# Clinical Cases: Thoracic Wall ## Case 1: Rib Fractures with Pulmonary Contusion ### Clinical Image ![Rib Fractures](case_01_image.jpg) *Source: [Wikimedia Commons - Rib Fractures](https://commons.wikimedia.org/wiki/File:Rib_fractures.jpg) - CC BY-SA 3.0* ### Case Presentation A 45-year-old construction worker is brought to the emergency department after a fall from a ladder, landing on his right side against scaffolding. He reports severe right-sided chest pain that worsens with deep breathing, coughing, and movement. He is slightly short of breath. Physical examination reveals tenderness and crepitus over the right lateral chest wall at ribs 6-9. There is splinting with shallow respirations. Oxygen saturation is 94% on room air. Auscultation reveals decreased breath sounds at the right lung base. Chest radiograph demonstrates fractures of right ribs 6, 7, 8, and 9 along the axillary line, with a small right hemothorax and patchy opacity in the right lower lung consistent with pulmonary contusion. CT chest confirms multiple rib fractures, a small hemothorax (150 mL), and pulmonary contusion without evidence of pneumothorax or great vessel injury. He is admitted for pain control with patient-controlled analgesia and intercostal nerve blocks, incentive spirometry, and respiratory monitoring. Serial chest X-rays show no progression of hemothorax, and he is discharged after 3 days with oral analgesics and instructions for follow-up. ### Key Learning Points - Ribs are curved flat bones; fractures typically occur at the weakest point (angle of the rib posteriorly) - Multiple rib fractures (3 or more) are associated with significant pulmonary morbidity - Ribs protect thoracic organs but fractures of lower ribs (9-12) should prompt evaluation for hepatic/splenic injury - Adequate pain control is essential to allow deep breathing, coughing, and prevent atelectasis and pneumonia - Intercostal neurovascular bundle (VAN: vein, artery, nerve) runs inferior to each rib - chest tubes placed above rib --- ## Case 2: Flail Chest with Respiratory Failure ### Clinical Image ![Flail Chest](case_02_image.jpg) *Source: [Wikimedia Commons - Flail Chest](https://commons.wikimedia.org/wiki/File:Flail_chest.jpg) - CC BY-SA 4.0* ### Case Presentation A 52-year-old man is brought to the trauma center after being struck by a car as a pedestrian. He was found conscious but in significant respiratory distress at the scene. On arrival, he has labored breathing with a respiratory rate of 32 and oxygen saturation of 88% on high-flow oxygen. Examination reveals paradoxical motion of the right anterolateral chest wall - during inspiration, the affected segment moves inward while the rest of the chest expands outward. There is extensive ecchymosis and crepitus over the right chest. Breath sounds are diminished on the right. Chest radiograph reveals fractures of right ribs 3-7 in two places each (creating a free-floating segment), right-sided pneumothorax, and extensive pulmonary contusion. A right chest tube is placed with evacuation of air and 400 mL of blood. Despite this, he remains hypoxic with increasing work of breathing. Arterial blood gas shows PaO2 of 55 mmHg on 100% FiO2 and PaCO2 of 52 mmHg. He is intubated for respiratory failure and admitted to the surgical ICU. The underlying pulmonary contusion is the primary cause of his respiratory failure. He requires mechanical ventilation for 8 days with gradual improvement in lung compliance and gas exchange. ### Key Learning Points - Flail chest occurs when three or more consecutive ribs are fractured in two places, creating a free-floating segment - Paradoxical motion: the flail segment moves inward during inspiration and outward during expiration - Respiratory failure is primarily due to underlying pulmonary contusion, not the mechanical chest wall defect - Positive pressure ventilation "internally splints" the flail segment and treats the associated lung injury - Severe cases may benefit from surgical rib fixation to reduce ventilator days and improve outcomes --- ## Case 3: Tension Pneumothorax ### Clinical Image ![Tension Pneumothorax](case_02_image.jpg) *Source: [Wikimedia Commons - Tension Pneumothorax](https://commons.wikimedia.org/wiki/File:Tension_pneumothorax.jpg) - CC BY-SA 3.0* ### Case Presentation A 28-year-old man is brought by EMS from the scene of a motorcycle crash. EMS reports he was hypotensive at the scene with blood pressure 70/40 mmHg and respiratory distress. On arrival, he is agitated and diaphoretic with severe respiratory distress. Vital signs: HR 135, BP 75/50, RR 38, SpO2 78% on non-rebreather mask. Examination reveals distended neck veins (JVD), tracheal deviation to the left, absent breath sounds on the right, and hyperresonance to percussion on the right chest. The left chest has normal breath sounds. Given the clinical picture of tension pneumothorax, immediate needle decompression is performed at the right second intercostal space in the midclavicular line with a 14-gauge angiocatheter. A rush of air is heard, and within seconds his blood pressure improves to 105/70 and oxygen saturation rises to 92%. A right tube thoracostomy is then placed with continuous air leak and 200 mL of blood output. Post-procedure chest X-ray shows improved lung expansion with the chest tube in good position. He is taken to the operating room for exploratory thoracotomy which reveals a lacerated intercostal artery requiring ligation. ### Key Learning Points - Tension pneumothorax is a clinical diagnosis requiring immediate intervention - do not wait for chest X-ray - Air enters the pleural space through a one-way valve mechanism, causing progressive hemodynamic compromise - Increased intrathoracic pressure causes lung collapse, mediastinal shift, kinking of great vessels, and decreased venous return - Classic findings: hypotension, JVD, tracheal deviation, absent breath sounds, hyperresonance on the affected side - Needle decompression at 2nd intercostal space, midclavicular line is life-saving, followed by tube thoracostomy