Delayed aortic injury following multiple rib fractures: a case report

Delayed hemothorax due to aortic injury is rare, and its delayed diagnosis can be fatal. Herein, we report a case of delayed hemothorax owing to aortic injury following blunt chest trauma, which was successfully treated through emergency surgery.

A woman in her 70s fell on an escalator at a train station and was brought to our emergency department. Initial evaluation with computed tomography (CT) imaging revealed a thoracic vertebral fracture, bilateral lower rib fractures, and a right-sided hemothorax. She was admitted for observation and supportive care, and her condition remained stable for days. On day 9 of hospitalization, the patient suddenly experienced cardiac arrest. A plain chest X-ray showed a massive pleural effusion on the left side, prompting the insertion of a chest tube. The drainage was hemorrhagic, and laboratory tests showed a significant decline in the hemoglobin level to 4.9 g/dL. Following successful cardiopulmonary resuscitation and the return of spontaneous circulation, a contrast-enhanced CT scan of the chest was performed. However, no active extravasation or apparent source of bleeding was observed. Owing to ongoing hemodynamic instability and the substantial volume of hemothorax, emergency surgery was conducted to identify and control the source of hemorrhage. Intraoperatively, after evacuating a large hematoma from the left thoracic cavity, a small ulcerated hole was identified in the descending thoracic aorta, which appeared tortuous. Pulsatile bleeding was observed from this site. Manual compression was applied to achieve temporary homeostasis. Intraoperative ultrasound showed no evidence of aortic dissection. The bleeding site was sutured directly, and hemostasis was achieved. No additional significant intrathoracic injuries were identified. The aortic injury had resulted from mechanical irritation or penetration by the adjacent fractured lower rib. This represented a case of delayed hemothorax secondary to traumatic aortic injury, a rare but potentially fatal complication.

In cases of delayed hemothorax following blunt thoracic trauma-particularly with fractures of the lower left posterior ribs, clinicians should maintain a high index of suspicion for aortic injury. Prompt recognition and surgical intervention are critical for patient survival in such cases.