Clinical Case 009: Thor-racic Trauma

This is one of the freakiest cases I have ever seen, and it all happened exactly as below I swear.  Apologies for the apalling pun in the title, but it is so rare that I get the chance to combine Nordic mythology with trauma blogging – just had to do it…

Fit, healthy 25 yo labourer is dropped off to ED by workmates after a day toiling in a trench.  He states he felt something hit him in the chest whilst working with a pick and sledge hammer on some rocks.  He didn’t bother to look at the time, but now 3 hours later he noticed a bit of blood on his thick, flannel shirt, hence the trip to ED – “do I need stitches?”

So I did my usual thing – send in the Med Student to check it out.  He comes back with the following history:  fit guy aside from a spontaneous pneumothorax 3 years ago. Well, normal obs, complaining of mild pleuritic left chest pain “a bit like the pneumothorax”.  He as a small skin lac… 5 mm wide just over the pect major.  Chest exam all normal.

To examine: the wound was small, explored with a bit of local, it didn’t seem to be more than a cm deep, no track.  I wanted to sew it up and send the chap home, but my very astute, super-keen M.Student wanted to call the poor Radiographer in from her dinner to do a CXR in order to exclude a repeat PTX.  So I said:

“Fine, if you write the form and explain it to the cranky Xray staff then you can do a CXR.”  So we got one…

And what did it show?  I was thinking – I’ll teach this student to stop wasting money and irradiating patients when it comes back normal…

The CXR was done and 5 minutes later the Radiographer came running around looking a bit worried….click here to see why FYI there was no pneumothorax on the full view.
Umm yeah, is that where I think it is? And what is it?? Maybe a lateral CXR will show us some more…

Well after putting in a few big IVCs and making a phone call to a disbelieving cardiothoracic Reg we managed to track down one of the workmates who brought in one of the heavy sledge-hammers they had been using. On inspection there was a perfect little crescent of steel missing from one of the faces of the hammer that correlated nicely with what we were seeing on the CXRs. He was flown down south to Cardiothoracics and ad a thorascopy which revealed the shard was lodged about where your ligamentum arteriosum is! The team ended up converting to open thoracotomy to get it out. I am still trying to decide if this guy was the luckiest or unluckiest bloke I ever met.

 

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