Ann Thorac Surg 2009;88:1726-1727. doi:10.1016/j.athoracsur.2009.06.112
© 2009 The Society of Thoracic Surgeons
Correspondence
Reply
Vito Domenico Bruno, MD,
Timothy J.P. Batchelor, FRCS(CTh)
Department of Cardiothoracic Surgery, Bristol Royal Infirmary, Upper Maudlin St, Bristol, BS2 8HW United Kingdom
(Email: vitodomenicobruno{at}gmail.com).
To the Editor:
We would like to thank Peng and Sarkar [1] for their letter regarding our case report of a late aortic injury after a left-sided posterior rib fracture [2]. They have previously reported their experience of 2 patients who suffered delayed penetrating intra-thoracic injury after multiple rib fractures [3]. In both cases a relationship between the physical handling of the patient and a subsequent sudden bleed was noticed. Sharp, angulated left-sided posterior rib fractures were responsible for the late injuries (1 patient sustained an aortic injury; 1 patient sustained a diaphragmatic injury). We apologize for not picking up their report during our literature search.
The underlying mechanism of a delayed aortic injury after a left-sided posterior rib fracture is not easy to demonstrate. The descending aorta is clearly at risk in these patients due to its anatomical location. We considered excessive manual handling as a potential mechanism in our patient, but there did not appear to be any clear precipitating event [2]. Our only other explanation was that the injury occurred at the time of the initial trauma or several days later when the patient represented with a small pleural collection, only with the clot to become dislodged during the period of inpatient monitoring. Demonstrating this event is clearly not possible. However, we can not escape the fact that dislodgement and angulation of the rib remains the underlying cause. For this reason, a degree of caution is recommended when monitoring and mobilizing these patients. Indeed, there is a single report of a sharp rib fragment threatening to lacerate the aorta (as visualized on a computed tomographic scan), and this prompted prophylactic surgical intervention [4]. We agree with Peng and Sarkar [1] that with a rapid assessment and diagnosis and with prompt surgical treatment this complication can have a very good outcome.
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References
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- Peng EWK, Sarkar PK. Mechanism of delayed aortic injury in left-sided rib fractures (letter) Ann Thorac Surg 2009;88:1726.[Free Full Text]
- Bruno VD, Batchelor TJ. Late aortic injury: a rare complication of a posterior rib fracture Ann Thorac Surg 2009;87:301-303.[Abstract/Free Full Text]
- Ashrafian H, Kumar P, Sarkar PK, DeSouza A. Delayed penetrating intrathoracic injury from multiple rib fractures J Trauma 2005;58:858-859.[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 Surg 2007;55:252-254.[Medline]
Related Article
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Mechanism of Delayed Aortic Injury in Left-Sided Rib Fractures
- Edward W.K. Peng and Pradip K. Sarkar
Ann. Thorac. Surg. 2009 88: 1726.
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