Multiple pulmonary contusions and rib fractures in a trauma patient
Presentation
High speed motor vehicle accident. A CT trauma series was performed.
Patient Data
Conclusion:
- Bilateral pulmonary contusions and pneumothoraces with bilateral ICC in situ.
- The left intercostal catheter extends into the mediastinum, without evidence of cardiac or great vessel injury.
- Extensive pneumomediastinum of secondary to the left intercostal catheter.
- Bilateral rib fractures as described below, with large right flail segment involving the right 4th-10th ribs.
- On the right, there are fractures at the 4th-10th ribs, constituting a large flail segment.
- Right lateral 4th and 5th rib fractures are moderately displaced.
- Fractures of the 7th and 8th ribs demonstrate cortical buckling.
- The 9th right rib is fractured in its anterior and posterior aspect.
- The left 6th - 8th ribs are fractured and minimally displaced at the costochondral junction.
- Findings highly suspicious for liver contusions within segment 6/7 and 4a/2.
Poorly defined region of low density within liver segment 6/7 is highly suspicious for a liver contusion, and is felt unlikely to represent artefact.
Within segment 4a/2, a further ill-defined low density most likely represents a further liver contusion. Low density adjacent to the ligamentum teres, within the left lobe of liver likely represent focal fatty infiltration.
Case Discussion
Pulmonary contusions are a common thoracic trauma injury and occur in 30-75% of patients sustaining major chest injuries. Common mechanisms of injury include falls and motor vehicle accidents1.
Pathologically, pulmonary contusions are the result of hemorrhage from a pulmonary laceration into the surrounding alveolar spaces2.
While radiograph and CT are both used for initial assessment and evaluation, both have their limitations. Radiograph has a poor sensitivity and will miss many diagnoses of pulmonary contusion. This is because the pathological change doesn't occur until 6 hours later. On the other hand, CT may be overly sensitive, detecting changes which may not be clinically relevant.
Chest radiograph may show singular or multiple patchy alveolar infiltrates consistent with intra-alveolar hemorrhage. On CT, pulmonary contusions may show up as hazy infiltrations, hypodense to the normal parenchyma with the normal vasculature seen coursing through the contusion.
Complications of intercostal catheter insertion is commonplace, with figures of 21-30% being quoted in the literature3,4. In this case, the intercostal catheter has been malpositioned in the mediastinum. Complications of unintentional mediastinal position include compressive or perforating damage to the heart, esophagus and nerves5.
Rib fractures are a common traumatic occurrence, where the 4th to 9th ribs are most commonly fractured. Superior rib fractures of the 1st to 3rd ribs are more commonly associated with subclavian vasculature as well as brachial plexus injury. More inferior rib fractures of the 10th to 12th ribs are associated with visceral injury, in particular, the spleen, kidney and liver6. In general, the greater the number of fractured ribs, the more severe the causative injury.
Rib fractures can have multiple complications. These include:
- Pneumothorax
- Hemothorax
- Pulmonary contusions
- Flail chest
- Pneumonia
- Atelectasis
Case contributed by A/Prof. Pramit Phal.
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