Lung herniation (LH) is a rare clinical entity involving the protrusion of lung outside the thoracic cage. It has a variety of etiologies and clinical presentations, making diagnosis difficult. We present a case of a 20-year-old male who reported pleuritic pain after falling from a skateboard. Evaluation through computed tomography (CT) scanning of the chest revealed an anterior lung hernia associated with rib fractures. This case emphasizes the need for clinicians to include lung herniation in the differential diagnosis of patients with trauma and inexplicable or persistent pulmonary issues.
Lung herniation (LH) is the migration of pulmonary tissue outside the thoracic cage [
A 20-year-old healthy male presented to the emergency department after falling from a skateboard. He sustained blunt trauma to his right chest wall, resulting in pleuritic pain and mild dyspnea. Diagnostic workup included chest radiography (CXR), which showed no acute findings (Figure
Anterior-posterior chest radiograph showing no obvious abnormalities in the thoracic cavity.
Axial contrast-enhanced CT of the chest. Note the disruption in the thoracic cavity with lung anterior herniation due to fractured ribs (arrow).
The patient was admitted for observation and pain management. His pain and dyspnea improved and he was managed conservatively. A repeat CXR on hospital day two was stable, and the patient was discharged home. Ten days after discharge a follow-up chest CT scan was completed and demonstrated a decrease in herniated lung (Figure
Axial contrast-enhanced CT 10 days after injury. Note the improvement in lung herniation (arrow).
Lung herniation is a rare entity that is seldom life-threatening. According to Morel-Lavallee, LH can be classified based on etiology and location [
Etiology of LH can be classified into congenital and acquired type [
Acquired LH is the most common etiology of pulmonary protrusion outside the thoracic cage [
It is important to recognize that the development of LH requires a combination of anatomical and physiological factors. To promote migration of lung tissue outside its usual domain there must be weakness or defect in the structural boundaries and sudden or chronic increase in intrathoracic pressure [
The clinical presentation of LH varies. It is important to include this in the differential diagnosis of patients with a history of chest trauma, thoracic surgery, or persistent pulmonary symptoms. Some patients with LH present with a crepitant chest wall mass that worsens with Valsalva and improves with normal breathing [
Another diagnostic option is ultrasonography. In trauma, patients are evaluated with the eFAST or extended focus assessment with sonography in trauma. This rapid diagnostic test involves assessment of the pleural cavities to identify pneumothoraces [
Computed tomography (CT) scan of the chest is the most sensitive diagnostic exam for LH. It provides excellent characterization of LH [
When a patient is diagnosed with LH, it is paramount that the etiology, location, and associated symptoms are assessed and evaluated to determine treatment. The management of LH depends primarily on its associated symptoms. Large lung hernias creating physical deformities, presence of lung tissue necrosis, recurrent infections, pain, and failure of symptoms to improve with conservative management warrant operative intervention [
Although LH is rare and usually benign, it is imperative to evaluate this injury any time a patient has sustained trauma to the chest wall. Any chest wall trauma, defect, or thoracic surgical intervention may allow lung tissue to protrude into the thoracic cavity. Patients with these histories who worsen or do not clinically improve will require evaluation for LH and surgical management. Those who are diagnosed with small asymtomatic lung hernias can be closely followed up but may require surigcal intervention if the LH enlarges or symtoms develop. Therefore, early consultation with a trauma or thoracic surgeon upon diagnosis of LH is recommended.
The authors declare that they have no competing interests.