Emergency Repair of an Isolated Traumatic Avulsion of the Right Main Stem Bronchus in a 7-Year-Old Girl.

Isolated tracheobronchial injury after blunt trauma of the chest is rare. Because of the high elasticity of the chest in children, they occur mainly in the pediatric population.  We report a case of a 7-year-old girl who experienced complete avulsion of the right main bronchus at the level of the carina after a horse-riding accident. The patient presented with extensive emphysema of the upper chest, neck, and face and severe respiratory distress. Endotracheal intubation led to tension pneumothorax. After insertion of two 17-mm thoracostomy tubes, pneumothorax and a massive air leak persisted. Isolated central bronchial injury was confirmed by computed tomography of the chest. Bronchoscopically guided selective intubation of the left main stem bronchus failed and the patient desaturated, requiring immediate salvage right posterolateral thoracotomy. Simultaneous occlusion of the defect, stabilization, and subsequent selective left lung intubation was possible only after placing a suture at the tracheal rim of the defect for retraction allowing compression of the defect and keeping the lumen open at the same time.  A cluster of clinical signs with subcutaneous emphysema and refractory pneumothorax with air leak of the thoracotomy tube is indicative of bronchial injury. Endotracheal intubation should be postponed in these cases until after thoracostomy tube placement, if possible. Placing a retraction suture during repair is a maneuver that helps to occlude the defect and keep the remaining tracheobronchial lumen open at the same time to establish crucial ventilation of the contralateral lung.