Pectus Excavatum in Blunt Chest Trauma

A Case Report

Emmanouil Liodakis; Eirini Liodaki; Hrayr G Basmajian; Nael Hawi; Maximilian Petri; Christian Krettek; Michael Jagodzinski


J Med Case Reports. 2013;7(22) 

In This Article


Patients with cardiac rupture following blunt thoracic trauma rarely survive and most die at the scene or in the emergency room before the cardiac lesions are disclosed. The most common feature of blunt traumatic cardiac rupture is cardiac tamponade.[6] However, the Beck's triad (muffled heart sound, engorged jugular vein, and hypotension) has insufficient sensitivity and specificity in cases of multiple systemic trauma. The diagnosis may be delayed because of the co-existing swelling from injury, inadequate hypovolemic correction, or because of the protective cervical collar. If the pericardium has been lacerated, massive hemothorax will be the leading manifestation.

Previous studies showed that blunt cardiac rupture is an exceedingly rare injury, occurring in one of 2400 patients with blunt trauma.[7] The incidence of patients with cardiac rupture reaching the hospital ranges from 0.16% to 2%.[1,6] At autopsy, damage to the heart was found to be the cause of death in 5% to 10% of victims of blunt chest trauma[4,8] with chamber rupture present in 36% to 65% of cases.[9]

In patients who arrive alive at the hospital, traumatic blunt cardiac rupture is associated with a high mortality rate;[7] these patients can be saved by prompt diagnosis and immediate, adequate surgical repair.[10] The mortality rate for these patients is between 27.3% and 89%.[1,7]

Automobile crashes are the main cause of blunt injury to the heart (73%), followed by pedestrian struck by auto (16%), and falls from a height (8%).[7] The spectrum of injury varies, including cardiac contusion, rupture of the pericardium or the myocardium (free wall or septum), cardiac valvular disruption, and lacerations of the coronary arteries.[4]

According to Santavirta and Arajarvi, more than half of victims of blunt cardiac rupture have six or more fractured ribs or a sternum fracture, indicating a common thoracic crushing force mechanism.[11] Several precordial impactions with cardiac squeezing between the sternum and spine is one possible mechanism.[3,4] In the English literature, however, this is the first case of a patient with pectus excavatum having a blunt rupture. Rationally, the incidence should be higher in these patients because this congenital deformity is a posterior depression of the sternum and adjacent costal cartilages which often compresses the right atrium and ventricle. Another popular theory about blunt traumatic cardiac rupture is rapid decelerations with resultant disruption of the atria from their connections to the vena cava and pulmonary veins.[6]

Seat belt use has been mandatory in Germany since 1976 for front seat passengers, and since 1990 for the rear seat. Due to the increase in road traffic accidents and seat belt compliance, the rate of injuries resulting from seat belt use are on the rise. A specific pattern of injuries such as sternal fracture, bowel trauma, or lumbar spine injuries have been categorized as part of the seat belt syndrome;[12] the sternal fracture is the most common seat belt injury. The incidence of traumatic cardiac rupture remains remarkable in fatally injured seatbelt wearers.[11]