Case Report

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American Journal of Emergency Medicine

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Pulmonary laceration secondary to a traumatic soccer injury: a case report and review of the literature?

Abstract

Pulmonary lacerations are an uncommon injury typically associ- ated with high-impact trauma. Most cases occur as a result of high- speed road traffic collisions. Although chest wall and pleural injuries are commonly associated with sports-related Thoracic trauma, Pulmonary injuries are far less common. There are only a few reported cases of significant pulmonary trauma associated with sports injuries, the majority of which have described pulmonary contusions occurring as a result of thoracic injury sustained while playing high- impact contact sports such as American football. Pulmonary laceration occurring as result of soccer-related thoracic trauma has never previously been reported.

We present the case of a 14-year-old Adolescent boy who presented to the emergency department with left sided chest pain and hemoptysis following an injury sustained whilst playing soccer. A diagnosis of pulmonary laceration was made on the basis of multi- detector computed tomographic (MDCT) imaging findings. We highlight the diagnostic importance of hemoptysis in patients presenting with sports related thoracic trauma and the role of further imaging in these cases.

A 14-year-old previously healthy male patient presented to the emergency department with a 3-day history of hemoptysis and mild left-sided chest pain following a kick to the left side of the chest sustained while playing soccer. On examination, the patient was afebrile and hemodynamically stable with a heart rate of 74 beats per minute, a blood pressure of 134/76 mm Hg, a respiratory rate of 16 breaths per minute, and oxygen saturations of 97% on room air. Result of an examination of the respiratory system was unremarkable, with normal symmetrical chest expansion, percussion note, and air entry on auscultation.

An initial chest radiograph demonstrated ill-defined opacification within the left lower lobe (Fig. 1). An ultrasonographic scan of the chest had a normal result. Because of repeated episodes of hemoptysis, an emergency bronchoscopy was performed that demonstrated altered blood within the left lower lobe bronchus.

An arterial pHase contrast agent-enhanced CT of the chest was performed to establish the source of the altered blood. This demonstrated multiple ill-defined pulmonary cysts within the left lower lobe surrounded by relatively high-attenuation ground-glass opacification in keeping with a diagnosis of traumatic Pulmonary hemorrhage and pulmonary lacerations (Fig. 2). The patient was managed conservatively with no complications and discharged from hospital after 2 days. The patient remained well and symptom free,

? Conflicts of interest: none declared.

with complete resolution of the radiographic findings at 2-month follow-up.

Pulmonary laceration occurs as a consequence of traumatic disruption of lung parenchyma with subsequent filling of the traumatic intraparenchymal defect with air and/or blood [1]. Because of the elastic nature of lung tissue, the normal pulmonary parenchyma adjacent to the site of laceration recoils to create round or oval defects. As a result, pulmonary lacerations significantly differ in morphological appearance from the more linear defects associated with solid organ laceration seen elsewhere in the body [1,2]. In the first 48 to 72 hours following injury, pulmonary lacerations may be obscured on the initial chest radiograph by underlying contusion or hemorrhage [1,2]. Pulmonary lacerations are readily demonstrated on MDCT in the acute setting as round or oval parenchymal cavities with pseudomembranes that may occasionally demonstrate air fluid levels if they contain

Fig. 1. Initial chest radiograph demonstrating ill-defined opacification within the left lower lobe.

0735-6757/$ – see front matter (C) 2013

Fig. 2. Arterial phase contrast agent-enhanced CT of the chest demonstrating multiple ill-defined pulmonary cysts within the left lower lobe surrounded by relatively high- attenuation ground-glass opacification.

blood [2]. They may be single or multiple, uniloculated, or multi- loculated in appearance [3].

Pulmonary lacerations may be classified into 4 main subtypes based on the mechanism of trauma, MDCT appearance, and location of associated rib fractures [4]. Type 1 lacerations (compression rupture injury) are the most common subtype and are caused by direct compression with resultant deep pulmonary tissue damage. These are typically centrally located and large, measuring up to 8 cm [1,4]. Type

2 lacerations (compression shearing injury) typical occur in the paravertebral aspect of the lower lobes. These are caused by shearing forces created by sudden compression of the lower lobes against the adjacent vertebra typically due to sudden blunt trauma across the inferior aspect of the thorax [4]. Type 3 lacerations (rib penetration tears) are caused by penetrating trauma related to rib fractures. These are typically peripherally located adjacent to the site of acute rib fractures and are usually associated with a pneumothorax [4]. Type 4 lacerations (adhesion tears) are lacerations that occur at fixed sites of pleuropulmonary adhesion and are usually only apparent at surgery or postmortem [2,4]. Patients may sustain multiple lacerations of differing subtypes [4]. Pulmonary lacerations are more commonly seen in children and young adults because of the greater pliability of the chest wall in these age groups [1-4].

Pulmonary laceration is an uncommon complication of blunt trauma and usually occurs as a result of high-impact road traffic collisions [5]. Although chest wall and pleural injuries are well- recognized complications of contact sports, pulmonary injuries are rare [5]. While a few cases of pulmonary contusion in athletes have previously been reported, most notably among American football players, pulmonary laceration has never previously been reported in soccer related trauma [6-8].

Clinically, patients with pulmonary injury typically present acutely with pain, dyspnea, or hemoptysis [8,9]. Although auscultation of the

chest may demonstrate reduced air entry or crackles, examination findings may be entirely normal. As in our case of pulmonary laceration, all 3 of the previously reported cases of pulmonary contusion secondary to sports-related trauma presented with he- moptysis. This highlights the potential Diagnostic significance of hemoptysis in sports-related thoracic trauma and the need for further imaging in this group of patients [6-8]. The management of pulmonary laceration is conservative in the vast majority of cases, with more invasive intervention reserved for patients with severe associated pulmonary hemorrhage or complicated by large abscess formation [10,11].

In conclusion, we present a unique case of an adolescent boy with pulmonary laceration sustained while playing soccer. Although significant pulmonary injury is only rarely seen in athletes, our case highlights the importance of further imaging in patients presenting with hemoptysis following a sports-related traumatic thoracic injury.

Sanjin Idriz MBBS

Radiology ST4 at St. Georges Healthcare NHS Trust

Ausami Abbas MBBS

Radiology ST4 at University Hospital Southampton

NHS Foundation Trust E-mail address: [email protected]

Sufi Sadigh MBBS

Radiology ST4 at Chelsea & Westminster Hospital

Simon Padley MBBS

Royal Brompton & Harefield NHS Foundation Trust

http://dx.doi.org/10.1016/j.ajem.2013.06.032

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