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Chapter 21: The Thorax and
Abdomen
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
Preventing Injuries to the Thorax
and Abdomen
• Utilize appropriate protective equipment
– Imperative in collision sports
• Abdominal musculature strengthening to
protect underlying viscera
• Be sure hollow organs are empty prior to
competition
– Reduces chance of injury to them
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Assessment of the Thorax
Abdomen
• Injuries to this region can produce lifethreatening situations
• ATC’s evaluation should focus on signs and
symptoms that indicate potentially lifethreatening conditions
• Continually monitor breathing, circulation
and any indication of internal bleeding or
shock
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• History
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What happened to cause this injury?
Was there direct contact or a direct blow?
What position were you in?
What type of pain, was it immediate or gradual,
location(s)?
Difficulty breathing?
What positions are most comfortable?
Do you feel faint, light-headed or nauseous?
Chest pain?
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Hear or feel snap, crack or pop in your chest?
Muscle spasms?
Blood or pain during urination?
Was the bladder full or empty?
How long has it been since you last ate?
Is there a personal or family history of any
heart, abdominal problems or other diseases
involving the abdomen and thorax?
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• Observations
– Is the athlete breathing? Are they having difficulty
breathing? Does breathing cause pain?
– Is the athlete holding the chest wall?
– Is there symmetry of the chest during breathing?
– If the athlete’s wind was knocked out, is normal
breathing returning? How rapidly?
– Body position
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– Check for areas of discoloration, swelling or
deformities
• Around umbilicus = intra-abdominal bleed
• Flanks = swelling outside the abdomen
– Protrusion or swelling in any portion of
abdomen (internal bleeding)
– Does the thorax appear to be symmetrical?
– Are the abdominal muscles tight and guarding?
– Is the athlete holding or splinting a particular
part?
– Monitor vital signs (pulse, respiration, BP)
• Rapid weak pulse or drop in BP is an indication of a
serious internal injury (involves blood loss)
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• Palpation
– Thorax
• Check for symmetry of chest wall movement and
search for areas of tenderness
• Palpate along ribs and intercostal spaces as well as
costochondral junctions – locate points of tenderness
– Abdomen
• Patient should have arms at side, knees and hips
flexed to relax abdomen
• Feel for guarding and tenderness, rigidity (internal
bleeding)
• Be aware of possibility of referred pain
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
Recognition and Management of
Specific Injuries
• Rib Contusion
– Cause of Injury
• Blow to the rib cage can bruise ribs, musculature or
result in fracture
– Signs of Injury
• Painful breathing (particularly if muscles are
involved)
• Point tenderness; pain with rib compression
– Care
• RICE and NSAID’s
• Rest and decrease in activity
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• Rib Fractures
– Cause of Injury
• Caused by a direct blow or the result of a violent
muscular contraction
• Can be caused by violent coughing and sneezing
– Signs of Injury
• History is critically important
• Pain with inspiration, point tenderness and possible
deformity with palpation
– Care
• Refer for X-rays
• Support and rest; brace
• Generally heals in 3-4 weeks
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• Costal Cartilage Injury
– Cause of Injury
• Result of a direct blow to the anterolateral aspect of
the rib cage
– Signs of Injury
• Localized pain in region of costochondral junctions
• Pain with movement; difficulty with breathing
• Point tenderness and possible deformity
– Care
• Rest and immobilization
• Healing may take 1-2 months
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© 2005 The McGraw-Hill Companies, Inc. All rights reserved.
• Intercostal Muscle Injuries
– Cause of Injury
• Muscles are subject to contusions and strains
• Occur most often from direct blows or sudden
torsion of the trunk
– Signs of Injury
• Pain occurs on active motions; pain with inspiration
and expiration, coughing, sneezing and laughing
– Care
• Immediate pressure and application of cold for
approximately 20 minutes
• After hemorrhaging is controlled, immobilize the
injury to make the athlete comfortable
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• Lung Injuries
– Cause of Injury
– Pneumothorax • pleural cavity becomes filled with air, negatively
pressurizing the cavity, causing a lung to collapse
– Tension Pneumothorax
• Pleural sac on one side fills with air displacing lung
and heart, compressing the opposite lung
– Hemothorax
• Blood in pleural cavity causes tearing or puncturing
of the lungs or pleural tissue
– Traumatic Asphyxia
– Result of a violent blow or compression of rib cage
– Causes cessation of breathing and immediate medical
attention
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– Signs of Injury
• Breathing difficulty, shortness of breath, chest pain
on side of injury
• Coughed up blood, cyanosis, and potentially shock
• With collapse of lung medical attention is required
immediately
– Care
• Each of these conditions are medical emergencies
and require immediate attention
• Transport athlete to hospital immediately
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• Sudden Death Syndrome in Athletes
– Cause of Condition
• Hypertrophic cardiomyopathy- thickening of cardiac
muscle w/ no increase in chamber size
• Anomalous origin of coronary arteries
• Marfan’s syndrome- abnormality in connective
tissue results in weakening of aorta and cardiac
vessels
• Series of additional cardiac causes
• Non-cardiac causes include drugs and alcohol,
intracranial bleeding, obstructive respiratory disease
– Signs of Condition
• Most do not exhibit any signs prior to death
• May exhibit chest pain, heart palpitations, syncope,
nausea, profuse sweating, shortness of breath,
malaise and/or fever
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– Care
• Immediate medical attention is necessary – life
threatening condition
– Prevention
• Counseling and screening are critical in early
identification and prevention of sudden death
• Screening questions should address the following
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History of heart murmurs
Chest pain during activity
Periods of fainting during exercise
Family history
Thickening of heart or history of Marfan’s syndrome
• Cardiac screening - electrocardiograms and
echocardiograms may be needed to determine
existing pathology
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• Breast Problems
– Cause of Injury
• Constant uncontrolled movement (particularly in
large breasted women)
• Stretching of Cooper’s ligament
• Runner’s and cyclist’s nipple
– Management
• Females should wear well-designed bra that has
minimum elasticity and allows for little movement
• Special plastic cup-type brassieres may be required
in sports with high levels of physical contact
• Use of an adhesive bandage can be used to prevent
runner’s nipple
• Wearing a windbreaker can prevent cyclist nipple
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Injuries to the Abdominal Wall
• Abdominal Muscle Strain
– Cause of Injury
• Result of sudden twisting or reaching of trunk,
tearing abdominal musculature
• Contusions of Abdominal Wall
– Cause of Injury
• Caused by a compressive force - generally occurring
in collision sports
• Extent of injury depends on whether force is blunt
or penetrating
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– Signs of Injury
• May cause a hematoma to develop under fascia of
surrounding muscle tissue
• Swelling may cause pain and tightness w/in the region
– Care
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Cold pack and compression
Be sure to check for signs of internal injuries
Conservative management
Exercise should be kept pain free
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• Hernia
– Cause of Injury
• Protrusion of abdominal viscera through portion of
abdominal wall (congenital or acquired)
• Inguinal vs. femoral hernias
• Complications and strangulated hernias
– Signs of Injury
• Acquired hernia occur when natural weakness is
further aggravated by a direct blow or strain
– History of direct blow to groin area, pain and prolonged
discomfort, superficial protrusion with pain increasing
with coughing & reported pulling sensation in groin area
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– Care
• Most physicians prefer athlete to refrain from hard
physical activity until surgically repaired
• Mechanical devices are not suitable for athletics due
to friction and irritation they produce
• While exercise is thought to be beneficial with
regards to strengthening, that is not the case
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• Blow to Solar Plexus
– Cause of Injury
• Transitory paralysis of the diaphragm due to blow to
the middle portion of the abdomen
– Signs of Injury
• Stops respiration and leads to anoxia
• Generally transitory
– Care
• Must help athlete overcome apprehension
• Use short inspirations and long expirations
• Calm athlete, prevent hyperventilation, blow into a
paper bag
• ATC should question possibility of internal injury
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• Stitch in the Side
– Cause of Injury
• Idiopathic condition with obscure cause and several
hypotheses
– Constipation, intestinal gas, overeating, diaphragmatic
spasm, poor conditioning, lack of visceral support and
weak abdominals, distended spleen, breathing techniques
resulting in lack of oxygen, ischemia of diaphragm or
intercostal muscles
– Signs of Injury
• Cramp-like pain that develops on either the right or
left costal angle during hard physical activity
– Management
• Relaxation of the spasm
– Stretch arm on affected side as high as possible
– Flex trunk forward on the thighs
• Additional problems may warrant further study
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• Injury of the Spleen
– Cause of Injury
• Result of a direct blow
• Infectious mononucleosis (causing an enlarged
spleen)
– Signs of Injury
• Indications of a ruptured spleen involve history of a
direct blow, signs of shock, abdominal rigidity,
nausea, vomiting
• Kehr’s sign
• Ability to splint self may produce delayed
hemorrhaging - easily disrupted resulting in internal
bleeding
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– Care
• Conservative treatment involves 1 wk of
hospitalization and a gradual return to activity
• Surgery will result in three months of recovery
while removal of spleen will result in a 6 month
removal from activity
• In cases of mononucleosis athlete may resume
training in 3 weeks if spleen not enlarged and if
there is no fever
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• Kidney Contusion
– Cause of Injury
• Result of an external force (force and angle dependent)
• Susceptible to injury due to normal distention of blood
– Signs of Injury
• May display signs of shock, nausea, vomiting, rigidity
of back muscles and hematuria (blood in urine)
• Referred pain (costovertebral angle posteriorly
radiating forward around the trunk)
– Care
• Monitor status of urine (hematuria) - refer if necessary
• 24 hour hospitalization and observation with a gradual
increase in fluid intake
• Surgery may be required if hemorrhaging continues
• 2 weeks of rest and close surveillance following initial
return to activity is necessary
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• Liver Contusion
– Cause of Injury
• Blunt trauma - right side of rib cage
• More susceptible if enlarged due to illness (hepatitis)
– Signs of Injury
• Hemorrhaging and shock may present
• May require immediate surgery
• Presents with referred pain in right scapula, shoulder
and substernal area and occasionally in left anterior
side of chest
– Care
• Referral to a physician for diagnosis and treatment
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• Appendicitis
– Cause of Injury
• Inflammation of the vermiform appendix (chronic or
acute)
• Result of blockage, lymph swelling, or carcinoid tumor
• Early stages present as a gastric complaint that
gradually develops from red swollen vessel to a
gangrenous structure that can rupture into bowels
causing peritonitis
– Signs of Injury
• Mild to severe pain in lower abdomen associated with
nausea, vomiting and low grade fever
• Pain may localize in lower right abdomen (McBurney’s
point)
– Care
• Surgical intervention is often necessary (particularly if
it is resulting in an obstructed bowel = life threatening)
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• Injuries to the Bladder
– Cause of Injury
• Blunt force to the lower abdomen may cause injury
to urinary bladder if distended with urine
• Hematuria is often associated with contusion of
bladder during running (runner’s bladder)
– Signs of Injury
• Pain, discomfort of lower abdominal region,
abdominal rigidity, nausea, vomiting, shock,
bleeding from the urethra, increased quantity of
bloody urine
• Athlete should be instructed to monitor urine
• Inability to urinate will present in case of ruptured
bladder
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• Scrotal/Testicular Contusion
– Cause of Injury
• Result of blunt trauma and contusion to the
vulnerable and sensitive scrotum
– Signs and Symptoms
• Hemorrhaging, fluid effusion, muscle spasm, severe
pain (disabling)
• May cause nauseating, disabling and painful
condition
– Care
• Place athlete on side with knees to chest
• Apply cold pack as pain subsides
• If pain persist after 15-20 minutes referral will be
necessary
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• Gynecological Injuries
– Low incidence of injury in sports
– Most common occurrence involve contusion of
external genitalia (vulva - including the labia,
clitoris and the vaginal vestibule)
– Signs and Symptoms
• Hematoma results from contusion - may also
involve pubic symphysis resulting in osteitis pubis
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