Muronoi T, Kidani A, Oka K, Konishi M, Kuramoto S, Shimojo Y, Hira E, Watanabe H. Delayed massive hemothorax due to diaphragm injury with rib fracture: A case report.
Int J Surg Case Rep 2020;
77:133-137. [PMID:
33160173 PMCID:
PMC7649592 DOI:
10.1016/j.ijscr.2020.10.125]
[Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/03/2022] Open
Abstract
Diaphragmatic injury can cause delayed hemothorax.
A thoracotomy should be considered in patients with delayed hemothorax and shock.
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.
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