Whilst playing in an International friendly this player received a direct blow to the left side of his chest. He immediately felt substantial pain and was in a lot of distress. He was unable to continue and was removed from the field of play. The player was noted to have localised tenderness over the left side of his chest and appeared short of breath. He was taken to a local Emergency Department for further evaluation.
The x-ray images show there is significant surgical emphysema situated around the lateral aspect of the left thoracic cage extending into the axilla. There are fractures of the 4th and 5th ribs laterally with no overt displacement (these are difficult to visualise). There is evidence of a left pleural reaction which is best appreciated on the oblique imaging. Although there is no obvious lung edge demonstrated, on review of the chest radiograph, there appears to be an absence of lung markings in the apical region on the left (but normal lung markings in the apical region on the right) suggesting a small apical pneumothorax.
This pneumothorax and surgical emphysema prompted the player to be admitted to hospital, where a chest drain was inserted. Unfortunately the player was not able to fly home with the team as he was advised not to fly for a minimum of ten days. The chest tube remained in situ for 48 hours before being removed. A repeat x-ray confirmed that the pneumothorax had resolved. After returning home, the player’s symptoms settled quickly and he was able to return to normal training at matches within six weeks.
Several clinical guidelines state that a pneumothorax is an absolute contraindication to air travel. There is some variability about when a patient can be allowed to travel however it is generally felt that it is generally safe 2–3 weeks after successful drainage and/or after radiographic resolution of the pneumothorax. This imposed waiting period can cause significant logistical challenges. The advice not to travel by air following a pneumothorax relates to how gases behave in enclosed spaces. Boyle’s law states that at constant temperature, the absolute pressure and the volume of a gas are inversely proportional. This means that as the atmospheric pressure falls (with an increase in altitude during flight) gas trapped inside a body cavity will expand. This has been estimated to result in a 25–30% increase in volume compared to sea levels when travelling on a commercial aircraft. This expansion of a pneumothorax could potentially lead to respiratory and circulatory compromise.
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