A 46-year-old obese man (body mass index: 40.2) was presented to our emergency department with moderate left-sided chest pain that started immediately after heavy lifting 2 days before the examination. The patient had no history of trauma, surgical procedures in his thoracic wall, or COPD. His comorbidities were arterial hypertension, congestive heart failure, and type II diabetes mellitus. At the time of admission, the patient was alert and oriented. His vital signs were as follows: blood pressure – 140/90 mmHg, heart rate – 90 per minute, respiratory rate – 18 per minute, and body temperature – 36.7°C. Physical examination revealed a swelling of the left flank (from mid-thorax to the gluteus) with red-bluish colorization of the skin and tenderness on palpation []. On auscultation, diminished breath sounds on the left were established.\nChest X-ray presented stable intercostal lung herniation – through sixth intercostal space []. Subsequent chest computed tomography (CT) confirmed the stable left intercostal lung herniation. Moreover, hematoma of the left flank, displaced fracture of the seventh left rib, and fluid into the left costophrenic angle with a density of 21 Hounsfield units were found [Figure and ]. The spirometry test was performed with volume of a FEV1 of 2.42 L (64% of predictive) and FEV1/FVC of 72%.\nThe patient was hospitalized and operated on the 2nd day of his hospitalization. Left mid-lateral thoracotomy under general anesthesia with intubation with a double-lumen endotracheal tube was performed. The incisional line was made over the side of the thoracic wall defect (through sixth intercostal space). Exploration of the left hemothorax revealed thoracic wall hematoma, lung herniation through the sixth intercostal space with compressed herniated part of the lung, minimal hemothorax in costophrenic angle (<150 ml), dislocated fracture of the left seventh rib-type “costochondral joint separation,” and laceration of the diaphragm (approximately 4 cm and close to esophageal hiatus), with herniation of a small portion of the great omentum into the pleural cavity.\nBlood from costophrenic angle was sucked out. The herniated part of the great omentum was reponated back into the peritoneal cavity, and the defect of the diaphragm was closed by nonabsorbable interrupted sutures. The pleural cavity was irrigated with sterile saline solution. The thoracic cage was closed with pericostal sutures around the 6th and 7th ribs, after inserting a chest tube drain. Thoracic wall hematoma, along the incisional line, was cleaned, and the soft tissues were irrigated with povidone-iodine 10 % solution.\nThe patient was discharged on the 9th postoperative day in a good condition. Control chest CT 2 years after the operation found no deformation of the thorax or recurrence of the lung herniation.\nWritten informed consent was obtained from the patient for his anonymized information to be published.
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’.