Chapter 26: The Thorax and Abdomen

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Chapter 26 The Thorax and Abdomen
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Assessment of the Thorax Abdomen

• Injuries to this region can produce
  life-threatening situations
• ATCs evaluation should focus on signs and
  symptoms that indicate potentially
  life-threatening conditions
• Continually monitor breathing, circulation and
  any indication of internal bleeding or shock

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• History
• 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 athletes wind was knocked out, is normal
  breathing returning? How rapidly?
• Body position
• Thorax injury - leaning towards side that is
  injured and splinting area w/ hand
• Abdominal injury - lie on side w/ knees pulled to
  chest
• Male external genitalia injury - lying on side
  holding scrotum

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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?
• Blood -
• Bright red lung injury
• Vomiting bright red and frothy injury to
  esophagus and stomach although blood may be
  swallowed from mouth and nose

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• Cyanosis - respiratory difficulty
• Pale, cool, clammy skin indicates low BP
• Monitor vital signs (pulse, respiration, BP)
• Rapid weak pulse or drop in BP is an indication
  of a serious internal injury (involves blood
  loss)
• 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
• AP pressure to rib cage to assess for fracture
• Transverse pressure assesses costochondral
  junction
• Semi-reclining position is useful if athlete is
  having difficulty breathing

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• Abdomen
• Patient should have arms at side, knees and hips
  flexed to relax abdomen
• Four abdominopelvic quadrants (move clockwise
  starting from upper right quadrant)
• Feel for guarding and tenderness, rigidity
  (internal bleeding)
• Rebound tenderness
• Assess each organ (if possible)
• Auscultation
• Heart Sounds
• Lubbdupp (may hear 3rd sound in children)
• Listen for murmur (abnormal period due to valve
  insufficiency)
• Functional murmur versus pathogenic condition

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• Breath sounds
• Should be consistent
• Abnormal patterns
• Cheyne-Stokes breathing (rate changes over 1-3
  minutes)
• Biots breathing - normal rate followed by
  cessation
• Apneustic breathing - pauses in respiratory cycle
  at full inspiration
• Wheeze or rhonchi or rales
• Perform over apex, centrally and at base of each
  lung, both anteriorly and posteriorly
• Bowel sounds
• Liquid-like gurgling due to peristalsis

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• Percussion
• Place fingers on abdomen and strike with other
  hand
• Solid organ dull sound
• Hollow organ tympanic or resonant sound

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Recognition and Management of Specific Injuries

• Rib Contusion
• Etiology
• Blow to the rib cage can bruise ribs, musculature
  or result in fracture
• Signs and Symptoms
• Painful breathing (particularly if muscles are
  involved)
• Point tenderness pain with rib compression
• Management
• RICE and NSAIDs
• Rest and decrease in activity

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• Rib Fractures
• Etiology
• Caused by a direct blow or the result of a
  violent muscular contraction
• Can be caused by violent coughing and sneezing
• Signs and Symptoms
• History is critically important
• Pain with inspiration, point tenderness and
  possible deformity with palpation
• Management
• Refer for X-rays
• Support and rest brace

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• Costochondral Separation
• Etiology
• Result of a direct blow to the anterolateral
  aspect of the rib cage
• Signs and Symptoms
• Localized pain in region of costochondral
  junctions
• Pain with movement difficulty with breathing
• Point tenderness and possible deformity
• Management
• Rest and immobilization
• Healing may take 1-2 months

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• Sternum Fractures
• Etiology
• Result of high impact blow to the chest
• May also cause contusion to underlying cardiac
  muscle
• Signs and Symptoms
• Point tenderness over the sternum
• Pain with deep inspiration and forceful
  expiration
• Signs of shock, or weak rapid pulse may indicate
  more severe injuries
• Management
• X-ray and monitor athlete for signs of trauma to
  the heart

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• Muscle Injuries
• Etiology
• Muscles are subject to contusions and strains
• Occur most often from direct blows or sudden
  torsion of the trunk
• Signs and Symptoms
• Pain occurs on active motions pain with
  inspiration and expiration, coughing, sneezing
  and laughing
• Management
• Immediate pressure and application of cold for
  approximately one hour
• After hemorrhaging is controlled, immobilize the
  injury to make the athlete comfortable

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• Breast Injury
• Etiology
• Constant uncontrolled movement (particularly in
  large breasted women)
• Stretching of Coopers ligament
• Runners and cyclists 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
  runners nipple
• Wearing a windbreaker can prevent cyclist nipple

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• Breast Cancer
• Should be of great concern to all women
• Most common cause of cancer in females
• Females over 20 years old should perform breast
  self-examinations every month and receive a
  clinical evaluation every 3 years
• Not all lumps are cancer -- may be benign fibrous
  cyst
• Mammograms are not recommended until age 40

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• Lung Injuries
• Etiology
• Pneumothorax -
• pleural cavity becomes filled with air,
  negatively pressurizing the cavity, causing a
  lung to collapse
• Will produce pain, difficulty with breathing and
  anoxia
• Tension Pneumothorax
• Pleural sac on one side fills with air displacing
  lung and heart, compressing the opposite lung
• May cause shortness of breath, chest pain,
  absence of breath sounds, cyanosis, distention of
  neck veins, deviated trachea
• Hemothorax
• Blood in pleural cavity causes tearing or
  puncturing of the lungs or pleural tissue
• Painful breathing, dypsnea, coughing up frothy
  blood and signs of shock

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• Traumatic Asphyxia
• Result of a violent blow or compression of rib
  cage
• Causes cessation of breathing
• Signs include purple discoloration of the trunk
  and head, conjunctivas of the eye
• Condition requires immediate mouth to mouth
  resuscitation
• Management
• Each of these conditions are medical emergencies
  and require immediate attention
• Transport athlete to hospital immediately

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• Hyperventilation
• Etiology
• Rapid rate of ventilation due to anxiety induced
  stress or asthma
• Develop a decreased amount of carbon dioxide
  relative to oxygen
• Signs and Symptoms
• Athlete has difficulty getting air in and seems
  to struggle with breathing
• Panic state with gasping and wheezing
• Management
• Decrease rate of carbon dioxide loss
• Slow respiration rate and alter respiration
  techniques
• Breath into a bag
• Normal respiration should return within 1-2
  minutes, initial cause must be determined

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• Heart Contusion
• Etiology
• Result of compression between sternum and spine
• Most severe consequence would involve an aortic
  rupture
• Signs and Symptoms
• Severe shock and heart pain
• Heart may exhibit arrhythmias causing a decrease
  in cardiac output, followed by death if medical
  attention is not administered
• Management
• Immediate referral to an emergency room
• Prepare to administer CPR and treat for shock

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• Sudden Death Syndrome in Athletes
• Etiology
• Hypertrophic cardiomyopathy- thickening of
  cardiac muscle w/ no increase in chamber size
• Anomalous origin of coronary arteries
• Marfans 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 and Symptoms
• 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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• Management/Prevention
• Counseling and screening are critical in early
  identification and prevention of sudden death
• Screening questions should address the following
• History of heart murmurs
• Chest pain during activity
• Periods of fainting during exercise
• Family history
• Thickening of heart or history of Marfans
  syndrome
• Cardiac screening - electrocardiograms and
  echocardiograms

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• Kidney Contusion
• Etiology
• Result of an external force (force and angle
  dependent)
• Susceptible to injury due to normal distention of
  blood
• Signs and Symptoms
• 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)
• Management
• Monitor status of urine (hematuria) - refer if
  necessary
• 24 hour hospitalization and observation with a
  gradual increase in fluid intake if an
• 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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• Kidney Stones
• Etiology
• Unknown cause
• Signs and Symptoms
• Calculus - stone composed of crystalline mineral
  salts that forms in urinary tract
• Painful condition
• Management
• Usually passes through the urethra and is
  excreted (very painfully)

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• Contusion of Ureters, Bladder and Urethra
• Etiology
• Blunt force to the lower abdomen may avulse
  ureter or contuse/rupture bladder
• Hematuria is often associated with contusion of
  bladder during running (runners bladder)
• Injury to the urethra (more common in males) may
  produce severe perineal pain and swelling
• Signs and Symptoms
• Pain, discomfort of lower abdominal region,
  abdominal rigidity, nausea, vomiting, shock,
  bleeding from the urethra, increased quantity of
  bloody urine,
• Inability to urinate will present in case of
  ruptured bladder

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• Contusion of Ureters, Bladder and Urethra
• Signs and Symptoms (continued)
• Referred pain to low back and trunk as well as
  upper thigh region anteriorly and suprapubically
• Prevention
• Check periodically for blood in urine
• Empty bladder prior to practice or competition
• Wear protective equipment

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• Cystitis
• Inflammation of the bladder associated with a
  urinary tract infection
• May involve kidney, prostate, and urethra
• Causes frequent, painful urination, chills and
  fever
• Antibiotics are required for treatment
• Urinary Tract Infections
• Caused by staphylococcus bacteria or chlamydia
• Causes burning and painful urination and requires
  antibiotics for treatment
• Can be prevented through increased fluid intake,
  practicing sanitary bowel and bladder habits,
  washing genitals before intercourse, emptying the
  bladder after intercourse, removal of
  contraceptive diaphragms and sponges following
  intercourse

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• Urethritis
• Inflammation of the urethra -- generally caused
  by gonorrhea or by other nongonococcal organisms
• Symptoms include pain on urination along with
  urethral discharge
• Treated with antibiotic therapy

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• Gastrointestinal Bleeding
• Etiology
• Distance running, gastritis, iron-deficiency
  anemia, ingestion of aspirin or NSAIDs, stress,
  bowel irritation, colitis
• Signs and symptoms
• Blood in stool
• Abdominal pain, watery stool (w/pus) dehydration,
  intermittent fever (if colitis is involved)
• Management
• Refer to physician is bleeding is occurring

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• Liver Contusion
• Etiology
• Blunt trauma - right side of rib cage
• More susceptible if enlarged due to illness
  (hepatitis)
• Signs and Symptoms
• 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
• Management
• Referral to a physician for diagnosis and
  treatment

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• Pancreatitis
• Etiology
• Inflammation of pancreas (acute or chronic) due
  to obstruction of pancreatic duct
• Acute conditions may lead to necrosis,
  suppuration, gangrene and hemorrhage
• Chronic cases may develop scar tissue, causing
  malfunction -- may develop due to chronic
  alcoholism
• Signs and Symptoms
• Acute epigastric pain causing vomiting, belching,
  constipation and potentially shock
• Tenderness and rigidity to palpation
• Chronic cases may result in jaundice, diarrhea
  and mild to moderate pain that radiates into the
  back

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• Pancreatitis (continued)
• Management
• In acute cases, re-hydration is necessary along
  with pain reduction, treatment of shock,
  reduction of pancreatic activity through
  medication
• Surgery if the duct is blocked
• Chronic cases require large doses of analgesics,
  pancreatic enzymes and modified diet

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• Indigestion (Dyspepsia)
• Etiology
• Some athletes develop food idiosyncrasies which
  cause them distress after eating
• Reactions before competition
• Emotional stress, esophageal and stomach spasms,
  or inflammation of mucous linings in stomach and
  esophagus
• Signs and Symptoms
• Increased HCl secretion, nausea, and flatulence
• Management
• Elimination of irritating foods, development of
  regular eating habits, avoidance of anxieties
  that cause gastric distress
• If problems persist or athlete appears high
  strung and nervous -- follow-up with a physician
  is needed

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• Vomiting
• Etiology
• Result of some irritation, most often in the
  stomach
• Stimulates vomiting center of the brain, causing
  a series of forceful diaphragm and abdominal
  contractions to compress stomach
• Management
• Antinausea medications should be administered
• Fluids to prevent dehydration (by mouth or
  intravenously depending on the situation)

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• Food Poisoning (Gastroenteritis)
• Etiology
• Ranges from mild to severe
• Caused by infectious microorganisms that
  contaminate food particularly during warm weather
  and periods of improper refrigeration
• Signs and Symptoms
• Nausea, vomiting, cramps, diarrhea and anorexia
• Usually subsides within 3-6 hours (staph.
  infection)
• Salmonella infection may last 24-48 hours or more
• Management
• Rapid replacement of fluids lost
• Bed rest in all but mild cases
• Nothing should be given by mouth if vomiting and
  nausea persist
• Re-introduce easy food first

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• Peptic Ulcer
• Etiology
• Acids destroy mucous lining of stomach or small
  intestine
• Occurs in individuals with long periods of severe
  anxiety
• Signs and Symptoms
• Gnawing pain, localized to gastric region
• Appears 1-3 hours following a meal
• Dyspepsia, heartburn, nausea, vomiting, w/ pain
  lasting minutes rather than hours
• Management
• Antacids if pain persists
• If hemorrhaging or perforation occurs, surgery
  may be required

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• Gastroesophageal Reflux
• Etiology
• Reflux or backward flow of the acidic gastric
  contents into the esophagus (malfunctioning
  esophageal sphincter)
• Result of a hiatal hernia w/ incidence increased
  with activity
• Repeated bouts can result in inflammation of
  lower esophagus
• Signs and Symptoms
• Heartburn-like retrosternal pain - similar to
  angina pectoris sensation
• Burning feeling with sour liquid taste in throat
• Management
• Medication first, surgery if condition persists

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• Diarrhea
• Etiology
• Abnormal, loose stool or passage of fluid,
  unformed stool
• Acute or chronic
• Caused by a problem in diet, inflammation of the
  intestinal lining, GI infection, ingestion of
  certain drugs and psychogenic factors
• Signs and Symptoms
• Abdominal cramps, nausea, vomiting and frequent
  elimination of stools
• Loss of appetite, and a light brown or gray,
  foul-smelling stool
• Extreme weakness caused by dehydration

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• Diarrhea (continued)
• Management
• Determine cause (irritant, infection, or
  emotional upset)
• ATC can treat less severe cases by omitting
  certain foods from athletes diet
• Have athlete consume bland food that does not
  irritate system
• Provide pectins 2-3 times daily to absorb excess
  fluid

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• Constipation
• Etiology
• Failure of the bowels to evacuate feces
• Causes include, lack of abdominal tone,
  insufficient moisture in the feces, lack of
  roughage and bulk in diet to stimulate
  peristalsis, poor bowel habits, nervousness,
  anxiety, and overuse of laxatives and enemas
• Signs and Symptoms
• Feeling of fullness, with occasional cramping and
  pain in lower abdomen
• If straining occurs during defecation, blood
  vessels may be ruptured
• Management
• Regulate eating patterns (cereal, fruits,
  vegetables)
• Deal with psychological aspects
• Avoid medications unless prescribed by a physician

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• Irritable Bowel Syndrome
• Etiology
• Group of gastrointestinal tract disorders
• Signs and Symptoms
• Abdominal pain that is relieved with defecation,
  irregular pattern of defecation (at least 25 of
  the time), alterations in stool frequency, form,
  and passage, abdominal bloating and distension
• Management
• Refer to physician for long-term management
• Diet modification and antidiarrheal medications
  may be helpful initially as well as psychological
  counseling
• Long term prognosis -- good

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• Appendicitis
• Etiology
• Inflammation of the vermiform appendix (chronic
  or acute)
• Result of blockage, lymph swelling, or carcinoid
  tumor
• Early stages it presents as a gastric complaint,
  that gradually develops from red swollen vessel
  to a gangrenous structure that can rupture into
  bowels causing peritonitis
• Signs and Symptoms
• Mild to severe pain in lower abdomen, associated
  with nausea, vomiting and low grade fever
• Pain may localize in lower right abdomen
  (McBurneys point)
• Management
• Surgical intervention is often necessary
  (particularly if it is resulting in an obstructed
  bowel life threatening)

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• Hemorrhoids (Piles)
• Etiology
• Varicosities of the hemorrhoidal venous plexus of
  the anus
• Constant straining or constipation may result in
  stretching of anal vessels, protrusion and
  bleeding, or a thrombus forming in the external
  vessels
• Signs and Symptoms
• Painful nodular swellings near the anal sphincter
• May cause slight bleeding and itching
• Management
• Use of proper bowel habits, ingestion of mineral
  oil daily to assist in lubricating a dry stool,
  application of suppository and anesthetic (for
  pain and itching)
• Surgery may be required if these measures fail

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• Scrotal Contusion
• Etiology
• Result of blunt trauma and contusion to the
  vulnerable and sensitive scrotum
• Signs and Symptoms
• Hemorrhaging, fluid effusion, muscle spasm,
  severe pain (disabling)

• --Management
• Reduction of testicular spasm
• Application of cold pack
• Unresolved pain after 15-20 minutes requires
  referral to a physician

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• Spermatic Cord Torsion
• Etiology
• Result of testicle revolving in the scrotum
  following a direct blow or as the result of
  coughing or vomiting
• Signs and Symptoms
• Acute testicular pain, nausea, vomiting and
  inflammation in the area
• Management
• Immediate medical care is required to prevent
  irreparable complications

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• Traumatic Hydrocele of the Tunica Vaginalis
• Etiology
• Fluid accumulation caused by a severe blow to the
  testicular region (venous plexus on the posterior
  aspect of the testicle becomes engorged)
• Rupture of the plexus results in rapid
  accumulation of blood in the scrotum (hematocele)
• Signs and Symptoms
• Pain and significant swelling in the scrotum
• Management
• Cold pack application and referral to a physician

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• Vaginitis
• Etiology
• Inflammation of the vagina can be caused by a
  variety of microorganisms, bacterial infections,
  chemicals from douching, irritation from a tampon
  or poor hygiene habits
• Signs and Symptoms
• Purulent and bloody vaginal discharge strong
  odor with vaginal itching
• Frequent and painful urination
• Vagina is red and painful to the touch
• Management
• Vaginitis caused by an STD will require
  appropriate antibiotic or antifungal medication
• Instruction on proper bladder and bowel hygiene
  as well as sexual behavior may also be necessary

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• Contusion of the Female Genitalia
• Etiology
• 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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• Injury of the Spleen
• Etiology
• Result of a direct blow, infectious mononucleosis
  (causing an enlarged spleen)
• Signs and Symptoms
• Indications of a ruptured spleen involve history
  of a direct blow, signs of shock, abdominal
  rigidity, nausea, vomiting
• Kehrs sign
• Management
• Ability to splint self may produce delayed
  hemorrhaging - easily disrupted resulting in
  internal bleeding
• 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

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• Abdominal Muscle Strain
• Etiology
• Result of sudden twisting or reaching of trunk,
  tearing abdominal musculature
• Signs and Symptoms
• Severe pain and hematoma formation
• Generally involves rectus abdominus
• Management
• Ice and compression with conservative treatment
• Exercise within pain free limits

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• Contusions of Abdominal Wall
• Etiology
• Caused by a compressive force - generally
  occurring in collision sports
• Extent of injury depends on whether force is
  blunt or penetrating
• Signs and Symptoms
• May cause a hematoma to develop under fascia of
  surrounding muscle tissue
• Swelling may cause pain and tightness w/in the
  region
• Management
• Cold pack and compression
• Be sure to check for signs of internal injuries

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• Hernia
• Etiology
• Protrusion of abdominal viscera through portion
  of abdominal wall (congenital or acquired)
• Inguinal vs. femoral hernias
• Complications and strangulated hernias
• Signs and Symptoms
• 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
• Management
• Surgery is preferred by most physicians
• Mechanical devices are not suitable for athletics
  due to friction and irritation they produce

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• Blow to Solar Plexus
• Etiology
• Transitory paralysis of the diaphragm
• Signs and Symptoms
• Stops respiration and leads to anoxia
• Generally transitory
• Management
• Must help athlete overcome apprehension
• Use short inspirations and long expirations
• Calm athlete, prevent hyperventilation
• ATC should question possibility of internal injury

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• Stitch in the Side
• Etiology
• 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 and Symptoms
• 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