Textbook of Urgent Care Medicine, Chapter 35, Chest Wall and Other Thoracic Trauma

Sean M. McNeeley

Originally published in 2014. Substantially updated and clinically reviewed in 2026.

INTRODUCTION

Trauma to the chest wall and remainder of the thorax is a common presentation in the acute care setting. Many injuries are minor and easily managed. Life-threatening injuries do, however, sometimes present at urgent care centers. Because of their infrequent nature, serious injuries can be easily missed if not considered in every patient.

The urgent care clinician must quickly distinguish isolated chest wall pain from injury that may compromise breathing or circulation. Mechanism, vital signs, oxygen saturation, ability to breathe deeply, and associated injuries guide the need for emergency department evaluation. A normal initial chest radiograph does not exclude significant intrathoracic injury. [1,2]

PRESENTATION

Presentation of thoracic injuries varies widely because these patients may have sustained serious injuries due to high-speed or high-height accidents or simple falls. As expected, signs and symptoms vary just as widely, from chest pain, tachycardia, tachypnea, hypotension, and hypoxia to minor lacerations or bruising. Patients with this type of injury may present immediately after injury or much later as symptoms appear.

TRIAGE PEARLS

• Evaluate the patient’s general appearance:
  • Check the ABC’s (airways, breathing, and circulation).
  • Abnormal vital signs are the first indication of possibly serious injury.
  • Identify and address hypoxemia and evidence of shock; activate EMS immediately for respiratory distress, poor perfusion, significant penetrating trauma, or an unstable chest injury. Do not delay transfer to complete imaging or laboratory studies. [1,2]

• Determine the mechanism of injury because it can greatly affect possible diagnoses.
  • A severe injury, such as being hit by a car
  • A moderate- to high-speed motor vehicle collision
  • A fall from a significant height (more than two to three times the patient’s height)
  • Frailty, older age, anticoagulant use, chronic pulmonary disease, and reduced respiratory reserve may increase risk even after a lower-energy mechanism. [1]

• Assess for the following life-threatening conditions:
  • Pulmonary contusion
  • Pneumothorax
  • Tension pneumothorax
  • Cardiac tamponade
  • Damage to the great vessels
  • Massive hemothorax
  • Sucking chest wound

• Suspected tension pneumothorax is a clinical emergency. Tracheal deviation and distended neck veins are late or unreliable signs; their absence does not make a patient safe. Emergency decompression, when required, should be performed only by appropriately trained and equipped clinicians under emergency response protocols. [2,3]

HISTORY PEARLS

• Ascertain the mechanism of injury.
• Localize symptoms.
• Do not use the duration of symptoms alone to rule out a serious injury. Pulmonary contusion, an evolving pneumothorax, and other complications may become apparent after the initial event. [2]
• Symptom course: Are symptoms decreasing, or are they worsening instead?
  • Dyspnea
  • Chest pain
  • Palpitations
  • Arm or shoulder disability
  • Numbness or weakness of upper extremities
  • Hematuria

• Other injuries that may reveal severity of trauma
• Previous cardiopulmonary disease
• Medication that might affect care
• Symptoms may also be referred to the contiguous local anatomy such as the abdomen, upper extremities, or neck.
• Clarify antiplatelet or anticoagulant use, baseline oxygen requirement, smoking or lung disease, and ability to cough and take a deep breath. [1]

PHYSICAL EXAM PEARLS

• Vital signs:
  • Tachycardia or bradycardia
  • Arrhythmia
  • Tachypnea
  • Hypoxia
  • Hypotension

• Record respiratory rate, pulse oximetry, blood pressure, heart rate, mental status, and work of breathing; repeat measurements if the patient remains in the clinic. A normal oxygen saturation alone does not exclude pneumothorax or pulmonary contusion. [1,2]
• Inspect for the following:
  • Abrasions
  • Lacerations
  • Depth
  • Bruising
  • Rib and sternum shape
  • Paradoxical movement
  • Distended neck veins

• Flail chest presents with a section of the chest wall demonstrating paradoxical and possibly decreased motion and other significant abnormalities.
• Palpate to assess for the following injuries:
  • Neck for tracheal deviation and subcutaneous emphysema
  • Clavicles
  • Scapula
  • Ribs and sternum

• Percuss lung fields for the following:
  • Dullness (indicative of hemothorax)
  • Hyper-resonance (indicative of pneumothorax)

• Auscultate all lung fields for the following:
  • Rales
  • Rhonchi
  • Decreased breath sounds

• Assess the heart.
  • Sounds (i.e., murmurs)
  • Arrhythmia

• Chest wall tenderness, equal breath sounds, or an apparently benign examination cannot independently exclude an internal injury after significant trauma. Examine the abdomen and shoulder girdle for associated injury. [2]

TESTING PEARLS

• An electrocardiogram (ECG) should be obtained when blunt cardiac injury is suspected; a normal ECG alone does not exclude the diagnosis. Definitive screening uses ECG together with cardiac troponin in the emergency department or hospital. Troponin testing should not be assumed to be available as a CLIA-waived urgent care test. [4]
• Chest x-ray may show the following:
  • Rib fractures
  • Pulmonary contusion
  • Pneumothorax
  • Hemothorax
  • Abnormal air, fluid, or foreign bodies

• A chest radiograph is an appropriate initial imaging study for many stable patients with isolated minor blunt chest trauma. Dedicated rib films generally do not change management in an uncomplicated isolated injury. [5,6]
• Clavicle x-rays are used to check for fracture or displacement.
• With significant mechanism, abnormal examination, hypoxemia, or concern for internal injury, CT imaging and other trauma studies are arranged at the receiving emergency department. Contrast-enhanced CT or CT angiography may be needed when major thoracic vascular injury is suspected; a normal chest radiograph does not safely exclude it. [2,7]
• Point-of-care ultrasound or eFAST may help identify pleural air or fluid in a properly trained trauma setting. Neither a negative bedside examination nor a normal initial radiograph overrides concerning clinical findings. [2]

DIAGNOSIS PEARLS

Common Urgencies

• Contusions:
  • Visible bruising
  • Localized tenderness
  • Discomfort with movement

• Lacerations:
  • Exposure is important.
  • Assess depth.
  • Examine for and assess risk for presence of foreign bodies.
  • Penetrating wounds or wounds whose full depth cannot be confidently determined should be referred for emergency assessment rather than explored deeply or closed in urgent care. [2,3]

• Rib strains:
  • Diagnosis by exclusion
  • Same symptoms and signs as rib fractures without demonstrable bone damage

• Rib fracture:
  • Localized bruising, palpable tenderness, or step-off
  • Multiple lower rib fractures may indicate injury to the liver or spleen or kidneys.
  • Chest x-ray may demonstrate displaced fractures or associated pneumothorax, but normal images do not exclude rib fracture or intrathoracic injury. [1,5]
  • First- and second-rib fractures after major trauma should increase suspicion for associated vascular or intrathoracic injury. [2]
  • A chest x-ray may miss nondisplaced rib fractures. More important than confirming every fracture is recognizing associated intrathoracic injury and impaired ventilation. Multiple displaced fractures, flail segment, poor cough, or severe pain require emergency assessment. [1,5,6]

• Sternum fracture:
  • Often caused by significant force
  • Findings usually include localized tenderness and occasionally palpable deformity; therefore, also assess for damage to great vessels and for cardiac contusion or displacement.
  • An isolated sternal fracture does not by itself prove blunt cardiac injury; use mechanism, examination, ECG, and hospital-level troponin assessment where indicated. [4]

• Clavicle fracture:
  • Palpable tenderness and deformity
  • Clavicle films are diagnostic.

• Scapulothoracic dissociation:
  • Pain and swelling of the posterior shoulder
  • History of a motor vehicle accident or life-threatening fall
  • Usually visible on x-rays as lateral displacement of the scapula
  • Suspect major neurovascular injury; immobilize, document distal perfusion and neurologic function, and arrange EMS transfer. [2]

• Scapula fracture:
  • History of trauma (direct or indirect through the arm)
  • Localized tenderness
  • Hard to see on chest x-ray; usually visible on dedicated scapular views
  • Requires a significant amount of force; therefore, look for additional injuries.

• Blunt cardiac injury (historically called cardiac contusion):
  • Consider after a significant blunt chest mechanism, especially with dysrhythmia, unexplained hypotension, or other evidence of cardiac dysfunction. An ECG is the appropriate initial urgent care study; patients requiring cardiac troponin, monitoring, or echocardiography need hospital evaluation. [4]

• Pulmonary contusion:
  • Possible dyspnea
  • Possible hypoxia
  • Usually accompanied by other significant trauma:
    • Rib fractures
    • External bruising
  • Patients can be initially minimally symptomatic despite evolving lung injury. [2]
  • Chest radiography may be unrevealing early; oxygenation and respiratory status can worsen over subsequent hours. Suspected pulmonary contusion warrants emergency department evaluation. [2]

• Pneumothorax:
  • Chest pain
  • Dyspnea
  • Tachycardia
  • Rib fracture
  • Usually seen on chest x-ray
  • Pneumothorax may be occult on initial radiography. Any suspected traumatic pneumothorax requires emergency assessment. Selected stable small pneumothoraces can undergo monitored observation, but this is an ED/hospital pathway, not a short unsupervised urgent care observation period. [2]

Rare Urgencies

• Tension pneumothorax:
  • Hypotension or evidence of hypoperfusion
  • Unilateral decreased breath sounds
  • Can rapidly cause obstructive shock. Late findings may include distended neck veins or tracheal deviation; do not wait for them. Immediate EMS response is indicated, and specialized decompression is reserved for trained clinicians with an appropriate emergency protocol. [2,3]

• Cardiac tamponade:
  • May present with shock, tachycardia, hypotension, and distended neck veins. Beck’s triad is often incomplete. Suspect tamponade after penetrating or major blunt chest injury with poor perfusion; arrange immediate EMS transport. [2]

• Massive hemothorax:
  • Decreased breath sounds
  • Decreased chest wall movement
  • Dullness to percussion on the affected side
  • Suspected significant hemothorax is a hospital-level emergency; do not delay transfer to quantify blood loss. [2]

• Open pneumothorax (sucking chest wound):
  • Often obvious in penetrating trauma but may have a small-appearing entrance wound. Activate EMS immediately and avoid procedures that delay transport. A vented chest seal may be used by trained clinicians following protocols; monitor for deterioration because an occluded seal can precipitate tension physiology. A routine three-sided dressing is no longer recommended. [3,8]

TREATMENT AND DISPOSITION PEARLS

• Unstable patients and those with potential emergency conditions require immediate EMS activation and preparation for transfer; oxygen is appropriate for hypoxemia, with monitoring and resuscitative support within the clinic’s capabilities. Do not delay transport for intravenous access or imaging. [1,2]
• Contusions:
  • Pain can last several weeks
  • Treat with cold for 24 hours, and then heat after the first day for 20 minutes three times daily.

• Lacerations:
  • Superficial wounds may be irrigated and repaired when the wound depth and associated injury have been safely assessed. Do not close a penetrating thoracic wound until pleural injury has been excluded in an appropriate setting. Review tetanus status. [2]
  • See Chapter 37, “Laceration Repair and Wound Management,” for more information on wound care.

• Rib and chest wall strains:
  • Provide adequate pain control with acetaminophen and, when appropriate, a nonsteroidal anti-inflammatory drug. Reserve short-course opioids for selected patients with severe pain after weighing sedation and respiratory risks. Encourage comfortable deep breathing, supported coughing, mobilization, and pulmonary hygiene. Avoid circumferential rib binding. [1]

• Rib fracture: Uncomplicated and minimally displaced or nondisplaced rib fractures may be treated as rib strains when vital signs, breathing, pain control, and associated-injury assessment support discharge.
• Older patients, those with multiple fractures or chronic lung disease, and anyone unable to breathe deeply or cough despite analgesia require a lower threshold for emergency evaluation or hospital observation. [1]
• Sternal fracture: An isolated fracture in an otherwise healthy patient may heal with analgesia and breathing exercises, but assess for blunt cardiac injury and other thoracic trauma before deciding on outpatient care. [4]
• Clavicle fracture:
  • For isolated or minimally displaced fractures, prescribe rest for the arm, use of a sling, ice, and orthopedic follow-up.
  • Displaced fractures or threatened skin integrity require timely specialist evaluation; associated chest or neurovascular injury requires emergency transfer.

• Scapulothoracic dissociation: Because of the severe nature of trauma necessary to sustain this injury and a high rate of accompanying vascular injury, these patients must be taken to an emergency department.
• Scapula fracture:
  • Without urgent complications, treat these fractures conservatively with rest, a sling, and analgesics.
  • Specialist consultation is recommended because of the high prevalence of other injuries and significant force involved in such injuries.

• Blunt cardiac injury: Transfer patients with concern for this diagnosis for ECG/troponin-based assessment and monitoring as indicated; do not attempt to rule it out using an urgent care ECG alone. [4]
• Pulmonary contusion: Observation is best conducted at a hospital, with oxygenation and respiratory monitoring as needed.
• Pneumothorax: Any traumatic pneumothorax diagnosed or suspected in urgent care should be evaluated in an emergency department. Stable, small pneumothoraces may be monitored nonoperatively there, with the 2025 WSES-AAST guidance describing at least 24 hours of observation for selected patients. [2]
• Tension pneumothorax, cardiac tamponade, massive hemothorax, and open pneumothorax: Activate EMS, provide supportive care within training and equipment limits, and arrange immediate transfer; definitive thoracic interventions are managed by emergency or trauma teams. [2,3]

Urgent Care Disposition

Disposition is individualized. Even with a normal chest radiograph, a concerning mechanism or evolving symptoms may justify emergency evaluation. [1,2,5]

MEDICOLEGAL PEARLS

• Patients often incorrectly self-triage and may report to urgent care setting even after significant trauma. Maintain a high index of suspicion for serious injury.
• Thoracic aortic disruption has been reported in patients involved in seemingly low-speed motor vehicle accidents. First and second rib fractures, scapular fractures, widening of the mediastinum, blunting of the aortic knob, and depression of the pulmonary arteries are all subtle signs of possible aortic disruption. Time is of the essence to transport these patients.
• Look closely at chest x-rays for a subtle, small pneumothorax.
• A normal chest radiograph does not exclude vascular injury, small pneumothorax, or early pulmonary contusion. Document repeated vital signs and oxygen saturation, the mechanism, associated injuries, clinical reassessment, transfer decision, and patient instructions. [2,7]
• ECGs are important when blunt cardiac injury is suspected, but hospital-level troponin and observation pathways may still be necessary. [4]

KEYWORDS

Blunt thoracic trauma; chest wall injury; rib fracture; traumatic pneumothorax; tension pneumothorax; hemothorax; pulmonary contusion; blunt cardiac injury; urgent care disposition.

REFERENCES

1. American College of Surgeons Trauma Programs. Best Practices Guidelines in the Management of Chest Wall Injuries. American College of Surgeons; 2025. Source
2. Coccolini F, Cremonini C, Moore EE, et al. Thoracic trauma WSES-AAST guidelines. World J Emerg Surg. 2025;20:78. doi:10.1186/s13017-025-00651-1. Source
3. National Association of EMS Physicians. Prehospital Trauma Compendium: Traumatic Pneumothorax Care: Position Statement and Resource Document. Prehosp Emerg Care. Published online 2024. doi:10.1080/10903127.2024.2416978. Source
4. Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 suppl 4):S301-S306. Source
5. American College of Radiology. ACR Appropriateness Criteria: Rib Fractures. American College of Radiology. Accessed October 30, 2026. Source
6. Zandee van Rilland ED, Fayad LM, Link TM, et al. Optimizing radiography utilization: multidisciplinary expert consensus recommendations. Radiology. 2026;319(2):e252309. doi:10.1148/radiol.252309. Source
7. American College of Radiology. ACR Appropriateness Criteria: Major Blunt Trauma. American College of Radiology. Accessed October 30, 2026. Source
8. American Heart Association and American Red Cross. 2024 American Heart Association and American Red Cross Guidelines for First Aid. 2024. Source