In 1954, Stratemeier and Barry (1) reported what appears to be the first case of torsion of the lung following trauma recorded in medical literature. Their patient, a six-year-old boy who was struck by a vehicle, had a tire mark on the lower left chest. X-ray examination showed a curved, striated pattern extending from the left hilus upward to the left apex, with a partial pneumothorax bilaterally. Death occurred six hours after admission. At autopsy, the left lung was found to be rotated anteriorly, with its base assuming a superior position and its apex in an inferior position. The inversion was 180° about a transverse (coronal) axis through the left hilus. The curved, striated pattern represented the inverted vascular trunks supplying the lower lobe, then in the apex of the left thoracic cavity. The torsion was believed to have been brought about by the sudden compression of the left lower chest by the weight of the vehicle, causing displacement of the lower lobe cephalad. The sudden release of the pressure allowed the expanded upper lobe to move more caudad and occupy the space normally filled by the lower lobe. Recently, we observed a case of torsion of the lung which was strikingly similar to that of Stratemeier and Barry. On March 24, 1955, a seven-year-old white girl fell from a moving vehicle and a front wheel passed over the lower chest anteriorly. Examination, on admission to the emergency room of the Jackson Memorial Hospital, revealed a 2-inch laceration of the extensor surface of the left arm, fractures of the fourth to ninth left ribs, and a fracture of the left femur. The initial roentgenogram of the chest is shown in Figure 1. The physical findings suggested intra-abdominal bleeding, and an exploratory laparotomy was done twelve hours after admission. An extracapsular rupture of the spleen and retroperitoneal hemorrhage were found, and splenectomy was performed. Roentgenograms made on the second and third hospital days disclosed homogeneous clouding of the left chest, which was assumed to represent a massive hemothorax. Attempts at thoracentesis, however, were unsuccessful. Because of the patient's critical condition, management was by supportive therapy during the next six weeks. There was slow improvement during this period, but a low-grade fever persisted. Films continued to show a homogeneous density of the left chest. On May 4, a left thoracotomy was performed for decortication of the presumed organized left hemothorax. The surgeon, however, was unable to find a cleavage plane and broke through the visceral pleura. The lung tissue was necrotic and friable, and a pneumonectomy was therefore undertaken. At exposure of the hilus, the lung was seen to have rotated 180° in a clockwise direction, viewed from the lateral to the medial aspect. All structures of the lung root were included in the torsion.
Read full abstract