From the Experts
SIP Trunking News
[August 17, 2011]
Blunt Breast Trauma: Is There a Standard of Care? [American Surgeon, The]
(American Surgeon, The Via Acquire Media NewsEdge) The incidence of female blunt breast trauma (FBBT) is unknown, and there are no established treatment guidelines. The purpose of this study was to establish the incidence of FBBT, define associated injuries, and develop a treatment algorithm. This is a retrospective analysis of FBBT at a Level I trauma center from October 2000 through December 2008. The incidence, mechanism, and severity of injury, associated injuries, therapeutic interventions, and clinical outcomes were evaluated. A total of 14,499 patients were evaluated. Of these, 13,637 were blunt trauma victims and 5,305 were female blunt trauma victims. One hundred and eight (2%) were diagnosed with FBBT. Although the average injury severity score (ISS) was 12.3 for all FBBT patients, 60 per cent of patients had an ISS > 15. Ninety-four per cent were caused by motor vehicle crashes, with the most common injuries being long bone fractures (45%) and rib fractures (44%). One hundred and one (93.5%) of the injuries were simple hematomas managed expectantly; seven patients (6.5%) had expanding hematomas with radiological evidence of active bleeding that ultimately required invasive procedures, with six of them undergoing arteriogram and four successfully embolized. One patient was taken directly to the operating room for surgical ligation of a bleeding vessel. These data represent the largest series of breast injuries ever reported. Because FBBT is a marker for severe associated injuries, our treatment algorithm recommends that women with radiological evidence of active bleeding who are hemodynamically stable be evaluated with a chest arteriogram plus or minus embolization. However, unstable patients with no other source of hemorrhage should undergo definitive urgent operative repair. All other patients should be managed expectantly.
Blunt breast trauma is both minimally described and underreported in the trauma literature. Therefore, the true incidence remains unknown, and there is no standard of care or treatment algorithm established for the management and treatment of blunt breast trauma. We define blunt breast trauma as any severe injury to the breast resulting from a nonpenetrating mechanism (e.g., motor vehicle accidents, falls resulting in clinically significant signs or symptoms of injury).
Injury to the breast can have serious anatomical and physiological consequences, with some small studies suggesting that breast injury may result in long-term complications, including an increased risk for breast cancer. Based on anecdotal observations of patients with breast injury at our institution, we sought to determine the incidence of blunt breast injury and the frequency of associated injuries, with a subsequent proposal of a treatment algorithm for diagnosing and treating blunt breast trauma.
Methods We performed a retrospective chart review of all trauma patients from October 2000 to December 2008 at our Level I trauma center. Using our clinical database, patients were included in the study if: 1) they were classified with the ICD-9 code for diagnosis of breast trauma or breast hematoma, and 2) they were victims of blunt trauma. Patient data were entered into an Excel (Microsoft, Redmond, WA) spreadsheet and included age, mechanism of injury, Injury Severity Score (ISS), number and frequency of associated injuries, radiographic modalities, therapeutic interventions, and clinical outcomes. For the purposes of this study, breast trauma was stratified into "complex" or "simple" hematomas. Complex hematomas were defined as those with clinical or radiologic evidence of active bleeding. All others were classified as simple hematomas. Once stratified, a treatment algorithm was then created for the diagnosis and treatment of blunt breast trauma. Patients who were hemodynamically unstable and had no other sources of bleeding were taken to the operating room for exploration. Patients who had signs of active bleeding (e.g., blush on radiologic studies or a clinically expanding hematoma) were taken to interventional radiology. Patients who had signs of blunt breast trauma but were hemodynamically stable with no signs of active bleeding were managed expectantly.
Data Analysis All data are presented descriptively as means and standard deviations for normally distributed continuous data and frequencies with percentages for categorical data. Data were analyzed in Microsoft Excel and SPSS version 12.0 (SPSS, Inc., Chicago, IL).
Results A total of 14,499 patients were evaluated at our trauma center. Of these, 13,637 were blunt trauma victims and 5,305 were female blunt trauma victims. One hundred eight of these women (2%) were treated for blunt breast trauma. The overwhelming majority of patients (98%) were victims of motor vehicle collisions, whereas the rest had experienced falls. The average age was 56-years-old. All patients received a chest radiograph. Chest computer tomography (CT) scanning was conducted as clinically indicated by the Traumatologist. All but seven of these patients were determined to have simple breast hematomas and were managed expectantly. The remaining seven patients were determined to have complex breast hematomas requiring further invasive testing. The average ISS score was 12.3 for all patients. The average ISS score for patients with complex breast hematomas requiring intervention was 13.7 Four of the seven patients with complex breast hematomas had extravasation of contrast on initial CT scanning of the thorax (Fig. 1). Three others had evidence of active bleeding on angiography performed on admission to evaluate a clinically expanding hematoma. Ultimately, six of the seven patients with complex breast hematomas had angiography with selective angio-embolization of the culprit vessel (Figs. 2 and 3). One patient became hemodynamically unstable, requiring operative intervention and surgical ligation of the actively hemorrhaging blood vessel after all other sources of bleeding were ruled out (Fig. 4). All patients with complex hematomas had no further evidence of expansion of their hematomas after either angio-embolization or operative intervention.
Overall, the vast majority of patients suffering breast trauma had associated injuries. The most common associated injuries were long bone extremity fractures (47%), rib fractures (15%), solid organ injury (11%), and pneumothoraces/hemothoraces (10%), all requiring chest tube placement (Fig. 5). The overall complication rate from blunt breast trauma was 1.8 per cent, whereas the number of complications due to a subsequent intervention was 14.3 per cent (1/7). The single patient with an intervention-related complication experienced a brachial artery injury due to an arteriogram requiring thrombectomy. One patient who was classified as having a simple hematoma later went on to develop overwhelming fat necrosis of her breast requiring mastectomy and breast reconstruction. Among the breast trauma patients, there was a 5.5 per cent mortality rate, but no deaths resulted directly from the trauma.
Based on these study findings, we proposed a classification system and treatment algorithm to help clinicians make more well-informed decisions regarding the management of blunt breast trauma (Fig. 6). As previously stated, simple breast hematomas have no signs of active bleeding. In contrast, complex hematomas present clinical or radiological evidence of active hemorrhage, which can manifest as a hematoma that is actively expanding, increasingly painful, or containing radiographical evidence of active bleeding (e.g., blush on CT scan of the thorax).
During primary and secondary surveillance of the patient, identification of a simple breast hematoma in the setting of hemodynamic stability requires no further intervention and can be managed expectantly. However, identification of a complex breast hematoma requires additional therapeutic maneuvers. In the hemodynamically stable patient, CT of the thorax is a fast, noninvasive tool that can accurately identify the presence or absence of active bleeding by demonstrating a contrast blush. If no blush is identified, further invasive procedures are not required, and the patient can be managed conservatively. Conversely, if active bleeding is identified, angiography can be used as both a diagnostic and therapeutic intervention, whereby embolization can be used to control the bleeding. If a complex hematoma is identified in a hemodynamically unstable patient, and all other causes of hemorrhage are ruled out, patients should be taken to the operating room for definitive surgical correction of the source of bleeding within the breast.
Discussion To date, this retrospective study includes the largest series of breast trauma patients in the literature. Although the actual incidence of blunt breast trauma at our institution was relatively rare (2%), the frequency of associated injuries was extremely high. Therefore, the presence of breast trauma should raise clinical suspicion for other potentially serious and life-threatening injuries in the thoracoabdominal region, much as a "seatbelt sign" raises clinical suspicion for intraabdominal injury, with this indicator occurring in up to 64 per cent of patients with an associated intra-abdominal injury.1 The fact that our study revealed blunt breast trauma to be an indicator of associated injury in an even greater percentage of patients supports its use as a similar injury marker.
Despite the novelty and clinical relevance of our study, we acknowledge its limitations. First, retrospective chart reviews may be subject to chart misclassifications, abstraction errors, or other inaccuracies. Second, although our use of descriptive statistics provides an overview of breast trauma incidence, it does not allow us to make inferences or draw definitive conclusions from the data. Third, although we proposed a treatment algorithm based on our study findings, we acknowledge that some patients with a complex hematoma who are hemodynamically stable may be treated with more conservative measures such as external compression, trending of hemoglobin, and close monitoring of hemodynamics. Future research should investigate these different treatment options. Similarly, we recognize that the terms "simple" and "complex" were applied to our data retrospectively and that, although none of the patients labeled as simple hematomas ever evolved into complex hematomas in our study sample, the potential always exists in a trauma setting. Therefore, our algorithm must be validated with large patient samples before its use is fully accepted or endorsed.
The final study limitation is lack of long term follow-up of our sample group. This is especially important when one considers the potential complications of breast trauma over time, including the possibility of malignancy. Although not definitively established in the literature, some studies have shown that inflammation may predispose patients to developing breast cancer, and that even one episode of trauma could lead to malignant degeneration in the affected organ. Another study reported that women with breast cancer were more likely to report an episode of breast trauma in the 5 years before their diagnosis compared with matched women without breast cancer.2 Given that these studies suggest an association between breast trauma and subsequent cancer risk, further research is needed to establish proper long-term follow-up for patients suffering blunt breast trauma.3-5 Another potential complication over time is fat necrosis of the breast due to the abundance of fatty and glandular tissue. Fat necrosis is usually a benign and self-limiting process. However, as evidenced by the single patient in our study who required mastectomy, fat necrosis may have lasting anatomical and physiological effects,6 particularly because it can appear as malignant lesions on screening mammograms, possibly leading to further invasive testing or surgical procedures.7,8 Conclusion Although the incidence of blunt breast trauma is low, its immediate and potential long-term complications cannot be ignored. Although there is a paucity of research on the subject, including identification of optimal treatment and surveillance modalities,9 our study, with its classification system and accompanying treatment algorithm, represents the largest of its kind. Although there is still much work to be done on the subject of blunt breast trauma, our study can be used as a foundation for further research to better characterize this unique type of injury with its long-term anatomical, physiological, and even psychological impact on patients.
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6. Pignatelli V, Basolo F, Bagnolesi A, et al. Hematoma and fat necrosis of the breast: mammographic and echographic features. Radiol Med (Torino) 1995;89:36-41.
7. Ganau S, Tortajada L, Escibano F, et al. The great mimicker: fat necrosis of the breast-magnetic resonance mammography approach. Curr Probl Diagn Radiol 2009;38:189-97.
8. Trombetta M, Valakh V, Julian TB, et al. Mammary fat necrosis following radiotherapy in the conservative management of localized breast cancer: does it matter? Radiother Oncol 2010;97: 92-4.
9. Bilgen IG, Usten EE, Memis A. Fat necrosis of the breast: clinical, mammographie and sonographic features. Eur J Radiol 2001;39:92-9.
CHRISTOPHER SANDERS, M.D., IAMES CIPOLLA, M.D., CHRISTY STEHLY, B.S., BRIAN HOEY, M.D.
From St. Luke's Hospital, Bethlehem, Pennsylvania Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Chattanooga, TN, February 12-15,2011.
Address correspondence and reprint requests to Christopher Sanders, M.D., St. Luke's Hospital, 801 Ostrum Street, Bethlehem, PA 18015. E-mail: firstname.lastname@example.org, email@example.com.
(c) 2011 Southeastern Surgical Congress
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