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Rib fracture is known to cause a variety of intrathoracic and intra-abdominal injuries. It is associated with intra-abdominal solid organ injuries, but rarely is itself a cause of hollow viscus perforation. We report a case of a woman who sustained a blunt injury during which a segment of fractured rib penetrated through the diaphragm and perforated the stomach.
A 33 year old woman was brought to the accident and emergency department at West Cumberland Hospital following an accident in which she was crushed by a grabber from behind, sustaining blunt injuries to the chest and abdomen. She complained of pain in the chest and abdomen and vomited once. She denied any respiratory, cardiovascular, or gastrointestinal symptoms. She was conscious, coherent, and haemodynamically stable, with normal pulse and blood pressure. Her Glasgow coma score was 15. Examination revealed tenderness and subcutaneous emphysema in the left lower chest with good air entry bilaterally. Examination of the abdomen revealed a laceration measuring 5 cm in length, with tenderness and guarding in the left upper quadrant.
Dipstix examination of the urine showed moderate amounts of blood. Full blood count and serum biochemistry was normal. Chest x ray showed fractures of the eighth and ninth ribs on the left side, and confirmed local subcutaneous emphysema in the soft tissues overlying the fractures. There was no evidence of pneumo/haemothorax or pneumoperitoneum. A computerised tomography (CT) scan of the abdomen was performed, which showed normal solid abdominal viscera with intact spleen and well perfused kidneys. There was some free intraperitoneal gas and fluid. The CT scan again confirmed rib fractures and local emphysema close to the splenic flexure, suggesting colonic perforation. The stomach was distended and appeared intact. Major vessels were intact. Minor posterior atelectasis was noted at the base of the lungs, but there was no pneumothorax or significant pleural effusion. CT scan also showed a fracture of the left transverse process of L4 vertebrae with intact vertebral body and psoas swelling.
In the light of the CT scan, exploratory laparotomy was performed, which revealed copious amounts of bilious free fluid in the abdomen. Two perforations close together were noted in the posterior wall of the body of the stomach. A large piece of the fractured rib, which had penetrated the diaphragm, was seen protruding through the retroperitoneum below the spleen. There was a 3 cm tear in the transverse mesocolon, and a breach in the peritoneum overlying the left lumbar transverse process close to the ureter. A laceration in the left psoas muscle was noted. The remaining intra-abdominal viscera, including the small and large bowel, liver, spleen, pancreas, kidneys, and ureter, were normal. The area with the perforations in the posterior wall of the stomach was excised, and the stomach closed with linear stapler. The peritoneal cavity was lavaged with copious amounts of normal saline, and the abdomen was closed using the mass closure technique after placing drains in the left subphrenic space and pelvis. The laceration over the abdomen was closed with interrupted nylon sutures. A prophylactic chest drain was inserted in the left fifth intercoastal space in the mid-axillary line.
The patient had an uneventful recovery from surgery. The chest drain was removed with no further complications. The fracture of the lumbar transverse process was managed conservatively with analgesics, physiotherapy, and mobilisation. She was symptom free at follow up.
Fracture of the ribs can cause a variety of intrathoracic and intra-abdominal complications. Apart from the usual complications of surgical emphysema and pneumothorax, it has also been reported to cause mediastinal emphysema and pneumopericardium.1 During blunt injuries, lower rib fractures are associated with intra-abdominal, solid organ injury, in particular to the liver and spleen, but the fractured segment itself is rarely a cause of intra-abdominal hollow viscus injury. Gastric perforation is a very rare complication of fractured rib, and to our knowledge, has not previously been reported in the English language literature, although a similar case with multiple rib fractures that resulted in a segment of the fractured rib penetrating through the diaphragm to the stomach was reported in the Japanese literature.2
Imaging investigations can at times be misleading, as in our present case. The initial chest x ray did not reveal either pneumothorax or pneumoperitoneum. The CT scan did not show pneumothorax; it suggested a colonic rather than gastric perforation due to a presumed intact and distended stomach and the proximity of rib fractures to this splenic flexure. In our case, a segment of fractured rib had penetrated through the diaphragm and perforated the stomach.
Gastric perforation is an interesting and a rare complication of rib fracture. As the clinical examination and investigations can be misleading, there should be a high index of suspicion of intra-abdominal organ injury, particularly in patients with lower rib fractures. This case emphasises the importance of thorough exploration of all intra-abdominal organs during laparotomy, and the physician should not be falsely reassured by the imaging investigations.
Competing interests: none declared