Millimeters from catastrophe: The pericardium as a lifesaving shield

ABSTRACT

We report a rare case of a 2-year-old child presenting 48 h after accidental penetrating chest trauma due to a fall from a motorcycle, with a retained foreign body lodged within the pericardial sac. Imaging revealed an opaque object overlying the cardiac silhouette. On median sternotomy, approximately 50 mL of pericardial blood was evacuated, and a piece of metallic debris was found resting beneath the left atrial appendage without injury to cardiac structures. The foreign body was successfully removed without cardiopulmonary bypass, and the child had an uneventful recovery. Retained foreign bodies in the pericardium following blunt–penetrating trauma in pediatrics are exceedingly rare and require a high index of suspicion and appropriate imaging. Surgical exploration remains the definitive treatment when pericardial injury or cardiac tamponade is suspected.

INTRODUCTION

Penetrating thoracic trauma in children is usually uncommon but can carry significant morbidity due to the proximity of vital organs within a small thoracic cavity. Retained foreign bodies lodged in the mediastinum or pericardial space are rare, and outcomes depend on prompt presentation, identification, and surgical management.

CASE REPORT

A 2-year-old male child presented to our emergency department 2 days after a roadside accident where he fell from a motorcycle. The father reported limited details of the injury, with only a “suspicious” track mark observed over the left anterior chest [Figure 1]. The child was hemodynamically stable with no respiratory distress.

Figure 1.

Entry wound

Initial chest X-ray demonstrated a radiopaque foreign body overlying the front of the cardiac silhouette [Figure 2]. Contrast-enhanced computed tomography (CT) of the chest suggested a bony or metallic artifact migrated behind the heart with no obvious pulmonary or vascular injury [Figure 3].

Figure 2.

X-ray with foreign body

Figure 3.

Migration of the foreign body

Given the risk of cardiac tamponade and possible pericardial involvement, the patient was taken from the emergency to the operating room for median sternotomy. Upon opening the pericardium, ~50 mL of old blood was evacuated. Careful inspection revealed a possibility of a metallic fragment resting beneath the left atrial appendage without evidence of penetration into myocardium, coronary, or pulmonary vessels. The object was removed and found to be a broken glass bangle [Figure 4]. And pericardial lavage was performed. No cardiopulmonary bypass was required. The postoperative course was uneventful, and the child recovered well.

Figure 4.

Three-dimensional computed tomography scan, showing migration

DISCUSSION

Penetrating thoracic trauma in the pediatric population is rare and accounts for a small fraction of trauma-related admissions compared to adults. However, due to the relatively small thoracic cavity and close proximity of vital structures, even low-energy penetrating injuries can result in significant cardiac or great vessel involvement. Retained foreign bodies within the pericardial space are exceedingly uncommon in children and are most often described in isolated case reports.[1,2]

In most reported cases, pericardial foreign bodies result from high-velocity mechanisms such as gunshot wounds, sharp object assaults, or iatrogenic causes.[3,4] In contrast, the present case demonstrates an unusual mechanism, a road traffic accident with a fall from a motorcycle, leading to penetration of an object into the pericardial cavity without overt external signs or immediate hemodynamic compromise.[1,5] The trivial appearance of the entry wound likely contributed to delayed presentation, highlighting the diagnostic challenge in pediatric trauma.

Delayed presentation after penetrating cardiac or pericardial injury is well documented and may be attributed to a “sealed” myocardial or pericardial breach, clot formation, or the tamponading effect of surrounding tissues.[4,6] In children, compensatory physiological mechanisms may further mask early symptoms. In our case, the child remained clinically stable despite the presence of hemopericardium and a retained foreign body in close proximity to the left atrial appendage, an area particularly vulnerable due to its thin wall and proximity to coronary structures.[3,6]

Radiological evaluation plays a critical role in such scenarios. Chest radiography remains a useful initial tool for detecting radiopaque foreign bodies, especially bony or metallic objects.[7] However, precise localization and assessment of surrounding structures require contrast-enhanced CT. Contrast CT imaging not only aids in determining the exact position of the foreign body but also evaluates associated injuries to the myocardium, lungs, great vessels, and ribs.[1,4] In our case, Contrast CT suggested a metallic or rib fragment adjacent to the heart, raising suspicion of pericardial involvement and prompting surgical exploration, as well as it showed migration in comparison to the image of chest radiograph.[2] The retained foreign body was not visible on echocardiography; it only showed pericardial effusion.

The management of retained intrathoracic or intrapericardial foreign bodies remains controversial, particularly in asymptomatic patients. Some authors advocate conservative management for stable patients with deeply embedded objects and no evidence of complications.[7] However, foreign bodies within the pericardial space pose a higher risk due to potential migration, erosion into cardiac chambers or coronary arteries, delayed tamponade, infection, or arrhythmias.[3,4,6] Therefore, most authors recommend surgical removal when the foreign body is intrapericardial or in close proximity to vital cardiac structures.[4,6,8]

Median sternotomy provides excellent exposure of the heart and pericardium and remains the preferred approach when the exact extent of injury is uncertain.[7] In pediatric patients, this approach allows safe control of potential bleeding and facilitates rapid initiation of cardiopulmonary bypass if required. In the present case, thorough preparation for emergent bypass was prudent given the unknown trajectory of the object and its proximity to the left atrium. Fortunately, the foreign body was free-lying within the pericardial cavity without myocardial penetration, allowing removal without the need for bypass.[4,6]

The presence of approximately 50 mL of pericardial blood indicates a prior breach of pericardial integrity, which had likely sealed spontaneously. Such a contained hemopericardium can remain clinically silent but carries the risk of sudden decompensation or mortality.[3,6] This underscores the importance of maintaining a low threshold for operative intervention in similar cases, even in the absence of classical signs of cardiac tamponade.

Another noteworthy aspect of this case is the nature of the foreign body, a piece of glass bangle [Figures 5 and 6], which is unusual and emphasizes the unpredictable trajectory of objects during road traffic accidents. In further history, parents said that the mother was holding the child, and due to a fall, multiple bangles were broken. Obviously, one of the fragment penetrated the chest and lodged into the pericardial cavity. Similar unusual intrapericardial foreign bodies have been described rarely.[2,4] This also highlights the need for careful clinical correlation in pediatric trauma, as the mechanism of injury may not always be immediately apparent.

Figure 5.

Removal of foreign body

Figure 6.

Broken glass bangle

Postoperative outcomes following timely surgical removal of pericardial foreign bodies are generally favorable, particularly when myocardial structures are spared. Early intervention prevents late complications such as constrictive pericarditis, chronic inflammation, or infectious sequelae.[6,7,8]

CONCLUSION

This case underscores the importance of high clinical suspicion, detailed imaging, and timely surgical intervention in pediatric penetrating thoracic trauma with retained metallic foreign bodies. Early recognition and operative management can lead to excellent outcomes even in unusual presentations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.