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Flexion-distraction injury of the upper thoracic spine associated with tracheoesophageal perforation. A case report.

Blunt chest trauma with tracheoesophageal perforation is an unusual and potentially catastrophic event. More than 60% of patients with these injuries-which are often associated with multiple major vessel tears, cardiopulmonary tamponade, or tension pneumothorax-die before reaching a hospital or during resuscitation1. Tracheoesophageal perforations in the cervical region are most often caused by penetrating injuries or by blunt trauma causing cervical hyperextension. Such injuries are less frequently recognized in the thoracic area2,3. Combined perforations of the "common weak wall" of the trachea and esophagus in the upper thoracic region can present challenges such as airway obstruction, septic pleuromediastinitis, and unstable hemodynamics. Furthermore, concurrent vertebral fracture with spinal cord damage can confound the course of management. We report a case of a motorcyclist with an upper thoracic spine fracture associated with incomplete spinal cord damage and a tracheoesophageal perforation.

A twenty-year-old male motorcycle rider was hit by an automobile and struck the road, landing on the upper part of his back. In the emergency room, he was found to be in shock and unconscious and to have severe neck swelling, subcutaneous emphysema, and dyspnea. A supine chest radiograph revealed mediastinal widening, a right pneumothorax (Fig. 1, A ), and fractures of the right third through sixth ribs. A thoracostomy yielded abundant air, 200 mL of blood, and food debris. Neurological assessment of the limbs was impossible because the patient was unconscious (a score of 7 of 15 on the Glasgow coma scale4 ). However, a computed tomographic evaluation was negative for intracranial hemorrhage. Subsequent supine radiographs of the chest showed a persistent air leak, massive subcutaneous emphysema, and a pneumomediastinum (Fig. 1, B ), but no bone abnormalities were noted on radiographs of the cervical spine.

Because the patient was having respiratory difficulty, an endotracheal …