunt trauma, it is usually associated with carotid artery

 A case of Horner’s syndrome in a 22-year-old man after

blunt trauma to the neck and head unrelated to carotid artery dissection

Case report
A 22-year-old man was brought to the

emergency room after motorcycle fall, with history of transitory loss of conscience. At hospital, he was alert and orientated, the carotid pulses were symmetric, regular with no bruits. The chest and the abdomen had no signs of abnormalities.

Case report
The patient related moderate cervical pain but no neurological deficits were noticed except for the asymetric pupils that measured 5 mm on the right and 2 mm on the left side. Foto motor reflexes normal The left eyelid was 1–2 mm lower than the right , The extraocular movements were intact and the cranial nerve examination was

Assimetric pupils and left semiptosis

Case report
 The chest X-ray did not reveal any rib, sternal fractures or

mediastinal enlargement.  Skull computed tomography (CT) showed no abnormality so as the carotid ultrasonography Doppler and the angiotomography of the head and neck.  Cervical spine CT showed a fracture of left C7 transverse process  Chest CT disclosed a mediastinal hematoma extending to the left lung apex, exhibiting mass effect over surrounding structures without signs of aortic dissection .  A conservative management was adopted and the patient left the hospital three days later but still with the neurologic signs.  Follow up four weeks after discharge revealed a normal neurologic examination and no complaints.

Mediastinal hematoma extending to the left apex

Case report
Horner,s syndrome is an uncommon occurrence in

all age groups (0.08% of blunt trauma patients). Diagnosis is namely based on clinical findings, and after careful history and examination, the physician must decide whether further investigation is necessary. There is a wide variety of conditions that may cause this syndrome, postsurgical and iatrogenic causes comprise most of the cases. Penetrating neck injuries, cervical spine dislocation and birth trauma are the major factors that lead to traumatic injury to the

Case report
A history of trauma preceding these findings should prompt the clinician to consider that the carotid artery, which lies directly over the sympathetic chain in the neck, may have been injured, particularly if signs of head or neck trauma are present.  The investigation of choice considered by some authors is a magnetic resonance imaging and angiography scan of the head and neck.  Therefore, to exclude carotid injury the authors performed an ultrasonography Doppler and an angio-tomography what seems to be less invasive and with a high sensivitity.  The carotid dissection diagnosis implies an emergent condition that can lead, if misdiagnosed, to major catastrophes including massive ischemic stroke, even in a patient with minor symptoms at admission.

Case report
 In this case further investigation showed a mediastinal and

left lung apical hematoma which probably caused compression of the sympathetic ganglia, as the clinical findings appeared in first day of trauma.
 The fracture of the left C7 transverse process could explain

the cervical pain and hematoma
 Mediastinal hematoma due to trauma is associated with

sternal fracture, aortic dissection and extrapericardial cardiac tamponade.

Case report
 In this case, the patient was

hemodynamically stable and no surgical intervention was necessary. This report illustrates a condition that can be seen in the trauma emergency department and shows that a meticulous investigation with proper complementary exams is necessary because such signs can be just the "iceberg tip".

Horner’s syndrome is a very rare condition

after mild neck and chest trauma.
The understanding of this clinical entity

may help the surgeon to make a better differential diagnosis in trauma patients in whom correct and prompt diagnosis can be lifesaving.

Case report 2
 41-year-old male developed a hemothorax after sustaining a

stab wound in the right chest.  The patient was managed conservatively with thoracostomy tube drainage for 3 days and was subsequently discharged home.  Two weeks later the patient returned to the hospital with pleuritic chest pain and shortness of breath.  Imaging studies revealed a right-sided pleural effusion and an enlarged cardiac silhouette, which was consistent with pericardial effusion as per ultrasonography.  Thoracoscopic exploration revealed an enlarged heart, that following pericardiotomy drained 400 mL of frank blood. Subsequently, cardiac contractility improved, and no further bleeding was evident.

Case report 2
 The majority of patients suffering penetrating wounds to the

heart do not survive long enough to receive any medical assistance.  However, among those who reach the hospital, most cardiac injuries are discovered at admission and treated accordingly, whether initially decompressed with a subxiphoid pericardial window, or approached with an open thoracotomy.  Infrequently, a penetrating injury to the heart may be missed on initial assessment, the patient returning to the hospital a few weeks later with different degrees of hemopericardium.  Delayed hemopericardium after penetrating chest injury has been described in the literature, with the therapeutic approach invariably involving pericardiocentesis or open

Case report 2
Thoracoscopic pleuropericardial window

has been popularized as a way to drain different types of pericardial effusion:
 with the advantage of better exposure than the

traditional subxiphoid pericardial window, but without the morbidity associated with an open thoracotomy..

Case rerport 2
A 41-year-old male was seen in the emergency

department after a stab wound to the right chest. At admission the patient was in stable condition, with a CXR positive for hemopneumothorax, and without evidence of cardiac enlargement.  A thoracostomy tube was placed in the right hemithorax, and 3 days later the patient was discharged after the chest tube was removed and adequate lung expansion verified.

Case report 2
Two weeks later, the patient returned to the

emergency department complaining of increasing right-sided pleuritic chest pain and shortness of breath. Initial assessment revealed bilateral pleural effusions on CXR predominantly in the right side, as well as an enlarged cardiac silhouette . A thoracostomy tube was placed in the right chest again and connected to wall suction, draining 300 mL of serosanguineous fluid upon insertion.

CXR- right pleural effusion, increased cardiac size

Case report 2
Further imaging studies included a 2-D

echocardiogram, which was positive for pericardial effusion. A CT of the chest showed bilateral pleural effusions and fluid around the pericardium .  The patient was taken to the operating room for thoracoscopic exploration, with the presumptive diagnosis of bilateral loculated hematomas and associated hemopericardium.

Pleural effusions, fluid around pericardium

Case report 2
It is worth mentioning that during the first

admission, pericardial ultrasound was not performed on the patient, since at that point it was not yet readily available in the emergency department.
The operation was performed under general

anesthesia with double-lumen orotracheal intubation.
The patient was placed in the right lateral position

and draped in the standard fashion as for a formal

Case report 2
After deflation of the left lung, a thoracoscope

was introduced one finger breadth below the tip of the scapula, next to the posterior axillary line, in the 6th. IC space. Full assessment of the left hemithorax was performed, and 200 mL of blood was drained. During inspection, the heart was revealed to be enlarged, suggesting a retained hemopericardium after penetrating injury to the heart. After identifying the phrenic nerve, a 4 cm. longitudinal incision was made in the pericardial sac- 400 ml. of frank blood was drained from the pericardial cavity, with immediate evidence of improved

Case report 2
The camera was advanced and introduced

inside the sac, visualizing sparse clots and no active bleeding evident at that time.
After complete inspection of the left

hemithorax, anterior and posterior chest tubes were left in place for continuous drainage.

Case report 2
The patient was then placed in the left lateral

position to approach the right hemithorax.  Access was gained following the same landmarks used for the left chest, and with selective deflation of the left lung. Full inspection of the right hemithorax revealed sparse adhesions, and 400 mL of retained blood was removed. The adhesions were taken down, the chest cavity irrigated, and a chest tube left in place.

Case report 2
The patient tolerated the procedure and

was extubated on the first postoperative day. With drainage progressively decreasing, the thoracostomy tubes were removed four days later. Chest films revealed no reaccumulation of pleural or pericardial effusions. The patient was finally discharged with no major complaints, and 8 months after

Case report 3
A 65 years old female was a driver

involved in a front-impact car versus tree crash. The impact occurred slightly to the left of the car’s centerline, with a 15–20" intrusion of the tree into the engine compartment, displacing the front bumper, grille and engine. The steering wheel was bent, and because neither door could be opened, a rescue operation was conducted to remove the

Case report 3
Paramedics arrived within four minutes and found

the patient in the vehicle, complaining of severe chest pain and dyspnea. There was no chest wall asymmetry or paradoxical movement, and equal bilateral breath sounds were present. The patient was conscious and alert, recalling events and denying loss of consciousness.
 Initial vital signs: Pulse 124, respirations 24, BP


Case report 3
During the 14-minute extrication, the patient

continued to experience severe anterior chest pain and increasing dypsnea. She became pale and more tachycardic. Hypotension developed, with palpable BP dropping to 80 systolic at approximately minute 10 of the extrication. Because the patient was becoming unstable, rescuers expedited their efforts and decided to perform a rapid extrication maneuver once the door was removed.

Case report 3
 Approximately one minute prior to successful extrication,

the patient developed agonal breathing and her carotid pulses were lost.  Once the door was removed, the patient was moved onto a long backboard, CPR was performed, and the patient was intubated and transported to a Level 1 trauma center.  On arrival at the trauma center, resuscitation proceeded rapidly.  A focused assessment sonogram for trauma showed a pericardial tamponade.  Surgeons performed an immediate thoracotomy and pericardiotomy, which revealed a right atrial rupture .  Resuscitative efforts failed to return organized heart activity, and the patient died.

Blunt cardiac injuries
 (BCI) is a spectrum of injuries ranging from asymptomatic

myocardial contusion to cardiac chamber rupture and death.  Mechanisms by which BCI may occur include motor vehicle crashes, falls from heights, direct blows to the chest and explosions.  The most common mechanism of BCI is an MVC.  Occasionally an isolated direct blow to the chest may cause ventricular fibrillation and death, a condition termed  commotio cordis.     Differential dg.: hemorrhage, tension pneumothotrax, hypoxia.

Case report 3
Rupture of a cardiac chamber, coronary

artery or intrapericardial portion of a great vessel leads to cardiogenic shock from pericardial tamponade and rapid death.
Cardiac rupture is associated with a 60–

100% mortality rate in the literature.    

Large tear in the right atrium

BCI is difficult to diagnose without the aid of

echocardio. Prehospital providers should inspect the scene of the injury and surrounding circumstances, as well as conduct a thorough physical exam. Patients may complain of chest pain, shortness of breath or palpitations. Vital signs may be completely normal with minor contusions, or demonstrate tachycardia, arrhythmia or hypotension in more severe forms of injury.

Although physical examination is non-

specific, sternal tenderness or ecchymoses may be found. On auscultation, the finding of a murmur, rub or muffled heart sounds should raise suspicion of BCI, but these findings aren’t typically present.  Because BCI is often associated with other injuries to the thorax, subcutaneous emphysema, flail chest and bony crepitus secondary to rib fractures may be present. 

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