A 20-year-old healthy male presented to the emergency department after falling from a skateboard. He sustained blunt trauma to his right chest wall, resulting in pleuritic pain and mild dyspnea. Diagnostic workup included chest radiography (CXR), which showed no acute findings (). Further evaluation with chest computed tomography (CT) scan demonstrated fractures of the right 4th through 6th ribs. Herniation of the middle lobe of the right lung was also identified on CT scan ().\nThe patient was admitted for observation and pain management. His pain and dyspnea improved and he was managed conservatively. A repeat CXR on hospital day two was stable, and the patient was discharged home. Ten days after discharge a follow-up chest CT scan was completed and demonstrated a decrease in herniated lung ().
A 65 years old man presented to the emergency department with left-sided flank pain that started after a popping sound was heard following a cough spell. There was no history of trauma. He is an active smoker, and his past medical history includes congestive heart failure, hypertension, coronary artery disease, diabetes mellitus, chronic pain secondary to lumbar disc disease requiring multiple epidural injections and multiple orthopedic procedures including knee replacement and rotator cuff repair. He did not have any history of surgical procedures on his chest wall. His medications included hydrochlorothiazide, lisinopril, metoprolol, metformin, aspirin, clopidogrel and diclofenac. Examination was negative for any tenderness or deformity on the left flank. Electrocardiogram was unremarkable, and chest X-ray was negative for any acute pathology. He was discharged home on pain medications with a diagnosis of muscular spasm. A few days later, he represented with non-resolution of symptoms. This time on examination he was found to have a large hematoma of the left flank tracking inferiorly to the left gluteus. There was no fullness, tenderness or crepitus on palpation. Computed tomography (CT) thorax revealed a chest wall defect on the left side between eighth and ninth ribs with herniation of lung tissue (Fig. , red arrow) and a 5 cm × 3 cm hematoma but did not reveal any fractures. He was managed conservatively with pain medications as there was no evidence of vascular compromise to the lung tissue. A month later, he presented again with poorly controlled chest pain and shortness of breath. Chest X-Ray showed stable herniation of lung tissue with widening of eighth intercostal space (Fig. ). Subsequent CT thorax revealed progression of lung herniation (Fig. , red arrow) associated with left lower lobe atelectasis, alongside acute, displaced fractures of left eighth and ninth ribs (Fig. , green arrow). No surgical repair was performed based on a recent positive stress test and his elevated perioperative risk of cardiovascular events. He was discharged on opioid pain medications. At the follow-up visit, he still continues to have pain in the left lower chest, even though he is on a high dose of pain medications. We also tried intercostal nerve blocks, which seems to be ineffective in his case. There appears to be some respiratory compromise unsure whether secondary to chronic heart failure or ‘lung herniation fracture’.