A 10-year retrospective analysis of 82 patients with suspected thoracic aortic rupture (TAR) due to blunt chest trauma was performed to define which symptoms and signs were helpful in making an early diagnosis. Symptoms and signs associated with TAR included midscapular back pain (in the absence of thoracic spine fracture), unexplained hypotension, upper extremity hypertension, bilateral femoral pulse deficits, and initial chest tube output in excess of 750 mL. Chest roentgenographic signs seen with significantly greater frequency in the 12 patients with TAR than in 70 patients without such rupture included a widened paratracheal stripe (7 patients), deviation of the nasogastric tube or central venous pressure line (5 patients), blurring of the aortic knob (9 patients), abnormal paraspinous stripe (6 patients), and rightward tracheal deviation (5 patients). Mediastinal widening of greater than 8 cm occurred in 11 of the 12 patients with TAR (sensitivity, 92%); its specificity, however, was only 10% (11 true-positive and 63 false-positive results). In patients in hemodynamically stable condition who display these findings, immediate aortography should be considered. The presence of myocardial contusions, intraabdominal injuries, and pelvic fractures also occurred more frequently in patients with TAR. We conclude that a detailed history, physical examination, and chest roentgenography, with rapid progression to aortography in suspicious cases, represent the safest and most reliable approach to patients with TAR.