Breast injury is an uncommon form of blunt chest trauma. In a review of 5305 women with blunt chest trauma, only 108 (2 %) presented with breast trauma [
4]. The mechanisms of breast trauma from a seat belt include both shear and crush injuries that result from the shoulder restraint. Majeski proposed a classification of breast trauma associated with seat belt injuries. From class 1 to 4, they ranged from mild bruising and tenderness to an avulsion of the breast from the chest wall with rupture of the blood vessels and active bleeding in to the chest [
5]. The complete classification can be seen in Table
1. The most serious injuries to the breast are mammary duct avulsion and a vascular injury. The arterial supply to the breast comes from several sources, the internal mammary artery with perforators though the chest wall supplies the medial breast and the lateral thoracic branch of the axillary artery provides blood flow to the lateral breast. The majority of breast trauma patients had associated injuries. Of those, the most common were long bone extremity fractures (47 %), rib fractures (15 %), solid organ injury (11 %), and pneumothoraces/hemothoraces (10 %), all requiring chest tube placement [
1]. Tam Song et al. reviewed all seat belt-related injuries and found 13 patients who presented to the emergency department at the time of the motor vehicle accident [
2]. Of the immediate presentations, 4 patients had minor injuries such as lacerations and breast implant related injuries and were treated conservatively with outpatient plastic surgery follow-up. Nine patients required urgent attention and were found to have a rapidly expanding breast. Six of them deteriorated hemodynamically and were found to have arterial extravasation from the internal mammary artery, the lateral thoracic artery, and the accessory scapular branch of the axillary artery. Two pregnant patients had an enlarged breast due to accumulation of milk secondary to avulsed milk ducts. The last patient had an inflammatory air pocket in communication with an underlying pneumothorax, which resolved after chest tube placement. There is currently no established standard of management and treatment of blunt breast trauma. Patients should be assessed and treated like any major trauma patient following the ATLS guidelines. Sanders et al. proposed an algorithm based on their study [
4]. Patients were divided as either having a simple or a complex breast trauma. Simple breast trauma patients defined as having an abrasion, a small laceration or pain over the affected breast were managed conservatively. Hemodynamically stable patients with complex breast trauma defined as a crush injury to the breast resulting in skin loss or an intramammary hematoma underwent a CT scan of their chest. Patients with no active arterial extravasation were monitored and treated symptomatically. Patients with a blush on CT were taken to interventional radiology for angiography and embolization [
4]. Because this occurred at a community hospital without a trauma designation, both trauma services and timely interventional radiology were unavailable. The patient was successfully managed with blood product transfusion and a compressive band around the affected breast. The binder was used as a temporizing measure to provide external compression on the breast and to tamponade the bleed. The role of post traumatic mammography is controversial as it is generally unnecessary as long as clinical follow-up ensures resolution of any mass effect after recovery [
1]. However, some authors advocate for a baseline mammogram at 3–6 months post injury with annual mammograms thereafter to ensure complete resolution of any masses and to rule out any post traumatic malignant breast malignancy [
6]. Typical post traumatic mammographic findings involve fat necrosis in different stages of evolution that range from acute contusion to calcified oil cysts [
2].
Table 1
Breast injury clasification
Grade 1 | Mild crush injury consisting of bruising, ecchymosis, skin blistering, breast swelling, tenderness, friction burns over contact area. |
Grade 2 | Moderate crush injury consisting of intramammary hematoma, fat necrosis, skin avulsion or loss, skin laceration, skin ulcer |
Grade 3 | Severe crush injury consisting of subcutaneous partial or complete transection of the breast resulting in a permanent diagonal furrow across the breast corresponding to the line of the seat belt that cleaved the breast tissue into two parts |
Grade 4 | Avulsion breast injury consisting of subcutaneous avulsion of the breast from the chest wall with rupture of perforating branches of intercostal vessels, active bleeding into the breast and the space between the breast and chest wall caused by the traumatic shearing force |