Symptoms on admission are most often related to concomitant injuries. In a series of 54 patients, all had other serious injuries - 17% neurological, 60% abdominal, 35% pelvic fracture and 65% fracture elsewhere - distracting attention away from the chest injury [10]. It has also been reported that 30% of the patients with aortic trauma will have no external signs of chest injury on presentation [43]. Finally there is no single physical finding or combination of findings that is typical for aortic trauma.

Duhaylongsod et al. [11] reviewed the English-language surgical literature from 1970 to 1990 and presented data on 1188 patients among 59 reports. The mean age was 32.4 years (range 4.5-81 years) with a male:female ratio of 5:1. Motor vehicle occupants were involved in 75%, motorcyclists in 15.7%, pedestrians in 7.4% and falls from a height in 2.8% of the cases. The most common presenting symptoms were:

No patient had a complete negative physical examination and each presented with at least one associated injury. Classically cited associated findings pointing to the diagnosis of aortic trauma include: Multiple rib fractures Fractures of first and second rib Fractured sternum Pulse deficits

Interscapular systolic murmur Blood in the carotid or subclavian sheath Hoarseness or voice change without laryngeal injury Superior vena cava syndrome [64].

However, their incidence varies considerably among different series. The same is true for the so-called typical acute coarctation syndrome characterized by:

hypertension in the upper limbs and

• a difference in pulse amplitude between the arms and the legs, which was described in 1973 by Symbas et al. [56] (Fig. 4.3.3).

Fig. 4.3.3 Acute coarctation syndrome following thoracic aortic trauma: angiographic appearance

the most important factor leading to the diagnosis of thoracic aortic rupture.

Taking into account the pathogenesis, thoracic aortic trauma should be suspected after any fall from more than three storeys or in any motor vehicle accident at speeds in excess of 60 km/h.

Additional circumstances such as severe associated injuries or the death of other automobile occupants should alert the physician.

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