Traumatic Pneumothorax in a Division I College Football Player
Abstract Category: Case Report
Findings: A 21 year old male Division I college football player suffered a blow to the left side of his torso with approximately 3 minutes left in the 4th quarter. He did not participate in the game further beyond this episode. He was observed on the sideline floor with labored breathing and complaints of left sided upper abdominal pain and left sided rib pain. Symptoms were exacerbated with movement and inhalation. The head athletic trainer did not think this was an urgent issue, but rather a mild musculoskeletal injury. The medical team was later informed that the patient had nearly collapsed in the shower with worsening symptoms. He was immediately transferred to the emergency department.
- Physical Exam: Blood pressure 105/67, pulse rate 92 bpm, respiratory rate 20 breaths per minute and pulse oximetry was 96% on room air. He had pain and tenderness in the left upper abdominal quadrant and left lateral ribs T8-T10. Lungs were clear to auscultation bilaterally.
- Tests Results: CT scan of the chest: small left lung contusions, acute minimally displaced fractures of the left 6th, 7th and 8th ribs and a 30 percent left sided pneumothorax.
- Differential Diagnosis #1: Rib Contusion
- Diagnosis #2: Splenic Injury
- Differential Diagnosis #3: Pulmonary Contusion
- Differential Diagnosis #4: Rib Fracture
- Differential Diagnosis #5: Traumatic Pneumothorax
Discussion: Traumatic pneumothorax should be included in the differential of any blunt force injury to an athlete's torso. Symptoms may include chest pain, chest tightness, rib pain, shortness of breath and pain worsened with inhalation. The pain is usually unilaterally located representing the involved lung. Signs may include tachypnea, tachycardia and hypoxia. Hyper-resonance to percussion and decreased breath sounds on the affected side are also possible findings. The athlete may present with atypical symptoms that could potentially delay appropriate treatment. In fact, approximately 10% of patients with a pneumothorax are asymptomatic when initially evaluated. Care must be taken to monitor and re-evaluate the athlete periodically after the initial presentation.
A strong working relationship between the physician and head athletic trainer is important for appropriate medical care of the athlete. An athletic trainer may be numb to injury complaints received from “chronic complainers”. When this is the case, the athlete may not receive the proper medical attention required. The physician must use his own clinical judgment irrespective of the athletic trainer’s views on the athlete or their initial diagnostic impression. The physician should maintain a high degree of clinical suspicion for a traumatic pneumothorax in any athlete with pain and/or dyspnea after a direct blow to their torso.
Due to the rarity of traumatic pneumothorax in athletes, there have been no published return to play guidelines. There is general consensus that an athlete should not be allowed to return to play until there is radiographic evidence of complete resolution of the pneumothorax. Case studies and expert opinions have established timelines with return to play ranging from 2 -10 weeks. However, goal-oriented return to play has become more favorable than time-based return to play, consisting of a symptom guided activity progression.
Outcome: A left sided chest tube was placed in the ER and the athlete was admitted to the ICU for observation. After hospital day #2, chest x-ray showed complete resolution of the left sided pneumothorax and the chest tube was removed. He was discharged home in stable condition.
Follow Up: Return to play involved low impact aerobic conditioning for one week, followed by non-contact regular activity for 1 week with a flak jacket, and then full contact regular activity with a flak jacket. He was cleared to play in a football game 29 days after his traumatic pneumothorax. He participated fully with no in game complaints.
2018 West Kendall Baptist Hospital Scholarly Showcase
Ceus, McKirven, "Traumatic Pneumothorax in a Division I College Football Player" (2018). All Publications. 2750.