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Compression of the Thoracic Aorta by a Fractured Rib
EJVES Extra 6, 117–118 (2003) doi: 10.1016/S1533-3167(03)00103-1, available online at http://www.sciencedirect.com on
SHORT REPORT
Compression of the Thoracic Aorta by a Fractured Rib S. Nitecki1*, A. Ofer2, T. Karram1 and L. A. Best3 Departments of 1Vascular Surgery, 2Radiology, 3Thoracic Surgery, Rambam Medical Center and The Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel Key Words: Aortic injury; Rib fracture.
Introduction Vascular thoracic trauma most commonly affects the aorta. Severe injury commonly leads to death through exsanguination. A fractured rib segment penetrating the posterior aortic wall is an uncommon finding. Such a case is reported here together with a literature review.
Case Report A 52-year-old woman brought to the emergency room after being involved in a motor vehicle accident as a pedestrian. Physical examination revealed a conscious, anxious patient in pain and in hypovolemic shock. The blood pressure was 90/50 with a heart rate of 128. The haematocrit was 26%. Multiple skin bruises and haematomata were noticed. After fluid resuscitation further assessment was performed in the radiology suite. Fig. 1 shows an axial slice from CTA of the upper chest below the level of the carina. There is a left haemothorax, a fracture of the left fifth and sixth ribs in the mid axillary line with a bony fragment of the sixth rib compressing the posterior wall of the descending aorta. Additional injuries included lung contusion, fractures of the facet process of vertebrae C7 and T1, fractures of spinal process of vertebrae T3-5 and T8-9, fracture of the left scapula, fracture of the *Corresponding author. Department of Vascular Surgery and Transplantation, Rambam Medical Center, P. O. Box 9602, Haifa 31096, Israel. Tel.: þ972-4-8543119/8543498; fax: þ 972-4-8543119.
pubic ramus and left sacrum, and fracture of the right tibia and fibula. After insertion of a double lumen endotracheal tube, an extended posterolateral thoracotomy was performed. The dissection was carried down to the aorta revealing two rib fragments compressing the aortic wall. Fragments were removed only after obtaining proximal and distal control. There was no active bleeding or injury necessitating a repair of the aorta. Other operations were performed consecutively. The patient had an uneventful, albeit a slow, recovery. Today, 8 months after the injury the patient is back to part-time work. A CTA was obtained after a follow-up visit and no pathology (specifically a pseudoaneurysm) was encountered.
Discussion Trauma to the great vessels in the chest during road accidents most commonly affects the aorta. There are 7000 – 8000 of these per year in the United States.1 Deceleration shear forces cause damage to the aorta at the ligamentum arteriosum, the point where the aorta disappears behind the parietal pleura and becomes relatively fixed. Crush injury of the aorta between the sternum and the vertebral column can also occur.2 Aortic injury is associated with a high mortality and over 70% of the patients die before arrival in hospital. The injury is mostly followed by massive haemorrhage and exsanguination.3 Nearly 30% of survivors from aortic disruption die within 6 h if no treatment is started.4 The patient reported here presented with
1533–3167/000117 + 02 $35.00/0 q 2003 Elsevier Ltd. All rights reserved.
118
S. Nitecki et al.
Only three similar case reports have been reported. In two5 the diagnosis was initially missed and surgical intervention was delayed resulting in mortality. In the first patient, the delay of surgical intervention was by approximately 10 h. The other patient was discharged from the emergency room but was readmitted a few days later in severe hypovolemic shock and died. Immediate diagnosis and intervention6 saved the life of a third patient. Thus a high index of suspicion is recommended, for this potentially lethal injury, with early diagnosis followed by prompt surgical intervention.
References
Fig. 1. An axial slice from CTA of the upper chest below the level of the carina; showing a left haemothorax, a fracture of the fifth left rib in the mid axillary line with a bony fragment of the sixth rib compressing the posterior wall of the descending aorta.
hypovolemic shock and although there was not a massive haemothorax a fractured rib segment was found to be compressing the posterior aortic wall. This was a potentially fatal situation whereby immediate or delayed penetrating injury to the aorta could have caused exsanguination.
EJVES Extra, 2003
1 Bongard F, Dubrow T, Klein SR. Vascular injuries in the urban battleground: experience at a metropolitan trauma center. Ann Vasc Surg 1990; 4: 415 –418. 2 Kemmerer WT, Eckert WG, Gathright JB. Patterns of thoracic injuries in fatal traffic accidents. J Trauma 1961; 1: 595–599. 3 Mattox KL. Thoracic vascular trauma. J Vasc Surg 1988; 7: 725 –729. 4 DelRossi AJ, Cernaianu AC, Madden LD, Cilley JH, Spence RK, Alexander JB, Ross SE, Camishion RC. Traumatic disruptions of the thoracic aorta: treatment and outcome. Surgery 1990; 108: 864–870. 5 Mareo JV, Gregory JS. Posterior fracture of the sixth rib causing late aortic laceration: case report. J Trauma 1997; 42: 736– 737. 6 Kern JA, Chan BB, Kron IL, Young JS. Successful treatment of exsanguinating injury from a fractured rib. Am Surg 1998; 64: 1158–1160. Accepted 20 November 2003
SHORT REPORT
Compression of the Thoracic Aorta by a Fractured Rib S. Nitecki1*, A. Ofer2, T. Karram1 and L. A. Best3 Departments of 1Vascular Surgery, 2Radiology, 3Thoracic Surgery, Rambam Medical Center and The Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel Key Words: Aortic injury; Rib fracture.
Introduction Vascular thoracic trauma most commonly affects the aorta. Severe injury commonly leads to death through exsanguination. A fractured rib segment penetrating the posterior aortic wall is an uncommon finding. Such a case is reported here together with a literature review.
Case Report A 52-year-old woman brought to the emergency room after being involved in a motor vehicle accident as a pedestrian. Physical examination revealed a conscious, anxious patient in pain and in hypovolemic shock. The blood pressure was 90/50 with a heart rate of 128. The haematocrit was 26%. Multiple skin bruises and haematomata were noticed. After fluid resuscitation further assessment was performed in the radiology suite. Fig. 1 shows an axial slice from CTA of the upper chest below the level of the carina. There is a left haemothorax, a fracture of the left fifth and sixth ribs in the mid axillary line with a bony fragment of the sixth rib compressing the posterior wall of the descending aorta. Additional injuries included lung contusion, fractures of the facet process of vertebrae C7 and T1, fractures of spinal process of vertebrae T3-5 and T8-9, fracture of the left scapula, fracture of the *Corresponding author. Department of Vascular Surgery and Transplantation, Rambam Medical Center, P. O. Box 9602, Haifa 31096, Israel. Tel.: þ972-4-8543119/8543498; fax: þ 972-4-8543119.
pubic ramus and left sacrum, and fracture of the right tibia and fibula. After insertion of a double lumen endotracheal tube, an extended posterolateral thoracotomy was performed. The dissection was carried down to the aorta revealing two rib fragments compressing the aortic wall. Fragments were removed only after obtaining proximal and distal control. There was no active bleeding or injury necessitating a repair of the aorta. Other operations were performed consecutively. The patient had an uneventful, albeit a slow, recovery. Today, 8 months after the injury the patient is back to part-time work. A CTA was obtained after a follow-up visit and no pathology (specifically a pseudoaneurysm) was encountered.
Discussion Trauma to the great vessels in the chest during road accidents most commonly affects the aorta. There are 7000 – 8000 of these per year in the United States.1 Deceleration shear forces cause damage to the aorta at the ligamentum arteriosum, the point where the aorta disappears behind the parietal pleura and becomes relatively fixed. Crush injury of the aorta between the sternum and the vertebral column can also occur.2 Aortic injury is associated with a high mortality and over 70% of the patients die before arrival in hospital. The injury is mostly followed by massive haemorrhage and exsanguination.3 Nearly 30% of survivors from aortic disruption die within 6 h if no treatment is started.4 The patient reported here presented with
1533–3167/000117 + 02 $35.00/0 q 2003 Elsevier Ltd. All rights reserved.
118
S. Nitecki et al.
Only three similar case reports have been reported. In two5 the diagnosis was initially missed and surgical intervention was delayed resulting in mortality. In the first patient, the delay of surgical intervention was by approximately 10 h. The other patient was discharged from the emergency room but was readmitted a few days later in severe hypovolemic shock and died. Immediate diagnosis and intervention6 saved the life of a third patient. Thus a high index of suspicion is recommended, for this potentially lethal injury, with early diagnosis followed by prompt surgical intervention.
References
Fig. 1. An axial slice from CTA of the upper chest below the level of the carina; showing a left haemothorax, a fracture of the fifth left rib in the mid axillary line with a bony fragment of the sixth rib compressing the posterior wall of the descending aorta.
hypovolemic shock and although there was not a massive haemothorax a fractured rib segment was found to be compressing the posterior aortic wall. This was a potentially fatal situation whereby immediate or delayed penetrating injury to the aorta could have caused exsanguination.
EJVES Extra, 2003
1 Bongard F, Dubrow T, Klein SR. Vascular injuries in the urban battleground: experience at a metropolitan trauma center. Ann Vasc Surg 1990; 4: 415 –418. 2 Kemmerer WT, Eckert WG, Gathright JB. Patterns of thoracic injuries in fatal traffic accidents. J Trauma 1961; 1: 595–599. 3 Mattox KL. Thoracic vascular trauma. J Vasc Surg 1988; 7: 725 –729. 4 DelRossi AJ, Cernaianu AC, Madden LD, Cilley JH, Spence RK, Alexander JB, Ross SE, Camishion RC. Traumatic disruptions of the thoracic aorta: treatment and outcome. Surgery 1990; 108: 864–870. 5 Mareo JV, Gregory JS. Posterior fracture of the sixth rib causing late aortic laceration: case report. J Trauma 1997; 42: 736– 737. 6 Kern JA, Chan BB, Kron IL, Young JS. Successful treatment of exsanguinating injury from a fractured rib. Am Surg 1998; 64: 1158–1160. Accepted 20 November 2003