Pneumothorax and pulmonary contusions in multitrauma patient

Case contributed by Dr Dayu Gai

Presentation

This 20-year-old male was involved in a motorbicycle accident. A chest X-ray was performed.

Patient Data

Age: 20 years
Gender: Male

There are patchy airspace opacities seen in the right upper lobe, reflecting either pulmonary contusion or hemorrhage.

Lucency is seen adjacent to the left heart border suggestive of a pneumothorax.

Case Discussion

Chest injury is a common occurrence in the trauma setting, with up to one third of admitted trauma patients sustaining serious chest injuries 1.

Pulmonary contusions are a common thoracic trauma injury and occur in 30-75% of patients sustaining major chest injuries. Common mechanisms of injury include falls and motor vehicle accidents 5

Pathologically, pulmonary contusions are the result of hemorrhage from a pulmonary laceration into the surrounding alveolar spaces 2.

While radiograph and CT are both used for initial assessment and evaluation, both have their limitations. Radiograph has a poor sensitivity and will miss many diagnoses of pulmonary contusion. This is often because the pathological change doesn't occur until 6 hours later. The radiograph will often be the first imaging performed on admission, and these changes haven't occurred yet. On the other hand, CT may be overly sensitive, picking up subtle parenchymal changes which have no or minimal clinical impact.

Chest radiograph may show singular or multiple patchy alveolar infiltrates consistent with intra-alveolar hemorrhage. 

Pneumothorax is defined as the presence of air between the parietal and visceral pleura 3. It can be divided into simple and tension pneumothoraces. While diagnosis has been typically with a plain radiograph, CT and more recently ultrasound have been shown to be more sensitive and specific for diagnosing pneumothorax 4. Chest radiograph findings may include the following:

  • increased thoracic volume
  • increased rib separation
  • flattening of heart border
  • mediastinal deviation
  • mid-diaphragmatic depression

Case contributed by A/Prof Pramit Phal.

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