A Swiss flag through the chest: a case report of a rare transmediastinal impalement.

INTRODUCTION: Management of transmediastinal penetrating injuries (TMI) is challenging. We report an educational flagpole-related case. CASE PRESENTATION: A 61-year-old woman arrived at our trauma center after a boating accident resulting in transthoracic impalement from a fall onto a flagpole. She was hemodynamically stable, fully conscious, and without additional injuries. Chest X-ray showed an approximately 30-cm foreign body penetrating the thorax from the left and ending paramediastinally on the right, suggesting mediastinal and pulmonary involvement. CT confirmed that the flagpole entered through the left third intercostal space (ICS), traversed the left upper lobe and mediastinum near the aortic arch and between the trachea and esophagus, and ended in the right lung. Bronchoscopy and esophagoscopy excluded endoluminal injury. A clamshell thoracotomy was performed via the fourth ICS and was extended to the flagpole entry site. The flagpole penetrated both upper lobes and the mediastinum near the aortic arch. It was carefully withdrawn, and a minor adventitial injury to the aortic arch was identified. Pulmonary lacerations and a left upper lobe segmental artery were sutured. Tracheal exploration revealed no injury. She was extubated 7 hours postoperatively, remained in the ICU for three days, and was discharged after an uneventful 18-day stay. Follow-up showed no complications. CLINICAL DISCUSSION: Unlike common thoracic injuries, TMIs often require surgery due to the frequent involvement of critical organs. This case illustrates that stable patients benefit from detailed CT and endoscopic assessment to guide operative strategy. Controlled flagpole shortening enabled CT imaging. Clamshell thoracotomy provided optimal exposure of all involved structures. CONCLUSION: This TMI case highlights the importance of cautious shortening of impaling objects that exceed CT gantry limits and the critical role of multidisciplinary trauma management. GRAPHICAL ABSTRACT AVAILABLE AT: https://links.lww.com/IJSCR/A126.