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Thoracic Trauma

Author: Gavin Lloyd / Editor: Jason M Kendall, Stewart McMorran / Codes: C3AP1a, HAP26 / Published: 08/05/2017 / Review Date: 08/05/2020

 

Introduction

  • For each life-threatening thoracic injury this work will include:
  • A definition and context to include the incidence, likely mechanism of injury and (where appropriate) the likelihood of the injury being missed clinically and/or radiologically
  • Clinical assessment and identification of the injury
  • Treatment
  • Key learning points, pearls and pitfalls

Tension pneumothorax

Definition and context

Think expanding pneumothorax that increasingly limits ventilation and venous return perhaps a better concept for teaching purposes. It is not an on/off phenomenon, rather a continuum.

So even impressive expansion, (Fig 1) may be well tolerated in young individuals with no co-morbidities and no other injuries. In fact tolerated so well that you may miss the clinical diagnosis no harm done .

Fig 1: Tension pneumothorax

thoracic_trauma_lge_1

Given that the expansion is dynamic, be vigilant in patients with a chest x-ray proven small pneumothorax in whom you elect not to insert a chest drain.

Clinical assessment and identification

Symptoms and signs depend on where your patient is on the expanding pneumothorax continuum clinical features become more obvious with expansion.

(a) For awake patients:

Universal features of tension pneumothorax are chest pain and respiratory compromise [1], neither of which are discriminatory of course.

Low oxygen saturations may be an early feature; hypotension tends to be late. Both may have other causes.

Lateralising the pneumothorax may not be straightforward listen for decreased breath sounds on the affected side. Listen in the axillae rather than over the anterior chest wall.

Note the classical signs of hyper-resonance and tracheal deviation are soft and difficult to elicit.

(b) For ventilated patients:

Early reliable signs are:

  • Decrease in oxygen saturations this is likely to be prompt
  • Decrease in BP
  • Tachycardia

Look too for raised ventilation pressure (greater than 40) ensure that the ventilator pressure alarm settings are set appropriately (Fig 2). Lateralising signs are the same as for awake patients.

Fig 2: Ventilator

thoracic_trauma_2

If your patient is not critical then there is time to get an urgent resus room CXR. This should help you:

  • Confirm or refute the diagnosis
  • Confirm the side of pneumothorax
  • Rule in or out other diagnoses

Learning Bite

A portable CXR is recommended for tension pneumothorax, unless the patient is critical radiological evidence of tensioning does not necessarily correlate clinically

Treatment

Needle thoracocentesis is advocated for tension pneumothorax in the first instance in the ATLS manual [2]. Potential drawbacks to this strategy are:

  • It tends to get over used, particularly in stable resus room patients in whom portable CXR is readily available and chest drain is the preferred treatment
  • A lack of hiss (or bubbling, if you have put some saline in a syringe attached to the needle) might be considered as evidence of no tension pneumothorax the procedure doesnt have 100% sensitivity
  • A (4.5 cm) 14 gauge cannula may not reach the pleural space via the second intercostal space. In one study [3], this was the case in about a third of the patients. This might account for the point above
  • The cannula can kink and cease to function
  • A pneumothorax may be caused if the diagnosis is incorrect. This is of particular concern if the patient receives IPPV

In peri-arrest patients with suspected tension pneumothorax (particularly those with penetrating trauma) a thoracostomy (i.e. the initial part of a chest drain insertion) is probably the best option.

Learning Bite

avoid needle thoracocentesis in peri-arrest patients with suspected tension pneumothorax thoracostomy is the better option

Chest drain insertion is covered in detail in a dedicated skills session here. Here are some selected key learning points from that session:

  • The most common cause of serious injury (and death) as a result of chest drain insertion, is insertion at the incorrect site, usually too low
  • Confirm that the drain lies within the chest wall cavity by looking for fogging of the tube and swinging of the chest drain with respiration
  • Do not clamp the chest drain or apply suction
  • The underwater seal needs to remain below the insertion site at all times

Pearls

  • If you do perform needle thoracocentesis, have some saline in the syringe to demonstrate bubbling when the tension is hit
  • Gross surgical emphysema in combination with pneumomediastinum (as per CXR) and a chest drain that continues to bubble, suggests tracheo-bronchial injury (Fig 3)
  • If there is good clinical and radiological evidence of significant lateral chest wall injury, consider the second intercostal space anteriorly for the chest drain insertion its safer for the operator and less painful for the awake patient

Fig 3: Tracheo-bronchial injury

thoracic_trauma_lge_3

Pitfalls

  • One third of initial CXRs in trauma will not detect pneumothorax anaesthetic colleagues need to be aware of this if your patient leaves for theatre
  • Cardiac tamponade may give similar signs clinically shock, with distended neck veins. A combination of your FAST skills, urgent CXR and consideration of the mechanism of injury should help you distinguish the two
  • Beware other pathology masquerading as large (possibly tensioning?) pneumothorax on the CXR, for example an emphysematous bulla or gastrothorax (Figs 4 and 5). Reconsider the clinical presentation and consider CT where the CXR diagnosis remains in doubt

Fig 4: Emphysematous bulla

thoracic_trauma_lge_4

Fig 5: Gastrothorax

thoracic_trauma_lge_5

Learning Bite

  • A portable CXR is recommended for tension pneumothorax, unless the patient is critical radiological evidence of tensioning does not necessarily correlate clinically
  • Avoid needle thoracocentesis in peri-arrest patients with suspected tension pneumothorax thoracostomy is the better option

Open pneumothorax

Definition and context

Think hole in the chest. It is also known as a communicating pneumothorax or sucking chest wound. Rarely, it is caused by ballistic (shot gun) injury. Clearly, this unlikely to be missed clinically. As the patient takes a breath in, the hole in the chest competes with the normal airway (mouth/nose to trachea) for delivery of air.

Learning Bite

A hole of only 1 or 2 cm in radius may cause serious respiratory compromise, particularly in patients with comorbidities, and/or other injuries

Clinical assessment and identification

Prompt clinical inspection front and back; a small sucking chest wound is usually audible.

Treatment

  • Definitive treatment is surgical repair. The emergency physician must alleviate any respiratory embarrassment, exclude associated injuries and identify the need for timely thoracotomy or laparotomy
  • Cover the wound, if not already done so by the paramedics. Sheets of Jelonet will do. Specific chest seal devices (Ashermann or Bolin) exist (Fig 6). If the hole is too big for either of the above, then cover with a large opsite, make a small hole in the middle and place a chest seal device on top if available

Fig 6: Chest seal devices

thoracic_trauma_6_0

  • Temporarily release any wound dressing over the open pneumothorax if you suspect tensioning
  • Early intubation: IPPV solves the respiratory embarrassment created by the hole in the chest
  • For small open pneumothoraces, insert a chest drain remote from the wound on that side; this is practically easier once the patient is anaesthetised
  • Do not insert a chest drain in patients with a large open pneumothorax since muscle flaps may be needed for closure and can be damaged in the procedure

Massive haemothorax

Definition and context

A haemothorax with a volume greater than 1500 ml, or greater than one third of the patients blood volume. This is an uncommon injury which can be caused by blunt or penetrating trauma, and is unlikely to be missed radiologically.

It creates a problem because of shock (haemorrhagic and impaired venous return from the vena cava) and decreased ventilation (the lung on that side gets compressed).

Clinical assessment and identification

Think of the concept of expanding haemothorax (another continuum!): the signs will be less reliable in moderate haemothorax. Listen at the lung bases (Fig 7). There should be clear signs of shock prompting you to rule out the diagnosis. Use CXR and FAST to guide you.

Fig 7: Lung bases

thoracic_trauma_lge_7

FAST signs: the absence of a mirror image of liver/ lung or spleen/lung across the diaphragm suggests a haemothorax (Fig 8); alternatively free fluid in the abdomen alone should prompt you to reconsider the source of haemorrhage (Fig 9).

Fig 8: Haemothorax

thoracic_trauma_lge_8

Fig 9: Free fluid

thoracic_trauma_lge_9

Treatment

  • Intravenous fluid resuscitation
  • Appropriate use of blood and blood products
  • Chest drain only if there is respiratory compromise
  • Ideally connect the drain to a cell salvage/saver machine (autotransfusion) (Fig 10). If a cell saver is not readily available then use the usual apparatus, but prime the underwater seal with saline not sterile water the saline/blood collection can still be run through a cell saver later

Fig 10: Cell salvage/saver machine

thoracic_trauma_10

  • Occasionally a massive haemothorax may be well tolerated, typically in young patients with a chest stabbing. Delaying chest drain insertion until reaching thoracic theatre, where cell salvage exists, is an option
  • Whilst a guideline for thoracotomy exists (see table), have a low threshold for engaging thoracic surgeons early
  • In cases of exsanguinating haemorrhage, clamp the chest drain and arrange immediate thoracotomy in theatre

thoracic_trauma_10b

Pitfall

You may underestimate the size of the haemothorax on a supine CXR (Fig 11).

Fig 11: Haemothorax

thoracic_trauma_lge_11

Learning Bite

  • In massive haemothorax, insert a chest drain only if there are signs of respiratory compromise
  • Prime the underwater seal for the chest drain with saline not sterile water

Cardiac tamponade

Definition and context

Cardiac tamponade is a collection of fluid (blood in the context of trauma) in the pericardial sack causing haemodynamic compromise.

When faced with a penetrating injury to chest, back or upper abdomen, think tension pneumothorax, think massive haemothorax, and think cardiac tamponade. Exclude or confirm tamponade with a FAST scan.

Cardiac tamponade is not an on/off phenomenon (yet another continuum), though the progression to PEA cardiac arrest may be rapid. 50 to 200 ml of blood in the pericardial sac may be enough.

Cardiac tamponade as a result of blunt injury is exceptionally rare in those patients reaching hospital alive.

Clinical assessment and identification

FAST has particularly high sensitivity (about 95% according to ATLS [2]).

Do note that there are drawbacks in detecting and interpreting the classical clinical signs:

  • Neck veins may not be distended if the patient has haemorrhagic shock
  • Hypotension (and a raised respiratory rate) may have other causes
  • Muffled heart sounds unlikely to be heard in the ED!

Treatment

  • Fluid resuscitation to increase pre-load
  • If the patient is haemodynamically stable refer for urgent surgical exploration in theatre. Look for co-existing injuries (especially pneumothorax) on a portable CXR first
  • Thoracotomy (session link) if the patient presents within 10 minutes of cardiac arrest
  • Correctly performed pericardiocentesis is likely to fail because the blood within the pericardium is clotted. The procedure will also delay thoracotomy. We (the authors) advise against pericardiocentesis unless there is really no one capable of opening the chest. ATLS [2] advises pericardiocentesis only as a temporising measure, pending thoracotomy

Learning Bite

  • Cardiac tamponade as a result of blunt injury is exceptionally rare
  • FAST scanning is highly sensitive
  • Thoracotomy, not pericardiocentesis is recommended

Flail chest

Definition and context

This occurs when a series of ribs (usually 3 or more) are fractured segmentally (i.e. in more than one place) resulting in a free or floating section of the chest wall. This injury is relatively common small flails may be missed clinically.

Learning Bite

  • Beware underlying pulmonary contusions which are inevitable, and may cause significant morbidity and mortality in any age group
  • Considerable force is required to create a flail chest in young people look carefully for other injuries, both intra and extra-thoracic
  • Multiple rib fractures are a potential source of significant haemorrhage

Clinical assessment and identification

By palpation as well as inspection.

A CXR might identify associated pneumothorax, haemothorax and pulmonary contusions (Fig 12). The appearance of early pulmonary contusions is particularly worrying; evidence of further and perhaps extensive contusion (with physiological effect) may evolve.

Fig 12: Pulmonary contusions
thoracic_trauma_lge_12

Treatment

  • Treatment options depend largely on the respiratory embarrassment caused: consider your patients clinical condition, the size of the flail chest, associated injuries, age, co-morbidities and destination from resus (theatre, CT scan, ITU or ward)
  • For patients with major trauma (apply common sense in defining this) proceed to intubation and ventilation (IPPV). This enables you to take better control of respiratory compromise, addresses your patients pain (remember to give adequate morphine post RSI) and facilitates clinical procedures e.g. chest drain insertion and CT scan
  • Insert a chest drain for associated pneumothorax and haemothorax. CT is likely to pick up occult pneumothoraces; whilst usually small, chest drain insertion is recommended if the treatment option is ventilation
  • Judicious fluid resuscitation since excessive fluid floods injured lung tissue
  • Definitive surgery (internal fixation of ribs) at the discretion of cardiothoracic surgeons
  • Discuss treatment options with ICU and thoracic surgical colleagues for patients with a flail segment causing limited respiratory embarrassment, and in whom there are no other life-threatening injuries. A conservative approach might include the use of thoracic epidural4, intercostal nerve blocks or patient controlled analgesia, and CPAP and physiotherapy

Pulmonary contusion

Definition and context

Bruised lung; unlikely to be missed radiologically unless the CXR is early.

Potentially life threatening since:

  • The patient is at risk of hypoxaemia
  • Because of the force involved to cause the injury, associated injuries are common
  • Injured lung is vulnerable to flooding from aggressive fluid resuscitation

Patients with co-morbidities and/or advanced age are particularly at risk from this injury.

Clinical assessment and identification

  • Look for patchy white areas progressing to frank consolidation on the CXR (aspiration and haemorrhage are differential diagnoses) (Fig 13)

Fig 13: Lung contusion

thoracic_trauma_lge_13

  • Contusions visible on the initial CXR suggests significant injury, with further radiological changes and blood gas derangement likely to follow
  • Look for associated rib fractures and haemo/pneumothorax
  • Rib fractures do not always co-exist, particularly in the young (where their existence indicates that significant force created the injury)

Treatment

  • IPPV with Positive End Expiratory Pressure (PEEP) for the sicker patients
  • Judicious use of fluids consider insertion of a central line and arterial line
  • No evidence for steroids or prophylactics antibiotics
  • Avoid colloids since these will breach injured lung tissue and worsen hypoxia
  • Discuss disposition of each patient with ITU and thoracic surgical colleagues

Learning Bite

  • Lung contusion is a marker of significant injury
  • Early CXR evidence of contusion is particularly worrying

Myocardial contusion

Definition and context

Myocardial bruising caused by blunt injury, including deceleration and ballistic mechanisms.

The key problem with interpreting the literature is the lack of a diagnostic gold standard (apart from post mortem).

Clinical assessment and identification

  • A normal ECG effectively rules out the condition [4,5]
  • Unexplained tachycardia may be a clue. Look too for atrial and ventricular ectopics.
  • Consider bedside echocardiogram
  • Consider troponin [6]

Treatment

There is no direct ED-based intervention to treat the myocardial contusion itself; treat the following if identified:

  • Hypoxaemia
  • Acidaemia
  • Fluid status
  • Low haemoglobin

Monitor ECG. Consider a central and arterial line.

Pitfall

Beware labelling ST changes as myocardial contusion; there may have been a primary cardiac event that precipitated the accident.

Learning Bite

A normal ECG effectively rules out myocardial contusion [2]

Aortic injury

Definition and context

Consider carefully in rapid deceleration injuries, e.g. road traffic accidents and falls. Missing the diagnosis both clinically and on CXR is quite common.

The few patients (about 10%) who make it alive to the ED will have haemorrhage tamponaded by aortic adventitia (a vulnerable pseudo-aneurysm).

There is no increased risk of injury related to atherosclerosis. It is young males who engage most in risk taking activities that end in rapid deceleration accidents (Fig 14).

Fig 14: Rapid deceleration accident

thoracic_trauma_15

Clinical assessment and identification

Most patients will complain of other associated injuries rather than specific symptoms of aortic injury.

The majority of ruptures in patients reaching hospital alive are just distal of the left subclavian artery, so a difference in blood pressure between both arms is not necessarily a feature.

Occasional clinical clues include generalised hypertension, upper extremity hypertension in combination with weak or absent femoral pulses, and a harsh systolic murmur.

An erect good-quality CXR has good but not perfect sensitivity in ruling out the diagnosis in low risk patients [7]. Such a CXR is not achievable in most multi-trauma patients, Neither are these patients necessarily low risk.

Several CXR features might suggest the injury according to ATLS [2]:

  • Widened mediastinum the most reliable sign
  • Fractures of the first and second ribs
  • Obliteration of the aortic knob
  • Deviation of the trachea to the right
  • Presence of a pleural cap
  • Elevation and rightward shift of the right main stem bronchus
  • Depression of the left main stem bronchus
  • Obliteration of the space between the pulmonary artery and the aorta
  • Deviation of the nasogastric tube to the right

Contrast CT thorax is the investigation of choice.

Aortic injury is one of many causes of mediastinal haematoma; sternal fracture and thoracic vertebral fracture are also associated with mediastinal haematomas (Fig 15).

Fig 15: Mediastinal haematoma

thoracic_trauma_lge_16

Treatment

Surgical repair or endovascular stenting, which may require transfer from your facility. Competing and likely overriding injuries include life-threatening head, abdominal or pelvic injuries.

Control hypertension (systolic no more than 110 mmHg) and tachycardia with appropriate analgesia; labetalol is the agent of choice to control acute hypertension in this setting.

Learning Bite

Young males are the most likely candidates for aortic injury

Diaphragmatic injury

Definition and context

Diaphragmatic injury is usually caused by penetrating rather than blunt injury. It is easily missed both clinically and radiologically.

In blunt injury it is three times more common on the left (the right hemi-diaphragm being protected by the liver) and nearly always at the weakest point, posterolaterally.

A diaphragmatic breach will not heal spontaneously because of the differential pressure gradients between chest and abdomen. Abdominal content herniation is a possibility and may be picked up years later.

Figs 16 and 17: Diaphragmatic injury

thoracic_trauma_lge_17

thoracic_trauma_lge_18

Clinical assessment and identification

Symptoms are likely to be masked by associated injuries.

Diaphragm injuries resulting from knives or bullets are more likely to be detected on surgical exploration.

In blunt injuries, particularly those causing an abrupt rise in intra-abdominal pressure, be careful not to interpret a gastrothorax (Fig 18) for a large pneumothorax; both will cause respiratory embarrassment.

Fig 18: Large gastrothorax

thoracic_trauma_lge_19

Treatment

Insert a nasogastric tube gently to drain stomach content.

A cautiously placed chest drain using the traditional open technique, not Seldinger, is indicated.

Surgical repair needs to be considered in the context of associated injuries.

Learning Bite

  • Examine the CT carefully in patients who have sustained a (blunt) abrupt increase in intra-abdominal pressure
  • Diaphragmatic injury needs excluding by surgical colleagues in cases of penetrating injury requiring theatre

Oesophageal injury

This rare injury is often initially missed both clinically and radiologically.

Other associated injuries will normally predominate the clinical presentation e.g. a neck stabbing with tracheal and vascular disruption.

Operative repair or endoluminal stenting should be considered in the context of other associated injuries.

Tracheal/bronchial injury

Definition and context

This rare injury is typically caused by significant deceleration injuries; most patients die at the scene of the accident. It is unlikely to be missed clinically or radiologically in survivors, since clinical effects are usually dramatic.

Clinical assessment and identification

A massive air leak is suggested by gross surgical emphysema, pneumomediastinum and a vigorously bubbling chest drain that has failed to alleviate respiratory compromise.

Haemoptysis is an additional clue.

Treatment

Discuss intubation strategy with senior anaesthetic colleagues (consider single or double cuffed tubes, use of fibre optics, etc).

Consider additional large bore chest drain on the affected side (one intercostal space further up). Do not attach suction to the chest drain.

Other significant patient injuries may influence your resuscitation strategy.

Learning Bite

Two large bore chest drains may be needed to counter the air leak of a tracheo-bronchial injury

Simple pneumothorax

This is a common injury which is readily missed on CXR and subsequently discovered on CT.

Small, asymptomatic/occult pneumothoraces may be observed, even if the patient is ventilated [8]. About a third may deteriorate clinically, necessitating a drain.

No guideline regarding the safe timing for flying following a simple traumatic pneumothorax exists. A pragmatic approach may be to adopt British Thoracic Society guidelines for spontaneous pneumothorax: flying is permissible, once chest x-ray confirms resolution of the pneumothorax.

Fig 19: Simple pneumothorax

thoracic_trauma_lge_21

Rib fractures

Significant force is required to break ribs in the young; underlying injury is typical, especially lung contusions. Whilst less force is required in the elderly, even an isolated rib fracture can result in significant morbidity (e.g. secondary pneumonia) particularly in those with pre-existing comorbidities.

In addition to standard therapy consider the role of patient-controlled analgesia, thoracic epidural and physiotherapy for vulnerable patients.

Sternal fractures

These are relatively benign injuries but may be associated with underlying myocardial or pulmonary contusion. Consider the role of patient-controlled analgesia or local anaesthetic via a sternal catheter [9] in vulnerable patients.

Fig 20: Sternal fracture

thoracic_trauma_lge_22

Posterior sternoclavicular joint dislocation

This an exceptionally rare injury. It is clinically important since the medial clavicular head may compromise the airway or major vessels.

If there is evidence of compromise, reduction of the dislocation should be attempted. Abduct the arm to 90 and extend 10-15 and apply traction (with counter attraction to the torso from another colleague); maintain traction and pull the medial end of the clavicle forward with your fingers and thumb. If this fails, prepare the skin with iodine and local anaesthetic and repeat with a towel clip [10].

 

MedicoLegal and other considerations

Key Learning Points

  • A portable CXR is recommended for tension pneumothorax, unless the patient is critical radiological evidence of tensioning does not necessarily correlate clinically (Grade D, level 5)
  • Avoid needle thoracocentesis in peri-arrest patients with suspected tension pneumothorax thoracostomy is the better option. (Grade D, Level 5)
  • The most common cause of serious injury (and death) as a result of chest drain insertion, is insertion at the incorrect site, usually too low (Grade D, Level 5)
  • Confirm that the drain lies within the chest wall cavity by looking for a fogging of the tube and swinging of the chest drain on respiration (Grade D, Level 5)
  • A hole of only 1 or 2cm in radius may cause serious respiratory compromise, particularly in patients with comorbidities, and/or other injuries (Grade C, Level 4)
  • Prime the underwater seal for the chest drain with saline not sterile water for suspected massive haemothorax (Grade D, Level 5)
  • Cardiac tamponade as a result of blunt injury is exceptionally rare (Grade C, Level 4)
  • FAST is highly sensitive in detecting blood in the pericardium (Grade C, Level 4)
  • Thoracotomy, not pericardiocentesis is recommended for cardiac tamponade (Grade D, Level 5)
  • Pulmonary contusions are near inevitable in patients with a flail chest, and may cause significant morbidity and mortality in any age group (Grade C, Level 4)
  • Lung contusion is a marker of significant injury (Grade C, Level 4)
  • Early CXR evidence of pulmonary contusion is particularly worrying (Grade C, Level 4)
  • Multiple rib fractures are a potential source of significant haemorrhage (Grade C, Level 4)
  • A haemothorax visible on chest x-ray requires a large bore chest drain (Grade D, Level 5)
  • A normal ECG effectively rules out myocardial contusion (Grade C, Level 4)
  • Young males are the most likely candidates for aortic injury (Grade C, Level 4)
  • Examine the CT carefully in patients who have sustained an abrupt increase in intra-abdominal pressure (Grade D, Level 5)
  • Diaphragmatic injury needs excluding by your surgical colleagues in cases of penetrating injury requiring theatre (Grade D, Level 5)
  • Two large bore chest drains may be needed to counter the air leak of a tracheo-bronchial injury (Grade D, Level 5)

 

References

  1. Leigh-Smith S, Harris T. Tension pneumothorax time for a re-think? Emerg Med J 2005;22:8-16.
  2. Advanced trauma life support. 8th edn. Chicago: American College of Surgeons.
  3. Wax DB, Leibowitz AB. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesth Analg 2007;105:1385-1388.
  4. Foil MB, Mackersie RC, Furst SR et al. The asymptomatic patient with suspected myocardial contusion. Am J Surg 1990;160:638-642.
  5. Norton MJ, Stanford GG, Weigelt JA. Early detection of myocardial contusion and its complications in patients with blunt trauma. Am J Surg 1990;160:577-581.
  6. Jackson L. Use of troponin for the diagnosis of myocardial contusion after blunt chest trauma. BestBETs, 2004. View report
  7. Ekeh AP, Peterson W, Woods RJ et al. Is chest x-ray an adequate screening tool for the diagnosis of blunt thoracic aortic injury? J Trauma 2008;65:1088-1092.
  8. Jenner R. Chest drains in traumatic occult pneumothorax. BestBETs, 2005. View report
  9. Appelboam A, McLauchlan C, Murdoch J et al. Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique. Emerg Med J 2006;23:791-793.
  10. MacDonald P, Lapointe P. Acromioclavicular and Sternoclavicular Joint Injuries. Orthopedic Clinics of North America. 2008;39:535-545.

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2 Comments

  1. brookesa238 says:

    Good module,

  2. Rebecca Whale says:

    Good module, useful learning points

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