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Thoracic Trauma (TT) is a leading cause of severe injuries and fatalities and is the second leading cause of traumatic death after head trauma. Although the unique structural properties of the thoracic cage prevent many TT patients from sustaining fatal injuries, the presence of vital organs and all great vessels in the thorax lead to the high morbidity and mortality rate.1,2

Twelve injuries have been named the “Deadly Dozen” of TT. These comprise the “Lethal Six;” immediately life-threatening injuries that require immediate evaluation and treatment—airway obstruction, tension pneumothorax, massive hemothorax, pericardial tamponade, open pneumothorax, and flail chest. In contrast, the “Hidden Six” are potentially life-threatening injuries that warrant diagnosis and intervention but should not interfere with immediate care. These injuries are often diagnosed only with second-tier diagnostic imaging and include blunt aortic injury, tracheobronchial injury, myocardial contusion, pulmonary contusion, esophageal tear, and diaphragmatic injury.

Blunt injuries are the most common TT, and motor vehicle accidents are the most common injury mechanism, accounting for over 80% of all TT patients. Out of blunt injuries, rib fracture is the most common injury affecting 50% of blunt TT patients3 with hemothorax being the second most common diagnosis found in 25% of cases, often combined with other injuries such as fractures and pneumothorax.

Intentional and violence-related injuries primarily cause penetrating TT, with an incidence rate that varies based on crime rates and the presence of violent conflicts. Penetrating TT accounts for 10% of all combat injuries and approximately 25% of casualties in modern armed conflicts. This chapter will review the management of major TT injuries and selected non-traumatic thoracic pathologies.


The thorax consists of the chest wall and the thoracic viscera. The components of the chest wall are the rib cage, sternum, and spinal column. The posterior chest wall is reinforced with the scapulae and its muscles; the anterior chest wall includes the pectoralis major and minor muscles and the clavicles. The chest wall has a dual function: it facilitates the respiratory mechanism allowing ventilation and protects the thoracic viscera.

Neurovascular bundles run along the inferior aspect of every rib, supplying perfusion and innervation for the chest wall. The chest wall is covered with a parietal pleura on the internal aspect and the mediastinum. Visceral pleura covers the lungs. The pleural space is formed between the pleura; this potential space holds a small amount of physiologic fluid. Like trauma or infection, certain pathologic states may cause an accumulation of large volumes of air, blood, or fluid displacing the lung and causing compressive atelectasis. This volume can compress other adjacent organs such as the great vessels, heart, and diaphragm. The mediastinum is limited anteriorly by the sternum and posteriorly by the spinal column, positioned between the left and right hemithorax. It holds the heart and great vessels and the esophagus, trachea, thoracic duct, ...

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