Delayed massive hemothorax due to a diaphragmatic laceration caused by lower rib fractures

Delayed massive hemothorax after blunt thoracic trauma requiring thoracotomy by VATS: a case report

Delayed hemothorax after thoracic trauma is a rare type of thoracic injury that may require angioembolization and surgical treatment. We report a case of a 59-year-old man with a delayed massive hemothorax from a fall-induced blunt thoracic trauma, causing multiple right lower rib fractures. The patient fell from a chair while standing on and working from it. He was diagnosed with right 7th–11th rib fractures, scanty hemothorax and liver contusion. The patient was hospitalized and received conservative treatment, and a delayed massive hemothorax was present on the fourth day after the injury. Chest tube drainage and video-assisted thoracoscopic surgery were performed, and the patient was discharged 16 days after the surgery without bleeding or other complications. Delayed hemothorax should be considered when thoracic trauma patients complain of chest discomfort, dyspnea, cold sweating or fatigue. Early recognition, appropriate diagnosis and rapid intervention can improve prognosis and lead to successful patient treatment.

Delayed massive hemothorax due to diaphragm injury with rib fracture: A case report

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Diaphragmatic injury can cause delayed hemothorax.

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A thoracotomy should be considered in patients with delayed hemothorax and shock.

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Delayed hemothorax required surgery to control bleeding from diaphragmatic injury.

Introduction

Delayed massive hemothorax after blunt trauma is rare, although associated with significant morbidity and mortality. In most cases, the intercostal artery is the main bleeding source. We report a rare case of delayed massive hemothorax due to a diaphragm injury with a lower rib fractures.

Presentation of case

A 58-year-old man, transported to our hospital four hours after a 2-meter fall from a ladder, had left-sided fractures to ribs 11 and 12, thoracic and lumbar vertebral fractures, and traumatic subarachnoid hemorrhage. On admission, no left hemothorax was documented; however, 17 h post-injury he developed hypovolemic shock. Plain chest radiographs showed a massive left hemothorax with a mediastinal shift. Chest contrast-enhanced computed tomography revealed extravasation of the contrast agent in the chest cavity. No intercostal arterial bleeding was evident on emergency angiography. A left anterolateral thoracotomy through the 6th intercostal space revealed rib fractures and active bleeding from the dorsal side of the left hemidiaphragm. Suture hemostasis was performed for the diaphragm injury and the disrupted ribs were repaired.

Discussion

Embolization of diaphragm-feeding arteries is not a simple or fast procedure. Clinically, predicting delayed hemothorax is challenging, and careful observation of trauma patients with lower rib fractures is needed. Thoracotomy should be considered for immediate hemostasis in patients with sudden shock, with complete hematoma drainage and repair of the disrupted rib.

Conclusion

Diaphragmatic injury with lower rib fractures can result in delayed hemothorax, requiring thoracotomy.

Cardiac injury due to the rapid progress of the dislocation of rib fractures: A rare case that required urgent open reduction and internal rib fixation

Background

Most rib fractures are treated conservatively, but patients with severe trauma may require surgical treatment. We report a rare case of delayed pericardial injury due to a fractured rib stump.

Case presentation

A 61-year-old man fell while riding a bicycle and was transferred to our hospital. A computed tomography (CT) scan showed mild rib fractures on the 4th-6th ribs, and he was hospitalized because of acute pain. A few days later, his respiratory condition had worsened. CT showed that the rib fractures progressed significantly, and the stump was in contact with the heart, so we performed an urgent surgical rib fixation. Operative findings revealed intrathoracic hemorrhage by the pericardial laceration because of the rib stump. The 4th-7th ribs were internally fixed using a screwless titanium metal plate, and he was discharged without complications on the 20th postoperative day.

Conclusion

We experienced a rare case of pericardial injury caused by a rapid dislocation of rib fractures. Urgent surgical treatment was able to prevent a serious complication.