Purpose or Case Report: Post-traumatic intercostal lung herniation (ICLH) is defined as a protrusion of lung tissue through a defect in the intercostal space musculature and is a rare result of chest trauma. Due to its rarity, the management and imaging work up has been based on the adult experience, with Computed Tomography (CT) the most common diagnostic tool and surgery the primary management approach.
The purpose of this study is to describe the sonographic appearance and technique utilized in diagnosis of post-traumatic ICLH and to support their inclusion in a proposed imaging algorithm to aid in management in the pediatric population.
Methods & Materials: We present a recent case of post-traumatic ICLH with follow-up and systematic review of all 15 cases in the literature found through a Pubmed, Embase, Ovid, Scopus and Cochrane search. Extracted data includes mechanism of trauma, clinical presentation, imaging performed, treatment and outcomes. Data was compared with the adult population.
Results: On Sonography, ICLH typically appears as loss of fascial plane delineation involving the external, internal and innermost intercostal muscles. The degree of disruption of this latticework of structures and the resulting loss of structural support determines the severity of the lung herniation, which is best depicted on real time assessment with utilization of maneuvers to increase intrathoracic pressures. ICLH usually presents as a soft non-tender mass exaggerated by coughing and/or straining and may present long after the initial injury. ICLH was located in the anterior chest wall in 81% of pediatric patients. The most common mechanism of trauma was blunt handlebar injury. Chest radiograph was used to diagnosis in 88% and CT scanning in 44% of patients. Sonography was utilized in 19% of cases. Management was surgical in 63% of patients, with thoracotomy with primary closure the preferred treatment. The remainder of the patients received non-surgical management with chest strapping, with resolution in 2-6 weeks.
Conclusions: Given the rarity of ICLH in pediatric patients and the lack of diagnostic and management guidelines, pediatric surgeons have mostly relied on published reports in the adult literature to guide work-up and management. The recent literature supports the feasibility of non-surgical management and the proposed imaging guidelines (Fig. 1) expanding the use of Sonography are meant to aid in the determination of surgical vs conservative treatment.