|Year : 2016 | Volume
| Issue : 1 | Page : 4-7
Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance
Moheb A Rashid1, Mohammad A Rashid2
1 Department of Surgery/Östra, The Institute of Surgical Sciences, Sahlgrenska University Hospital, Gothenburg University, Gothenburg; Jacobsgårdarnas Health Center, Borlänge; Department of Surgery, Örnsköldsvik Hospital, Örnsköldsvik, Sweden; Department of Surgery, Lillehammer Hospital, Lillehammer, Norway; Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden
2 Guest Rsearch fellow in Cardiothoracic Trauma, Military Hospitals, Cairo, Egypt
|Date of Web Publication||15-Nov-2016|
Moheb A Rashid
Department of Surgery/Östra, The Institute of Surgical Sciences, Sahlgrenska University Hospital, Gothenburg University, Gothenburg; Jacobsgårdarnas Health Center, Borlänge; Department of Surgery, Örnsköldsvik Hospital, Örnsköldsvik, Sweden; Department of Surgery, Lillehammer Hospital, Lillehammer, Norway; Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden
Source of Support: None, Conflict of Interest: None
Objective: Contrecoup injuries are well-known lesions in the neurosurgical practice, while their existence in other medical disciplines is lacking. Another term of confusion is the contralateral lesion that is ill defined when compared to the contrecoup injury. A nomenclature, mechanism, and clinical significance of such lesions in cardiothoracic trauma patients are warranted.
Patients and Methods: Only one patient with thoracic contracoup injuries was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Östra, Gothenburg, Sweden. The other four cases with contrecoup injuries were encountered in a prospective manner in different places both in Sweden and Norway. All the four prospective cases were witnessed and well documented during trauma occurrence and management.
Results: All patients developed significant contralateral chest wall symptoms and signs requiring treatment. One patient developed huge contrecoup pneumothorax. Two patients developed contrecoup hemothoraces. One patient developed contrecoup cardiac injury. One patient developed contralateral chest wall rib fractures. Two patients developed contralateral sternal fractures; one of them was unstable and required surgical fixation.
Conclusions: Nomenclatures to what are have called contrecoup and contralateral lesions in cardiothoracic practice are suggested. Discrepancy between the trauma side of the chest and the resulting lesions exactly on the contralateral part may make the diagnosis difficult to understand and could give a suspicion concerning the trauma site, and whether the patient was conscious or simply not telling the truth as in case of trauma with medicolegal aspects.
Keywords: Contralateral rib fractures, contralateral sternal fractures, countercoup hemothorax, countercoup pneumothorax, chest trauma mechanism, thoracic contralateral injuries, thoracic coup and contrecoup injuries, cardiac contrecoup injury
|How to cite this article:|
Rashid MA, Rashid MA. Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance. J Cardiothorac Trauma 2016;1:4-7
|How to cite this URL:|
Rashid MA, Rashid MA. Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance. J Cardiothorac Trauma [serial online] 2016 [cited 2021 Mar 8];1:4-7. Available from: https://www.jctt.org/text.asp?2016/1/1/4/194051
| Introduction|| |
Contralateral lesions have never been reported in another discipline in medicine other than neurosurgery and once mentioned, the term "contrecoup" is usually used. Contrecoup injury is actually named after Emile Contre-Coup in 1548.  The modern mechanism of countercoup injury has been described.  However, contrecoup injury has been previously described in thoracic trauma in a Swedish report.  Two additional cases were recently reported from India.  We have found that not all lesions on the contralateral side of the chest in case of trauma are contrecoup lesions. ,,,, A nomenclature, mechanism, and the clinical significance of such unique entities are warranted.
| Patients and Methods|| |
Only one patient with contrecoup huge pneumothorax, and contrecoup mild hemothorax, together with contralateral rib fractures was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Östra, Gothenburg, Sweden. The other four cases were encountered in a prospective manner in different places in Sweden and Norway. All the four prospective cases were witnessed during trauma occurrence. A meticulous and detailed history was taken from the patients and those who witnessed the accident and followed with the patients to the hospital. Old injuries were never found on the ipsilateral or contralateral side in all patients including the oldest one who was mentally clear enough to give history as his case was a retrospective one.
A well-oriented 85-year-old man fell down on his left side and complained of severe pain and tenderness on the right side of the chest. Chest X-ray showed right-sided multiple rib fractures, huge pneumothorax, and mild hemothorax. The patient was treated with a chest tube and analgesics and did well during follow-up. As this case was a retrospective one, there were no available photographs of the patient denoting the side of trauma although thoroughly reported in the medical record of the patient.
A 17-year-old girl fell down (witnessed fall) on her back with outstretched arms during gymnastic training. She experienced pain on the front of the chest but not on the back and was tender over the sternum. A sternal X-ray showed a sternal fracture [Figure 1]a and b. Electrocardiogram and cardiac enzymes excluded cardiac injuries. Chest X-ray and radiograph of the cervicothoracic spine were unremarkable. The patient was treated with analgesics and did well during follow-up.
|Figure 1: The external appearance of the front of the thoracic wall where the markings drawn on the chest showing points of severe tenderness and were not struck by the fall (a). Lateral sternal radiogram shows a sternal fracture (b) (Case 2)|
Click here to view
A 60-year-old man fell down (witnessed fall) on his back and complained of severe chest pain particularly on movement. He was severely tender over the sternum [Figure 2]a and b. Myocardial contusion was confirmed, and a sternal fracture was diagnosed. The fracture was unstable; therefore, it was surgically repositioned and transfixed. The patient was doing relatively well during follow-up.
|Figure 2: The front of the thoracic wall that was not struck, where the markings drawn on the chest were the points of severe tenderness (a). CT scan of the chest shows a displaced unstable sternal fracture that was severely painful and was clicking on palpation (b) (Case 3). The fracture was surgically repositioned and transfixed|
Click here to view
A 51-year-old man fell down (witnessed fall) on his right side while driving his motorcycle at about 40 k/h and complained of chest pain. There was no trauma to the left side. On examination, he was severely tender on the left side with bruising on the right side [Figure 3]a and b. CT scan of the chest showed bilateral lung contusions and hemothoraces more on the opposite side of trauma [Figure 3]c. He was conservatively treated and did well.
|Figure 3: The impacted right side of the body with bruising (a), while the left side was not involved (b). CT scan of the chest depicted bilateral lung contusions and hemothoraces more on the contralateral side of trauma (c) (Case 4)|
Click here to view
A 32-year-old man fell down (witnessed fall) on his right side while cycling his mountain bike at down-hill race. He complained of chest pain on the right side. There was no trauma to the left side. On examination, he was tender on his right side with bruising [Figure 4]a and b, and a clavicular fracture was confirmed by X-ray. CT scan of the chest depicted bilateral lung contusions more on the trauma side [Figure 4]c. He did well with conservative treatment.
|Figure 4: The right side of the body with bruising (a) denoting the side of trauma, while the left side was not involved (b). CT scan of the chest showed bilateral lung contusions more on the ipsilateral side of trauma (c) (Case 5)|
Click here to view
| Discussion|| |
All cases developed significant contralateral chest wall symptoms and signs requiring treatment and represented different dimensions of the chest wall, different ages and gender, and occurred at different parts in Scandinavia. This discrepancy between the trauma side of the chest and the resulting lesion exactly on the contralateral part makes the diagnosis difficult to understand, and a suspicion usually arises concerning the trauma site and whether the patient was conscious and oriented at the time of trauma, or simply not telling the truth as in case of trauma with medicolegal aspects. All patients were conscious without amnesia, dementia, or old trauma. It has been assured that the chest wall was not involved in sequential trauma before touching the ground in all cases.
Contrecoup thoracic injuries
It is suggested to be defined as a lesion on the contralateral part of the chest but confined to an internal thoracic organ struck by the chest wall from inside, on the opposite side of trauma, as clearly described in lung contusion.  Simply, all thoracic contrecoup injuries are thoracic contralateral injuries, but not all thoracic contralateral injuries are thoracic contrecoup injuries. However, both contrecoup and contralateral injuries could coexist as seen in cases 1 and 3. In this small case series, we could suggest the following nomenclature, namely, contrecoup pneumothorax could be defined as a pneumothorax developed on the contralateral side of impact due to a countercoup lung injury as in case 1. Contrecoup hemothorax is defined in the same manner as in cases 1 and 3. Contrecoup cardiac injury could be defined as cardiac injury due to trauma to the back of the chest (as falling on the back), moving the heart anteriorly toward the sternum that may be fractured as clearly shown in this study in case 3.
Contralateral thoracic injuries
A thoracic contralateral injury is suggested to be defined as a lesion found on the opposite side of the chest compared to the side of trauma, whether right or left (cases 1, 4, and 5) and anterior or posterior (cases 2 and 3). We found that once the back is impacted by falling, then the weaker sternum was fractured as in cases 2 and 3. However, contralateral chest wall rib fractures and sternal fractures are easier to understand where the rib cage acts as a ring. A trauma to one part of the ring may rupture another part of it, particularly in the opposite side of impact as in cases 1, 2, and 3. The authors suggest certain characteristics for such definitions as shown in [Table 1] and [Table 2]. Historically, sternal contralateral fractures are named countercoup fractures.  According to the suggested mechanism in this study and based on understanding the modern scientific basis by which such injuries could take place, ,,,,, a contrecoup sternal fracture is a misnomer, and a more precise definition would be more appropriate as the suggested contralateral sternal fractures. The same nomenclature could be applied for the rest of the thoracic cage, particularly rib fractures, which are the most common injuries in chest trauma.
|Table 1: Differences and similarities between cardiothoracic coup and contrecoup lesions|
Click here to view
|Table 2: Differences and similarities between cardiothoracic contralateral and contrecoup lesions|
Click here to view
Contrecoup thoracic injuries
In this small series, one could postulate that the trauma mechanism by falling back in 2 cases and on one side in 3 cases bears the fact that patients were struck over large area of the chest (a whole back or a whole side) which has a greater tendency to cause a significant blow against a stationary object and here is the ground. A compression wave or rebound theory could be suggested in this study to play a role in injury development. When the chest or part of it is struck by force as falling down, the movable chest wall is pushed inward on the underlying compressible lungs or mediastinal structures. Then, a wave of compression will move through the lungs and mediastinal structures toward the opposite side of the chest that suddenly thrown upon an unyielding rigid chest wall producing injury by the impact from inside. ,
Contralateral thoracic injuries
A suggested explanation was that trauma to a part of one side of the chest wall might cause injury to the contralateral part, as the chest wall, in particular, the ribs, sternum, and spine constitute a circle, and trauma to any part of the circle could lead to injury to another part of it. The trauma wave may be transmitted through the clavicle, descending chin, or ribs as previously suggested  when falling on the fully extended arms as in cases 2 and 3. The clavicle could act as a lever and help wrench the manubrium from the body of the sternum. The ribs, particularly the upper two ones, may transmit the forces to the sternum, displacing the manubrium that is firmly attached to the spine by short and rigid ribs. Conversely, the body of the sternum is joined by longer and more flexible ribs, creating a weak point for fracture.  Another explanation could be that once a part of the chest wall was struck, then the energy of trauma creates a positive intrathoracic pressure that could be exerted on the contralateral thoracic wall. Therefore, the development of a similar contrecoup injury of the brain, but inside the chest, probably needs more powerful trauma  and then traumatic energy hits the chest wall, which is easier to be broken than does the skull.
It is suggested that a countercoup or contralateral lesion should be taken into consideration when managing patients with cardiothoracic trauma to one side of the chest, presented with contralateral findings. This did not necessarily mean that the patient got amnesia or gave a wrong history or simply not telling the truth. It is also important mostly to avoid confusion during the urgent treatment of such cases. It could play a role in the explanation of certain trauma cases medicolegally. Furthermore, any advance to be made in the prevention of thoracic injuries should be aware of such a new mechanism in thoracic trauma that can definitely contribute to the design of protective vests. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jacoby MG. A historical note on the life and times of Emile Contre-Coup. Ala J Med Sci 1973;10:213-5.
Drew LB, Drew WE. The contrecoup-coup phenomenon: A new understanding of the mechanism of closed head injury. Neurocrit Care 2004;1:385-90.
Rashid MA. Contre-coup lung injury: Evidence of existence. J Trauma 2000;48:530-2.
Kumar S, Joshi MK, Qureshi AQ. Contre-coup injury in chest: Report of two cases. J Emerg Trauma Shock 2013;6:230-1.
De Tarnowsky G. VII. Contrecoup fracture of the sternum. Ann Surg 1905;41:252-64.
Fowler AW. Flexion-compression injury of the sternum. J Bone Joint Surg Br 1957;39:487-97.
Moccetti M, Wyttenbach R, Santini P, Previsdomini M, Corti R, Gallino A. Images in cardiovascular medicine. Posttraumatic cardiac contrecoup: In vivo
evidence by cardiac magnetic resonance imaging. Circulation 2009;119:1538-40.
Cooper GJ. Protection of the lung from blast overpressure by thoracic stress wave decouplers. J Trauma 1996;40 3 Suppl: S105-10.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]