Ann Thorac Surg 2002;73:1950-1951
© 2002 The Society of Thoracic Surgeons
Case report
Seat belt-related chondrosternal disruption with lung herniation
David Rice, MB, BCha*,
Naveen Bikkasani, MDc,
Raphael Espada, M.D.a,
Kenneth Mattox, MDa,b,
Matthew Wall, MDa,b
a Divisions of Cardiothoracic Surgery, Houston, Texas USA
b Trauma and Critical Care Service, Houston, Texas USA
c Department of Radiology, Ben Taub General Hospital and Baylor College of Medicine, Houston, Texas USA
Accepted for publication November 6, 2001.
* Address reprint requests to Dr Rice, Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 445, Houston, TX 77030-4009 USA
e-mail: drice{at}mdanderson.org
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Abstract
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A case of blunt chest trauma resulting in anterior chondrosternal separation with right lung herniation and hemothorax is presented. The injury is related to the use of a seat belt restraint. The patient underwent surgical repair with polytetrafluoroethylene chest wall reconstruction. Postoperative recovery was complicated by respiratory insufficiency due to underlying pulmonary contusion and multiple rib fractures.
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Introduction
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Seat belt–related injuries have been well characterized and predominately involve the intraabdominal organs. Significant injury to the chest wall, cervical vasculature, and intrathoracic structures is infrequent, however. We report a case of severe chest wall injury with resulting lung herniation after a motor vehicle accident in which the driver was restrained.
A 54-year-old 270-lb male was a restrained driver in a rollover motor vehicle accident at highway speeds. Emergency room evaluation revealed that he was hemodynamically stable and had no evidence of neurological injury but was in respiratory distress. A linear superficial skin abrasion extended diagonally from the left clavicle across his right chest. Breath sounds were diminished on the right side. His right pectoral region was tender, fluctuant to palpation, and slightly depressed. Because of increasingly labored breathing, he underwent endotracheal intubation. Chest roentgenogram revealed both lungs expanded with an area of hyperlucency in the right medial basal zone. Chest computed tomography (CT) showed the presence of multiple right-sided rib fractures, a right hemothorax, and a large herniation of the right lung through the anterior chest wall at the right parasternal region (Fig 1). Head and abdominal CT and arch aortography were negative. He subsequently underwent operative intervention.
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Fig 1. Computed tomography of chest showing right lung herniation, right rib fracture, and right hemothorax.
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At surgery, a midline skin incision was made and was extended in a right inframammary direction. The right pectoralis major muscle was elevated from the chest wall and the underlying defect and hernia cavity were exposed. The herniation occurred through the pectoralis major muscle with a defect in the fascia and extended in a cephalad manner into the subcutaneous tissues. There was fracture of the second through the sixth costal cartilages, the majority occurring at the chondrosternal junctions with resultant chondrosternal separation. The fifth and sixth costal cartilages had multiple fractures. In addition, there were fractures of ribs 3 through 7 along the anterior axillary line. Remarkably, the right internal mammary artery was intact. The herniated lung appeared normal and was easily reduced back into the chest cavity. After thorough exploration of the right chest and evacuation of a 500-mL hemothorax, the defect was repaired by securing a polytetrafluoroethylene mesh between the ends of the ribs, laterally and the right sternal border, medially. This was accomplished by drilling holes in the lateral border of the sternum using a high-speed pneumatic drill and passing interrupted sutures of no. 1 polypropylene through the holes into the mesh. The fractured ends of the costal cartilages were reapproximated over the mesh using no. 1 braided polyester suture to facilitate their healing.
Postoperatively, the patient required prolonged ventilatory support. His chest roentgenograms showed worsening of his pulmonary contusion and his course was complicated by development of a staphylococcal pneumonia. Ultimately, he was extubated after 18 days. He has continued to do well and has no functional limitations.
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Comment
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Traumatic lung herniation is rare and there are fewer than 300 cases reported in the literature. Herniation may be the result of either penetrating or blunt injury to the chest wall. In cases of blunt trauma, herniation typically occurs in the parasternal region, perhaps related to the fact that the external intercostal muscles are absent in this area. Widespread usage of three-point safety restraint systems in automobiles has lead to recognition of a spectrum of seat belt–related injuries. Although these typically involve injury to the intraabdominal organs from the lap belt, shoulder harnesses have been implicated in chest injury, most commonly sternal fracture [1]. There have been at least four other reports documenting severe chest wall injury with lung herniation in restrained drivers [2–5]. In three of these, as in our report, the victim was obese. It has been postulated that the shoulder harness provides relatively greater stabilization of the left chest while allowing a shearing force to be applied across the right chest wall at times of sudden deceleration. Whether or not patients of greater mass apply more decelerating force to their chest wall is unknown.
In this case, although a flail chest was obvious, the diagnosis of lung hernia was not arrived at until the patient had undergone chest CT. The findings of chest wall deformity, pain, fluctuance, and crepitance may be equally present in cases of chest wall injury with pneumothorax and subcutaneous emphysema, an occurrence that is significantly more common than lung herniation. Standard antero-posterior chest roentgenograms, although suggestive, are rarely diagnostic, and oblique views are not routinely obtained in most emergency centers. Therefore, chest CT scanning will likely remain the most efficient diagnostic modality for lung herniation. Because the condition is rare and infrequently considered, there have been a number of reports of patients who did not receive CT scans as part of their initial evaluation, where the diagnosis of lung herniation was delayed [4, 6]. Therapeutic decisions must distinguish between spontaneous and congenital lung hernias and those due to trauma. The former are typically asymptomatic and conservative treatment may be advocated [7, 8]. In general, all lung hernias due to penetrating trauma should undergo surgical repair, and it is strongly recommended in cases where there is evisceration of pulmonary parenchyma [9]. Most authors recommend operative intervention for herniation secondary to blunt injury, although small asymptomatic hernias could conceivably be followed with close observation [8]. There is a theoretical risk of incarceration and devitalization [9], although the incidence of this occurrence appears to be extremely rare. The principles of surgical correction are those of any hernia repair, namely, the reduction of the hernia and the buttressing of the defect. Although direct repair of the chest wall defect may be occasionally performed [2, 5], most authors have reported using some sort of intrathoracic prosthetic patch, most commonly polytetrafluoroethylene [3, 4, 6, 10], Vicryl (Ethicon, Somerville, NJ) [8], or polypropylene mesh [11]. There have been two reports of successful hernia repair using video-assisted thoracoscopic techniques [6, 11]. Ultimate outcome after repair of lung hernias depends on the extent of the underlying parenchymal contusion and on the presence of other concomitant injuries. In the case outlined above, the patient had severe respiratory compromise related to pulmonary contusion, multiple rib fractures, and subsequent pneumonia. As in all cases of chest wall injury, rigorous postoperative chest physical therapy and excellent pain control are imperative.
In summary, traumatic lung herniation is a rare injury. The association with seat belt usage is well described, and obesity may possibly be a cofactor. Most injuries will require operative intervention, which usually requires buttressing of the chest wall defect with prosthetic mesh. The extent of parenchymal contusion, chest wall instability, and associated injuries are the major factors influencing recovery.
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References
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Abstract
Introduction
