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| POSTGRADUATE FORUM |
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| Year : 2022 | Volume
: 2
| Issue : 3 | Page : 119-121 |
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An unusual site for chest wall trauma
Ravindran Chetambath1, NK Sneha2, TS Maneesha2
1 Department of Pulmonary Medicine, Baby Memorial Hospital, Calicut, Kerala, India
2 Department of Medicine, Baby Memorial Hospital, Calicut, Kerala, India
| Date of Submission | 05-Feb-2022 |
| Date of Acceptance | 06-Apr-2022 |
| Date of Web Publication | 17-Aug-2022 |
Correspondence Address:
Dr. N K Sneha
Baby Memorial Hospital, Calicut, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jalh.jalh_3_22
Blunt chest trauma can injure ribs, vertebra, or sternum and, in turn, lead to lung injury of various severities. However, trauma to the scapula is very rare and it suggests heavy impact on the chest wall during fall. Here, we discuss a case of a traffic accident where multiple ribs and scapula on the right side are fractured. This, in turn, precipitated contusion of the lung.
Keywords: Blunt trauma, contusion, scapula
How to cite this article:
Chetambath R, Sneha N K, Maneesha T S. An unusual site for chest wall trauma. J Adv Lung Health 2022;2:119-21 |
| Images | |  |
Patient presented to the ED with a history of fall from a two-wheeler while taking off. He hit right side of his chest on the road and had severe pain following the fall.
In the ED, his vitals were stable, and his radiological images showed a horizontal fracture of the right scapula [Figure 1] and multiple rib fractures [Figure 2]. He was put on analgesics and sedatives. After 48 h, the patient developed difficulty in breathing, and his oxygen saturation dropped to 88%–90%. | Figure 1: Showing a horizontal fracture of the right scapula in road traffic accident
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 | Figure 2: Anteroposterior image of ribcage showing fracture of right 4,5,6,7 ribs
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Chest X-ray (CXR) [Figure 3] and computed tomography (CT) scan of the thorax [Figure 4] were taken by the clinical diagnosis was established. | Figure 3: Chest X-ray posterior anterior view showing obliterated right costophrenic angle and diffuse parenchymal infiltrate in the right midzone
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 | Figure 4: Computed tomography thorax showing minimal pleural effusion and pleural-based parenchymal opacity on the right side
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| Question-1 | | |
What is the cause of breathing difficulty at this stage?
- Pulmonary thromboembolism
- Pleural effusion
- Pulmonary contusion
- Pneumonia.
Pulmonary thromboembolism is a possibility if the patient had a long bone fracture or is immobilized. This can also occur in obese, elderly individuals, or those having risk factors for thrombosis.
Pleural effusion is a possibility, especially when the rib fractures are dislocated and pierce the pleura. Pleural effusion occurs usually immediately after the trauma and mostly will be hemothorax.
Pulmonary contusion is a strong possibility following blunt trauma due to shear stress on lung tissue. Usually develop 6–48 h after the trauma. This can progress to acute respiratory distress syndrome if not recognized early.
Pneumonia is a possibility if the symptoms are associated with cough, expectoration, and fever.
| Question-2 | | |
What is the mechanism of lung contusion?
It is the most common type of lung injury in blunt chest trauma. Disruption of the capillaries of the alveolar walls and septa causes leakage of blood into the alveolar spaces and interstitium.[1] Three possible mechanisms of development of contusion are:
- Inertial effect – The lighter alveolar tissue is sheared from the heavier hilar structures because the two types of tissues accelerate at different rates
- Spalling effect – Spalling effect occurs in areas with large differences in density. Particles of the spalled denser tissue are thrown into the less dense particles
- Implosion effect – It occurs when a pressure wave passes through a tissue containing bubbles of gas. The bubblesfirst implode, then rebound, and expand beyond their original volume. The over expansion of the gas bubble stretches and tears alveoli.
Pulmonary contusions generally develop over thefirst 24 h and resolve in about 1 week.
| Question-3 | | |
What are the radiological signs?
Chest X-ray is the most common method used for diagnosis. Contusion is not restricted by the anatomical boundaries of the lobes or segments of the lung. It is not sensitive as it may be normal or show only nonspecific infiltrates. When a pulmonary contusion is apparent in an X-ray, it suggests that the trauma to the chest was severe.
High-resolution CT (HRCT) thorax – Most cases of lung contusions are seen by CT scan only.[2] HRCT thorax shows cut pumpkin sign[3] dense nonsegmental, subpleural, crescentic opacity on the side of impact, and the lesion becoming less dense and nonhomogenous (ground-glass opacity) toward the deeper parenchyma.
USG – Lung contusion is diagnosed by the presence of the alveolo-interstitial syndrome, which is defined by an increase in B-line artifacts, peripheral parenchymal lesion – defined by the presence of C-lines and hypoechoic, subpleural focal images with or without pleural line gap.
| Question-4 | | |
How will you manage lung contusion?
Most pulmonary contusions require supportive therapy until the contusion heals.[4] Because contusions can gradually evolve over thefirst 24–48 h after trauma, close monitoring is required. The goal of therapy is to prevent respiratory insufficiency, failure, and complications. There should be appropriate pain control to prevent splinting of chest muscles secondary to injury and to allow for lung expansion.
Supportive care such as postural drainage, suctioning, chest physiotherapy, incentive spirometry, encouraging coughing, and deep breathing can be tried to prevent atelectasis.[5]
Positive pressure ventilation using CPAP and BiPAP may be used. It is of utmost importance to provide minimum positive end-expiratory pressure to maintain the lungs open, recruit maximum alveoli, and prevent barotrauma. Prone positioning of the patient with contusion reduces pressure on the diaphragm, and positioning of the contused lung in a nondependent position helps in recruiting alveoli.[6] Noninvasive ventilation can cause gastric distention and aspiration, especially if the level of consciousness is impaired. If positive pressure ventilation fails, invasive ventilation is required. Large tidal volume can have adverse effects; hence, the use of low tidal volume is suggested. Patients with severe hypoxia and with poor response to other therapies can benefit from nitric oxide.
Diuretics can be used in a contusion to reduce pulmonary venous resistance and pulmonary capillary hydrostatic pressure.
If fluid therapy is required to maintain euvolemia, measuring pulmonary artery pressure is recommended to avoid pulmonary edema.
Indications for surgical intervention in blunt traumatic injuries may be categorized according to the classification system previously described. These indications may be further stratified into conditions necessitating an immediate operation and those in which surgery is needed for delayed manifestations or complications of trauma.[7] Surgical stabilization may be required in the case of multiple rib fractures/flail chest to correct pulmonary mechanics. Cases refractory to all conventional therapies have been successfully managed by extracorporeal gas exchange. In polytrauma or chest trauma with multiple rib fractures, blood accumulates in the pleural cavity, further delaying the lung expansion. In such cases, early evacuation of the pleural cavity with intercostal drainage is required.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Farooq AG, Hafeezulla L, Ghulam Nabi L, Mohd Lateef W, Singh S, Abdual Majeed D, et al. Lung contusion: A clinico-pathological entity with unpredictable clinical course. Bull Emerg Trauma 2013; 1:7-16.  |
| 2. | Robert MR, Benjamin F, Mark IL, Brigitte MB, Daniel KN, Gregory WH, et al. Pulmonary contusion in the pan-scan era. Injury 2016;47:1031-4. |
| 3. | Chetambath R, Parengal J, Aslam M, Shivashankan S. Cut pumpkin sign- A diagnostic radiological sign in pulmonary contusion. J Med Sci Clin Res2017;5:25464-6. |
| 4. | Cohn SM, Dubose JJ. Pulmonary contusion: An update on recent advances in clinical management. World J Surg 2010;34:1959-70. |
| 5. | Požgain Z, Kristek D, Lovrić I, Kondža G, Jelavić M, Kocur J, et al. Pulmonary contusions after blunt chest trauma: Clinical significance and evaluation of patient management. Eur J Trauma Emerg Surg. 2018;44:773-7. |
| 6. | Allen GS, Cox CS Jr., Pulmonary contusion in children: Diagnosis and management. South Med J 1998;91:1099-106. |
| 7. | Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chin J Traumatol 2020;23:125-38. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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