Working Diagnosis:
Pneumomediastinum with small adjacent right medial pneumothorax.

Treatment:
The patient was observed overnight. Repeat CBC and CMP were within normal limits. Follow up chest x-ray demonstrated a resolving pneumomediastinum with no observed pneumothorax. Swallow barium was normal. The patient's diet was advanced and he was discharged in stable condition. He was advised by the trauma team to take one week off from contact and then to sport without restrictions.

Outcome:
He continued to have residual pain with deep breaths. Chest x-ray showed a resolved pneumomediastinum and a healing right 7th rib fracture. Given the nature of his pathology, a conservative approach to return to play was recommended. He rested from contact sport for two more weeks. He returned to activity once his symptoms completely resolved and finished the rest of football season.

Author's Comments:
Pneumomediastinum is the presence of air in the mediastinum and is rare in sport. Trauma-induced pneumomediastinum is a serious injury due to the association with complications and other injuries, such as pneumothorax and pneumopericardium. Pneumomediastinum injuries most frequently occur in tackling sports. The most common symptoms are sharp retrosternal chest pain and dyspnea. Symptoms are usually self-limited and there are no clear guidelines for treatment or return to play. Treatment typically includes observation until resolution of symptoms. It seems wise to proceed with a stepwise progression of activity to ensure resolution of symptoms prior to full return to play.

Editor's Comments:
Blunt chest trauma can result is serious and life threatening injuries. Initial evaluation and management should follow Advanced Trauma Life Support (ATLS) protocols which follows evaluation and stabilization of patient's airway, breathing, and circulation ("ABCs") known as "primary survey". Further evaluation may include an extended Focused Assessment with Sonography for Trauma (eFAST) as part of the secondary survey. Traumatic pneumomediastinum can be cause by trauma to the chest and common presenting symptoms include chest pain, dyspnea, and cough.

References:
1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 10th, American College of Surgeons, Chicago 2018.
2. Liman ST, Kuzucu A, Tastepe AI, et al. Chest injury due to blunt trauma. Eur J Cardiothorac Surg 2003; 23:374.

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