Chest Injury - Hockey

Abstract

HISTORY: A healthy 43 year-old male is cross checked in the back while playing in recreational hockey, causing immediate pain to his back and left posterior ribs. He is unable to continue playing. During the night, he notices swelling of his neck and face. The following day, the swelling has decreased, but he continues to complain of severe back and rib pain. He also notices a change in his voice. He denies shortness of breath or abdominal pain. He drives himself to the local community Emergency Department. PHYSICAL EXAMINATION: Patient is alert and oriented with all vital signs within normal limits and oxygen saturation of 99% on room air. He grades his pain at 8 of 10. Head is atraumatic and neck has subcutaneous emphysema. Left lateral ribs are tender at approximately #6, 7 and 8. Lungs are clear and equal bilaterally, but patient is splinting. Abdomen is soft and non-tender with no hepato-splenomegaly or tenderness. Patient has subcutaneous emphysema in neck, face, left shoulder and left chest. The remainder of exam is unremarkable. DIFFERENTIAL DIAGNOSIS: Pneumothorax, Pneumomediastinum, Tracheo-bronchial disruption, Rib fractures, Pulmonary contusion, Splenic injury TEST AND RESULTS: Chest X-ray: pneumomediastinum and subcutaneous emphysema. Soft Tissue Neck X-ray: subcutaneous emphysema. Chest, Abdomen, Pelvis CT scan: Pneumomediastinum, Pneumothorax, Fracture of rib # 6, no aortic dissection or hematoma, no pleural effusion, no pericardial effusion, no solid organ injury. Esophagram: no perforation FINAL WORKING DIAGNOSIS: Pneumothorax, Pneumomediastinum, Fracture rib, Subcutaneous emphysema TREATMENT AND OUTCOMES: 1. Chest tube to decompress pneumothorax 2. Admitted to Trauma service 3. Chest tube removed day 3, patient discharged from hospital day 4 4. Follow up chest x-ray on day 24 and 52 show fully expanded lung 5. Permitted to return to hockey day 52