Delayed Hemothorax After Conservative Treatment of Sternal Fracture Case Report

Delayed Hemothorax After Conservative Treatment of Sternal Fracture

Naoki Yamamoto,1) MD, PhD,＊ Masahiro Sakakibara,1) MD, Maki Murakami,1) MD, PhD, Koji Sakaguchi,2) MD

1) Department of Primary Care Service, Shinsei Hospital 2) Department of Thoracic Surgery, Suzaka Prefectural Hospital

Delayed hemothorax following blunt chest trauma is classified as a late presentation of hemothorax after a nearly normal chest X-ray on admission. Here, we present a case of delayed hemothorax 5 days after blunt chest trauma with ribs and sternal fracture.

Key Words: blunt chest trauma, delayed hemothorax, sternal fracture

Gen Med : 2011 ; 12 : 85-88

INTRODUCTION CASE REPORT Blunt chest injuries range from mild pulmonary A 73-year-old woman who suffered a motor vehicle contusions to complete chamber rupture of the heart. accident was brought to our hospital in an ambulance. Patients with minor rib and sternal injuries who are She had no obvious underlying medical history, able to cough and clear secretions usually can be including the use of anticoagulant therapy or pulmo- followed up on an out-patient basis. Clinical examina- nary disease. According to her deposition, she had tion, along with chest imaging, is often sufficient for been sitting in the front passenger seat and had diagnosis and proper treatment. Although major fastened a 3-point seat belt adequately before the operative repair is usually not needed, procrastination accident. She complained of pain on inspiration at and failure to meticulously treat even what appears to presentation, but without dyspnea. Tenderness over be a minor injury may result in rapid death or the sternum and right thorax without evidence of prolonged morbidity. We present a case of delayed asymmetry of the ribcage was observed. No paradoxi- hemothorax after blunt chest trauma with ribs and cal movement of a segment of the chest wall was sternal fracture. observed. Normal breathing sounds were heard over

Author for corresponding : Naoki Yamamoto M. D. Department of Primary Care Service Shinsei Hospital Obuse-cho 851, Kamitakai-gun, Nagano-ken, 381-0295 JAPAN E-mail address: [email protected] Received for publication 18 February 2011 and accepted in revised form 20 July 2011

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Figure 1. Roentgenogram and computed tomography（CT）scan taken about 1 hour after the accident. An almost normal lung field（A), and undisplaced fracture of the sixth and seventh ribs（white allows）（B, C）and displaced sternal fracture（white allow）（D）were observed on the roentgenogram. CT revealed undisplaced fracture of the fifth, sixth and seventh ribs（black allows）and displaced sternal fracture（white allow）（E, F).

the entire lung field. Palpation did not reveal crepitus gram revealed massive right-sided hemothorax, associated with broken ribs. Emergent radiography slight right-sided pneumothorax, and pericardial and computed tomography（CT）revealed a small, effusion（Figure 2). Moreover, the dislocation of the displaced fracture of the right seventh and eighth ribs broken seventh rib was found to be deteriorating. The and the sternum without pneumothorax, hemothorax, patient was given emergency transportation to a or pericardial effusion（Figure 1). She was admitted higher function hospital, receiving rapid intravenous to our hospital due to concomitant lumbar vertebral transfusion of 1000 ml of extracellular fluid. compression fracture. Her serum hemoglobin（Hb） Subsequent intercostal tube insertion drained 1000 ml level at admission was 11.0 g／dl. She was treated with of bloody discharge immediately. The rate of drainage analgesics and activity restrictions, and an elastic never exceeded 50 ml／hour after that and vanished bandage was applied around her entire chest in spontaneously within a week. Total pleural bloody primary setting at the beginning. Her recovery was discharge volume was 2700 ml. The patient was uneventful until 5 days after admission. Nearly 6 days hemodynamically resuscitated with 2000 ml of crystal- after admission, she started complaining of cough and loids and given a no-blood transfusion. An elastic chest discomfort and an associated fall in blood bandage was applied around her entire chest again, pressure and tachycardia. Her respiration was and her vital signs were stable. Her minimum Hb level paradoxical motion with flail segment at the site of the was 8.7 g／dl during her hospital stay. Her recovery sternal fracture. Immediate CT and chest roentgeno- was uneventful, requiring only conservative suppor-

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Figure 2. Chest X-ray examination and CT scan 6 days after the injury. The chest roentgenogram showed an opaque right hemothorax, with a contralateral shift of the mediastinum（A） and exacerbation of the displacement of the broken rib（black arrow）（C). CT revealed a right hemothorax and pericaldial effusion（B, D).

tive treatment. The intercostal tube was removed on fractures has increased threefold due to increasing the 14th day in hospital. She was discharged from the frequency in motor vehicle accidents, especially since hospital without any respiratory deficits. the introduction of seat belt legislation.2 Sternal fractures were once thought to be high-morbidity DISCUSSION injuries, with a mortality rate of 25-45% from Minor thoracic injuries（MTIs）with proven or associated injuries. Recent reports in the literature suspected rib fractures constitute a common presen- reveal that the morbidity rate associated with sternal tation in emergency departments（EDs). Most pa- fractures may be lower, yet caution is warranted tients with MTI are treated in ambulatory settings when evaluating and treating patients with this and less than 25% are admitted.1 injury. A severely displaced sternum may require We had to predict respiratory compromise from the surgical intervention to stabilize the sternum; howev- severity of the sternal fracture and extend external er, previous studies have demonstrated that admis- fixation period at first. The incidence of sternal sion for isolated sternal fracture is not generally

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necessary unless associated with other injuries.3,4 References Recently, it has been demonstrated that about 10% 1 Shields, J. F.; Emond, M.; Guimont, C.; Pigeon D. of patients with MTIs develop significantly delayed Acute minor thoracic injuries: evaluation of practice complications within 14 days of discharge from the and follow-up in the emergency department. Can ED.1 Several reports have been published regarding Fam Physician. 2010, vol. 56, p. 117-124. delayed presentation or missed diagnoses of injuries 2 Athanassiadi, K.; Gerazounis, M.; Moustardas, M. associated with blunt thoracic trauma. The incidence Sternal fractures: retrospective analysis of 100 cases. of delayed hemothorax in blunt chest trauma, as World J Surg. 2002, vol. 26, p. 1243-1246. reported in 2 recent studies, ranges from 5.0-7.4%.5,6 3 Peek, G. J.; Firmin, R. K. Isolated sternal fracture: In these studies, all cases of delayed hemothorax had an audit of 10 yearsʼ experience. Injury. 1995, vol. 26, p. at least 1 rib fracture on X-ray examination. It should 385-388. also be noted, however, that there have been 2 case 4 Sadaba, J. R.; Oswal, D.; Munsch, C. M. Manage- reports of delayed hemothorax after blunt trauma ment of isolated sternal fractures: determining the without any evidence of rib fracture.7,8 risk of blunt cardiac injury. Ann R Coll Surg Engl. The responsible vessel of hemothorax in our case 2000, vol. 82, p. 162-166. was not clear. Possible sources of bleeding in delayed 5 Sharma, O. P.; Hagler, S.; Oswanski, M. F. Preva- hemothorax include lung parenchyma, intercostal lence of delayed hemothorax in blunt thoracic trauma. vessels, internal mammary artery, and azygous Am Surg. 2005, vol. 71, p. 481-486. veins.7−9 Injury of intercostal veins, internal thoracic 6 Misthos, P; Kakaris, S; Sepsas, E. et al. A prospec- veins, or bone marrow of ribs or sternum might have tive analysis of occult pneumothorax, delayed pneu- been the cause of the hemothorax, according to mothorax and delayed hemothorax after minor blunt clinical course in our case. thoracic trauma. Eur J Cardiothorac Surg. 2004, vol. Generally speaking, even delayed hemothorax after 25, p. 859-864. blunt trauma is a unique entity occurring in patients 7 Kwon, O. Y.; Chung, S. P.; Yoo, I. S. et al. Delayed with multiple or displaced rib fractures.10 Moreover presentation of internal mammary artery rupture we have found no previous reported cases of delayed after blunt chest trauma: Characteristic CT and plain hemothorax after sternal fracture.2 In our case, we X-ray findings. Emerg Med J. 2005, vol. 22, p. 664-665. could not predict a massive hemothorax would 8 Bundy, D. W.; Tilton, D. M. Delayed hemothorax developed 6 days after admission in a patient in whom after blunt trauma without rib fractures. Mil Med. 2 undisplaced rib fractures coexisted with sternal 2003, vol. 168, p. 501-502. fracture at presentation. 9 Bowles, B. J.; Teruya, T.; Belzberg, H. et al. Blunt The usual presentation of delayed hemothorax is traumatic azygous vein injury diagnosed by comput- worsening pleuritic chest pain and dyspnea in ed tomography: Case report and review of the patients with multiple displaced rib fractures, often literature. J Trauma. 2000, vol. 49, p. 776-779. occurring 18-48 hours after the injury.10 Most patients 10 Simon, B. J; Chu, Q.; Emhoff, T. A. et al. Delayed who will develop complications will do so within 2 hemothorax after blunt thoracic trauma: An uncom- weeks, therefore follow-up should be undertaken mon entity with significant morbidity. J Trauma. 1998, during the 2 weeks after presentation.11 To date, there vol. 45, p. 673-676. is no established regimen for follow-up of patients 11 Misthos, P.; Kakaris, S.; Sepsas, E. et al. A with MTI, and a low proportion of patients are offered prospective analysis of occult pneumothorax, delayed planned follow-up visits, or any follow-up recommen- pneumothorax and delayed hemothorax after minor dations despite possible delayed complications and blunt thoracic trauma. Eur J Cardiothorac Surg. 2004, disabilities. Further clinical studies are necessary to vol. 25, p. 859-864. identify predictors of delayed MTI complications and enhance appropriate use of follow-up resources.

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