Fallen lung, pneumothorax, hepatic and pancreatic lacerations and retroperitoneal hematoma

Case contributed by Dr Heather Pascoe

Presentation

MVA 60kph.

Patient Data

Age: 50
Gender: Female

Chest

  • ETT and NGT
  • Large left pneumothorax with an element of tension.
  • Small right sided pneumothorax.
  • “Fallen lung” on the left with complete collapse of the left lower lobe.
  • Flail chest – Multiple bilateral rib fractures (lateral aspects 2nd-8th on the left and 3rd-8th on the right).
  • Gas tracking along the chest wall bilaterally.

Abdomen/Pelvis

  • Extensive hepatic lacerations involving segments 2, 3, 4A and 4B and extending to the porta hepatis (AAST Grade V) with 2 small foci of active hemorrhage. Small segment 8 laceration.
  • Hemoperitoneum with periportal tracking.
  • Sentinal clot adjacent to the spleen. No splenic injury identified.
  • Horizontal hypodensity through the pancreatic head was reported as a traumatic laceration. Subsequent MRCP demonstrated this to be a horizontally oriented distal common bile duct (images to follow).
  • Retroperitoneal blood with elevation of the aorta below the renal arteries. Contrast extravasation at this site likely due to lumbar artery avulsion.  
  • IVC slit like – consistent with hypovolemia
  • Right posterior perirenal hematoma with small posterior right renal laceration (AAST Grade III).

Incidental findings

  • Partly calcified ligamentum arteriosum.
  • The D-J flexure is to the right of the midline and the cecum is midline is keeping with midgut malrotation.
  • Grade 1 retrolisthesis of L5 on S1.

Selected MRCP images from the same patient demonstrate that the hypodensity in the pancreatic head is due to a horizontally oriented distal common bile duct.

Case Discussion

This case demonstrates the fallen lung sign. When there is complete transection of a bronchus, the lung on the side of the bronchial injury may fall posterolaterally away from the hilum. On CT the lung is seen posteriorly as the patient is supine.

The liver is one of the most commonly injured abdominal organs in blunt trauma. Many patients are managed with observation and supportive measures, whilst those with active bleeding are often treated with embolization. 

Although no pancreatic injury ended up being present in this patient, raising the possibility on the initial CT was appropriate. The findings of pancreatic injury can be subtle initially and an early diagnosis is critical in reducing morbidity and mortality. 

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Case information

rID: 37080
Published: 12th Feb 2018
Last edited: 16th Jul 2018
Tag: trauma
Inclusion in quiz mode: Included

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