Studies of the consequences and treatment of blunt thoracic trauma (BTT) remain hampered by a varying pathologic definition of the disease. Entities typically classified as BTT include chest wall lesions such as rib fractures, flail chest and soft-tissue contusion; intrapleural lesions such as hemothorax and pneumothorax; parenchymal lung injuries such as pulmonary contusion and lung laceration; and mediastinal lesions such as blunt cardiac injury. 1,2 For purposes of this evidence-based review, we are concerned primarily with those injuries to the chest wall that produce their morbidity through pain and its associated mechanical ventilatory impairment. Thus, blunt chest trauma is defined here to include soft-tissue trauma and injuries to the bony thorax such as rib fractures and flail chest. 3 Within the scope of this definition, the incidence and morbidity of BTT clearly remain significant. Rib fractures themselves are believed to be very common and have been documented in up to two thirds of cases of chest trauma. 4,5 In another review, 10% of all patients admitted to one trauma center had radiographic demonstration of rib fractures. 3 Isolated single or multiple rib fractures are one of the most common injuries in the elderly, at approximately 12% of all fractures, with an increasing incidence recorded as the population ages. 6 The true incidence of bony thoracic injury may be underreported, as up to 50% of fractures may be undetected radiographically. 7 For patients with blunt chest wall trauma, the morbidity and mortality are significant. These injuries are associated with pulmonary complications in more than one third of cases 3 and pneumonia in as many as 30% of cases. 3,8,9 Patients older than 65 years may be even more prone to major complications after blunt chest wall injury, 3,10 -12 with 38% respiratory morbidity from isolated rib fractures in another review. 13 Because blunt chest wall trauma causes death indirectly, through pulmonary and nonpulmonary complications, the true mortality rate for these injuries is hard to evaluate. In one study, 6% of patients with blunt chest trauma died, and at least 54% of these deaths could be directly attributed to secondary pulmonary complications. 3 An elderly group of patients suffered an 8% mortality rate from isolated rib fractures. 13 Mortality of isolated flail chest has been as high as 16%. 14 The incremental costs attached to pulmonary complications of blunt chest trauma have not been addressed in the literature but clearly would be measured in "intensive care unit (ICU) days" and "ventilator days," both of which are expensive commodities.The treatment for injuries of the bony thorax has varied over the years, ranging from various forms of mechanical stabilization 15,16 to obligatory ventilatory support. [17][18][19] It is now generally recognized that pain control, chest physiotherapy, and mobilization are the preferred mode of management for BTT. 9,20 Failure of this regimen and ensuing mechanical ventilation sets the stage for progressive respira...
