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Fatal blunt cardiac injury: are there any subtle indicators?

A 29-year-old man had a head-on collision with an oncoming truck while riding a bike. He sustained a fracture of the left first rib, fracture of the left talar neck with ankle dislocation and fracture dislocation of the right wrist. The patient was haemodynamically stable and underwent an emergency open reduction and internal fixation of the fractured talar neck to prevent further vascular compromise of the lower limb. Postoperatively, the patient deteriorated haemodynamically with persistent tachycardia and respiratory distress and died after 3 days despite ventilator support. The postmortem examination revealed a contused heart with dissection of the coronary arteries. Our case demonstrates that a first rib fracture may be associated with severe thoracic and cardiac injuries which may be masked by less severe but more obvious skeletal injuries.