Characteristic Pulmonary Finding in Traumatic

Complete Transection of a Main-stem Bronchus'

KOOK SANG OH/ M.D./2 FELIX G. FLEISCHNER/ M.D./3 and STANLEY M. WYMAN/ M.D.4

T H E INCIDENCE of severe chest injuries and direct

trauma to the tracheobronchial tree has risen
sharply during the past two decades, owing to the
widespread increase in mechanization and high-
speed travel (1, 2). Prompt diagnosis and imme-
diate surgical reconstruction of the trachea and
bronchi are mandatory to prevent stricture, loss of
function, and death.
A radiologic pulmonary finding apparently not
recorded previously has been observed-the lung
appears to fall away from the mediastinum. It is
believed to be characteristic, at least in the case
reported below, of complete transection of a main-
stem bronchus.
CASE REPORT
A 35-year-old woman was involved in an auto-
mobile accident and brought to the Emergency
Ward of the Massachusetts General Hospital.
She was semiconscious and in respiratory distress.
The right half of the chest showed a flailing motion,
massive subcutaneous emphysema was spread over
the chest and neck, and the abdomen was soft and
not distended.
A drainage tube was inserted into the right hemi-
thorax, thus releasing a small amount of bloody
fluid. Following this, radiographs of the head,
neck, and chest (Fig. 1) were obtained in the supine
position. These revealed fractures of the mandible,
second cervical vertebra, right clavicle, and right
first, second, third, and fourth ribs. There was a
right pneumothorax with 60 per cent collapse of
the lung, as well as mediastinal and subcutaneous
emphysema.
A tentative diagnosis of traumatic complete
transection of the right main-stem bronchus was
made, and an operation was performed immediately.
The right main-stem bronchus was found to be
completely transected 1.5 em distal to the carina.
The major blood vessels were intact, however, and
no injury to the diaphragm was found. The
bronchus was successfully reconstructed.
The patient recovered, and physical examination
and radiographs of the chest three and one-half
months later (Fig. 2) were normal.

Fig. 1. Supine anteroposterior radiographs of the chest taken on admission (A) and twenty minutes later
(B) show the lung collapsing and falling away from the mediastinum (arrows) after a drainage tube had been
inserted (A) and a four-poster cervical brace had been applied (B).

1 From the Departments of Radiology, Harvard Medical School and Massachusetts General Hospital Boston
Mass. Accepted for publication in October 1968. ' ,
2 Resident in Radiology, Massachusetts General Hospital.
3 Clinical Professor of Radiology, Emeritus, Harvard Medical School; Consultant Visiting Radiologist Massa-
chusetts General Hospital. '
4 Assistant Clinical Professor of Radiology, Harvard Medical School; Radiologist, Massachusetts General
Hospital.
RADIOLOGY 92: 371-372, February 1969. (J.C.)
371
 372 KOOK SANG OH AND OTHERS
Fig. 2. Erect postero-anterior radiograph of the chest, taken three and one-half months later. The lung is
well expanded and without visible abnormality. .
Fig. 3. A case of tension pneumothorax, showing the lung collapsing toward the mediastinum.
DISCUSSION
Complete transection of a main-stem bronchus is
rare. Of the 130 surgically and pathologically
proved cases reported in the literature and reviewed
by Burke (1), 86 per cent of all bronchial ruptures
involved the main-stem bronchus. Among these,
; 51 per-cent were right-sided, 47 per cent were left-
sided, and 2 per cent involved both main-stem
bronchi.
In addition to pneumothorax, mediastinal em-
physema, and subcutaneous emphysema, which
may occur with a severe chest injury, an acute
injury to the bronchus may include air surrounding
the bronchus, sharp angulation or obstruction in the
course of an air-filled bronchus, and tension pneumo-
thorax,as reported in the literature (2-4, 9-11).
Persistent atelectasis is likely to follow.
Tension pneumothorax is characterized by col-
lapse of the lung toward the mediastinum and dia-
phragm, displacement of the mediast~num to ~he
uninjured side, widening of t~e hemlth~ra:c .wlth
spreading of the ribs, depression and diminished
movement of the hemidiaphragm. In complete
transection of the main-stem bronchus, tension
pneumothorax seems less likely to ?ccur,. probably
because there is less chance for manifestation of the
ball-valve effect. The diagnosis of complete tran-
section of the bronchus can be suggested radiologi-
callv and can be confirmed by bronchoscopy or sur-
gical thoracotomy. The importance of maki~g this
diagnosis early is obvious. By prompt surgical re-
pair or reconstruction, the affected lung can be saved,
thus preventing other untoward sequelae.
(For REFERENCES
February 1969
. . .
In an average case of pneumothorax, spontaneous
or induced, the lung-anchored to the mediastinum
by the hilar structures, bronchi and vessels, and the
pulmonary ligament-falls toward the mediastinum
in the supine position and toward the mediastinum
and diaphragm in the erect position (Fig. 3). Only
in the presence of apical and lateral pleural adhe-
sions will it be held at a distance from the medias-
tinum and diaphragm.
In the observed instance, the chest radiographs
(Fig. 1), taken as an emergency procedure in the
supine position, show an increased density of the
right lung and no visible air in the right major
bronchi. This suggested the presence of fluid or
blood in addition to partial collapse of the lung.
The upper half of the moderately collapsed lung has
fallen away from the mediastinum without evidence
of pleural adhesions, and this prompted:t,he diag-
nosis. 'This finding, which should be corroborated
by further cases, will become a useful sign .for ~he
early diagnosis of traumatic complete transection
of a main-stern bronchus.
SUMMARY
A case of traumatic complete transection of the
right main-stem bronchus is presented. An appar-
. . d
ently unreported radiological observation is rna e:
the lung appears to fall away from the mediastinum,
in contrast to collapse of the lung in which it falls
toward the mediastinum in an average case of
pneumothorax without pleural adhesions.
Massachusetts General Hospital
Boston, Mass. 02114
please turn to page 376)