High-speed Motor Vehicle Accident Research Articles

Management of Comminuted Frontal Depressed Fracture Using Split Calvarial Graft: A Novel Technique

AbstractFrontal depressed fracture generally results from high-speed motor vehicle accidents. The frontal fractures can be closed or open depending upon the involvement of the overlying skin. Frontal fracture can be comminuted if the bone is broken in at least two or more places. Because of the proximity of the frontal bone to critical structures like the frontal sinus, frontal dura with underlying brain parenchyma, and orbit with its content, an injury resulting in a frontal depressed fracture can result in a multitude of clinical symptoms. If not addressed promptly with an experienced team, these fractures can result in cerebrospinal fluid leak, osteomyelitis of the frontal bone, meningitis, and ocular and olfactory dysfunction with poor cosmetic outcomes. Thus, repairing the frontal depressed fracture should be considered a priority. The standard practice is to elevate the depressed fracture and repair any dural defect. In case of a comminuted fracture, elevation is not possible, and we generally remove the fracture pieces and repair the defect using titanium mesh. In this case report, we propose a novel technique of repair of the defect using a split calvarial graft, which is fashioned after separating the outer table from the inner table of the posterior frontal bone. This technique reduces the theoretical risk of infection and is cost-effective as our procedure does not require any external implant in cranioplasty.

Isolated traumatic retroclival interdural hematoma causing craniocervical instability: A case report of pathology in a rare location and literature review

Introduction. Retroclival hematomas (RCH) are a rare entity primarily as a post-traumatic phenomenon in the pediatric population. We present a case of Retroclival interdural hematoma in a 12 y/o female with a previous record of craniocervical trauma. A RCH is identified initially by CT and easily overlooked. MRI cervical spine to evaluate the Tectorial membrane and other craniocervical ligaments integrity. Case report. A 12-year-old female presented with bilateral abducens nerve palsies and a Glasgow Coma Score (GCS) of 13 following a high-speed motor vehicle accident. Initial CT brain revealed an infra-tentorial extra-axial focal hyperdense collection (hemorrhage) along the retroclival region in the interdural space measuring approximately 9 × 29 × 58 mm. Subsequent imaging and evaluations suggested cranio-cervical instability, leading to surgical intervention. Conclusions. Prompt diagnosis of RCH with conservative or surgical management is essential to avoid neurological deficits and mortality. Despite the significant potential for morbidity and mortality, the majority of patients show a benign clinical course with conservative care, underscoring the importance of quick diagnosis and close observation.

A 12-year experience in the management of blunt thoracic aortic injury in Otautahi Christchurch.

Blunt thoracic aortic injury (BTAI) is associated with a high mortality and is the second most common cause of death from trauma. The approach to major trauma, imaging technology and advancement in endovascular therapy have revolutionised the management of BTAI. Endovascular therapy has now become the gold standard technique replacing surgery with its high mortality and morbidity in unstable patients. We aim to assess the outcomes following management of BTAI. This is a retrospective study of all patients with BTAI between 1 January 2010 and 1 January 2022. Data were obtained from electronic health records. The grading of BTAI severity was done based on the Society of Vascular Surgery (SVS) Criteria. Fifty patients were included in the study analysis. The most common cause of BTAI was due to high-speed motor vehicle accidents (MVA) (36 patients, 72%). Grade 1 and grade 3 BTAI injuries were mostly encountered in 40% and 30% of the study cohort, respectively. Twenty-three patients (46%) underwent thoracic endovascular aortic repair (TEVAR). There was no secondary aortic re-intervention, conversion to open surgery or aortic-related deaths at 30days or at most recent follow-up. Management of BTAI in our centre compares well with currently published studies. Long-term studies are warranted to guide clinicians in areas of controversy in BTAI management.

Endovascular reconstruction of aortic bifurcation for aortic pseudoaneurysm in a pediatric trauma patient

Endovascular treatment options for vascular injury in pediatric patients are quite limited owing to concerns regarding long-term durability and the lack of devices suitable for the pediatric anatomy. However, in rare circumstances, open surgical therapy will not be an option, and patients will require unconventional endovascular solutions for lifesaving or limb-saving therapies. In the present report, we describe an endovascular treatment of a pediatric patient for whom initial surgical management of a blunt abdominal aortic injury had failed, with subsequent development of an aortic pseudoaneurysm. A 10-year-old girl had presented after a high-speed motor vehicle accident with a seatbelt sign. Multiple abdominal injuries were identified, including blunt aortic injury, significant devitalization of the small bowel, colonic perforation with fecal contamination, multiple lumbar spine fractures, and pulmonary contusions. The patient developed bilateral lower extremity ischemia from the aortic injury and had initially undergone open repair. One month later, the patient had developed a pseudoaneurysm of the aorta near the aortic bifurcation. Because of the hostile abdomen and ensuing short gut syndrome, the pseudoaneurysm was managed using endovascular techniques. The limb of an Excluder internal iliac branch endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ) was used as the endograft. The aortic bifurcation was raised and reconstructed using four Viabahn self-expanding stents (W.L. Gore & Associates). The completion angiogram showed complete resolution of the pseudoaneurysm. The follow-up computed tomography angiogram showed widely patent stent grafts with complete resolution of the pseudoaneurysm. Endovascular management of traumatic vascular injuries in pediatric patients is feasible. The likelihood of reintervention in the future is high with patient growth. However, it is a viable option in lifesaving or limb-saving situations in which open repair is high risk.

Relationship Between Restraint System Use and Brachial Plexus Injuries in Motor Vehicle Accidents: A Case–Control Study from the National Trauma Databank

High-speed motor vehicle accidents (MVAs) are an important cause of brachial plexus injury (BPI). Some case reports have demonstrated shoulder seat belt use resulting in traction injuries to the brachial plexus. We used a national trauma registry to determine the association between seat belt use and brachial plexus injury in MVAs. The authors queried the National Trauma Databank between 2016 and 2017 for patients with a hospital admission following an MVA. Cases with BPI were identified using International Classification of Diseases, Tenth Edition, Clinical Modification, diagnosis codes. Case-control matching by age and sex was performed to identify 2 non-BPI controls for every case of BPI. Multivariable conditional logistic regression adjusting for body mass index, alcohol use, and drug use was then performed to determine the adjusted association between safety equipment use (seat belt use and airbag deployment) and BPI. A total of 526,007 cases of MVAs were identified, of which 704 (0.13%) sustained a BPI. The incidences of BPI in patients were the following without any protective device (0.16%), with airbag deployment alone (0.08%), with seat belt use alone (0.08%), and with combined airbag deployment and seat belt use (0.07%). Following 1:2 case-control matching by age and sex and multivariable conditional logistic regression, seat belt use (odds ratio [OR] 0.55; 95% confidence interval [CI] 0.42-0.71; P < 0.001) and airbag deployment (OR 0.52; 95% CI 0.33-0.82; P= 0.004) were found to be associated with decreased odds for BPI, with the least odds observed with combined seat belt use and airbag deployment (OR 0.49; 95% CI 0.33-0.74; P= 0.001). Despite anecdotal evidence suggesting increased likelihood of BPI with shoulder seat belt use, case-control analysis from a national trauma registry demonstrated that both seat belt use and airbag deployment are associated with lower odds of sustaining BPIs in MVAs, with the greatest protective effect observed with combined use. Future studies adjusting for rider location (passenger vs. driver) and other potential confounders such as make, type and speed of vehicle may help further characterize this association.

Functional outcome of comminuted upper metaphyseal tibial fracture treated with circular external fixators

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; High speed motor vehicle accidents are on the rise over the past few years. These are responsible for most of the complex fractures of the tibial metaphysic. Proper treatment of these fractures is of paramount importance. The use of circular fixators for the definitive treatment of such fractures entails a minimally invasive technique of insertion that gives good fracture reduction and stability combined with minimal postoperative complications.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This study was prospective and conducted over 22 patients diagnosed with upper comminuted metaphyseal tibial fracture treated with circular external fixator.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In this series, all 22 patients (100%) were male. Fourteen cases (64%) involved the left tibia and eight (36%) fractures were on right. The mean patient age was 49.5 years (range 26-75). Road traffic collisions accounted for most of the injuries (n=14), while fall from bike (n=8). In this study, using knee society score evaluation, excellent results (KSS&amp;gt;80) were seen in 8 patients (36.36%), good results (KSS 70-79) were seen in 10 patients (45.45%), fair (KSS 60-69) in 4 patient (18.18%) and poor (KSS&amp;lt; 60) in 0 patient (0%). Complication seen was pin tract infection in 2 patients (9.9%), which was managed by regular pin site dressings. Another complication was non-union in 1 patient (4.54%). No other complication was encountered.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Circular external fixation is a promising modality for surgical treatment of comminuted upper metaphyseal tibial fractures. It allows satisfactory realignment of the fractured fragments and their stabilization, besides early mobilization of the joints and care of associated soft tissue injuries, without significant complications.&lt;/p&gt;

A Not Quite Right Ventricle

A 19-year-old man was brought to hospital following a high-speed motor vehicle accident without syncope. A trauma CT pan-scan was performed which revealed a hepatic contusion as well as the unexpected finding of marked right ventricular dilatation with a filling defect in the RV apex with associated non-occlusive segmental pulmonary emboli. ECG showed dominant R waves with T wave inversion in V1-V3.

AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome.

AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome.

Association Between Frailty Status and Odontoid Fractures After Traumatic Falls: Investigation of Varying Injury Mechanisms Among 70 Elderly Odontoid Fracture Patients.

To determine significant associations between patient frailty status and odontoid fractures across common traumatic mechanisms of injuries (MOIs) in the elderly. Retrospective review. Single, academic-affiliated hospital with full surgical services. Patients 65 years or older with traumatic odontoid fractures were included. Nonoperative management (soft/hard collar, halo, traction tongs, and Minerva) and/or operative fixation. Modified frailty index (mFI), MOI, concurrent injuries, inpatient length of stay (LOS), reoperation, and mortality rates. Seventy patients were included (80.6 ± 8.5 years, 60% F, 88% European, 10% Maori/Pacific, 1.4% Asian, Charlson Comorbidity Index 5.3 ± 2.2, mFI 0.21 ± 0.15). The most common MOIs were falls (74.3%), high-speed motor vehicle accidents (MVAs) (17.1%), low-speed MVAs (5.7%), and pedestrian versus car (2.9%). Patients with traumatic falls exhibited significantly higher mFI scores (0.25) compared with low-speed MVAs (0.16), high-speed MVAs (0.08), and pedestrian versus car (0.01) (P = 0.003). Twenty-seven patients with odontoid fractures were frail, 33 were prefrail, and 10 were robust. Ninety-two percent of frail patients had a traumatic fall as their MOI, as opposed to 73% of prefrail and 30% of robust patients (P < 0.001). Prefrail and frail patients were 4.3 times more likely than robust patients to present with odontoid fractures through traumatic fall [odds ratio (OR): 4.33 (1.47-12.75), P = 0.008], and frailty increased likelihood of reoperation [OR: 4.2 (1.2-14.75), P = 0.025] and extended LOS [OR: 5.71 (1.05-10.37), P = 0.017]. Frail patients had the highest 30-day (P = 0.017) and 1-year mortality (P < 0.001) compared with other groups. Patients with traumatic odontoid fractures from falls were significantly more frail in comparison with any other MOIs, with worse short- and long-term outcomes. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cervical cord transection secondary to C2-C3 dissociation

A 14-year-old previously healthy female was brought to the emergency department (ED) after being involved in a high speed motor vehicle accident. After resuscitation, a computed tomography (CT) scan brain revealed multifocal intraventricular and subarachnoid hemorrhage (Figure 1). CT scan of the cervical spine showed a traumatic spondylolisthesis at C2/C3 with posterior displacement of C3 vertebral body indicating a probable spinal cord injury at the C2/C3 level (Figure 2). MRI scan of the cervical spine showed a severe cervical central spinal canal stenosis with cord displacement and compression reflecting a combination of contusion and myelopathy (Figure 3). The patient was diagnosed with cervical cord transection due to C2- C3 dissociation. She underwent posterior arthrodesis extending from the occiput C1 to C1-2, C2-3, C4-5, C5-C6; using of an occipital place, lateral mass screws fixation under live fluoroscopy (Figure 4). Because of a surgical wound CSF leak, a lumbar drain was placed for one week. After two month as an inpatient, the patient was only able to move her facial muscles and had suffered from stage 2 bed ulcers. She was medically and hemodynamically stable, and was discharged to a traumatic brain injury facility.

Traumatic intrapericardial diaphragmatic hernia

This article describes the case of a 33-year-old male who sustained blunt trauma to his torso in a high-speed motor vehicle accident. He presented to the emergency room with abdominal pain, chest pain, dyspnea, distended neck veins, and shock. There was no history of pretraumatic chest symptoms or congenital abnormalities. Computed tomography (CT) of the chest showed bowel loops extending into the pericardium through a large rent in the diaphragm. A diagnosis of traumatic intrapericardial diaphragmatic hernia (TIPDH) was made. Hence, the patient was transferred to the theater where surgical mesh repair was done through an open laparotomy. TIPDHs are rare, forming about 0.9% of traumatic diaphragmatic hernias with only 96 cases reported in worldwide literature as at 2014. However, they are potentially life-threatening and require a high index of suspicion to diagnose. They often result from blunt abdominal trauma. Symptoms include chest pain, abdominal pain, and dyspnea, with or without features of cardiac tamponade or bowel obstruction. CT scan is the best diagnostic tool. Primary repair through open laparotomy is recommended in acute cases, with mesh reinforcement for large diaphragmatic tears to ensure the repair is tension-free.

Endovascular Salvage for Traumatic Midthoracic Aortic Rupture with Left Diaphragmatic Injury

Patients with traumatic aortic rupture rarely reach the hospital alive. Even among those who arrive at the hospital alive, traumatic aortic rupture after high-speed motor vehicle accidents leads to a high in-hospital mortality rate and is associated with other major injuries. Here, we report a rare case of descending midthoracic aortic rupture with blunt diaphragmatic rupture. Successful management with emergency laparotomy after an immediate endovascular procedure resulted in a favorable prognosis in this case.

A prospective study of locking plate fixation in tibial plateau fractures

Introduction: Originally described as the fender fracture tibial plateau fractures resulted primarily from low-energy pedestrian versus car bumper accidents. The majority of tibial plateau fractures reported in the recent literature have resulted from high-speed motor vehicle accidents and falls from a height. Injuries to the tibial plateau occur as a result of a force directed either medially (valgus deformity, the classic “bumper fracture”) or laterally (varus deformity), an axial compressive force or both an axial force and a force from the side. Locking Compression plates have become and imminent tool in the management of these complex fractures. Aim: The aim of the study is to analyze prospectively by clinical, radiological and functional methods the results of open/closed reduction and internal fixation of closed tibial plateau fractures treated by Locking Compression Plates. Method: This is a prospective study conducted in Chengalpattu Medical College and Hospital, Chengalpattu. Twenty patients who satisfied the following criteria were included in our study. Depending on the type of fracture and severity of soft tissue injury all the patients were stabilized initially and closed or open reduction of the fracture done and fracture stabilized with locking compression plate. Discussion and Conclusion: The results were analyzed both clinically and radiologically using the Knee scoring system by Hospital for Special Surgery. Results based on Knee Scoring System, Hospital for Special Surgery (HSS) we had excellent result in 10 cases, good result in 7 cases, fair result in 3 cases and we had no poor result. From our study, we conclude that, Open/closed reduction and internal fixation of closed tibial plateau fractures with locking compression plate is an effective method of treatment provided there is no extensive soft tissue injury. Locking compression plate provides good angular stability with its triangular reconstruction principle.

Isolated unilateral adrenal gland hemorrhage following motor vehicle collision: a case report and review of the literature

BackgroundAdrenal gland trauma is a rare condition that typically stems from blunt force trauma, and is associated with multiple organ injuries. Alternatively, isolated adrenal gland trauma is extremely rare, accounting for only 1.5 to 4% of all adrenal trauma cases. While isolated adrenal trauma is a mostly self-limiting condition, it is potentially life-threatening, representing a significant cause of bleeding, and/or hypotension due to adrenal insufficiency and adrenal crisis. Due to its rare occurrence, there are no reported guidelines for monitoring and observing isolated adrenal trauma.Case presentationHere we report on an isolated adrenal hemorrhage from a blunt trauma without associated injuries. A 53-year-old white man presented with abdominal pain after a high-speed motor vehicle accident. An initial evaluation revealed minimal abdominal pain and negative focused assessment with sonography for trauma examination; computed tomography imaging revealed a significant fluid collection consistent with adrenal hemorrhage. He was observed in our intensive care unit for 24 hours, and had stable hemoglobin and vital signs, after which he was discharged. At 1-month follow-up, he reported persistent intermittent abdominal pain, which was completely resolved by the 4-month follow-up.ConclusionsThis case report demonstrates isolated adrenal gland injury resulting from significant blunt trauma to the abdomen. There are no current guidelines for monitoring isolated adrenal hemorrhage. Recognizing possible adrenal injury in blunt trauma cases is important due to potentially severe adrenal hemorrhage; therefore, we recommend follow-up with serial abdominal computed tomography until the resolution of hemorrhage and symptoms.

Purely Ligamentous Flexion-Distraction Injury in a Five-Year-Old Child Treated with Surgical Management&#x0D;

Chance fractures by definition are a type of flexion-distraction injury with concomitant vertebral body fracture. Although uncommon in the pediatric population, they are associated with motor vehicle accidents and typically involve the thoraco-lumbar spine. Injury occurs when the spine rotates about a fixed axis, such as a lap belt. Our case reports the management of a five-year-old girl involved in a head-on collision who suffered a purely ligamentous flexion-distraction injury (Chance-type injury, without bone involvement) at the L2-L3 vertebral level. Previously these injuries were managed conservatively with serial casting; however, we present a case in which surgical management was used. A five-year-old girl sustained multiple injuries after being involved in a high-speed motor vehicle accident. At presentation, there was obvious abdominal bruising with a seat-belt sign and marked kyphosis of the spine with severe tenderness at the L2-L3 level. She required immediate exploratory laparotomy for her intraabdominal injuries. After stabilization, an orthopedic consult was deemed necessary. She was found to have occipital-cervical injury with mild anterolisthesis of C2 on C3 and disruption of the apical ligament. There was evidence of bilateral dislocation of the L2-L3 facet joints with marked disruption of the posterior ligaments and a hematoma sack. She required open reduction and internal fixation with an L2-L3 laminectomy, pedicle screw and rod placement. The kyphotic deformity was reduced using a compression device and stable alignment was achieved intraoperatively.This was a rare and difficult case with limited evidence on the appropriate management of such an injury. Due to the severe instability of her injury, a surgical approach was taken. At two years postoperative, the patient is neurologically intact and pain free. Imaging revealed stable alignment of her lumbar hardware. Ultimately, this has resulted in an excellent outcome at the current follow-up.

Isolated Bronchial Injury: A Diagnostic and Management Challenge

Injuries to the trachea or major bronchi in high-speed motor vehicle accidents are mostly accompanied by fatal pulmonary contusion, vascular injury, abdominal injury, head injury, spine injury, and orthopaedic injury. Isolated major bronchial injury without any other major organ or vascular injury in blunt chest trauma is a rare entity. In most of these cases, the trauma may be trivial but sudden compression of chest leads to isolated tracheo-bronchial disruption. The diagnosis and management approach depends upon the existence and severity of other injuries. Cause of concern in a missed or delayed diagnosis is high mortality due to tension pneumothorax and significant morbidity due to progressive respiratory failure because of continuous major air leaks and/or debilitating chronic complications (persistent pneumothorax, atelectasis, fibrosis, pneumonitis, and empyema). Prompt diagnosis, skilful airway management along with early surgical intervention can greatly reduce the morbidity and mortality. The present retrospective study is over a period of eleven years (2004-2015). The demographic data including the aetiology, clinical features, radiological, bronchoscopic and operative findings were compiled from the records. A total of five cases, all males were diagnosed with major bronchial injuries. One case was diagnosed within 8 h, one was diagnosed after 48 h and in these cases primary repair was done. In three cases, diagnosis was made after 3 weeks and delayed repair was done. The average hospital stay was 21 days and follow up was 6 months. The clinical presentation and outcome stress the key role of early diagnosis and timely surgical intervention.

Floating Lateral Mass Fractures of the Cervical Spine.

Level I trauma center case series. The purpose of this study was (i) to characterize the floating lateral mass (FLM) fracture with the mechanism of injury, anatomical injury pattern, associated vascular injuries, neurological deficits, and key radiographic features; and (ii) to better understand the most effective method of treatment. An uncommon and poorly described subset of unilateral lateral mass fractures is FLM with fractures of the adjacent pedicle and lamina. Prospectively collected trauma registries were assessed to identify all patients with FLM fractures involving C3 to C7 between January 1, 2007 and December 31, 2012. After institutional review board approval, 60 consecutive cases were identified from the trauma registries. The mean follow-up was 9 months (range 0-42 months). The most common level was C6. The most common mechanism of injury was a high speed motor vehicle accident (45%). Radiographic rotational displacement manifested as an anterolisthesis. CT showed facet joint widening at the level above and below in 63%. Vertebral artery injuries occurred in 22%. Neurological deficits occurred as radiculopathy in 38% and spinal cord injury in 18%. All eight patients, who were treated nonoperatively, developed subluxation despite external immobilization and six patients required surgery. Of the 58 patients treated operatively, 31 (53%) patients underwent a 2 level Anterior Cervical Discectomy and Fusion (ACDF) alone. Nine (15%) patients had one level ACDF, with 83% demonstrating radiographic failure. Posterior fusion alone or combined with ACDF/corpectomy was performed in 6 patients (10%) and 7 patients (12%), respectively. A FLM fracture results from a high energy injury and involves two motion segments. Vertebral artery injuries and neurological deficits frequently occur. Magnetic Resonance demonstrates a significant disc injury in 81% of patients, usually at the lower level. Two level ACDF or Posterior Spinal Instrumented Fusion are effective means of treatment. 3.

Aortic valve rupture after blunt chest trauma presenting at a District General Hospital

Traumatic aortic regurgitation is a rare complication of blunt chest wall injury. Cardiovascular decompensation can occur rapidly as the heart struggles to maintain cardiac output. As the condition is often not apparent at the time of injury, these patients may be brought by ambulance to trauma units without cardiothoracic facilities under the care of general and orthopaedic surgeons. Here, we report a case of traumatic aortic regurgitation secondary to a high-speed motor vehicle accident and the management in a district general trauma unit leading to transfer to a cardiothoracic centre. The diagnosis of traumatic aortic regurgitation should be considered in patients who experience blunt chest wall injuries and demonstrate signs of cardiac decompensation.

Traumatic atlantooccipital dissociation

A 38-year-old woman presented to our clinic after a highspeed motor vehicle accident. Extrication at the scene was prolonged, and she sustained an incomplete spinal cord injury characterized by right-sided hemiparesis. Imaging revealed atlantooccipital dissociation with bilateral non-displaced C1 lateral mass fractures without C1 arch involvement and a basion-dental interval of 13 mm (Fig. 1A and B). The occipital condyle-C1 interval was determined bilaterally and the condylar sum was found to be 10 mm (Fig. 1G and H). The Powers ratio was determined to be 1.1 (Fig. 1C). Magnetic resonance imaging demonstrated complete tearing of the tectorial membrane (Fig. 1D) and left alar ligament (Fig. 1E), as well as partial tear of the right alar ligament (Fig. 1F). The patient then underwent occiput to C2 fixation (Fig. 2). Three months postoperatively, she was able to move her left upper and lower extremity, with increased strength.

Traumatic right diaphragmatic rupture with hepatothorax: a diagnostic challenge!

Traumatic injuries of the diaphragm remain an entity of difficult diagnosis especially when it comes to the right diaphragm. It is a recognized consequence of high velocity blunt trauma to the abdomen, usually as a result of road traffic collisions or lateral intrusions into the vehicle and occasionally, penetrating thoraco-abdominal trauma. It has been reported that the rate of initial missed diagnosis of traumatic diaphragmatic injury ranges from 12% to 63% on CT (1). A missed diagnosis is associated with a mortality of 30% to 60% due to late presentation of intrathoracic visceral herniation and strangulation (2,3). After a high speed motor vehicle accident, a 30-year-old Saudi male was received in the trauma room. He was confused, hypotensive and in respiratory distress. The initial diagnostic workup included chest X-ray and full body non-contrast spiral CT scan, revealing fracture of the nasal bone and right hemothorax. No other radiological findings were detected in the initial assessment. Due to an assumed massive rightsided hemothorax ( Figure 1 ), a thoracic tube was inserted and 750 mL of blood coming in the chest drain. After initial stabilization the patient was then transferred to the surgical unit of Sabya General Hospital, Saudi Arabia.