1. Abdominal, Thorax, and Throat Injuries
Chapters 12 & 13
Abdominal, Thorax, and Throat Injuries

2. Abdominal Cavity Boundaries Superior – Diaphragm Inferior – Pelvis
Posteriorly – Lumbar Spine
Anteriorly – Abdominal Musculature
The abdominal cavity lies between the diaphragm and the bones of the pelvis and is bounded by the margin of the lower ribs, the abdominal muscles, and the vertebral column. The abdominal cavity is sometimes called the abdominopelvic cavity, although there is no physical separation between the abdomen and the pelvic cavities.
Picture 1 – p. 3

3. Abdominal Quadrants Abdomen divided into 4 quadrants
Right Upper Quadrant RUQ
Left Upper Quadrant LUQ
Right Lower Quadrant RLQ
Left Lower Quadrant LLQ
Based on the patient’s left and right side not the evaluator.
Midsagittal (Median) Line– divides the abdomen into right and left halves (vertical line)
Transverse (Transumbilical) Line – divides the abdomen into upper and lower halves
Quadrants are commonly used by clinicians to describe the site of pain, tumors, or some other abnormality.
Upper right – contains liver, portion of the pancreas, right kidney, gall bladder, portion of the large and small intestine.
Upper left – contains stomach, portion of the liver, portion of the pancreas, left kidney, spleen, and portions of the large and small intestine.
Lower right – contains small intestine, appendix, a portion of the bladder, uterus and right ovary (in females), prostate (in males).
Lower left – contains large and small intestine, a portion of the bladder, uterus and left ovary (in females), and prostate (in males).

4. Abdominal Regions
Abdomen is divided into 9 regions by two horizontal lines and two vertical lines.
Regions are:
Top row (R to L)
Right Hypochondriac
Epigastric
Left Hypochondriac
Middle Row (R to L)
Right Lumbar
Umbilical
Left Lumbar
Bottom Row (R to L)
Right Inguinal (Iliac)
Hypogastric
Left Inguinal (Iliac)
9 regions are commonly used for anatomical studies to show more detail. The top horizontal line goes just under the ribs and is known as the subcostal line. The bottom horizontal line is just inferior to the ASIS (top of the hip) and is known as the transtubercular line. The two vertical lines run from the midpoint of the clavicle (medial border of the right and left scapula) through the pelvis and are know as the right and left midclavicular lines.
The regions are divided up as follows: (“right” and “left” being the patient’s “right” and “left” not the evaluator’s):
Right Hypochondriac Region – (below the cartilage – referring to the rib articular cartilage; top right column and top row) contains the gall bladder, part of the right kidney and part of the liver.
Epigastric Region – (above [epi-] the belly [-gastric]; top middle column and top row) contains the duodenum, part of the liver, part of the stomach, and part of the pancreas.
Left Hypochondriac Region – (below the cartilage – referring to the rib articular cartilage; top left column and top row) contains the spleen, part of the stomach, part of the left kidney, and part of the large intestine.
Right Lumbar Region – (middle row, right column) contains parts of the large intestine, parts of the small intestine, and part of the right kidney.
Umbilical Region – (middle row, middle column; belly button) contains parts of the transverse colon and parts of the small intestine.
Left Lumbar Region – (middle row, left column) contains part of the large intestine, part of the small intestine, and part of the left kidney.
Right Inguinal (Iliac) Region – (bottom row, right column; iliac is the largest part of the pelvic bone) contains the bottom of the cecum of the colon, the appendix, and part of the small intestine.
Hypogastric Region – (below [hypo-] the belly [-gastric]; bottom row, middle column) contains the urinary bladder, the (sigmoid) colon, and parts of the small intestine.
Left Inguinal (Iliac) Region – (bottom row; left column) contains part of the large intestine and part of the small intestine.

5. Hollow vs. Solids Organs
Hollow organs:
Injuries rarely result in rapid death.
Tendency to move out of the way when hit.
Are basically tubes used to transport substances from one organ to another.
Solid Organs:
Aid in body chemistry
Can cause rapid death because of large blood supply
Hollow organs – bladder, intestines, stomach, appendix
Solid Organs – liver, kidney, spleen

6. Digestive System Pathway: Salivary Glands Liver Gallbladder Pancreas
Mouth
Pharynx
Esophagus
Stomach
Small Intestine
Large Intestine
Rectum
Anus
Salivary Glands
Liver
Gallbladder
Pancreas
Mouth – (AKA Oral Cavity) Food is mechanically processed and moistened with secretions.
Pharynx – No digestion occurs here. Connection between the oral cavity and the esophagus.
Esophagus – Transportation tube for food to the stomach. Tube passes through the thoracic cavity, pierces the diaphragm, then attaches to the stomach.
Stomach – Primarily found in the upper left quadrant. Sits between the esophagus (superior end of stomach) and the small intestine (inferior end of stomach). Main function is for food storage and a mixing chamber. Some digestion and absorption occurs in the stomach. Gastric secretions assist in the partial digestion of proteins and the absorption of alcohol and caffeine. Ingested food is mixed w/secretions from the stomach to forma semifluid mixture called chyme, which passes from the stomach to the small intestine.
Small Intestine - Connected to the inferior portion of the stomach. Has three parts: duodenum, jejunum, and the ileum. It is approx. 20 ft. long. Secretions from the liver and pancreas mix with secretions form the small intestine to help break down chyme into smaller nutrients that can be absorbed. Chyme is move through the small intestine through a series of peristaltic (wave-like) contractions. Chyme can stay in the small intestine for 3-5 hours. Most of the digestion and absorption of nutrients occurs in the small intestine.
Large Intestine – The large intestine is approximately 6 ½ feet long. It has three divisions: Cecum, Colon, rectum. The appendix extends from the cecum. Water absorption occurs in the large intestine.
Rectum – Prior to defecation, indigestible waste is stored in the S-shaped rectum.
Anus – Feces exits the body here.
Salivary Glands – Supply enzymes for CHO digestion in the oral cavity.
Liver – The largest internal organ of the body. Located in the upper right quadrant against the inferior surface of the diaphragm. Weighs approx. 3 lbs. Consists of two major lobes (right and left). Performs digestive and excretory functions, absorbs and stores excessive glucose, processes nutrients, and detoxifies harmful chemicals. It secretes bile, which is essential in neutralizing and diluting stomach acid and for digesting fat in the small intestine during the digestive process.
Gallbladder – pear-shaped, saclike structure located on the inferior surface of the liver. Serves as a storage site for bile. Shortly after a meal, the gallbladder secretes bile into the small intestine. Gallstones are a result of large amounts of cholesterol in the diet. Gall stones can block release of bile. They will need to be removed surgically.
Pancreas – Located between the small intestine and the spleen. Secretes pancreatic juice, which is critical in the digestion of fats, CHOs, and PROs. Produces insulin and glucagon, hormones that control the amount of glucose and amino acids in the blood.
Picture 1 – p. 217

7. Urinary System Kidneys Ureters Bladder
Kidneys – located on either side of the spine, approximately in the center of the back. Bean shaped and are approx. 4.5 inches long, 2 inches wide, and 1 inch thick. The right kidney is usually slightly lower than the left (b/c of liver). Responsible for maintaining acid-base balance of the blood/body. If unable to due this due to injury or illness, body systems will start shutting down and death will occur. If either kidney has inadequate blood supply, it can also cause hypertension (high BP) Also responsible for removing waste products from the body in liquid form.
Ureters – Tubes that extend from the kidney to the bladder.
Bladder – Hollow container that lies posterior to the pubic symphysis. Function is to store urine.

8. Thoracic Cavity Bony Anatomy Ribs Costal Cartilage Sternum
True Ribs
False Ribs
Floating Ribs
Costal Cartilage
Sternum
Manubrium
Body
Xiphoid Process
Thoracic Vertebrae
True Ribs The first seven pairs of rib bones (beginning at the top of the sternum) are called "true ribs."  They connect to the spine (by ligaments) at the back, and connect to the sternum by costal cartilage in the front.  Costal cartilage is elastic and allows the ribcage to expand during respiration.
False Ribs The next three pairs of rib bones (8, 9 and 10) are called "false ribs."  Like the true ribs, false ribs are connected to the spine at the back.  The primary difference in true ribs and false ribs comes in where the false ribs connect at the front.  Instead of connecting to the sternum, false ribs (which are also slightly shorter than true ribs) actually connect to the lowest true ribs (this may be observed in the picture, above).
Floating Ribs The last two pairs of ribs (11 and 12) are the smallest of all of the rib bones, and are called "floating ribs."  They get the name "floating rib" because they are connected to the spin at the back, but are not connected to anything at the front, thus appearing to "float."
In addition to protecting vital organs, such as the heart and lungs, the ribs serve other important purposes in the human body.  The ribs give shape and support to the chest.  They protect parts of other organs, including the stomach, spleen and kidneys.  The ribs also help humans to breathe.  The cartilage that connects the true ribs to the sternum allows the chest to expand when you inhale and the lungs fill with air.  The rigidity and mass of the rib bones then help to contract the lungs and expel air when you exhale.
The costal cartilages are bars of hyaline cartilage which serve to prolong the ribs forward and contribute to the elasticity of the walls of the thorax. Costal cartilage is only found at the anterior ends of the ribs.
Sternum – Breastbone
Manubrium - a handle-shaped projection or part, in particular; the broad upper part of the sternum, with which the clavicles and first ribs articulate.
Body (AKA Corpus) - A long flat bone, articulating with the cartilages of the 2nd – 7th ribs, forming the middle part of the anterior wall of the thorax, has the manubrium superior to it and the xiphoid process inferior to it.
Xiphoid Process - the cartilaginous section at the lower end of the sternum, which is not attached to any ribs and gradually ossifies during adult life.
Picture 1 – p. 3

9. Circulatory System Starting at: Right Atrium Right Ventricle
Pulmonary Artery Trunk
Right & Left Pulmonary Arteries
Right & Left Pulmonary Arterioles
Right & Left Pulmonary Capillaries
Right & Left Pulmonary Venules
Right & Left Pulmonary Veins
Left Atrium
Left Ventricle
Aorta
Thoracic Aorta
Abdominal Aorta
Carotid Arteries
Upper Extremities Arteries, Arterioles, & Capillaries
Thoracic Organs Arteries, Arterioles, & Capillaries
Abdominal Organs Arteries, Arterioles, & Capillaries
Lower Extremities Arteries, Arterioles, & Capillaries
Upper Extremities Venules & Veins
Thoracic Organs Venules & Veins
Abdominal Organs Venules & Veins
Lower Extremities Venules & Veins
Inferior Vena Cava
Superior Vena Cava
Azygous Vein
Right and left pulmonary capillaries surround the alveoli (single air sac) in the lung and this is where CO2 is exchanged for O2 so the blood goes from being deoxygenated to oxygenated.
Picture 1 – p. 169

10. Respiratory System Pathway of Air Nose/Mouth Pharynx Larynx Trachea
Sinuses
Pharynx
Larynx
Epiglottis
Trachea
Right/Left Mainstem Bronchus
Right/Left Bronchial Tree
Alveoli
Pathway –
Nose/Mouth – initial entrance of air and final exit of air.
Sinuses – Frontal (shown), Sphenoid (shown), Maxillary, and Ethmoid sinuses – Air is “conditioned” to the body temperature before moving down to the lungs.
Pharynx – Connection between the Oral cavity and the larynx.
Larynx – First portion of the passageway leading to the lungs.
Epiglottis – flap-like structure guarding the entryway to the larynx
Trachea – (AKA windpipe) continuous with the larynx, supported by cartilaginous rings
Right and Left Mainstem Bronchus – Main branches from the trachea
Right and Left Bronchial Tree – minor branches from the mainstem bronchus
Alveoli - The bronchi continue dividing into smaller and smaller divisions until they end in clusters of air sacs called alveoli. Alveoli facilitate the exchange of O2 and CO2 with the capillaries.
The lungs are elastic and spongy. The expand and contract in response to contraction of the diaphragm muscle.
Lobes of the Lung – Right side – 3 lobes (upper, middle, lower)
Left side – 2 lobes (upper, lower)
Lobes divided by fissures – right side - 2 fissures (horizontal, oblique)
left side – 1 fissure (oblique)
Picture 1 – p. 237

11. Lymphatic System Network of tissues and organs Spleen Thymus
600 to 700 lymph nodes
The lymphatic system is a network of tissues and organs that primarily consists of lymph vessels, lymph nodes and lymph. The tonsils, adenoids, spleen and thymus are all part of the lymphatic system. There are 600 to 700 lymph nodes in the human body that filter the lymph before it returns to the circulatory system.
Spleen – The spleen is the largest lymphatic organ in the body. It weighs approximately 6 ounces (170 grams) and is approximately 5 inches (12.5 cm) long. It lies under the diaphragm on the left side and behind the 9th, 10th, and 11th ribs. It is surrounded by a fibrous capsule that is firmly invested by peritoneum. The spleen’s main functions are to serve as a reservoir of red blood cells; to regulate the number of red blood cells in the general circulation, to destroy ineffective red blood cells, to produce antibodies for immunological function, and to produce lymphocytes (cells that are the primary means of providing the body with immune capabilities).
Thymus – The thymus is located in the thorax just anterior and above the heart. The function of the thymus is to produce lymphocytes, which migrate to other lymphatic tissues to respond to foreign substances. The thymus is relatively large in the infant and after puberty gradually decreases in size.

12. Muscles of the Abdomen & Thorax
Rectus Abdominis
Origin
Pubic crest, pubic symphysis.
Insertion
Cartilage of fifth, sixth, and seventh ribs and xiphoid process.
Action
Flex the vertebral column and tilt the pelvis posteriorly.
Picture 1 – p. 69
Picture 2 – p. 71

13. Muscles of the Abdomen & Thorax
External Obliques
Origin
External surfaces of fifth to twelfth ribs.
Insertion
Anterior part of the iliac crest, abdominal aponeurosis to linea alba.
Action
Unilaterally – Laterally flex the vertebral column to the same side, rotate the vertebral column to the opposite side.
Bilaterally – Flex the vertebral column, compress the abdominal contents.
Picture 1 – p. 69
Picture 2 – p. 71
Picture 3 – p. 73

14. Muscles of the Abdomen & Thorax
Internal Obliques
Origin
Lateral inguinal ligament, iliac crest and thoracolumbar fascia.
Insertion
Internal surface of lower three ribs, abdominal aponeurosis to linea alba.
Action
Unilaterally – Laterally flex the vertebral column to the same side, rotate the vertebral column to the opposite side.
Bilaterally – Flex the vertebral column, compress the abdominal contents.
Picture 1 – p. 69
Picture 2 – p. 71
Picture 3 – p. 73

15. Muscles of the Abdomen & Thorax
Transverse Abdominis
Origin
Lateral inguinal ligament, iliac crest, thoracolumbar fascia and internal surface of the lower six ribs.
Insertion
Abdominal aponeurosis to linea alba.
Action
Compress the abdominal contents.
Picture 1 – p. 69
Picture 2 – p. 71

16. Muscles of the Abdomen & Thorax
Pectoralis Major
Origin
Medial half of clavicle, sternum and cartilage of the first through sixth ribs.
Insertion
Crest of the greater tubercle of the humerus.
Action
All fibers – Adduct the shoulder, medially rotate the shoulder, assist to elevate the thorax during forced inhalation (with the arm fixed).
Upper fibers – flex the shoulder, horizontally adduct the shoulder.
Lower fibers – Extend the shoulder.
Picture 1 – p. 69

17. Muscles of the Abdomen & Thorax
Latissimus Dorsi
Origin
Inferior angle of the scapula, spinous processes of the last six thoracic vertebrae, last three to four ribs, thoracolumbar aponeurosis and posterior iliac crest.
Insertion
Intertubercular groove of the humerus.
Action
Extend the shoulder, adduct the shoulder, and medially rotate the shoulder.
Picture 1 – p. 69
Picture 2 – p. 73

18. Muscles of the Abdomen & Thorax
Serratus Anterior
Origin
External surfaces of the upper eight or nine ribs.
Insertion
Anterior surface of the medial border of the scapula.
Action
With origin fixed – abduct the scapula, upwardly rotate the scapula, depress the scapula, hold the medial border of the scapula against the rib cage.
With the scapula fixed - may act to elevate the thorax during forced inhalation.
Picture 1 – p. 69
Picture 2 – p. 73

19. Muscles of the Abdomen & Thorax
Deltoid
Origin
Lateral one-third of the clavicle, acromion process, and spine of the scapula.
Insertion
Deltoid tuberosity of the humerus.
Action
All fibers – Abduct the shoulder.
Anterior fibers – Flex the shoulder, medially rotate the shoulder and horizontally adduct the shoulder.
Posterior fibers – Extend the shoulder, laterally rotate the shoulder and horizontally abduct the shoulder.
Picture 1 – p. 69
Picture 2 – p. 73

20. Muscles of the Abdomen & Thorax
Pectoralis Minor
Origin
Third, fourth and fifth ribs.
Insertion
Medial surface of the coracoid process of the scapula.
Action
Depress the scapula, abduct the scapula, downwardly rotate the scapula.
With the scapula fixed – Assist to elevate the thorax during forced inhalation.
Picture 1 – p. 69
Picture 2 – p. 71

21. Muscles of the Abdomen & Thorax
External Intercostals
Origin
Inferior border of the rib above, external side of rib.
Insertion
Superior border of rib below, external side.
Action
Draw the ribs superiorly to assist with inhalation (increases space in the thoracic cavity).
Picture 1 – p. 69
Picture 2 – p. 71

22. Muscles of the Abdomen & Thorax
Internal Intercostals
Origin
Inferior border of the rib above, internal side of the rib.
Insertion
Superior border of the rib below, internal side of the rib.
Action
Draw the ribs inferiorly to assist with exhalation (decreases the size of the thoracic cavity).
Picture 1 – p. 69
Picture 2 – p. 71

23. Muscles of the Abdomen & Thorax
Subclavius
Origin
First rib and cartilage.
Insertion
Inferior surface of the middle one-third of the clavicle.
Action
Depress the clavicle and draw it anteriorly, elevate the first rib (assist on inhalation), stabilize the sternoclavicular joint.
Picture 1 – p. 69

24. Muscles of the Abdomen & Thorax
Sternocleidomastoid
Origin
Sternal Head – Top of the manubrium
Clavicular head – Medial one-third of the clavicle.
Insertion
Mastoid process of the temporal bone and the lateral portion of the superior nuchal of the occipital bone.
Action
Unilaterally – Laterally flex the head and neck to the same side, rotate the head and neck to the opposite side.
Bilaterally – Flex the neck and to assist in elevating the ribcage during inhalation.
Picture 1 – p. 69
Picture 2 – p. 73

25. Muscles of the Abdomen & Thorax
Diaphragm
Origin
Costal attachment – Inner surface of the lower six ribs.
Insertion
Central tendon.
Action
Draw down the central tendon of the diaphragm to increase the volume of the thoracic cavity during inhalation.
Picture 1 – p. 71

26. Muscles of the Abdomen & Thorax
Quadratus Lumborum
Origin
Posterior iliac crest.
Insertion
Last rib and transverse processes of the first though fourth lumbar vertebrae.
Action
Unilaterally – Laterally tilt (elevate) the pelvis, laterally flex the vertebral column to the same side, and to assist in extension of the vertebral column.
Bilaterally – Fix the last rib during forced inhalation and exhalation.
Picture 1 – p. 71

27. Muscles of the Abdomen & Thorax
Trapezius
Origin
External occipital protuberance, medial portion of the superior nuchal line of the occipital bone, ligamentum nuchae and spinous processes of C7 through T12.
Insertion
Lateral one-third of the clavicle, acromion process and spine of the scapula.
Action
Upper Fibers – Bilaterally – Extend the head and neck.
Upper Fibers - Unilaterally – Laterally flex the head and neck to the same side, rotate the head and neck to the opposite side, elevate the scapula and upwardly rotate the scapula.
Middle Fibers – Adduct the scapula and stabilize the scapula.
Lower Fibers – Depress the scapula and upwardly rotate the scapula.
Picture 1 – p. 73

28. Muscles of the Abdomen & Thorax
Serratus Posterior Superior
Origin
Spinous processes of C7 through T3.
Insertion
Posterior surface of the second through fifth ribs.
Action
Elevate the ribs during inhalation.
Picture 1 – p. 73

29. Muscles of the Abdomen & Thorax
Serratus Posterior Inferior
Origin
Spinous processes of t12 through L3.
Insertion
Posterior surface of ninth through twelfth ribs.
Action
Depress the ribs during exhalation.
Picture 1 – p. 73

30. Muscles of the Abdomen & Thorax
Erector Spinae Group
Origin
Common tendon (thoracolumbar aponeurosis) that attaches to the posterior surface of the sacrum, iliac crest, spinous processes of the lumbar and last two thoracic vertebrae.
Insertion
Various attachments at the posterior ribs, spinous and transverse processes of the lumbar and last two thoracic vertebrae.
Action
Unilaterally – Laterally flex the vertebral column to the same side.
Bilaterally – Extend the vertebral column.
Picture 1 – p. 73

31. Referred Pain
Pressure upon palpation of the abdominal organs may elicit referred pain in predictable patterns away from the source.

32. Common Thoracic & Abdominal Injuries
Kidney Contusion
Liver Contusion
Pancreatitis
Appendicitis
Scrotal Contusion
Injury to the Spleen
Abdominal Contusion
Hernia
Solar Plexus Injury
Side Stitch
Rib contusion
Rib fracture
Costochondral Separation/Dislocation
Sternum Fracture
Pneumothorax
Hemothorax
Flail Chest
Hyperventilation
Heart contusion
Sudden Death Syndrome in Athletes

33. Rib Contusion Etiology Signs & Symptoms Treatment
Etiology – A blow to the rib cage can contuse intercostal muscles or, if severe enough, produce a fracture. Because the intercostal muscles are essential for the breathing mechanism, both expiration and inspiration become very painful when they are bruised.
Signs & Symptoms – Characteristically the pain is sharp during breathing, coughing, laughing, and sneezing; there is point tenderness, and pain is elicited when the rib cage is compressed. X-ray examination should be routine in such an injury to rule out a fracture.
Treatment – PRICE and antiinflammatory agents are commonly used. Like most rib injuries, contusions to the thorax are self-limiting; they respond best to rest and to the cessation of sport activities.

34. Rib Fracture Etiology Signs & Symptoms Treatment
Etiology – Rib fractures are not uncommon in sports and have their highest incidence in collision sports, particularly wrestling and football. Fractures can be caused by either direct or indirect traumas and can, infrequently, be the result of violent muscular contractions. A direct injury is caused by a kick or a well-placed block, with the fracture developing at the site of force application. An indirect fracture is produced as a result of general compression of the rib cage such as may occur in football or wrestling. Ribs have also been known to fracture from forces caused by coughing and sneezing. Ribs 5 through 9 are the most commonly fractured. Multiple rib fractures can be severe. A flail chest involves a fracture of three or more consecutive ribs on the same side and will be discussed further later. The structural and functional disruption sustained in a rib fracture varies according to the type of injury that has been received. The direct fractures cause the most serious damage, because the external force fractures and displaces the ribs inwardly. Such a mechanism may completely displace the bone and cause an overriding of fragments. The jagged edges of the fragments may cut, tear, or perforate the tissue of the pleurae, causing hemothorax, or they may collapse one lung (pneumothorax). Contrary to the direct injury, the indirect injury usually causes the rib to spring and fracture outward, producing an oblique or transverse fracture. Stress fracture of the first rib is becoming more prevalent. It can result from repeated arm movements such as those in pitching or in rowing. Stress fractures to other ribs have resulted from repeated coughing or laughing. Injury to the pectoral muscles may mask signs of rib fracture.
Signs & Symptoms – The rib fracture is usually quite easily detected. The history informs the ATC of the type and degree of force to which the rib cage has been subjected. After trauma, the athlete complains of severe pain during inspiration and has point tenderness. A fracture of the rib will be readily evidenced by a severe, sharp pain and possibly crepitus (crackling sound heard during the movement of ends of broken bones) during palpation.
Treatment – PRICE initially and then the athlete should be referred for x-rays. An uncomplicated rib fracture is often difficult to identify on x-ray. Therefore, the physicians plans the treatment according to the symptoms presented. The rib fracture is usually managed with support and rest. Simple transverse or oblique fractures heal with in 3-4 weeks. A rib brace can offer the athlete some rib cage stabilization and comfort. However, rib supports may predisposed the athlete to the development of hypostatic pneumonia, which has the potential to occur whenever an individual does not take full inspirations because of pain and some mechanical restriction.

35. Costochondral Separation/Dislocation
Etiology
Signs & Symptoms
Treatment
Etiology – In sport activities, the costochondral separation or dislocation has a higher incidence than do fractures. This injury can occur from a direct blow to the anterolateral aspect of the thorax or indirectly from a sudden twist or a fall on a ball that compresses the rib cage. The costochondral injury displays many signs that are similar to the rib fracture, with the exception that pain is localized in the junction of the rib cartilage and rib.
Signs & Symptoms – The athlete complains of sharp pain during sudden movement of the trunk and has difficulty breathing deeply. There is point tenderness with swelling. In some cases, there is a rib deformity and a complaint that the rib makes a crepitus noise as it moves in and out of place.
Treatment – Treat initially with PRICE. Like a rib fracture, the costochondral separation is managed by rest and immobilization by rib brace. Healing takes place anywhere from one to two months and precludes any sports activities until the athlete is symptom free.

36. Sternum Fracture Etiology Signs & Symptoms Treatment Gymnast video
Etiology – Fracture of the sternum results from a high-impact blow to the chest. Sternum fractures are more likely to occur in automobile collisions than in athletics. Injuries to the ribs or costochondral junction are more likely in an athlete. An impact severe enough to cause fracture of the sternum may also cause contusion to the underlying cardiac muscle.
Signs & Symptoms – There may be point tenderness over the sternum at the site of the fracture that is exacerbated by deep inspiration or forceful expiration. Signs of shock or a weak, rapid pulse may indicate a more severe internal injury.
Treatment – Treat with PRICE initially and then refer athlete to physician for x-rays. The athlete should also be closely monitored for signs of trauma to the heart.

37. Pneumothorax Etiology Signs & Symptoms Treatment Video
Etiology – Is a condition in which the pleural cavity becomes filled with air that has entered through an opening on the chest. As the negatively pressured pleural cavity fills with air, the lung on that side collapses.
Signs & Symptoms – The loss of one lung may produce pain, difficulty breathing and anoxia (lack of oxygen).
Treatment – Medical emergency, activate EMS ASAP. Requires surgical intervention.
Tension Pneumothorax occurs when the pleural sac on one side fills with air and displaces the lung and heart toward the opposite side which compresses the opposite lung. There will be a shortness of breath and chest pain on the side of the injury. There will be absence of breath sounds, cyanosis (bluish skin), and distension (causing its outward expansion beyond the normal) of neck veins. The trachea may deviate away from the side of the injury. A total collapse of the opposite lung is possible; therefore, medical attention is required immediately.

38. Hemothorax Etiology Signs & Symptoms Treatment
Etiology – Presence of blood within the pleural cavity. It results from tearing or puncturing of the lung or pleural tissue, which involves the blood vessels in the area. A violent blow or compression of the chest without an accompanying rib fracture may cause a lung hemorrhage.
Signs & Symptoms – Like pneumothorax, hemothorax produces pain, difficulty breathing and cyanosis. This condition results in severe pain during breathing, dyspnea (difficulty breathing), coughing up frothy blood, and signs of shock.
Treatment – Should be treated for signs of shock and immediately referred to a physician (Call 911).

39. Flail Chest Etiology Signs & Symptoms Treatment Video
Etiology – Fracture of three or more ribs on the same side, each in two or more places, usually caused by a direct blow to the chest.
Signs & Symptoms – Injured section will move in and out with inspiration/expiration, however it will be moving in the opposite direction. On inspiration, the loose section will move into the body and on expiration, the loose piece will move out. Extremely painful and difficult to breath with.
Treatment – Treatment is to try and stabilize loose piece to prevent movement as much as possible. Athlete should also be treated for shock and EMS should be activated and the athlete should be transported to the hospital for further care.

40. Hyperventilation Etiology Signs & Symptoms Treatment
Etiology – An athlete who has an excessively rapid rate of ventilation usually due to anxiety-induced stress or asthma gradually develops a decreased amount of carbon dioxide in the blood (hypocapnia).
Signs & Symptoms – The athlete appears to be having great difficulty in getting air and seems to be struggling to breathe. He or she is in somewhat of a panic state. There may also be some gasping or wheezing. While it appears that the athlete is not getting enough oxygen, the problem is that the levels of carbon dioxide are too low relative to the amount of oxygen.
Treatment – The immediate treatment consists of decreasing the rate of carbon dioxide loss. This is accomplished by first having the athlete slow the rate of respiration and concentrate on breathing in through the nose and out through the mouth. Another technique would be to have the athlete inhale and exhale through one nostril with the other pinched closed and the mouth closed. A third technique involves having the athlete breath slowly into a paper or plastic bag. All of these techniques should help to rapidly increase the level of carbon dioxide. Typically within a minute or two the athlete has returned to a normal respiratory pattern. After the acute phase of hyperventilation has been treated, it is necessary to determine the underlying cause and take appropriate treatment measures.

41. Heart Contusion Etiology Signs & Symptoms Treatment Video
Etiology – A heart contusion may occur when the heart is compressed between the sternum and the spine by a strong outside force. Examples are if an athlete is bit by a pitched ball or bounces a barbell of the chest in a bench press. The right ventricle is most often injured. The most severe consequence of a violent impact to the heart would be a rupture of the aorta, which would be immediately life threatening.
Signs & Symptoms – This injury produces severe shock and heart pain. The heart may exhibit certain arrhythmias that cause a decrease in cardiac output, which is followed by death if medical attention is not administered immediately.
Treatment – The athlete should be taken immediately to the ER. The ATC should be prepared to administer CPR and treat the athlete for shock.

42. Sudden Death Syndrome in Athletes
Etiology
Hypertrophic Cardiomyopathy (HCM)
Anomalous Origin of the Carotid Artery
Marfan’s Syndrome
Signs & Symptoms
Prevention
Treatment
Etiology – It is estimated that 1 in 280,000 men under age thirty experience sudden death each year. More than twenty different causes have been identified. In athletes thirty-five and younger, the most common cause of exercised–induced sudden death is some congenital cardiovascular abnormality. The three most prevalent conditions are hypertrophic cardiomyopathy, anomalous origin of the carotid artery, and Marfan’s Syndrome.
Hypertrophic cardiomyopathy (HCM) is a condition in which there is thickened cardiac muscle, with no evidence of chamber enlargement, and extensive myocardial scarring. With this condition, the is an increased frequency of ventricular arrythmia (irregular heartbeat). In anomalous origin of the carotid artery, one of the two coronary vessels originates in a different site than normal, which compromises or obstructs the artery because of its unusual course. People with Marfan’s Syndrome have an abnormality of the connective tissue that results in a weakening of the structure of the aorta and cardiac valves, which can lead to a rupture of either a valve or the aorta itself. Mitral valve prolapse (a heart problem in which the valve that separates the upper and lower chambers of the left side of the heart does not close properly.) has been associated with both HCM and Marfan’s Syndrome.
Other potential cardiac causes of sudden death in athletes include coronary artery disease (CAD), which results from atherosclerosis, in which there is a narrowing of the coronary arteries that is usually due to hypercholesterolemia (an excess of cholesterol in the bloodstream) in the young athlete; right ventricle dysplasia, in which enlargement of the right ventricle causes a potentially lethal disturbance in heartbeat; cardiac conduction system abnormalities, which can result from abnormalities of the sinus or atrioventricular nodes; aortic blood pressure and cardiac collapse during exercise; Wolff-Parkinson-White syndrome, in which an abnormality in cardiac rhythm manifests itself as ventricular tachycardia; and myocarditis, an inflammation of the heart associated with a viral condition.
Non-cardiac causes of sudden death have been attributed to the use of certain drugs, including alcohol, cocaine, amphetamines, and erythropoietin (stimulates red blood cell production). A vascular event – bleeding in the brain caused by cerebral aneurysm, for example, or head trauma that causes intracranial bleeding – may also result in sudden deaths. Obstructive respiratory disease such as asthma can result in sudden death because of drug toxicity or under-treatment.
Signs & Symptoms – Most afflicted athletes have no symptoms before death. Common symptoms and signs associated with cardiac causes of sudden death include chest pain or discomfort during exertion, heart palpitations or flutters, syncope (temporary loss of consciousness caused by a fall in blood pressure), nausea, profuse sweating, heart murmurs, shortness of breath, general malaise, and fever.
Occasionally the symptoms and signs of athletic heart syndrome raise concern when there is no disease present. Athletic heart syndrome is normal for any individual who is exercising. Like skeletal muscle, cardiac muscle will hypertrophy (the enlargement of an organ or tissue from the increase in size of its cells) in response to exercise. It is characterized by heart enlargement, a systolic heart murmur, slow heart rate, and electrocardiogram changes.
Prevention – It has been suggested that a major number of deaths could be avoided by counseling, screening, and early identification of preventable causes of sudden death. The use of diagnostic tests to screen for cardiovascular abnormalities has proven to be ineffective. It appears that currently, a history and physical exam in accordance with American Heart Association guidelines is the most effective method of preparticipation screening. Initial screening should include the following questions:
Has a physician ever told you that you have a heart murmur?
Have you had chest pain during exercise?
Have you fainted during exercise?
Has anyone in your family under the age of thirty-five ever died suddenly?
Has anyone in your family been diagnosed with a thickened heart?
Does anyone in your family have Marfan’s Syndrome?
If the answer to any of these questions is yes, a more-in-depth medical examination should be performed. Resting and exercise electrocardiograms and echocardiograms may be necessary to determine existing pathology.
Treatment – Activate EMS immediately and be prepared to give CPR/use an AED.

43. Kidney Contusion Etiology Signs & Symptoms Treatment
Etiology – The kidneys are seemingly well protected within the abdominal cavity. However, on occasion, contusions and even ruptures of these organs can occur. The kidney may be susceptible to injury because of its normal distention by blood. An external force, usually one applied to the back of the athlete, will cause abnormal extension of an engorged kidney, resulting in injury. The degree of renal injury depends on the extent of the distention and the angle and force of the blow.
Signs & Symptoms – An athlete who has received a contusion to the kidney may display signs of shock, nausea, vomiting, rigidity of the back muscles, and hematuria (blood in urine). Like injuries to other internal organs, kidney injuries may cause referred pain to the outside of the body. Pain may be felt high in the costovertebral angle posteriorly and may radiate forward around the trunk into the lower abdominal region. Any athlete who reports having received a severe blow to the abdomen or back should be instructed to urinate two to three times and to look for blood in the urine. If there is any sign of hematuria, the athlete must be referred to the physician immediately (go to ER).
Treatment – Medical care of a kidney contusion usually consists of a twenty-four hour hospital observation and a gradual increase in fluid intake. If the hemorrhage fails to stop, surgery may be indicated. Controllable contusions usually require two weeks of bed rest and close surveillance after activity is resumed. Protective padding (rib pads) can be used when returning to activity. In questionable cases, complete withdrawal from one active playing season may be required.

44. Liver Contusion Etiology Signs & Symptoms Treatment
Etiology – Compared to other organ injuries from blunt trauma, injuries to the liver are the second most common. In sports activities, however, liver injury is relatively infrequent. A hard blow to the right side of the rib cage can tear or seriously contuse the liver, especially if it has been enlarged as a result of some disease, such as hepatitis. Hepatitis is an inflammation of the liver caused by either viral infection or alcohol consumption. If not corrected, hepatitis can lead to cirrhosis of the liver, in which the liver function is impaired because liver cells die and are replaced by scar tissue.
Signs & Symptoms – Liver injury can cause hemorrhage and shock, requiring immediate surgical intervention. Liver injury commonly produces referred pain that is just below the right scapula, right shoulder, and substernal area and, on occasion, a referred pain located on the anterior left side of the chest.
Treatment – A liver contusion requires immediate referral to a physician for diagnosis and treatment. PRICE the contusion and refer to physician. MRI or CT scan will be used to detect bleeding.

45. Pancreatitis Etiology Signs & Symptoms Treatment
Etiology –Inflammation of the pancreas may be acute or chronic and is often related to obstruction of the pancreatic duct. An acute inflammation leads to necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply), suppuration (the formation of, conversion into, or process of discharging pus), gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection), and hemorrhage. Chronic inflammation results in the formation of scar tissue that causes malfunction of the pancreas; inflammation may occur gradually or from chronic alcoholism.
Signs & Symptoms – Acute epigastric pain causes vomiting, belching, constipation, and potentially, shock. There may also be tenderness and rigidity to palpation. Chronic pancreatitis causes jaundice, diarrhea, and mild to moderate pain that radiates to the back.
Treatment – Acute pancreatitis requires rehydration, pain reduction, treatment of shock, and reduction of pancreatic secretions using medication, and prevention of secondary infection. Surgery would be indicated only if the pancreatic duct is blocked. Treatment of chronic pancreatitis is difficult and requires large doses of analgesics, the administration of pancreatic enzymes, and a low-fat diet.

46. Appendicitis Etiology Signs & Symptoms Treatment
Etiology – Inflammation of the vermiform appendix can be chronic or acute. It is caused by a variety of conditions , such as fecal obstruction, lymph swelling or even a carcinoid tumor. Its highest incidence is in males between the ages of fifteen and twenty-five. Appendicitis can be mistaken for a common gastric complaint. In early stages, the appendix becomes red and swollen; in later stages, it may become gangrenous, rupturing into the bowels or peritoneal cavity and causing peritonitis (inflammation of the peritoneum, typically caused by bacterial infection either via the blood or after rupture of an abdominal organ). Bacterial infection is a complication of rupture of the inflamed appendix.
Signs & Symptoms – The athlete may complain of a mild-to-severe pain in the lower abdomen, associated with nausea, vomiting, and a low-grade fever ranging from 99o – to 100o F (37o – 38o C). Later, the cramps may localize into a pain in the right side, and palpation may reveal abdominal rigidity and tenderness at a point (McBurney’s point) between the anterior superior spine of the ilium and the umbilicus, about 1 to 2 inches (2.5 to 5 cm) above the umbilicus. A strain to the psoas muscle or an abscess in the sheath of the psoas can sometimes be mistaken for appendicitis.
Treatment – Surgical removal of the appendix is often necessary. If the bowel is not obstructed, there is no need to rush surgery. However, an obstructed bowel within an acute rupture is a life-threatening condition.

47. Scrotal Contusion Etiology Signs & Symptoms Treatment Video
Etiology – As the result of its considerable sensitivity and particular vulnerability, the scrotum may sustain a contusion that causes a very painful, nauseating, and disabling condition.
Signs & Symptoms – Like any other contusion or bruise, the scrotal contusion causes hemorrhage, fluid effusion, and muscle spasm, the degree of which depends on the intensity of the impact on the tissue.
Treatment – Immediately following a scrotal contusion, the athlete must be put at ease and testicular spasms must be reduced. Several techniques have been proposed to help reduce testicular pain following contusion. The most commonly used technique is to place the athlete in a sitting position, lift him a few inches, and drop him to the ground. Two other techniques are less commonly used. The first of these techniques is to place the athlete in a kneeling position and have him or her bounce up and down. The second technique is to place the athlete supine with knees and hips flexed to 90o and have him perform the Valsalva maneuver. These maneuvers will aid in reducing discomfort and relaxing muscle spasm. After pain has diminished, the athlete should be helped from the playing area, and a cold pack should be applied to the scrotum. Increasing or unresolved pain after fifteen to twenty minutes requires prompt referral to a physician for evaluation.

48. Injury to the Spleen Etiology Signs & Symptoms Complications Treatment
Etiology – Injuries to the spleen are relatively uncommon. If injury does occur, it is most often due to a fall or direct blow to the upper left quadrant of the abdomen when some existing medical condition has caused splenomegaly (enlargement of the spleen). Infectious mononucleosis is most likely the cause of spleen enlargement. Athletes with mononucleosis should not engage in any activity for three weeks because approximately 50% of sufferers exhibit splenomegaly, which is difficult to diagnose clinically.
Signs & Symptoms – The gross indications of a ruptured spleen must be recognized so that an immediate medical referral can be made. Indications include a history of a severe blow to the abdomen and possibly signs of shock, abdominal rigidity, nausea, and vomiting. The may be a reflex pain occurring approximately 30 minutes after the injury, called Kehr’s Sign, which radiates to the left shoulder and 1/3 of the way down the left arm.
Complications – The great danger with a ruptured spleen lies in its ability to “splint” itself and then produce a delayed hemorrhage. Splinting of the spleen is effected by a loose hematoma formation and the constitution of the supporting and surrounding structures. Any slight strain may disrupt the splinting effect and allow the spleen to hemorrhage profusely into the abdominal cavity, causing the athlete to die of internal bleeding days or weeks after the injury.
Treatment – Conservative, non-operative treatment is recommended initially with a week of hospitalization. At three weeks, the athlete can engage in light conditioning activities, and at four weeks, the athlete can return to full activity as long as no symptoms appear. If surgical repair is necessary, the athlete will require three months to recover, whereas removal of the spleen will require six months before the athlete can return to full activity.

49. Abdominal Contusion Etiology Signs & Symptoms Treatment
Etiology – Compressive forces that injure the abdominal wall are not common in sports. When they do happen, they are more likely to occur in collision sports such as football or ice hockey; however, any sports implements or high-velocity projectiles can injure. Hockey goalies and baseball catchers would be very vulnerable to injury without their protective torso pads. Contusions may occur superficially to the abdominal kin or subcutaneous tissue or much deeper to the musculature. The extent and type of injury vary, depending on whether the force is blunt or penetrating.
Signs & Symptoms – A contusion of the rectus abdominis muscle can be very disabling. A severe blow may cause a hematoma that develops under the fascial tissue surrounding this muscle. The pressure that results from hemorrhage causes pain and tightness in the region of the injury.
Treatment – A cold pack and a compression elastic wrap should be applied immediately after injury. The ATC must look for signs of possible internal injury.

50. Hernia Etiology Signs & Symptoms Treatment
Etiology – The term hernia refers to a protrusion of abdominal viscera through a portion of the abdominal wall. Hernias may be congenital or acquired. A congenital hernia sac is developed before birth, and an acquired hernia develops after birth. Structurally, an hernia has a mouth, a neck, and a body. The mouth, or hernial ring, is the opening from the abdominal cavity into the hernial protrusion; the neck is the portion of the sac that joins the hernial ring and the body. The body is the sac that protrudes outside the abdominal cavity and contains portions of the abdominal organs.
Hernias resulting from sports from sports most often occur in the groin area. Inguinal hernias, which occur more in men (more then75%), and femoral hernias, most often occurring in women, are the most prevalent types. Externally, the inguinal and femoral hernias appear similar because of the groin protrusion, but a considerable difference is indicated internally. The inguinal hernia results from an abnormal enlargement of the opening of the inguinal canal, through which the vessels and nerves of the male reproductive system pass. In contrast, the femoral hernia arises in the canal that transports the vessels and nerves that go to the thigh and lower limb.
Under normal conditions, the inguinal an femoral hernia canals are protected by muscle control against abnormal opening. When intra-abdominal tension affects these areas, muscle produce contractions around these canal openings. If the muscles fail to react or if they prove inadequate in their shutter action, abdominal contents may be pushed through the opening. Most physicians think that any athlete who has a hernia should be prohibited from engaging in hard physical activity until surgical repair has been made.
One danger of a hernia in an athlete is the possibility that it may become irritated by falls or blows. Besides the hernial aggravations caused by trauma, another concern that ATCs need to be aware of is the development of a strangulated hernia, in which the inguinal ring constricts the protruding sac and occludes normal blood circulation. If the strangulated hernia is not surgically repaired immediately, gangrene and death may ensue.
Signs & Symptoms – The acquired hernia occurs when a natural weakness is further aggravated by either a strain or direct blow. Athletes may develop this condition as the result of a violent activity. An acquired hernia may be recognized by the following signs: previous history of a blow or strain to the groin area that has produced pain and prolonged discomfort, superficial protrusion in the groin area that is increased by coughing, or reported feeling of weakness and pulling sensation in the groin area.
Treatment – The treatment preferred by most physicians is surgery. Mechanical devices, which prevent hernial protrusion, are for the most part unsuitable in sports because of the friction and irritation they produce. Exercise has been thought by many to be beneficial to a mild hernia, but such is not the case. Exercise will not affect the stretched inguinal or femoral canals positively.

51. Solar Plexus Injury Etiology Signs & Symptoms Treatment
Etiology – A blow to the sympathetic celiac plexus (solar plexus) produces a transitory (not permanent) paralysis of the diaphragm (“wind knocked out”).
Signs & Symptoms – Paralysis of the diaphragm stops respiration and leads to anoxia (lack of oxygen). When the athlete is unable to inhale, hysteria because of fear may result. These symptoms are usually transitory. It is necessary to allay such fears and instill confidence in the athlete.
Treatment – In dealing with an athlete who has had the “wind knocked out” of him/her, the ATC should adhere to the following procedures: help the athlete overcome apprehension by talking in a confident manner, loosen the athlete’s belt and clothing around the abdomen, have the athlete bend the knees, and encourage them to relax by initiating short inspirations and long expirations. Because of the fear of not being able to breathe, the athlete may hyperventilate. Hyperventilation is an increased rate of ventilation that results in a lowered carbon dioxide level. It causes a variety of physical reactions, such as dizziness, a “lump in the throat”, pounding heart, and fainting. The ATC should always be concerned that a blow hard enough to “knock the wind out” of someone could also cause internal organ injury.

52. Side Stitch Etiology Signs & Symptoms Treatment
Etiology – A “side stitch” is the name given to an idiopathic condition that occurs in some athletes. The cause is obscure, although several hypotheses have been advanced. Among these possible causes are the following: constipation, intestinal gas, overeating, diaphragmatic spasm as a result of poor conditioning , lack of visceral support because of weak abdominal muscles, distended spleen, breathing techniques that lead to a lack of oxygen in the diaphragm, ischemia of either the diaphragm or the intercostal muscles, and a fluid-engorged gut that tugs on visceral ligaments.
Signs & Symptoms – A side stitch is a cramp-like pain that develops on either the left or right costal angle during hard physical activity. Sports that involve running apparently produce this condition.
Treatment – Immediate care of a side stitch demands relaxation of the spasm, for which two methods have proved beneficial. First, the athlete is instructed to stretch the arm on the affected side as high as possible. If this method is inadequate, flexing the trunk forward on the thighs while tightening the abdominal muscles may prove of some benefit. Athletes with recurrent abdominal spasms may need special study. The identification of poor eating habits, poor elimination habits, or an inadequate fitness training program may explain the athlete’s particular problem. A side stitch, although not considered serious, may require further evaluation by a physician if abdominal pains persist.

53. For Your Quiz Students should be able to:
Identify the abdominal quadrants and regions and the particular organs that lie in each.
Identify the musculature of the thorax and abdomen.
Identify/explain the different injuries that occur to the abdomen and thorax.