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Clinical Update on Thoracic Trauma
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Clinical Update on Thoracic Trauma

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Respiratory Medicine".

Deadline for manuscript submissions: 20 October 2026 | Viewed by 4992

Special Issue Editor

Prof. Dr. Duilio Divisi

E-Mail Website
Guest Editor
Department of Life, Health and Environmental Sciences, University of L’Aquila, Thoracic Surgery Unit, “Giuseppe Mazzini” Hospital of Teramo, Teramo, Italy
Interests: lung cancer; chest trauma; chest wall tumors; mediastinum; pleural diseases; diaphragm; primary hyperhidrosis; EBUS/TBNB-TBNA

Special Issue Information

Dear Colleagues,

Surgery of the thorax after trauma is clinically challenging, and it deals with injuries and related diseases caused by chest trauma. We have seen developments in all aspects of surgery, using both invasive procedures and non-invasive and non-surgical methods to correct and treat lesions. Common problems include flail chest, isolated sternal fractures, lung and pleural lesions, manubrio-sternal dislocation, vascular injuries, diaphragm rupture, thoracoabdominal hernia, and chylothorax. Since these health conditions can greatly affect a person's quality of life, it is important for patients to receive a high level of treatment provided by an experienced physician. Consequently, there is also an increasing need for interdisciplinary treatment strategies, as these patients often present with underlying comorbidities that could have caused the injury itself, thus requiring specific treatment.

This Special Issue combines original research and review papers with a focus on recent advances in the trauma surgery of the thorax. We welcome the submissions of your best research.

Prof. Dr. Duilio Divisi
Guest Editor

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Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • flail chest
  • isolated sternal fractures
  • manubrio-sternal dislocation
  • pneumothorax
  • hemothorax
  • thoracic aortic injury
  • heart and pulmonary vessels lesion
  • intercostal artery injury
  • diaphragm rupture
  • thoracoabdominal hernia
  • chylothorax
  • esophageal perforation

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Published Papers (6 papers)

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Research

Jump to: Review, Other

15 pages, 1296 KB  
Article
Predictors of Blunt Thoracic Aortic Injury Requiring TEVAR in Patients with Left-Sided Hemothorax: Implications for Chest Drainage and Early CTA Assessment
by Giovanni Zambello, Alessandro Bonis, Riccardo Amatucci, Birgit Feil, Luiz Felippe Milazzo, Marco Damiano Pipitone, Filippo Gorgatti, Giovanni Coppi, Reinhold Perkmann and Francesco Zaraca
J. Clin. Med. 2026, 15(11), 4183; https://doi.org/10.3390/jcm15114183 - 28 May 2026
Viewed by 123
Abstract
Background: Blunt thoracic aortic injury (BTAI) is an uncommon but life-threatening consequence of blunt thoracic trauma. Left-sided hemothorax is frequently identified during initial evaluation and typically prompts early chest drainage. However, when an unrecognized BTAI is present, pleural decompression may precipitate hemodynamic instability. [...] Read more.
Background: Blunt thoracic aortic injury (BTAI) is an uncommon but life-threatening consequence of blunt thoracic trauma. Left-sided hemothorax is frequently identified during initial evaluation and typically prompts early chest drainage. However, when an unrecognized BTAI is present, pleural decompression may precipitate hemodynamic instability. This study aimed to identify early predictors of BTAI requiring thoracic endovascular aortic repair (TEVAR) in patients presenting with left-sided hemothorax. Methods: We conducted a single-center retrospective cohort study including consecutive trauma patients aged ≥ 16 years with radiologically confirmed left-sided hemothorax between 2015 and 2025. Patients were stratified according to the need for TEVAR. Clinical, laboratory, and radiological variables available at emergency department admission were analyzed. Independent predictors of BTAI requiring TEVAR were identified using multivariable logistic regression. Results: Among 146 included patients, 27 (18%) underwent TEVAR for confirmed BTAI. Patients requiring TEVAR were generally younger and more frequently involved in high-energy trauma. Independent predictors of TEVAR included high-energy mechanism (p = 0.048), lower admission hemoglobin (p = 0.007), presence of extra-thoracic fractures (p < 0.001), and a higher number of right-sided rib fractures (p = 0.018). The volume of left-sided hemothorax was not independently associated with BTAI. The model demonstrated strong discriminative ability (AUC = 0.926). Conclusions: In trauma patients with left-sided hemothorax, BTAI requiring TEVAR may occur even in the presence of minimal pleural effusion. Readily available admission parameters may help identify patients who could benefit from a CT angiography-first approach rather than routine early chest drainage, except in cases of immediate life-threatening pleural compromise. Full article
(This article belongs to the Special Issue Clinical Update on Thoracic Trauma)
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14 pages, 1876 KB  
Article
Management of Hemothorax After Blunt Chest Trauma: Results from a Level II Emergency Department
by Dania Nachira, Antonio Giulio Napolitano, Adriana Nocera, Maria Teresa Congedo, Marcello Covino, Claudia Bellettati, Claudia Leoni, Chiara Scognamiglio, Giovanni Punzo, Mariano Alberto Pennisi, Nicola Bonadia, Maria Letizia Vita, Leonardo Petracca-Ciavarella, Filippo Lococo, Elisa Meacci and Stefano Margaritora
J. Clin. Med. 2026, 15(8), 2814; https://doi.org/10.3390/jcm15082814 - 8 Apr 2026
Viewed by 739
Abstract
Background: Traumatic hemothorax is a common complication of blunt chest trauma and remains associated with significant morbidity and mortality. Although contrast-enhanced computed tomography (CT) is central to diagnosis, the optimal criteria for selecting patients who require invasive management versus conservative treatment remain unclear. [...] Read more.
Background: Traumatic hemothorax is a common complication of blunt chest trauma and remains associated with significant morbidity and mortality. Although contrast-enhanced computed tomography (CT) is central to diagnosis, the optimal criteria for selecting patients who require invasive management versus conservative treatment remain unclear. This study aimed to evaluate the management strategies and clinical outcomes of traumatic hemothorax and to identify predictors of surgical intervention and postoperative complications. Methods: We conducted a retrospective, single-center cohort study including adult patients admitted to a Level II Emergency Department with hemothorax following blunt chest trauma between January 2019 and December 2024. Primary outcomes were the need for urgent chest drainage or surgery. Secondary outcomes included postoperative complications, length of hospital stay, and intensive care unit admission. Univariable and multivariable regression analyses were performed to identify factors associated with surgical intervention and complications. Results: Seventy-two patients were included (mean age 60.0 ± 20.5 years; 80.6% male). Rib fractures were the most common cause of hemothorax (61.1%). Chest tube placement was required in 70.8% of cases, and 31.9% underwent urgent surgical intervention. Active bleeding on contrast-enhanced CT was identified in 16.7% of patients and was the only independent predictor of urgent surgery (OR 3.85, 95% CI 1.07–13.88; p = 0.039). The initial volume of blood drained after chest tube insertion did not differ between surgically and non-surgically managed patients. Conservative management was successful in 19.4% of cases. Postoperative complications occurred in five patients and were associated with a higher comorbidity burden. Overall mortality was 5.6%. Conclusions: In traumatic hemothorax following blunt chest trauma, active bleeding on contrast-enhanced CT seems to be the strongest predictor of urgent surgical intervention, whereas initial pleural drainage volume alone is not. Conservative management is safe in selected patients, while comorbidities influence postoperative outcomes. Multidisciplinary management and accurate radiological assessment are essential to guide timely and appropriate treatment. Full article
(This article belongs to the Special Issue Clinical Update on Thoracic Trauma)
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8 pages, 681 KB  
Article
Injuries of the Posterior Tracheal Wall: Insights from a High-Volume Single-Centre Experience
by Lavinia Gatteschi, Antonio Burlone, Stefano Bongiolatti, Simone Tombelli, Giovanni Mugnaini, Luca Voltolini and Alessandro Gonfiotti
J. Clin. Med. 2026, 15(1), 245; https://doi.org/10.3390/jcm15010245 - 28 Dec 2025
Viewed by 713
Abstract
Background: Major airway injuries, regardless of whether their aetiology is traumatic or iatrogenic, are rare but potentially fatal. In selected cases, surgery plays a key role; however, it has to be performed by highly experienced professionals in emergency settings. Methods: We [...] Read more.
Background: Major airway injuries, regardless of whether their aetiology is traumatic or iatrogenic, are rare but potentially fatal. In selected cases, surgery plays a key role; however, it has to be performed by highly experienced professionals in emergency settings. Methods: We reviewed all surgical procedures involving the trachea which were performed at our institution in the last 5 years (365 procedures). We report here our experiences with major airway injuries, both traumatic and iatrogenic (19 procedures). All patients, including individuals from within our hospital and from other peripheral centres, were treated in an emergency setting within 12 h of correct diagnosis. Results: The location and extent of tracheal lesions can be different in every patient. After a proper evaluation with CT scan and bronchoscopy, we approached all our cases of tracheal injuries with a cervicotomy, using, in some selected cases, an endoscopic camera to better visualise lesions that involved the carina. However, in extremely severe cases, such as one we report here, where multiple repair attempts fail and tissue viability is compromised, demolitive surgery by means of posterolateral thoracotomy may represent the only remaining therapeutic option. Conclusions: Surgery on tracheal injuries is complex, highly specialised, and time-dependent. In selected cases, it has to be performed quickly by highly qualified professionals after proper evaluation in an emergency setting. Every airway injury differs in its location, extent, aetiology, and clinical presentation, and there is no unanimous consensus on standardising treatment. Only high-volume centres with highly experienced professionals can guarantee correct management of this rare but life-threatening event. Full article
(This article belongs to the Special Issue Clinical Update on Thoracic Trauma)
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8 pages, 579 KB  
Article
Endovascular Repair of Blunt Aortic Trauma: A Multidisciplinary Approach and a Retrospective Multicenter Study
by Ilenia Di Sario, Enrico Franceschini, Emanuele Gatta and Gabriele Pagliariccio
J. Clin. Med. 2026, 15(1), 68; https://doi.org/10.3390/jcm15010068 - 22 Dec 2025
Cited by 1 | Viewed by 805
Abstract
Background/Objectives: Blunt traumatic thoracic aortic injury is a rare but often fatal condition, typically resulting from high-energy deceleration mechanisms such as motor vehicle collisions or falls from height. Mortality can reach 80–90% at the scene, with in-hospital mortality up to 46%. Early diagnosis [...] Read more.
Background/Objectives: Blunt traumatic thoracic aortic injury is a rare but often fatal condition, typically resulting from high-energy deceleration mechanisms such as motor vehicle collisions or falls from height. Mortality can reach 80–90% at the scene, with in-hospital mortality up to 46%. Early diagnosis and appropriate management are essential to improve outcomes. Methods: We retrospectively analyzed 45 patients (29 males, 16 females) with varying degrees of aortic isthmus injury treated between January 2007 and December 2024 at two Italian vascular surgery centers. Aortic lesions were graded 0–3, with 40 patients undergoing thoracic endovascular aortic repair. Procedures utilized Gore TAG or Medtronic Valiant endografts. Perioperative management included controlled hypotension and left subclavian artery coverage was performed when necessary. Results: Procedural success was achieved in all patients (100%), with one type II endoleak. No perioperative complications or spinal cord ischemia were observed. Coverage of the left subclavian artery was required in 28.9% of cases. Thirty-day mortality was 9%, with no deaths directly attributable to aortic injury. Postoperative CTA confirmed adequate endograft placement in all patients. Conclusions: Endovascular repair is a safe and effective approach for BTAI, with excellent short-term outcomes. Management should be tailored to injury severity and patient comorbidities, with ongoing vigilance for spinal cord ischemia. Full article
(This article belongs to the Special Issue Clinical Update on Thoracic Trauma)
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Review

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12 pages, 1184 KB  
Review
An Overview of Meta-Analyses on the Surgical Stabilization of Rib Fractures in Adults: A Narrative Umbrella Review (2020–2025)
by Maria Chiara Sibilia, Francesca Romboni, Sara Franzi, Lorenzo Bramati, Maria Carmela Andrisani, Mario Nosotti and Davide Tosi
J. Clin. Med. 2026, 15(10), 3648; https://doi.org/10.3390/jcm15103648 - 9 May 2026
Viewed by 419
Abstract
Background: Rib fractures are a common cause of morbidity in trauma patients. The surgical stabilization of rib fractures (SSRF) has gained increasing attention as a therapeutic option; however, evidence from multiple meta-analyses remains heterogeneous. Methods: We performed an overview of 11 meta-analyses, including [...] Read more.
Background: Rib fractures are a common cause of morbidity in trauma patients. The surgical stabilization of rib fractures (SSRF) has gained increasing attention as a therapeutic option; however, evidence from multiple meta-analyses remains heterogeneous. Methods: We performed an overview of 11 meta-analyses, including a total of 1,117,849 adult patients (narrative umbrella review), published between November 2020 and November 2025 to summarize and critically appraise high-level evidence comparing SSRF with non-operative management (NOM) in adults with traumatic rib fractures. PubMed (MEDLINE) and Embase were searched for eligible meta-analyses. Outcomes of interest included mechanical ventilation duration, pneumonia, ICU and hospital length of stay, mortality, pain, quality of life, and need for tracheostomy. Results: Eleven meta-analyses met the inclusion criteria. Across outcomes, the direction of effect generally favored SSRF in selected patients, particularly with respect to a shorter duration of mechanical ventilation (mean difference up to approximately 4–6 days), reduced pulmonary complications (risk ratio approximately 0.4–0.7), shorter ICU and hospital stay, and improved pain control. However, results varied substantially across studies. A consistent mortality benefit was not observed. Subgroup analyses suggested that the benefits of SSRF were more pronounced in patients with flail chest, severe fracture patterns, and early surgery, whereas findings were less consistent in elderly patients and in patients with less severe injuries. Conclusions: This narrative umbrella review suggests that SSRF is associated with improved short-term outcomes in selected adult patients with traumatic rib fractures but should not be considered a universal standard of care. Careful patient selection, timing of intervention, and multidisciplinary evaluation remain essential. Further high-quality prospective studies are needed to better define optimal indications and management strategies. Full article
(This article belongs to the Special Issue Clinical Update on Thoracic Trauma)
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Other

Jump to: Research, Review

13 pages, 1940 KB  
Perspective
Contemporary and Future Perspectives on Thoracic Trauma Care: Surgical Stabilization, Multidisciplinary Approaches, and the Role of Artificial Intelligence
by Chiara Angeletti, Gino Zaccagna, Maurizio Vaccarili, Giulia Salve, Andrea De Vico, Alessandra Ciccozzi and Duilio Divisi
J. Clin. Med. 2025, 14(22), 8041; https://doi.org/10.3390/jcm14228041 - 13 Nov 2025
Cited by 2 | Viewed by 1522
Abstract
Background/Objectives: Thoracic trauma remains a leading cause of trauma-related illness and death. Despite advances in imaging, ventilation strategies, and surgical fixation, its management remains a topic of debate, with varying practices across hospitals. Current Gaps: Although surgical stabilization of rib fractures (SSRF) has [...] Read more.
Background/Objectives: Thoracic trauma remains a leading cause of trauma-related illness and death. Despite advances in imaging, ventilation strategies, and surgical fixation, its management remains a topic of debate, with varying practices across hospitals. Current Gaps: Although surgical stabilization of rib fractures (SSRF) has shown a mortality benefit in cases of flail chest and in elderly patients, its indications for non-flail cases remain uncertain. Analgesia strategies are evolving, and epidural remains the gold standard; however, it is limited by contraindications. In contrast, regional blocks, such as the erector spinae plane block (ESPB) and serratus anterior plane block (SAPB), are emerging as safer alternatives to opioid and thoracic epidural analgesia (TEA). Artificial intelligence (AI) is transforming imaging interpretation and risk stratification; however, its integration into daily trauma care is still in its early stages of development. Perspective: This article examines the integration of surgical innovation, regional anesthesia, and AI-powered diagnostics as integral components of future thoracic trauma care. We emphasize the importance of standardized surgical criteria, multimodal pain management approaches, and AI-assisted decision-making tools. Conclusions: Thoracic trauma care is shifting toward a personalized, multidisciplinary, and technology-enhanced approach. Incorporating evidence-based SSRF, advanced pain management techniques, and AI-supported imaging can help reduce mortality, enhance recovery, and optimize resource utilization. Full article
(This article belongs to the Special Issue Clinical Update on Thoracic Trauma)
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