69-year-old male fell from a tree
Contributor: Russell Jones, MD
This guy fell from a tree about 12 feet up…
Here is his Chest X-ray:
What is wrong with this picture?
On the right side of the radiograph subcutaneous air can be seen lateral to the chest wall. Subcutaneous air with no physical exam supporting a puncture or a laceration is highly suspicious of a pneumothorax. Other sources of subcutaneous air can be from tracheal or laryngeal injury but usually this is associated with large subcutaneous air tracking in the area of the neck (but can be extensive).
The radiograph, however, is indicative of a small pneumothorax. The right lung appears to be fully inflated and it doesn’t show a deep sulcus sign.
This guy was seen at a level I trauma center and thus trauma was notified and recommended a CT scan to look for concominant injuries. Specifically their concern was liver injury and multiple occult rib fractures. A CT of the chest and abdomen were ordered with IV contrast to evaluate for these injuries as well as to quantify the severity of the pneumothorax.
On the Chest CT under lung window a small anterior pneumothorax can be seen. Other findings included a small pulmonary contusion in the right lower lobe and 2 non-displaced rib fractures (7 and 8).
The question is…does this guy need a tube thoracostomy (chest tube)?
I’ll leave the management decisions up to you…