A 53-year-old woman is brought to your facility complaining of right-side chest pain. Earlier this evening, while riding her horse, she was thrown off; the horse then fell on top of her. She denies any loss of consciousness. Most of her pain occurs when she inhales.

The patient’s medical history is unremarkable. Her vital signs are: blood pressure, 148/87 mm Hg; heart rate, 100 beats/min; respiratory rate, 14 breaths/min; and O₂ saturation, 100% with oxygen via nasal cannula.

Primary survey reveals moderate tenderness to palpation along the right side of the patient’s chest, with associated crepitus. Some decreased breath sounds are noted on the right, along with crackles. She is moving all of her extremities and otherwise appears neurologically intact. 

A stat portable chest radiograph is obtained in the trauma bay before the patient is transported for CT scans. What is your impression? 

Answer

The radiograph demonstrates several findings. First, there are multiple bilateral rib fractures. Five to six ribs are broken and displaced on both sides. In addition, there are bilateral small apical pneumothoraces. Finally, there is evidence of bilateral pulmonary contusions beginning to form, more so on the left than the right side. 

This patient was admitted to the ICU, where a chest tube was placed and a thoracic epidural was administered for pain control. As her contusions worsened, she was electively intubated and placed on mechanical ventilation for a few days. She subsequently underwent open reduction and internal fixation of her rib fractures. As her contusions improved, she was weaned off the ventilator and extubated, eventually making a full recovery.