Tracheobronchial Fracture

Epidemiology

  • Bronchial fractures are far more common than tracheal fractures

Etiology

  • Penetrating trauma to tracheobronchial tree:
  • Blunt trauma to tracheobronchial tree:

Physiology

  • Traumatic injury to trachea/bronchi

-Tracheal Fracture:
1) May occur in deceleration and thoracic crush injuries:

-Bronchial Fracture:
1) Often associated with fracture of the first 3 ribs
2) Usually occur in mainstem bronchi 1-2 cm distal to carina
3) Right mainstem bronchus is more commonly involved than the left mainstem bronchus
4) Pulmonary vessels are rarely injured
5) Displacement of bronchus may cause bronchial obstruction (and distal atelectasis/lung collapse)

-Mechanisms:
1) Sudden crushing compression of air against a closed glottis and a shearing action of the vertebral column against the airways
2) Lateral widening of the thorax and lungs, leading to lateral traction exceeding the elasticity of the bronchus


Diagnosis

  • FOB: diagnostic for tracheobronchial fracture
    • Careful inspection is crucial

CXR/Chest CT Pattern: 10% of cases have normal imaging studies
1) Pneumomediastinum: espeically in the absence of mechanical ventilation
2) Pneumothorax: especially one that is recurrent despite chest tube drainage
3) SQ Emphysema


Clinical

  • Tracheobronchial Obstruction (see [[Obstructive Lung Disease]])

Symptoms/Signs:
1) SQ Emphysema:
2) Dyspnea:
3) Wheezing:
4) Bronchial Stricture/Stenosis: may be delayed for weeks-months after injury, due to formation of granulation tissue
-10% of cases have normal imaging at the time of injury and only present later with stricture/stenosis


Treatment

  • Surgical Repair: preferred (more likely to be successful if diagnosed early)
  • Surgical Resection: may be only option if the diagnosed is delayed and patient already has stricture/stenosis
  • Trach: may be required if recurrent laryngeal nerves are damaged

References

  • Deslauriers J, Beaulieu M, Archambault G, et al. Diagnosis and long-term follow-up of major bronchial disruptions due to non-penetrating trauma. Ann Thorac Surg 1982; 33:32-39
  • Roxburgh JC. Rupture of the tracheobronchial tree. Thorax 1987; 42:681-688
  • Rollins RJ, Tocino I. Early radiographic signs of tracheal rupture. Am J Roentgenol 1987; 148:695-698