1 Introduction

Trauma to the chest wall and shoulder girdle are intimately related and typically result from similar high energy mechanisms, despite being thought of as injuries to separate body systems. Fractures of the clavicle, sternum, and scapula are of interest to the orthopaedic surgeon while a general trauma surgeon may be more attentive to fractures of first rib or multiple ribs, unstable chest wall/flail segments, and pneumothorax/hemothorax. While they are the domains of different surgical specialists, these injuries are closely related and their recognition helps the astute clinician in timely diagnosis and treatment. It is well accepted that presence of clavicle, scapula, and sternal fractures in the context of patients with multi-trauma can indicate higher rates of head, thoracic, and great vessel injury.¹

Initial evaluation of the traumatized patient begins with Advanced Trauma Life Support protocol and is followed with institution based radiographic evaluation, often times with initial plain radiographs of the chest and pelvis to evaluate for immediately life threatening injuries. Major chest wall trauma such as pneumothorax, hemothorax, rib fractures, sternal/manubrial fractures, widened mediastinum, and fractures of the clavicle or scapula can be diagnosed on the initial chest radiograph. Further investigation of the thorax with computed tomography can reveal detail such as great vessel injury, pulmonary contusion, location of rib fractures, and further delineation of any fractures or disruptions of the shoulder girdle.²

Non-operative management of multiple rib fractures or flail segments consists of pulmonary toilet, pain control, and even mechanical ventilation. Pain control modalities may include local intercostal blocks, patient controlled analgesia systems, oral pain medications, and even epidural anesthesia.³ Use of regional anesthesia appears to offer benefits in lung function as measured by incentive spirometry and with pain control in the acute period after injury.⁴ Non-operative management avoids the risks typically associated with surgery: bleeding, infection, scarring, and disruption of costal neurovascular bundles.

Operative treatment can be institution and surgeon dependent with several prior studies suggesting that ICU length of stay and bacteremia can be decreased with surgical treatment. Operative management may aide in restoring chest wall mechanics in the setting of true flail segments, reduce pain and disability, avoid chest wall deformity, and lessen the risk of symptomatic rib fracture nonunion.³ Furthermore, operative treatment may provide benefit to patients who require ventilatory support. One randomized study of ventilated patients demonstrated improved mortality, more ventilator free days, and decreased length of hospitalization in the group underdoing surgical stabilization of unstable chest wall injuries.⁵

While regional, institutional, and individual surgeon variation exists in the treatment of severe chest wall and shoulder girdle injuries it is well recognized that both the orthopaedic surgeon and general trauma surgeon must play an active role in the treatment of injuries. Knowledge of contemporary diagnosis and treatment strategies is crucial for both surgical specialties to deliver timely, thoughtful, and high quality surgical and nonsurgical care of these patients.

2 Case report

The patient is a 49 year old male who initially presented to a community hospital after a highway speed high-energy motor vehicle collision. His past medical history was significant for diabetes mellitus type 2, hypertension, and hyperlipidemia. His surgical and family history was non-contributory. He was stabilized in the outside emergency department, admitted to their intensive care unit for chest trauma, and subsequently transferred to a trauma center for definitive management of his injuries.

Upon arrival in the intensive care unit at the trauma center the patient was hemodynamically stable on 4 ​L of oxygen through nasal cannula. New interval chest and pelvic radiographs were obtained upon arrival. The initial chest radiograph revealed a right sided pneumothorax with loss of lung markings, numerous rib fractures, a comminuted left clavicle fracture, and notable air outlines of what appeared to be the pectoralis major muscles on both sides of the chest wall (Fig. 1). A right sided chest tube was placed to treat the pneumothorax, with improvement in the appearance of the lung fields and with a persistent “air myogram” of the pectoralis major muscle bellies (Fig. 2).

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Fig. 1

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Figure 2 A right sided chest tube was placed to treat the pneumothorax, with improvement in the appearance of the lung fields and with a persistent “air myogram” of the pectoralis major muscle bellies.

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Further radiographic evaluation with computed tomography revealed significant chest wall trauma: bilateral pneumothoraces with extensive pneumomediastinum, thoracic level 4-7 spinous process fractures, right anterior 3rd rib fracture, left anterior 2nd-6th rib fractures, left lateral 8th rib fracture, left posterior 1st-9th rib fractures, a comminuted left clavicular shaft fracture, and fracture of the right manubrial edge. The air communicating from the pleural space and mediastinum along muscular planes creating the “air myogram” of the pectoralis major muscles was readily apparent on the computed tomography scan (Fig. 3).

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Figure 3 Air communicating from the pleural space and mediastinum along muscular planes creating the “air myogram” of the pectoralis major muscles apparent on the computed tomography scan.

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The chest tube was maintained to wall suction initially and the regional anesthesia pain service was consulted for intercostal nerve catheter placement. The left clavicle fracture was managed with a simple sling and motion as tolerated for the patient, but only after a discussion of surgical and non-surgical options. Adequate pain control was achieved to permit use of incentive spirometry, and for the patient to sit upright and mobilize bed to chair. He was transferred out of the intensive care to the ward on hospital day 2 as his supplemental oxygen requirements lessened and then ceased. Serial daily chest radiographs confirmed resolution of the pneumothorax; the chest tube was put to water seal and eventually removed on hospital day 4. Pain was controlled on intravenous and then oral medications, his oxygen saturations remained normal on room air, and he was able to mobilize with physical therapy prior to discharge home on hospital day 6.

3 Discussion

Chest wall trauma and shoulder girdle injuries frequently co-occur and result from high energy trauma. They represent an overlap in clinical knowledge and care for orthopaedic and general trauma surgeons; thus both groups must have a contemporary understanding of their diagnosis and treatment to ensure best patient outcomes. Patients with multiple system trauma may benefit from surgical repair of multiple rib fractures, flail chest segments, and clavicle or scapular fractures to improve chest wall mechanics, lessen ICU stays, control pain, and possibly reduce infections of other orthopaedic fracture repairs.

Our unique case involved a patient with chest wall and shoulder girdle trauma so extensive that air from the pleural cavity extended along dissected tissue planes to provide an air “myogram” of the pectoralis musculature. Only with massive disruption of the lung parenchyma, bony stabilizers of the chest wall, and the chest wall musculature could such a radiographic finding occur. His injuries were recognized promptly upon transfer to our trauma center, and treatment initiated with chest tube placement. Numerous factors lead to the decision for nonsurgical treatment of his chest wall and shoulder girdle injuries. With chest tube placement and adequate analgesia the patient was able to participate with respiratory therapy, wean from supplemental oxygen, and have continued resolution of pneumothorax. He was not multiply injured, was able to be transferred out of the ICU in short order, and after discussion desired at least initial non-surgical treatment of the left clavicle fracture. Surgical management of the chest wall and shoulder girdle might have been considered with different clinical circumstances such as true multisystem trauma with further fracture repairs needed, inability to ventilate independently, or inadequate pain control.

4 Conclusions

The unique radiographic finding of the “pectoralis myogram” helped to diagnose the extent of injury, and guide treatment of this patient’s chest wall trauma. Input from both orthopaedic and general trauma surgeons yielded a treatment plan that led to improved respiratory status, rapid step down from ICU care, and eventual timely discharge from the hospital. Recognition of these complex injuries and multi-specialty planning is necessary for optimal patient outcome.

Funding sources

No funding or sponsor was necessary in the preparation of this case report.

Informed consent

The patient was informed that data concerning the case would be submitted for publication and agreed with the creation and publication of this article.

Approval by institutional review board

This retrospective description of a clinical case does not require local IRB approval as there is no intervention, no change in treatment, and no follow up.

Authors contribution

All authors equally shared in conceptualization and reviewing/editing. The corresponding author was responsible for data curation and writing the original draft, as well.