Torsion of the lung following thoracic trauma; a case report.

Abstract

Numerous cases of thoracic and pulmonary trauma are reported in the literature. Descriptions are to be found of pneumothorax, hemohydrothorax, atelectasis, pulmonary edema, interstitial and alveolar hemorrhage, ruptured alveoli, and ruptured bronchi. The following case is believed to be unique. On April 29, 1952, at 5:55 p.m., a six-year-old white boy was admitted to the Pediatric Ward from the Emergency Room. He had been struck by a vehicle approximately thirty minutes before admission, suffering a compound fracture of the right humerus and possible internal injuries. There were multiple abrasions, and a tire mark was evident over the left lower chest anteriorly. Roentgenograms of the right humerus, chest, and abdomen were immediately obtained. The fracture of the humerus was at the mid point of the shaft, comminuted and compounded. The flat film of the abdomen disclosed no unusual findings. The chest roentgenogram showed irregular clouding of the upper half of the right lung field with a peculiar striation pattern in the mid-portion of the left lung field. This striation extended from the hilus laterally and then swept upward in a curving fashion. Bilateral pneumothorax was present, most pronounced on the left. Several fractured ribs were seen on the left in the mid-portion of the chest (Fig. 1). Speculation as to the cause of the markings in the lung fields suggested a combination of pneumothorax with areas of atelectasis, pulmonary edema, and perhaps some hemorrhage within the lung tissue. The peculiar course of the striations on the left was not adequately explained. The child was taken to the operating suite after shock was controlled and 200 c.c. of blood given. The wound of the humerus was cleaned, and immobilization was effected. The patient returned from surgery at 11:30 p.m. with an endotracheal tube in place. Reddish colored froth came from the tracheal tube and respiration became irregular and labored. Death occurred at 12:40 a.m., some six hours and forty minutes after admission. At autopsy the external physical findings were again noted. On section the abdomen was found to be normal except for retroperitoneal hemorrhage in the splenic area. The thoracic cavity showed the left lung to be rotated anteriorly, with its base assuming a superior position and the apex in the inferior position. The cavity contained 500 c.c. of frank blood. Interstitial hemorrhage was present. There was also a small amount of bloody fluid in the right pleural cavity. The heart was normal. Microscopic examination showed interstitial and alveolar hemorrhage. Final Diagnosis: Automobile traumatism; torsion and inversion of the left lung; acute massive pulmonary infarction on the left, with hemothorax; pulmonary atelectasis and congestion on the right with interstitial pulmonary hemorrhage; perisplenic retroperitoneal hemorrhage; compound fracture of the right humerus; fracture of the fourth and fifth left ribs; multiple superficial abrasions, contusions, and lacerations; acute internal hemorrhage of the adrenals.