INTRODUCTION

Blunt traumatic pericardial rupture is an extremely rare injury, reported in only 22 cases among nearly 20,000 major trauma patients [1]. Pericardial rupture carries a substantial risk of complications such as cardiac herniation or strangulation, with mortality rates ranging from 30% to 64% [1,2]. Pericardial rupture is often associated with concurrent cardiac or vascular injury; however, in rare instances, it may occur in isolation [3]. Even without cardiac or vascular involvement, untreated pericardial rupture can result in fatal outcomes [4]. Preoperative detection remains particularly challenging, with reported diagnostic rates of only 18% to 38% [1,3,5]. Here, we present a patient with blunt trauma to the left chest who demonstrated an atypical right-sided pericardial rupture.

CASE REPORT

A 23-year-old woman with no significant medical history was injured in a motor vehicle accident while riding as a passenger. The vehicle overturned and partially collapsed, pinning her left side under the car during extraction.

On arrival, the patient was alert (Glasgow Coma Scale score of 14: eye response, 3; verbal response, 5; motor response, 6), maintained a secure airway, and was breathing spontaneously with a saturated oxygen value of 99%. Initial blood pressure was 77/54 mmHg, and heart rate was 104 beats per minute. A whole-body computed tomography (CT) scan was performed for further evaluation.

CT findings included cerebral concussion, right hemopneumothorax, left pneumothorax, multiple left rib fractures (third to fifth ribs), bilateral pulmonary contusions, left humerus fracture, a laceration of the right second finger, and a laceration of the left lower leg (Fig. 1). The injuries were predominantly thoracic, and the patient’s Injury Severity Score was 24.

A 28F chest tube was placed for the right hemothorax, with an initial drainage of 800 mL. Continued bleeding was noted, and hemoglobin declined from 10 to 8 g/dL. The patient received 2 units of red blood cell transfusion and was admitted to the intensive care unit (ICU) 3 hours after arrival. Ongoing drainage of 800 mL over 1 hour prompted further transfusion and exploratory thoracotomy 5 hours after admission for bleeding control.

Surgery was performed via a right lateral thoracotomy. Because left-sided pneumothorax was also present, a left chest tube was inserted after induction to avoid exacerbating pneumothorax during one-lung ventilation. The patient was placed in the left decubitus, and the chest was entered through the fifth intercostal space.

Intraoperatively, minimal hematoma was observed in the right pleural cavity. After irrigation, severe contusion and oozing were noted in the right upper mediastinum. A 10-cm right pericardial laceration was identified along the phrenic nerve, extending from the superior vena cava to the inferior vena cava. The defect exposed the right atrium and pulmonary veins externally, with thrombus formation within the pericardium. A pleural laceration was also noted near the insertion of the right upper lobe pulmonary vein.

To identify the bleeding source, a new pericardiotomy was made 3 cm anterior to the laceration, and thrombi were evacuated. No active bleeding was detected inside the pericardium, and saline irrigation confirmed hemostasis. The main bleeding source was identified as the pleural laceration near the right upper pulmonary vein insertion, which was repaired using 5-0 polypropylene sutures. The pericardial laceration was closed to prevent cardiac herniation, with pledgeted 5-0 polypropylene sutures placed along the phrenic nerve to minimize tension (Fig. 2). The newly created pericardiotomy was closed with continuous 5-0 polypropylene sutures.

Postoperatively, the patient developed right diaphragmatic palsy due to phrenic nerve injury, resulting in diaphragmatic elevation. Two days later, internal fixation was performed for the left humeral shaft fracture. On postoperative day 5, she was transferred from the ICU to the general ward, and on day 12, the chest tube was removed. Twenty days after admission, the patient was transferred to another hospital for rehabilitation due to left radial nerve palsy related to the humerus fracture.

Ethics statement

This study was approved by the Institutional Review Board of Armed Forces Capital Hospital (No. AFCH IRB 2025-02-002). The patient was fully informed about the study purpose, including publication of case details and clinical images. Written informed consent for publication of the research details and clinical images was obtained after completion of all treatments. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.

DISCUSSION

Blunt trauma–induced pericardial rupture is an exceedingly rare injury, with isolated cases, defined as those without intrapericardial or vascular involvement, accounting for approximately 17% to 29% of all blunt pericardial ruptures [1,3]. Previous studies have reported that rupture most often occurs in the left pleuropericardium (64%), followed by the diaphragmatic portion (18%) and the right pleuropericardium (9%) [1]. In this case, the patient presented with right-sided hemothorax but no evidence of cardiac or vascular injury. Because the majority of blunt traumatic pericardial tears occur on the left side, right-sided rupture represents an uncommon and atypical presentation, emphasizing the need for heightened clinical awareness of unusual injury patterns in chest trauma.

Pericardial rupture has been reported to occur in association with rib fractures or other skeletal injuries in nearly half of cases [1,5]. In this patient, multiple rib fractures and a humerus fracture were identified on the left side, while the right side demonstrated no osseous injury aside from hemothorax. This pattern suggests that a strong deceleration impact on the left chest likely transmitted forces across the mediastinum, producing a bursting-type injury responsible for the right pericardial rupture and the pleural tear near the insertion of the right upper pulmonary vein.

The diagnosis of pericardial rupture remains challenging. It is frequently established on clinical grounds, and in cases involving cardiac herniation, imaging studies such as CT may provide supportive evidence. CT, with its high-resolution imaging and ability to assess thoracic structures rapidly, is considered the most reliable diagnostic modality for major thoracic trauma and plays an important role in guiding surgical decision-making. However, the reported preoperative detection rate of pericardial rupture is only about 30% [5]. Although CT may offer indirect diagnostic clues, such as pneumopericardium, which is regarded as a critical sign [6], no such findings were identified in this case. The diagnosis was ultimately made during exploratory thoracotomy, performed because of persistent bleeding after chest tube placement. Without hemothorax, recognition of the rupture might have been delayed, which would have increased the risk of complications such as cardiac herniation and strangulation. This underscores the importance of maintaining a high index of suspicion for pericardial rupture even in initially asymptomatic blunt chest trauma.

Surgical repair is essential for large pericardial ruptures to prevent cardiac herniation [7]. In this patient, a 10-cm tear was identified and repaired with the potential for herniation in mind. The laceration extended parallel to the phrenic nerve, and the short posterior margin made the repair technically challenging. Because there was no gross evidence of direct phrenic nerve injury, we anticipated that nerve function would be either preserved or only transiently impaired. Therefore, primary closure was chosen rather than diaphragmatic plication. To minimize tension and avoid direct manipulation of the phrenic nerve, interrupted pledgeted sutures were placed beneath it. Despite these precautions, right diaphragmatic palsy developed postoperatively, resulting in elevation of the hemidiaphragm. Phrenic nerve skeletonization has been described as a preventive technique for postoperative palsy, but additional research is needed to clarify its long-term effectiveness.

In cases of severe blunt chest trauma, pericardial rupture should be included in the differential diagnosis. Although rare, these injuries carry potentially life-threatening consequences and demand careful consideration. While numerous case reports on pericardial rupture exist, systematic clinical studies remain lacking. Database-driven research is necessary to better define the incidence, diagnostic yield, and treatment outcomes of pericardial rupture. In particular, trauma registries could provide valuable insights into injury patterns and inform evidence-based strategies for optimal management of patients with pericardial rupture.

ARTICLE INFORMATION

Author contributions

Conceptualization: MH; Investigation: MH, HWK; Methodology: SS; Writing–original draft: MH, SS; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Initial computed tomography scans of the patient. (A) Right-sided hemothorax. (B) Bilateral pneumothorax. No evidence of cardiac herniation was observed.

Fig. 2.

Intraoperative findings. (A) The arrow points to the phrenic nerve, showing the repair sutures being placed while avoiding nerve injury. (B) The pericardium after the repair has been completed. In both images, the arrowheads indicate the cranial direction.

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