Thorax (1971), 26, 223.

Laceration of the lung following blunt traumaK. MOGHISSI1

Hammersmith Hospital, Royal Post-graduate Medical School, Du Cane Road, London W.12

Laceration of the lung was found in 4-4% of cases of chest injury caused by blunt traumaadmitted to two thoracic centres. Criteria for accurate diagnosis are presented. It is suggestedthat thoracotomy should be considered and carried out as soon as possible when the diagnosis ismade. It was found that cases treated with early thoracotomy did not require any pulmonaryresection. In others, lack of prompt diagnosis and a conservative approach led eventually to lossof lung parenchyma.

In civilian life chest injuries are responsible for ahigh mortality and morbidity in victims of roadtraffic accidents. A good deal has been writtenabout those injuries which result in an unstablechest with paradoxical chest movement and conse-quent respiratory difficulties and a higher fataloutcome (Barrett, 1960; Windsor and Dwyer,1961 ; Sellors, 1961).More trivial injuries in the form of isolated rib

fractures with minor visceral damage are also welldocumented and easy to diagnose and manage(Brown and Boyd, 1952; Glennie, 1965; Bassett,Gibson, and Wilson, 1968).

Laceration of the lung, on the other hand, hasreceived little attention. This type of injury is notcommon. Nevertheless it is our belief that itshould be diagnosed early and treated by thoraco-tomy. By so doing, little or no lung tissue need besacrificed, whereas late diagnosis and a conserva-tive approach lead eventually to surgery with amore substantial loss of pulmonary parenchyma.

In this paper we discuss the diagnosis andmanagement of laceration of the lung caused byblunt trauma to the chest.

SUBJECTS

A total of 182 patients with a variety of chestinjuries caused by blunt trauma in two chest sur-gery centres2 in England were studied. Thesepatients were obviously those who required ad-mission to such centres, i.e., their injuries were insome way complicated. A rational, though em-pirical, classification was adopted for working outthese cases (Table I).

Eight patients (4-4%) suffered laceration of thelung, proved by thoracotomy or postmortemlPresent address: Castle Hill Hospital, Cottingham. B. Yorkshire.2Wessex Regional Cardiothoracic Cemtre at Southampton ChestHospital and Harefield Hospital, Harefield, Middlesex.

TABLE ITYPE OF CHEST INJURY IN 182 PATIENTS

Type of Injury No. %

With stable chest.156 85-5Simple (isolated ribs)..48 26-5Complicated (bony and visceral) 108 59 0Haemopneumothorax 72 39 5Lung contusion .. 16 8-8Lung laceration 8 4-4Ruptured diaphrag .. . 7 3-8Heart or major vessels 5 2-8

With unstable chest 26 14 5Simple (bony) .. 21 11 5Complicated ..5 2-8Thoraco-abdominal ..3 1 7Thoracic and head .. 2 1-1

examination. All these eight patients had been in-volved in road traffic accidents. Two patients werepedestrians hit or run over by a motor vehicle.Three patients received their injuries by steeringwheel trauma. Three patients were motor-cyclistsin collision with a motor vehicle.

Table II presents ages and important symptomsand signs in these patients at the time of admis-sion.Shock was present in four patients suffering

from additional injuries with a considerable lossof blood or body fluid. Cyanosis was not a con-stant finding and was recorded only in those withmultiple injuries. In two patients (1 and 3) cyano-sis developed later. This is interesting becausethese two were treated conservatively at first.Expanding intrapulmonary haematoma and anincreasing degree of pulmonary collapse werethought to be the cause of later hypoxaemia andthe desaturation of blood.Haemoptysis of various magnitude was present

in every patient with lacerated lung. In fourpatients (4, 5, 6, and 7) bronchoscopy was per-formed early (within hours of accident), and blood

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TABLE IISYMPTOMS AND SIGNS OF PATIENTS WITH LACERATED LUNG

,Case Age Sex Shock Cyanosis Haemos Surgcal Paradoical Injuriesptysis Emphysema Breathing

1 23 M - (+ late) + + - Fractured ribs (2-5), laceration RLL2 50 M + + + _ - Fractured ribs (8-11), skeletal fractures, laceration LLL,

ruptured spleen3 20 M - (+ late) + _ - Fractured ribs (2-4), laceration LUL4 11 M + + + + - Fractured ribs, ruptured RUL bronchus, laceration RLL5 18 M - _ + _ - Fractured ribs (9-11), laceration LLL6 14 F _ _ + _ - Fractured ribs (2-6), laceration RML and RLL7 36 M + + + _ - Fractured ribs (6-11), fractured humerus, multiple lacera-

tions, lacerated LLL, ruptured diaphragm8 40 M + + + + - Multiple visceral injuries, laceration lung, ruptured

abdominal viscera and aorta (PM findings)

was seen seeping from a segmental or lobarbronchus corresponding to the site of injury. Inthree patients bronchoscopy was performed laterand localization of the bleeding was less clear.Haemoptysis is thus an important lead and a con-stant finding in these cases.

Surgical subcutaneous emphysema was presentin three patients. Ju'dging from our other cases ofchest injury it appears that the presence of surgicalemphysema does not always indicate serious pul-monary damage, and its absence does not rule outlacerated lung.

Paradoxical breathing has been constantly ab-sent in all our cases. Table I shows that in ourseries of 182 cases of chest injury, 26 patientspresented with an unstable chest caused by multi-ple fractures of the ribs or sternum. In none ofthese was pulmonary laceration recorded. It there-fore appears that if at the moment of impact theintegrity of the cage is disrupted the major stressis removed: the intrapulmonary tension is notthen sufficient to cause laceration. On the otherhand, when the chest remains stable followingan impact of great force, the major stress is trans-mitted to the interior. This will increase the intra-thoracic pressure which in turn causes the bronchito burst or the lung to tear, particularly if theglottic 'safety valve' is closed. It is interesting tonote that in only one case (case 1) in this seriescould the tears in the lung have been attributedto a fractured rib penetrating into the lung. In allthe others there was clear evidence that the lunghad literally burst, and the lacerations were notnecessarily near fractured ribs.

RADIOLOGICAL FINDINGS All cases sustained ribfractures, usually in one place-the posterior end.The number of ribs fractured did not exceed five.Haemothorax of variable size was present in

every case. Pneumothorax was also present in all.

The most characteristic radiological features(Figs 1, 2, and 3) were: 1. a shallow pneumo-thorax. There was only a 3 0-5 0 cm space betweenthe apices of the thorax and the lung in allpatients (except cases 4 and 8, who had, in addi-tion to the laceration, either avulsion of a lobe ora ruptured bronchus); 2. haemothorax of varyingsize but never more than 500-700 ml; 3. a fairlywell defined opacity in the lung substance withupward convexity. The lower part of this opacitymerged indistinctly with the basal haemothorax,even when the lower lobe was unaffected (Fig. 2).These radiological findings are, in our experi-

ence, diagnostic and can in most cases be differen-tiated from other injuries such as vascular inju-ries with a large haemothorax, pulmonary contu-sion with its patchy infiltration, or rupturedtrachea and bronchus, already well documented inthe literature (DeMuth and Smith, 1965; Stevensand Templeton, 1965; Chesterman and Satsangi,1966; Larizadeh, 1966). In our cases, after inser-tion of an intercostal tube and drainage of haemo-pneumothorax there was little change in the radio-logical appearances of the pulmonary opacity,whereas in a simple haemothorax following inter-costal drainage the chest radiograph usually showsconsiderable change and clearing.

INDICATIONS FOR SURGERY Seven patients had athoracotomy. Four patients (4, 5, 6, and 7-TableIll) were operated on within hours of admission.In these, early thoracotomy was performed be-cause of persistent haemoptyses or air leak andthe correct diagnosis of laceration of the lungwas confirmed; no resection was necessary anddebridement, haemostasis, and repair only wascarried out. In three other cases (1, 2, and 3-Table lII) thoracotomies were performed later.In these, the failure of the lung to expand, evi-dence of extension of the lung opacity, deteriora-

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Laceration of the lung following blunt trauma

FIG. 1. Case 5. Typical triad ofshallow pneumothorax, haemo-thorax, and a rounded opacity inthe substance of the lung.

tion of respiration, and persistent small haemop-tyses were the main reasons for stopping con-

servative treatment in favour of operation. Thediagnosis was confirmed at operation in each case.

OPERATIVE FINDINGS The seven patients were

operated on by three different surgeons. In eachpatient a major tear through the lung substancewas found. In four early thoracotomy cases (4, 5,6, and 7-Table III) no resection was required. Inthe three late thoracotomy cases (1, 2, and 3) a

major resection had to be undertaken. It is rele-vant to record the operative and pathologicalfindings in these three cases.

Case I The lower lobe of the lung had a tearleading into a cavity which was full of blood.The whole of the lobe was virtually destroyed.Right lower lobectomy was performed.

Case 2 There was a large tear in the left lowerlobe, the basal segments of which were found tobe almost completely haemorrhagic, forming a

friable mass; no repair could be undertaken anda left lower lobectomy was performed. A reporton the specimen removed read: 'The lobe has al-most been torn across. The tissue is congested andhaemorrhagic.' The histological report was asfollows: 'The whole picture is that of haemor-

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226 K. Moghissi

FIG. 2. Case 3. Typical features of laceration; this was in the left upper lobe.

EiqZ EI:q.

TABLE IIILESIONS AND OPERATIONS IN CASES OF LACERATED LUNG

Case Stay (ays Tracheostomy Lung Lesion Delay before Operation Final Result

1 22 _ Laceration RLL 5 days Right lower Goodlobectomy

2 22 + Laceration LLL 3 days Left lower lobectomy Good3 35 + LUL laceration 3 days Left upper lobectomy Good4 14 _ Avulsed upper lobe; 3 hours Repair RLL; Good

lacerated RLL lobectomyright upper

5 11 Lacerated LL lobe 2 hours Repair Good6 13 Lacerated RML 12 hours Repair Good

and RLL7 25 + Lacerated LLL 2 hours Repair Good8 Few hours + Lacerated LLL Necropsy findings _ Died before

and LUL operation

EMPE... .".71..--I.W.-,:.

Laceration of the lung following blunt trauma

FIG. 3. Case 6. Features oflaceration oflung, as described in the text.

rhage. The alveoli are distended with blood withresultant compression of the minor bronchi whichare collapsed.'

Case 3 There was a laceration of the upper lobe;this was leading to a cavity full of blood andsurrounded by a friable mass of shattered paren-chyma. A left upper lobectomy was performed.The specimen removed showed a ragged tear inthe lung extending towards the hilum and to acavity 12 x 4 x 2 cm. Histological examinationshowed a traumatic rupture of a large branch ofthe pulmonary artery with extensive interstitialhaemorrhage.

MANAGEMENT AND DISCUSSION

First aid and emergency measures in these casesare the same as for any major injury. Attentionmust be paid to relieving airway obstruction,

treating shock, and alleviating pain by appro-priate measures. Patients are then best examinedand assessed according to the symptoms andsigns already discussed.

In our experience it is unlikely that patientswith lung laceration will have an unstable chest-this may be taken as a lead.

Patients with an unstable chest often requireartificial respiratory help; so do some with ex-tensive multiple associated injuries. Other chestinjuries, including those with lung laceration,initially do not usually require any respiratoryassistance. After a thorough clinical examinationa chest radiograph is taken which will show thetypical appearance in cases of laceration alreadypointed out. In this connexion it is important torecall that on admission the films are usually takenin the supine position, and pneumothorax may noteasily be detected until some time has elapsedbetween the accident and the radiological exam-ination. For the same reason the haemothoraxmay appear trivial on early films.

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As soon as possible an intercostal drain is in-serted into the appropriate side of the pleuralcavity under local anaesthesia and the haemo-pneumothorax is drained. This improves thepatient's condition temporarily. A second radio-graph should then be taken to assess the appear-ance after pleural drainage. The presence ofhaemoptysis necessitates bronchoscopy-thisshould be carried out early, within hours of theaccident. Early bronchoscopy has the advantagethat it shows the site of the bleeding beforechanges in the bronchial mucosa have time todevelop. Later bronchoscopy necessitates suctionof the clot and altered blood before visualizationof the bleeding site. In such cases the adjoiningmucosa is swollen and inflamed and may containconsiderable amounts of thick secretion and bloodclot. Once the diagnosis of major lung lacerationhas been made failure of early improvement inthe patient's condition with conservative measures,persistent air leak, haemoptysis, and lung collapseindicate early thoracotomy. On the evidence pre-sented we believe that in the majority of cases anearly thoracotomy obviates or reduces to a mini-mum the need for lung resection. Bleeding into thesurrounding segments and the pleura can bestopped and debridement can be satisfactorilycarried out by early thoracotomy. The disadvan-tages of continuing a conservative approach arethat a number of patients will require thoracotomyeventually because of continuous air leak, haemor-rhage, and respiratory embarrassment, togetherwith increasing radiological evidence of lungcollapse. This delay leads to a more extensive re-section and less possibility of reparative proce-dures. In three of our patients (1, 2 and 3-TableIII) thoracotomy was performed after conserva-tive treatment had failed. A major pulmonaryresection then had to be carried out.

In four patients (4, 5, 6 and 7) the diagnosis oflaceration was established within hours of admis-sion. Each patient was treated by an early thora-cotomy, in which debridement, haemostasis, andreparative surgery could be undertaken. Only one(case 4) required major pulmonary excisionbecause, in addition to the right lower lobe lacera-tion, there was complete avulsion of the rightupper lobe. Right upper lobectomy was per-formed.

Table III also shows that the duration of hos-pitalization in our patients has been longer inthose at first treated conservatively. These three

patients (1, 2, and 3) were in hospital for a totalof 79 days, average 26-3 days per patient, whereasthe other four patients (4, 5, 6, and 7) were in fora total of 66 days, average 16 5 days per patient.

CONCLUSION

Our series of eight patients, although modest,shows that diagnosis can be made reasonablyaccurately at an early stage.The most constant diagnostic features were a

history of severe chest trauma causing fracturedribs, but no flail chest; haemoptysis was alwayspresent; shock and cyanosis and respiratory diffi-culties were mostly present in those with associa-ted injuries. Chest radiographs characteristicallyshowed haemopneumothorax and a large ovalopacity in the lung substance. Bronchoscopy in-dicated the anatomical site of the bleeding.

It is suggested that thoracotomy at an earlystage is the treatment of choice.

I am grateful to Mr. K. S. Mullard and Mr.I. K. R. McMillan for allowing me to study theircases at Southampton Chest Hospital. I am alsograteful to Mr. J. W. Jackson and Mr. H. C. Nohl-Oser for allowing me to study and include theirpatient. I should like to thank Miss Stephanie Nicholsfor secretarial assistance.

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Lancet, 1, 293.Bassett, J. S., Gibson, R. D., and Wilson, R. F. (1968).

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Chesterman, J. T., and Satsangi, P. N. (1966). Rupture ofthe trachea and bronchi by closed injury. Thorax,21, 21.

DeMuth, W. E. (Jr.), and Smith, J. M. (1965). Pulmonarycontusion. Amer. J. Surg., 109, 819.

Glennie, J. S. (1965). Thoracic trauma. In Thorax ed.d'Abreu, A. L. In Clinical Surgery, Edited by C. G. Roband R. Smith. Vol. 5, p. 11. Butterworths, London.

Larizadeh, R.* (1966). Rupture of the bronchus. Thorax,21, 28.

Sellors, T. H. (1961). The management of chest injuries.Thorax, 16, 1.

Stevens, E., and Templeton, A. W. (1965). Traumaticnonpenetrating lung contusion. Radiology, 85, 247.

Windsor, H. M., and Dwyer, B. (1961). The crushed chest.Thorax, 16, 3.

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