The accuracy of physical examination in identifying significant pathologies in penetrating thoracic trauma

Accurate physical examination (PE) remains a key component in the assessment of penetrating thoracic trauma (PTT), despite the increasing availability of advanced radiological imaging. Evidence regarding the accuracy of PE in identifying significant pathology following PTT is limited.

A retrospective review of 405 patients was undertaken over a twelve-month period to determine the accuracy of PE in identifying significant pathology (SP) subsequently confirmed on chest radiographs (CXRs) in patients who sustained stab injuries to the thorax.

Ninety-seven per cent (372/405) of patients were males, and the mean age was 24 years. The weapons involved were knives in 98 % (398/405), screwdrivers in 1 % (3/405) and unknown in the remaining 1 %. Fifty-nine per cent (238/405) of all injuries were on the left side. There were 306 (76 %) SPs identified on CXR. Ninety-nine (24 %) CXRs were entirely normal. Based on PE alone, 223 (55 %) patients were thought to have SPs present, 182 (45 %) patients were thought to have no SPs. The overall sensitivity of PE in identifying SPs was 68 % (63-73, 95 % CI), with a specificity of 86 % (77-92, 95 % CI). The PPV of PE was 94 % (90-97, 95 % CI) and the NPV was 47 % (39-54, 95 % CI). The sensitivity of PE for identifying a pneumothorax was 59 % (51-66, 95 % CI), with a specificity of 96 % (89-99, 95 % CI) and the sensitivity of PE for identifying a haemothorax was 79 % (72-86, 95 % CI), with a specificity of 96 % (89-99, 95 % CI).

PE is inaccurate in identifying SPs in PTT. The increased reliance on advanced radiological imaging and the subsequent reduced emphasis on PE may have contributed to rapid deskilling amongst surgical residents. The importance of PE must be repeatedly re-emphasised.