Trauma is the third most common cause of death in the West. In the US, approximately 90,000 deaths annually are traumatic in nature and over 75% of casualties from blunt trauma are due to chest injuries. Cardiac injuries from rib fractures following blunt trauma are extremely rare. We report the unusual case of a patient who fell from a height and presented with haemopericardium and haemothorax as a result of left ventricular and lingular lacerations and was sucessfully operated upon

B Susozko

CE Brathwaite

Ganti Somsekhar

Graeme Macauley

IF Galvin

JH Calhoon

M Harada

MJ Perchinsky

N Bourguignon

P Sareli

Pankaj Kaul

T Roth

Y Glock

Journal of Cardiothoracic Surgery

English

PubMed

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Secondary left ventricular injury with haemopericardium caused by a rib fracture after blunt chest trauma

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BioMed CentralJournal of Cardiothoracic Surgery
ssOpen AcceCase report
Secondary left ventricular injury with haemopericardium caused by 
a rib fracture after blunt chest trauma
Pankaj Kaul*, Ganti Somsekhar and Graeme Macauley
Address: Yorkshire Heart Centre, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, Leeds, UK
Email: Pankaj Kaul* - pankaj.kaul@leedsth.nhs.uk; Ganti Somsekhar - gantisom@hotmail.com; 
Graeme Macauley - graeme_macaulay@hotmail.com
* Corresponding author    
Abstract
Trauma is the third most common cause of death in the West. In the US, approximately 90,000
deaths annually are traumatic in nature and over 75% of casualties from blunt trauma are due to
chest injuries. Cardiac injuries from rib fractures following blunt trauma are extremely rare. We
report the unusual case of a patient who fell from a height and presented with haemopericardium
and haemothorax as a result of left ventricular and lingular lacerations and was sucessfully operated
upon.
Case report
A 55 year old man presented to the accident and emer-
gency department of a district general hospital after hav-
ing fallen 3 metres from a ladder while cutting his garden
hedge. He complained of left sided chest pain and wors-
ening shortness of breath and dizziness. On examination,
HR was 155/min, RR 37/min, BP 99/66 mm Hg, and JVP
5 cms above sternal angle. 5th and 6th ribs were tender but
there was no obvious crepitus. Breath sounds were dimin-
ished in the left base. Chest x-ray revealed fractures of 5th
and 6th ribs, a large left hemothorax and enlarged cardiac
silhouette (Fig 1a). An intercostal drain was inserted
which drained 1 lit of fresh blood but a follow up chest x-
ray continued to show a large cardiac shadow (Fig 1b). A
CT scan of chest revealed a 2 cm hemopericardium (2a)
and residual left pleural blood and clot (Fig 2b). He was
transferred to our regional cardiothoracic centre for fur-
ther management. A transthoracic echocardiogram on
arrival confirmed a global pericardial effusion with early
tamponade.
Patient was urgently taken to the operation theatre and a
median sternotomy performed with bypass standby. The
pericardium was tense. It was widely opened and 250 mls
of old blood evacuated. There was a 1.5 cm non bleeding
superficial left ventricular laceration posterolateral to the
apex within a large area of contused left ventricle with a
bleeding superficial vein. There was a corresponding 1 cm
tear of the pericardium posterior to the phrenic nerve. Left
pleura was widely opened and lung inspected. There was
a non bleeding laceration of the superior segment of the
lingula and about 500 mls of residual clot and blood in
the pleural cavity. There were fractures of 5th and 6th ribs
with wide displacement of the two segments of the frac-
tured 5th rib. The sharp jagged posterior end of the frac-
tured rib had been displaced medially inside the pleural
cavity and had lacerated the lingula and punctured the
pericardium and the left ventricle.
The sharp end of the fractured rib was excised, the bleed-
ing ventricular vein was diathermised, the left ventricular
contusion and nonbleeding laceration as well as the lin-
gular tear were covered with a generous application of Tis-
Published: 28 March 2006
Journal of Cardiothoracic Surgery2006, 1:8 doi:10.1186/1749-8090-1-8
Received: 24 January 2006
Accepted: 28 March 2006
This article is available from: http://www.cardiothoracicsurgery.org/content/1/1/8
© 2006Kaul et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2006, 1:8 http://www.cardiothoracicsurgery.org/content/1/1/8sel glue (Baxter biosurgery) and the pleural cavity was
evacuated of clot and blood. A posterior pericardial win-
dow into left pleural cavity was made. The sternotomy was
closed with drainage of left pleural and pericardial cavi-
ties.
Discussion
Cardiac injury from a fractured rib following a blunt
trauma to chest from a fall combines the mode and
mechanics of penetrating and nonpenetrating injury. 59%
of penetrating cardiac injuries are stab wounds, 26% gun-
shot wounds and 5% others, and 80% of patients die
before they reach hospital. Right ventricular injury is most
frequent (46%), followed by injuries to left ventricle and
right atrium (30% and 11%) [1].
Blunt chest trauma resulting in cardiac injury is not very
common. The cardiac injuries can be contusion, heart
Chest radiograph showing a) left hemothorax and enlarged cardiac silhouette b) residual hemothorax and persistent enlarged cardiac silhouette after pleural tub  drainageFigure 1
Chest radiograph showing a) left hemothorax and enlarged cardiac silhouette b) residual hemothorax and persistent enlarged 
cardiac silhouette after pleural tube drainage.
CT Scan of chest showing a) hemopericardium b) hemopericardium and residual left pleural clot and blood despite pleural drainageFigure 2
CT Scan of chest showing a) hemopericardium b) hemopericardium and residual left pleural clot and blood despite pleural 
drainage.Page 2 of 3
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chamber rupture, ventricular septal rupture, tricuspid
valve rupture, coronary arterio venous fistula, mitral ten-
sor apparatus rupture or rarely an aortic cuspal rupture
[2,3]. Cardiac contusion is by far the commonest of these,
is followed by cardiac rupture uncommonly (0.3%),
which, in turn, is associated with mortality as high as 80%
[4].
Cardiac injury following a fractured rib due to blunt
trauma to chest is an extremely rare event and there are
only isolated case reports in world literature [5-10]. All
these injuries except one [5] followed motor vehicle acci-
dents [6-10].
Suszoko reported the first cardiac laceration following
non-penetrating trauma in 1968 after a man struck his
chest while he fell onto a chair [5]. Perchinsky reported
one patient who had a cardiac perforation from a rib frag-
ment, 0.007% of all blunt traumas in his series [6].
Glock et al reported two left ventricular perforations with
rib fractures [5]. One patient exsanguinated and died and
the other one presented with late subacute tamponade
and underwent a successful cardiac repair [7]. Bourgui-
gnon reported a 60 year old man who had a right ventricu-
lar perforation by a rib fragment which came to light
following induction of anaesthesia for open fracture of
left arm when patient had a rapid cardiovascular collapse.
This patient had already had a tube thoracostomy for hae-
mopneumothorax and fractured ribs [8]. Galvin et al
described a motor vehicle accident in which a detached
fractured rib from a flail chest caused lung perforation and
haemopericardium, the full diagnosis of which was appre-
ciated on CT. A thoracotomy resulted in successful salvage
[9]. Roth et al described a 33 year old patient with blunt
chest trauma and left flail chest. 6 hours after admission
patient suddenly drained 1.5 L blood from left chest tube
with hypotension and tachycardia. An emergency sternot-
omy with left anterolateral extension revealed secondary
left ventricular perforation by a sharp rib fragment. This
was repaired and the outcome was favourable [10].
Although cardiac perforation with rib fracture following
blunt chest trauma is rare, it should be kept in mind when
1) there are anterior rib fractures in close proximity to the
heart, 2) when there is evidence of raised venous pressure,
and 3) when drainage of a haemothorax and replacement
of blood losses do not result in expected recovery even
though there is no ongoing blood loss. Echocardiogram
and CT scan clinch the diagnosis and an early operation
can be life saving.
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Secondary left ventricular injury with haemopericardium caused by a rib fracture after blunt chest trauma

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