Posterior Fracture of the Left Sixth Rib Causing Late Aortic Laceration: Case Report

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Traumatic rupture of the aorta is a life-threatening condition in which survival depends on early diagnosis and treatment. [1-3] Most of these injuries are identified in the emergency department soon after arrival to the hospital. [2] Only a single case of delayed aortic injury caused by a fractured eighth rib was noted in the literature. [4] We describe a case in which a posterior fracture of the left sixth rib caused aortic laceration 3 days after the traumatic event.CASE REPORTA 36-year-old man presented to the emergency department with an L-1 burst fracture, multiple rib fractures, facial lacerations, and numerous abrasions as a result of a motorcycle accident (Figure 1). The L-1 burst fracture was repaired with Harrington rods on the second hospital day. He was recovering uneventfully, was evaluated by physical therapy, and was scheduled to be discharged to rehabilitation on the fourth hospital day. On the night of the third hospital day, he developed tachycardia, pallor, diaphoresis, dyspnea, and hypotension with a blood pressure of 70/50 mm Hg. Pulmonary embolism was initially suspected, but a chest x-ray film showed massive left hemothorax (Figure 2 and Figure 3). A 36 French chest tube was placed, which drained 2000 mL of blood. The patient was immediately taken to the operating room for emergency thoracotomy.An aortic laceration was identified directly across from a rib fragment from the sixth rib. The lesion was oozing but not bleeding actively at the time, and there was no evidence of aortic dissection. As the patient was resuscitated with intravenous fluids and blood products, bleeding from the injury was noted. An area of contusion surrounded the central puncture in the aorta. This area actually represented a pseudoaneurysm, which tore during an initial attempt at repair. Finger tamponade was performed and the aorta was cross-clamped. The aorta was then repaired with a pledgeted suture of 4-0 Prolene in a U fashion. Rib fragments from the fifth and sixth ribs were rongeured off and covered with bone wax to prevent further aortic injury. The patient was extubated 12 hours later, discharged to the general ward 24 hours postoperatively, and to rehabilitation on postoperative day 13.DISCUSSIONA review of the literature from 1966 to 1995 found that most cases of traumatic injury to the aorta were caused by blunt deceleration forces such as those typically sustained in motor vehicle crashes. [2,4-6] Much of the literature associates fractures of the first and second ribs with aortic transection, [7,8] but does not implicate those fractures as causative. [1,3,8,9] One study found that the risk of aortic disruption was not higher in patients with fractures of the upper two ribs, compared with patients with fractures of other ribs, or patients with blunt chest trauma without rib fracture. [1]This case suggests that roentgenographic evidence of left posterior rib fracture may help predict a patient at risk of delayed aortic injury. Care should therefore be taken to consider this type of injury in the treatment of blunt chest trauma with left posterior rib fractures.

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