Pneumothorax and pulmonary contusions in multitrauma patient
This 21 year old male was involved in a motorbicycle accident. A chest X-ray was performed.
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- There are patchy airspace opacities seen in the right upper lobe, reflecting either pulmonary contusion or haemorrhage.
- Lucency is seen adjacent to the left heart border suggestive of a pneumothorax.
1 case question available
Chest injury is a common occurrence in the trauma setting, with up to one third of admitted trauma patients sustaining serious chest injuries1.
Pulmonary contusions are a common thoracic trauma injury and occurs in 30-75% of patients sustaining major chest injuries. Common mechanisms of injury include falls and motor vehicle accidents5.
Pathologically, pulmonary contusions are the result of haemorrhage from a pulmonary laceration into the surrounding alveolar spaces2.
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 haemorrhage.
Pneumothorax is defined as the presence of air between the parietal and visceral pleura3. 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 pneumothorax4. 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.
- 1. Miller DL, Mansour KA. Blunt traumatic lung injuries. Thorac Surg Clin. 2007;17 (1): 57-61, vi. doi:10.1016/j.thorsurg.2007.03.017 - Pubmed citation
- 3. Sharma A, Jindal P. Principles of diagnosis and management of traumatic pneumothorax. J Emerg Trauma Shock. 2008;1 (1): 34-41. doi:10.4103/0974-2700.41789 - Free text at pubmed - Pubmed citation
- 5. Cohn SM, Dubose JJ. Pulmonary contusion: an update on recent advances in clinical management. World J Surg. 2010;34 (8): 1959-70. doi:10.1007/s00268-010-0599-9 - Pubmed citation
- 2. Wagner RB, Crawford WO, Schimpf PP. Classification of parenchymal injuries of the lung. Radiology. 1988;167 (1): 77-82. doi:10.1148/radiology.167.1.3347751 - Pubmed citation
- 4. Rowan KR, Kirkpatrick AW, Liu D et-al. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT-initial experience. Radiology. 2002;225 (1): 210-4. doi:10.1148/radiol.2251011102 - Pubmed citation