From the Department of Radiology, Long Island Jewish-. Hillside Medical Center, Queens Hospital Center Affiliation,. 82-68 164th Street, Jamaica, New York.
BLUNT TRAUMA TO THE CHEST Earl M. Kabnick, MD, Leon Adler, MD, Todd P. Berner, MD, and Leslie L. Alexander, MD Jamaica, New York
Pulmonary contusions following blunt trauma often are visible roentgenographically immediately after injury. The case presented illustrates the need for prompt x-ray studies of the chest following blunt injury. Because of the frequency of blunt trauma to the chest, the emergency clinician should be prepared to diagnose conditions that either are life-threatening or require specific treatment. The most important resulting clinical entities that must be specifically looked for include rib fractures, pneumothorax, hemothorax, chylothorax, contusions, hematomas, and bronchial fractures. With the exception of local atelectasis resulting from splinting, inspissated mucus, blood clots, or aspiration, parenchymal contusion is the most frequent cause of the post-traumatic pulmonary opacification.1 Pulmonary contusion is characterized by the exudation of edematous fluid and blood into both alveolar and interstitial compartments of the lung. Symptoms and signs can arise in the traumatized side or the opposite side following a contracoup injury, as well as bilaterally in cases with blast
injuries.2 Pulmonary contusions are often visible roentgenographically immediately after injury, and are maximally seen within six hours. The changes noted are manifested in two ways: (1) as patchy, ill-defined, mottled densities, either localized, scattered, or coalesced, representing intra-alveolar
From the Department of Radiology, Long Island JewishHillside Medical Center, Queens Hospital Center Affiliation, 82-68 164th Street, Jamaica, New York. Requests for reprints should be addressed to Dr. Earl M. Kabnick, Department of Radiology, Long Island Jewish-Hillside Medical Center, Queens Hospital Center Affiliation, 82-68 164th Street, Jamaica, NY 11432.
hemorrhage, and (2) as hemorrhage into interlobar septae and peribronchial spaces giving rise to a reticular pattern.2'3
CASE REPORT A 26-year-old black man was admitted to Queens Hospital Center after having been involved in a motor vehicle accident. Physical examination was remarkable for decreased breath sounds in the right lower lung with crepitations at the right base. The patient was noted to have a compound fracture of the left tibia and fibula. The remaining physical examination was unremarkable. Past medical history was noncontributory. At this juncture, multiple radiographs of the chest and left leg and foot were taken. The left foot appeared to be dislocated and a compound fracture of the midshaft of the left tibia and fibula was seen. Examination of the chest revealed an ill-defined, patchy infiltrate in the right lower lung field that was highly suggestive of pulmonary contusion (Figure 1). No rib fractures were seen. Serial chest roentgenograms were taken and the previously noted infiltrate cleared within 48 hours (Figure 2). At this time the lungs were clear to auscultation. The patient was treated with prophylactic antibiotics and orthopedic surgery was performed to correct the fractures. His recovery was unremarkable.
DISCUSSION In a multiple series of major nonpenetrating chest traumas, 75 percent of cases presented with lung contusion and 48 to 66 percent with rib frac-
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LUNG CONTUSION
Figure 2. Roentgenogram of the chest showing clearing of the infiltrate after 48 hours
Figr 1 ongnogram of the chest showing an ill-dfnd acyin fltrate in the right lower lung
field
tures. The incidence of contusion alone was higher than for contusion plus bony thoracic fracture or fracture alone.4 More than one third of patients in a reported study were asymptomatic.2 The diagnosis can be missed even if the patient is mildly symptomatic and has a history of multiple trauma. Pain was not a prominent feature in cases of pulmonary contusion.4 Mild shortness of breath is occasionally seen with more severe contusions.5 No progression of severity of the lesion is seen beyond 48 hours. Resolution begins within the first 48 to 72 hou'rs, and in milder cases total clearing is seen within 24 hours. In more serious cases resolution may be prolonged, but this is unusual .2 Although the pattern of pulmonary contusion on a single chest radiograph cannot be distinguished from bronchopneumonia, a history of recent chest injury and detection of rapid clearing in the absence of specific treatment serve to differ414
entiate the two disorders. Any pulmonary infiltration that begins more than 48 hours after injury, or worsens after that time interval, should not be considered an uncomplicated pulmonary contusion. A superimposed pneumonia or atelectasis should be suspected.2'5 This case illustrates the need for prompt roentgenographic study of the chest following blunt trauma.
Literature Cited 1. Williams JR, Bonte FJ. The Roentgenological Aspect of Non-Penetrating Chest Injuries. Springfield, Ill: Charles C. Thomas, 1961, p 135. 2. Stevens E, Templeton AW. Traumatic non-penetrating lung contusion. Radiology 1965; 85:247-252. 3. Reynolds J, Davis TD. Injuries of the chest wall, pleura, pericardium, lungs, bronchi and esophagus. Radiol Clin North Am 1966; 4(2):383-390. 4. Williams JR, Stembrige VA. Pulmonary contusion secondary to nonpenetrating chest trauma. Roentgenology 1964; 91:284-288. 5. Fraser RG, Pare JAP. Diagnosis of Diseases of the Chest. Philadelphia: WB Saunders, 1979, p 1572.
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