Presentation
High speed MVA. Unrestrained passenger.
Patient Data
Chest wall and neck surgical emphysema bilaterally, greater on the left side. Multiple displaced left lateral rib fractures. No features of pneumothorax or mediastinal shift. Patchy air space opacities in the mid and lower zones, greater on the left side, likely represent contusions in the traumatic context but may also represent aspiration. Cardiomediastinal contours are within normal limits allowing for projection.
Complete sternomanubrial dislocation with posterior displacement of the body of the sternum with respect to the manubrium. The upper anterior mediastinum is separated from the chest wall, and there is free communication of the pleural spaces, with gas filling the sternal defect and tracking into the soft tissues of the chest wall and neck. Mild stranding of the anterior mediastinal fat suspicious for contusion. No focal mediastinal hematoma. Abrupt cutoff of both internal mammary arteries at the level of the dislocation. Partial avulsion of both pectoralis muscles from the sternal attachments with extensive intramuscular gas. In the midline, at the level of T4, the mediastinal vasculature and pleural cavity are covered by skin and subcutaneous tissue only.
Multiple bilateral rib fractures and intercostal injuries with significant deformity of the thoracic cavity:
right 2nd rib posterolaterally, comminuted, minimally displaced and fracture anteriorly, comminuted and displaced with fragment overlap
right 3rd rib posterolaterally, nondisplaced and fracture anteriorly, nondisplaced
right 4th rib laterally, moderately displaced
right 5th rib anteriorly, nondisplaced
right 12th rib posteriorly, moderately displaced
left 3rd and 4th ribs anterolaterally, completely off ended with the anterior fragments displaced by 4cm inferiorly
left 4th rib anteriorly, nondisplaced
left 5th rib laterally, moderately displaced
partial high-grade tear of the left 1st intercostal musculature anteriorly with mild separation
full thickness thickness rupture of the left 2nd and 3rd intercostal musculature from the lateral chest wall extending anteriorly, with marked widening of the 2nd interspace (~6cm anteriorly) with only pectoral musculature covering the pleural space
full thickness thickness rupture of the right 2nd intercostal musculature anteriorly, with marked widening of the 2nd interspace (~3cm anteriorly)
the 2nd costal cartilages are intact and articulate with the manubrium. The 3rd costal cartilages are intact and articulate with the sternal body
No fracture of the partially imaged clavicles, scapulae or proximal humeri. Elevation of the left hemidiaphragm, which appears intact, with no appreciable diaphragmatic defect or herniation of abdominal contents into the chest cavity.
Bilateral moderate volume hemopneumothoraces, which communicate freely in the anterior midline. The heart is unremarkable. No pericardial effusion. Normal contrast opacification of the great vessels. Patchy consolidation and ground-glass change within the upper lobes of both lungs in keeping with pulmonary contusions. Bibasal atelectasis. The central airways are patent.
Impression
Type I sternomanubrial dislocation with significant craniocaudal separation and marked deformity of the thoracic cage.
Right 2nd-4th and left 3rd-5th rib fractures in multiple sites with significant displacement.
Rupture of the left 2nd and 3rd and right 2nd intercostal musculature anteriorly with marked separation, more severe on the left than the right.
Separation of the superior aspect of the anterior mediastinum from the chest wall at the level of the sternomanubrial dislocation, with free communication of the pleural spaces across the midline.
Partial rupture of the pectoralis musculature from the sternomanubrial attachments.
As a result of the above injuries, there is only skin and subcutaneous tissue covering the mediastinal vasculature and pleural space at the defect site.
No pericardial effusion or mediastinal hematoma evident, however, mediastinal fat stranding is consistent with contusion. Recommend high index of suspicion for myocardial contusion.
Abrupt cutoff of both internal thoracic arteries at the level of the separation consistent with acute injury. No active bleeding evident on single phase imaging.
Bilateral moderate volume hemopneumothoraces (buffalo pneumothorax).
Left hemidiaphragmatic elevation suspicious for traumatic phrenic nerve injury.
T5-T8 spinous process fractures. Right 12th rib and right L1 transverse process fractures.
Internation fixation plates have been applied to the sternum, left anterior third, and right lateral second rib. No metalware complication was identified. Surgical clips at the right superior mediastinum.
Persistent opacification of the left mid and lower zone, in keeping with moderate left pleural effusion and left lower lobe consolidation. Increased interstitial lung markings.
Case Discussion
The patient had long but relatively uneventful post-operative recovery.
Buffalo pneumothorax is defined as the presence of bilateral pneumothoraces caused by abnormal physical communication between the two pleural spaces. Trauma is one of the known causes.
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