Extended surgical exposure in penetrating thoracic trauma: Combining clamshell thoracotomy and partial median sternotomy

Abstract

Background

Trans-thoracic impalement injuries are exceedingly rare and are associated with extremely high prehospital mortality. When a penetrating object traverses multiple thoracic compartments, rapid selection of a surgical approach that provides extensive exposure is crucial for safe assessment and repair.

Case presentation

A 48-year-old male construction worker sustained trans-thoracic impalement after falling onto an iron rod. The object entered the right posterior axillary line and exited through the left anterior chest wall. The patient was hemodynamically stable and transferred directly to the operating room. A clamshell thoracotomy was initially performed, revealing that the rod traversed the right upper lobe and coursed close to mediastinal vascular structures. To allow better evaluation of potential vascular injury, a partial median sternotomy was added. The rod was found to have penetrated the superior vena cava, which was tamponaded by the object itself. After placement of purse-string sutures at the entry and exit sites of the venous injury, controlled removal of the rod was achieved via pulmonary tractotomy. The sternum was reconstructed with wire sutures. The postoperative course was uneventful, and the patient was discharged on postoperative day 10.

Conclusion

In complex trans-thoracic impalement injuries involving both pulmonary and mediastinal structures, no single incision may provide sufficient exposure. A combined clamshell thoracotomy and partial median sternotomy offers excellent visualization of multiple thoracic compartments and may facilitate safe management of life-threatening injuries.