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A 57 year old woman was a restrained front seat passenger, involved in a high speed, head on, motor vehicle accident. She was trapped for 30 minutes, during which time she was reported as being conscious but complaining of difficulty in breathing. On arrival in the emergency room, primary survey showed her airway to be intact. There was reduced air entry in the right chest, and dullness to percussion at both bases, with a respiratory rate of 40 breaths/min. Her initial blood pressure was 95/70 with a regular pulse of 120/min. Neurologically, she was conscious with a GCS of 15. Secondary survey showed extensive bruising in a seat belt pattern over her chest and abdomen. Abdominal skin over her lower abdomen was disrupted by a degloving injury. The soft tissues of her right breast were noted to be grossly distended.
Radiological examination showed an unstable fracture of the C2 vertebra, a large right haemothorax with multiple rib fractures (T2–T7), and a small left haemothorax and fractured left first rib. Chest radiograph showed widened mediastinum. Other injuries included a compound fracture of the left tibia and right ulna.
A right chest drain was inserted without complication and drained 200 ml of blood in addition to air. She began to deteriorate haemodynamically and computed tomography of the chest was performed. This showed a large pocket of air in the right breast that was in communication with a large pneumothorax, which developed as a result of her initial trauma. The mediastinum was noted to be widened due to haematoma (fig 1A and B). She continued to deteriorate and was taken to theatre for an urgent laparotomy where she was found to have a ruptured large bowel with mesenteric avulsion. A halo frame was fitted to stabilise her cervical spine.
Postoperatively she was admitted to the intensive care unit (ICU). Repeat chest radiography showed resolution of the right haemopeumothorax but the right breast remained grossly distended by the large air pocket (fig 2A and B). The chest drain was removed on day 6 and the right breast returned to normal size over the following month as the air was resorbed. She made a remarkable and slow recovery from her injuries, complicated by pseudomonas septicaemia, and further abdominal surgery. She spent 30 days in ICU and a further three months on the ward before being discharged home.
The female breast comprises mostly of adipose tissue, lying within the superficial fascia of the anterior chest wall. Its base is a thin layer of retromammory fat extendingfrom the second to sixth rib, which lies anterior to deep fascia covering pectoralis major and serratus anterior muscles. The breast itself is divided into numerous fibrous septae radiating out from the nipple to form 15–20 lobules of glandular and adipose tissue.
Breast injury after motor vehicle accidents usually results from compression on the breast tissue by the shoulder restraint of the seat belt to cause a wide band of contusion. In cases of severe injury, bruising and oedema cause fat necrosis, which progresses over one to two months to form lipid cysts. As the lipid cysts and contusion resolve, a line of fibrosis develops, which may become calcified after three to four years.1 Surgical emphysema in subcutaneous tissues around the breast is relatively common after rib fractures, but in these cases air lies in superficial tissue planes and does not extend through the fibrous covering of the breast. Although surgical emphysema was present in tissues of the lateral chest wall, a large air pocket within the breast tissue is not a pattern of injury previously reported. The CT scan shows division of the right pectoralis major and minor muscles with communication of the right pneumothorax with a large air pocket within the breast tissue.
We believe that this is the first reported case of a traumatic pneumothorax communicating with soft tissue of the breast. The multiple rib fractures and ensuing pneumomammothorax reflect the severity of the mechanism of injury in this case. There were no specific clinical complications caused by the pneumomammothorax. This case report shows that air in the breast after trauma may indicate significant thoracic injury.
Dr Gary Smith was the consultant in charge of this patients care. It was Dr Smith who identified this as a unique case with a useful learning point if published. Professor Deakin completed a literature review, formulated the discussion, and helped produce the final draft. Dr Walker wrote up the case history, contributed to the discussion, and produced the final manuscript. Professor Deakin will act as guarantor.