Authors: Namita Jayaprakash, John Ryan / Editor: Tajek B Hassan / Reviewer: Tadgh Moriarty, Ines Corcuera / Codes: ResC8, SLO4, TP3Published: 20/05/2013 / Reviewed: 10/05/2024

A 23-year-old male was playing rugby 4 days ago. He was touching down in his in-goal area for a 5-metre scrum when he was kneed in the back towards his left side. (That is to say he fell on a ball on the ground.) He felt winded and had a sensation like he “could not breathe for a moment”. He came off of the pitch and did not finish the match. The following night he was lying in bed when he felt a thumping in his chest. His girlfriend thought she heard a double heartbeat and extra sounds coming from his chest.

He self presented to the emergency department (ED) 4 days following the initial injury because of on-going pain and discomfort in the left side of his chest and back.

On examination, his BP was 159/60, RR 16, HR 72bpm, and his oxygen saturation was 95% on room air. He was tender on palpation posteriorly over ribs 3 – 5 in the paravertebral region. His trachea was midline. He had equal breath sounds bilaterally on auscultation.

A departmental chest X-ray identified the presence of a small left sided apical pneumothorax and a left sided pneumomediastinum.

John Ryan COW - Pop Goes the Lung Image 3

John Ryan COW - Pop Goes the Lung Image 2

A clinical diagnosis of posterior rib fractures was also made based on the mechanism of injury and clinical examination findings.

The description of sounds heard in the chest by the patient’s girlfriend are in keeping with Hamman’s sign described in the presence of the pneumomediastinum, which in this case was identified on X-ray.

Given the small size of the pneumothorax no intervention was made. The patient was given regular analgesics and advised to follow up in one week to ensure resolution of the pneumothorax and pneumomediastinum. He was also advised against flying and deep sea diving until after imaged resolution of both the pneumothorax and pneumomediastinum. He was told not to return to contact sport for 3 to 4 weeks on account of all of his injuries including clinical rib fractures.

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