An update on thoracic trauma: a current challenge in thoracic surgery series

The story of thoracic injury and trauma has evolved dramatically over the past 25 years. It is a story of public health and how to address one of the most frequently encountered classes of injury affecting hundreds of thousands, if not millions of patients annually in the United States alone. It is a story of introspection where the preceding 50 years of injury dogma are being methodically scrutinized and challenged. It is a story of medical and surgical innovation coming together to integrate lessons learned across a multitude of disciplines. It is a story of steady progress. Thoracic injury interest groups are growing, being led by the enthusiastic and collaborative voice of the Chest Wall Injury Society, an international group of clinicians and researchers focusing on the millions of patients who bear the burden of such disease. All these efforts offer the prospect to help organize the field of thoracic trauma and decrease practice pattern variation while being flexible enough to adapt the best modern practices to individualized environments.

Thoracic trauma is a broad topic that encompasses all manner of injuries ranging from domestic to industrial, from accident to intentional, and traverses all social and economic strata. Victims of injury do not undergo the selection process familiar to elective surgical practices and associated research. They are a heterogeneous group that carries all manner of pre-hospital health and co-morbid conditions. In short, injury can befall anyone, and the array of possible injury combinations and reactions to injury necessitates individualized care. Chest injuries are often only one facet in the poly-traumatized patient; however, the interaction of chest injury consequences and co-injuries can be complex. Recent interest in the surgical treatment of rib fractures has reinvigorated an aspect of trauma care that was previously felt to be essentially non-operative. Surgical treatment of rib fractures, though an important topic, has already been well reviewed in other venues. When I was approached to organize a thoracic injury series for Current Challenges in Thoracic Surgery (CCTS), my goal was to bring forward topics that otherwise may be spotlighted. The authors who have contributed to this series aim to explore some of the less frequently covered aspects of the chest injury landscape. The four topics highlighted here serve as important collections of best practices and expert experience to guide clinicians involved in the care of the chest-injured patient.

Each topic, guided by a true leader in the field, examines a unique facet of thoracic injury. Three narrative reviews synthesize the existing knowledge regarding pulmonary contusions, diaphragmatic lacerations, and intercostal nerve management in rib fractures. The first, led by Dr. Forrester’s team out of Stanford University, follows a 50-year evolution of pulmonary contusion assessment and management (1). Advancements in imaging fidelity, novel scoring systems, and modern supportive strategies focusing on the prevention of contusion “blossoming” are outlined to guide the clinician. Next, Dr. Craugh’s team from Indiana University explores the infrequently studied interface of anatomic and physiologic consequences of traumatic diaphragmatic lacerations (2). Their accompanying detailed discussion of surgical management and ramifications of diaphragmatic repair points to future research and treatment opportunities in this often-overlooked area. Rounding out the narrative reviews, Drs. Muldiiarov and Bauman from the University of Nebraska take a deep dive into the growing field of neuraxial blockade and neurolysis for rib-fractured patients (3). From the early history through to technical details and an appraisal of the current state of evidence, they weigh the value of novel clinician-administered therapeutics for rib fracture analgesia.

In the final installment for this series, Dr. Cole’s team from the University of Minnesota offers one of the only peer-reviewed analyses of lateral implosion injury (4). This “syndrome”, seldom described in the literature, encompasses the intersection of concomitant scapular, clavicular, humeral, and rib injuries where the treatment complexity is more than just the sum of the individual injuries. Here, the patient benefits from a truly multidisciplinary approach to the reconstruction of the radical chest wall: shoulder girdle, accompanying joints, musculature and osseous scaffolding for respiration and hemi-thorax stability. As a unique interface for orthopedic, thoracic, vascular, and acute care surgeons, the review of lateral implosion injury is anticipated to be a cornerstone for future study.

While reading through this Chest Injury series, I would urge the reader to think about these unique patient populations. When was the last time you encountered one of these patients and what did you do? When do you anticipate seeing such injuries in your current or future practice? Would you change your practice based on the information and updates described herein? As mentioned earlier, there are a multitude of additional chest injury topics to explore (ranging from surgical stabilization of rib fractures to pleural space management, thoracic aortic and esophageal injuries, taxonomic and chest physiotherapeutic developments); however, our aim with this topic focus was to discuss advances in evolving areas of chest injury infrequently reviewed. I would like to thank all the authors for volunteering their time from busy clinical and professional schedules to produce the following high-quality peer-reviewed articles. On behalf of all the contributing authors, I would like to thank the Editorial Board for the opportunity to showcase advances in trauma care. I hope that the discussions here will be of interest and value to the audience of CCTS. The field of thoracic trauma is truly international in scope that has only been growing in prevalence and recognition over time. The next 25 years of improvements to the chest-injured patient will be guided by the collaborative efforts of numerous clinicians, researchers, innovators, and public health experts focused on thoracic medicine.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Current Challenges in Thoracic Surgery for the series “Chest Trauma”. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-48/coif). The series “Chest Trauma” was commissioned by the editorial office without any funding or sponsorship. C.F.J. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Current Challenges in Thoracic Surgery from September 2024 to August 2026. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Chau HS, Gutkin PM, Knight AW, et al. Contemporary management of pulmonary contusions: a narrative review. Curr Chall Thorac Surg 2025;7:26.
2. Craugh LE, Salyer C, Tarras S. Traumatic diaphragmatic injury: a narrative review. Curr Chall Thorac Surg 2025;7:17.
3. Muldiiarov V, Bauman ZM. Role of intercostal nerve block and cryoneurolysis in the management of rib fractures: a narrative review. Curr Chall Thorac Surg 2025;7:23.
4. Xu JL, Huaco AA, Winter JD, et al. Lateral implosion injury: a multidisciplinary management approach. Curr Chall Thorac Surg 2025;7:24.

Christopher F. Janowak