Ann Thorac Surg 2009;87:301-303. doi:10.1016/j.athoracsur.2008.05.075
© 2009 The Society of Thoracic Surgeons
Case Reports
Late Aortic Injury: A Rare Complication of a Posterior Rib Fracture
Vito D. Bruno, MD*,
Timothy J.P. Batchelor, FRCS(CTh)
Department of Thoracic Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
Accepted for publication May 27, 2008.
* Address correspondence to Dr Bruno, Department of Thoracic Surgery, Bristol Royal Infirmary, Upper Maudlin St, Bristol, BS2 8HW, United Kingdom (Email: vitodomenicobruno{at}gmail.com).
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Abstract
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Traumatic rib fractures are common and are often associated with a hemothorax or pneumothorax. Rib fractures can also be a marker of severe trauma, and aortic transection is a well-described cause of death, particularly after a deceleration injury. However, direct aortic laceration by a fractured rib segment is extremely rare. We describe the late presentation of such a case and discuss the possible mechanism of injury.
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Introduction
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Traumatic injury of the aorta is a life-threatening condition in which survival depends on early diagnosis and treatment. In those patients with blunt trauma and an associated aortic transection, only 15% survive to hospital. An overwhelming majority would die without surgical intervention [1]. Blunt aortic transection is the most common mechanism of traumatic injury. Direct damage to the aorta by fractured ribs has only been reported on two other occasions [2, 3]. We describe the case of an aortic laceration sustained as a result of a direct puncture by a sharp rib end 6 days after a low impact nonpenetrating left-sided chest injury.
An 87-year-old man was admitted to the emergency department. He had slipped at home and fallen down some stairs, injuring his left chest. Past medical history included a permanent pacemaker for sick sinus syndrome and chronic renal impairment. An initial chest roentgenogram demonstrated a fractured left eighth rib, but no associated pneumothorax or hemothorax (Fig 1). The patient was discharged home the same day with simple analgesia by the emergency room physicians. Four days later, after a new episode of sudden chest pain and shortness of breath, he was readmitted to the hospital. A second chest roentgenogram now revealed a left pleural effusion (Fig 2). An intercostal chest drain was inserted and 700 mL of sanguineous fluid was drained. As the patient's hemodynamic measurements were stable and he appeared well with no further chest drainage, he was transferred to the thoracic surgical unit for monitoring and chest drain management. Two days later, and 6 days after the initial trauma, there was sudden profuse bleeding from the chest drain. This was associated with hypoxia, hypotension, and a profound metabolic acidosis (pH, 6.9). His physiological measurements responded transiently to aggressive fluid resuscitation, and as a consequence he was immediately taken to the operating room. A left posterolateral thoracotomy was performed, and a large amount of fresh and clotted blood (about 2.5 L) was evacuated. The source of the bleeding was a 3-mm puncture site in the descending thoracic aorta. Although the eighth and ninth ribs were fractured, it was the sharp end of a fragment of the eighth rib that seemed to be the cause of the aortic injury. This rib was fractured in several places posteriorly. One fragment was angulated perpendicular to its original position with the sharp end in close proximity to the descending aorta. There was no evidence of aortic dissection or intramural hematoma, and so the puncture site was repaired by direct suture. The responsible rib fragment was excised and a lung laceration was repaired by direct suture. The patient was transferred to the intensive care unit and made a remarkable recovery. He was discharged home without complication after 8 days. At follow-up, in the clinic 2 months later, the patient was well with no complications from either the rib fractures or the thoracotomy.
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Fig 1. Chest roentgenogram after the patient's original admission. There is a fracture of the left eighth rib posteriorly, but no obvious hemothorax.
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Comment
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Thoracic trauma is present in 10% to 15% of all trauma cases and is responsible for approximately 25% of trauma-related deaths [4]. Rib fractures represent the most frequent chest injury [5] with an incidence reported to range between 7% and 40% [4]. However, the true incidence is not known, as up to half of these fractures are missed on standard chest roentgenograms [6]. The elderly are particularly susceptible to complications, and a larger number of rib fractures is associated with a higher risk [4]. The most frequent mechanical complications are hemothorax or pneumothorax resulting from intercostal vessel damage or lung laceration [7]. Injuries to the liver, kidneys, and spleen are also recognized [7]. Furthermore, rib fractures are a marker of significant solid organ injury [6].
Sharp great vessel injury as a direct consequence of a fractured rib has been described, but its incidence is rare. There is a single report of a sharp rib fragment threatening to lacerate the aorta [8] in addition to two other cases of direct aortic injury [2, 3]. In our patient, a posterior fracture of the left eighth rib resulted in a direct puncture of the descending aorta that did not manifest itself until 6 days after the traumatic event. The mechanism for this delay is not entirely clear. However, it is probable that the aortic injury occurred at the time of the original chest trauma and the aortic puncture site clotted off immediately (only for the clot to dislodge several days later). Physical handling of the patient in the hospital is unlikely to have resulted in movement of the chest wall and subsequent laceration of the aorta.
The eventual diagnosis was only discovered at the time of thoracotomy, 2 days after the patient's second admission. As the patient had remained in stable condition with no signs of active bleeding right up until the point of the sudden bleed, there was no reason to suggest any significant underlying injury. Hemothorax after a simple rib fracture is not uncommon and would normally be investigated with a chest roentgenogram and managed with an intercostal drain. If there had been signs of continued or active bleeding, then further investigation with a computed tomographic scan prior to thoracotomy may have been of benefit in planning surgery. However, once it became clear that there was a bleeding problem in this case, the patient's unstable condition and the presence of obvious massive hemorrhage mandated immediate surgery.
Although first and second rib fractures are more frequently associated with aortic trauma, our case report suggests that a different mechanism of aortic injury can complicate a lower posterior rib fracture, particularly if the rib has been fractured into several displaced fragments.
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References
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- O'Conor CE. Diagnosing traumatic rupture of the thoracic aorta in the emergency department Emerg Med J 2004;21:414-419.[Abstract/Free Full Text]
- Marco JV, Gregory JS. Posterior fracture of the left sixth rib causing late aortic laceration: case report J Trauma 1997;42:736-737.[Medline]
- Kigawa I, Fukuda I, Fuji Y, Yamabuki K. A sharp edge of the fractured ribs caused the aortic injury at body- position change: a case report Nippon Kyobu Geka Gakkai Zasshi 1992;40:1116-1120.[Medline]
- S
rmal M, Türüt H, Topçu S, et al. A comprehensive analysis of traumatic rib fractures: morbidity, mortality and management Eur J Cardiothorac Surg 2003;24:133-138.[Abstract/Free Full Text] - Keel M, Meier C. Chest injuries – what is new? Curr Opin Crit Care 2007;13:674-679.[Medline]
- Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly J Trauma 2000;48:1040-1047.[Medline]
- Collins J. Chest wall trauma J Thorac Imaging 2000;15:112-119.[Medline]
- Sata S, Yoshida J, Nishida T, Ueno Y. Sharp rib fragment threatening to lacerate the aorta in a patient with flail chest Gen Thorac Cardiovasc 2007;55:252-254.
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E. W.K. Peng and P. K. Sarkar
Mechanism of Delayed Aortic Injury in Left-Sided Rib Fractures
Ann. Thorac. Surg.,
November 1, 2009;
88(5):
1726 - 1726.
[Full Text]
[PDF]
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V. D. Bruno and T. J.P. Batchelor
Reply
Ann. Thorac. Surg.,
November 1, 2009;
88(5):
1726 - 1727.
[Full Text]
[PDF]
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Abstract
Introduction
