In this article, we will discuss rib fractures and lung herniation.
When we hear the word "herniation," we tend to think of the lumbar discs, but herniations can occur in other parts of the human body as well.
In this case, the herniation of the lung was caused by coughing after a rib fracture.
It is important to know that there are cases like this when dealing with rib fractures in the future.
Case Report
A 65-year-old man.
The patient was transported by ambulance because he heard a popping sound after coughing and suddenly developed abdominal pain on the left side.
There were no findings of trauma.
The man is an active smoker, and his past medical history includes congestive heart failure, hypertension, coronary artery disease, diabetes mellitus, chronic pain secondary to lumbar disc disease requiring multiple epidural injections, and multiple orthopedic surgeries including knee replacement and rotational cuff repair.
However, there is no history of any need for surgical procedures on the chest wall.
The medications the man was taking on a daily basis included hydrochlorothiazide, lisinopril, metoprolol, metformin, aspirin, clopidogrel, and diclofenac.
Examination was negative for tenderness or deformity of the left side abdomen.
EKG and chest x-ray were negative for acute lesions.
He went home with a diagnosis of pain due to muscle spasm and was prescribed painkillers.
A few days later, he went back to see the doctor because his symptoms had not resolved.
On this examination, he was found to have a large hematoma below his left gluteal muscle and on his left flank.
There was no fullness, tenderness, or twisting sound on palpation.
Examination of the chest by CT revealed a left-sided chest wall defect between the eighth and ninth ribs with herniation of the lung tissue and a 5 cm x 3 cm hematoma, so the fracture was not evident from opacities.As there was no evidence of vascular injury to the lung tissue, the man was recommended to be managed by conservative treatment with analgesics.
One month later, he again showed uncontrollable chest pain and shortness of breath.Chest radiographs showed a herniation of the lung tissue with enlargement of the eighth intercostal space.CT chest revealed progressive pulmonary herniation associated with atelectasis of the left lower lobe and acute displaced fractures of the left eighth and ninth ribs.
No surgical treatment was offered due to the most recent tests performed and the risks associated with the patient's medical and surgical history.
The man was discharged on opioid analgesic medication.
During a follow-up visit, he complained that he still had pain in his lower left chest despite taking high doses of analgesics.
We also tried an intercostal nerve block, but it did not seem to work in his case.
He seems to have breathing problems, which I don't know if it is secondary to chronic heart failure or "herniated lung fracture".
Adil S. Wani, Prachi Kalamkar, Sulaiman Alhassan, Michael J. Farrell, Spontaneous intercostal lung herniation complicated by rib fractures: a therapeutic dilemma, Oxford Medical Case Reports, Volume 2015, Issue 12, December 2015, Pages 378-381
Point
Pulmonary hernias are caused by rib fractures, lung infections, and infections.
It is also called a pathological hernia and includes chest wall abscess, sinusitis, osteomyelitis, and malignancy.
And even if a person who has been taking steroids for a long time and has chronic obstructive pulmonary disease, etc., just doing things such as coughing, sneezing, playing musical instruments, lifting heavy objects, etc. can cause a sudden increase in intrathoracic pressure and produce this syndrome.
However, it is difficult to detect abnormalities on X-ray examination, and most of the time it is detected by CT scan.
Conclusion
Although we have to pay attention to age and medical history, we sometimes have to make difficult decisions like this one.
Probably, even I would make a decision to observe the patient, but the situation might be different if I could interview the patient's medical history.
I guess it's important to ask questions.
