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CLASSIC CASES Late presentation of diaphragm rupture following blunt thoracic trauma Case Presentation A 67 year old woman was admitted via the emergency department complaining of nausea, vomiting and abdominal pain after meals. Chest X-ray on admission:
The Chest X-ray showed rupture of the left hemi-diaphragm with associated collapse of the left lung. On questioning, the patient admitted to having fallen 3 months previously and having sustained two broken ribs on the left chest. She was seen in the emergency department of another hospital and discharged after an overnight stay with analgesia. A chest X-ray was taken at the time, which presumably showed no evidence of diaphragmatic rupture. A CT scan showed the stomach in the left thoracic cavity, and the rib fractures responsible for the diaphragmatic laceration:
The patient was prepared for operation and underwent a scheduled procedure the following day.
A band-like constriction of the stomach by the diaphragm can be seen in the marks on the stomach:
The chest was washed out and the
diaphragmatic laceration was repaired with a continuous nylon
suture.
The abdomen was closed and the patient made an uneventful post-operative recovery. Discussion Blunt injury to the diaphragm occur in approximately 1% of all trauma adminssions. The diaphragm is most commonly injured by a direct blow to the abdomen, causing a sudden increase in intra-abdominal pressure, or by direct laceration from rib fractures. Rupture of the diaphragm rarely occurs in isolation, and associated injuries to the thoracic aorta, liver & spleen and pelvis are often present. Diagnosis is often difficult or missed, as the above case shows. A high index of suspicion is vital. Chest X-ray may reveal the injury if abdominal contents have herniated into the chest, may reveal a thickening or fuzziness of the diaphragmatic outline, an elevated hemidiaphragm or be completely normal - especially if the patient is intubated & ventilated. Haemopneumothoraces are a common associated finding. Overall the plain Chest X-ray has a 50% accurracy. Diaphragmatic injury may be detected on ultrasound - but rarely. CT scanning has a sensitivity of only around 70-80%. MRI may be the best non-invasive examination for blunt diaphragmatic injury. Laparoscopy or thoracoscopy have become the primary means of diagnosing diaphragmatic injury - though the are more frequently employed for penetrating trauma. As with CT and MRI scanning, the patient must be haemodynamically stable for these procedures. Delay in detecting and repairing diaphragmatic injury increased both morbidity and mortality. Operative repair is also technically more difficult, the longer the delay to surgery. Diaphragmatic injuries are usually repaired via a laparotomy incision.Abdominal contents are reduced and the diaphragm can usually be repaired simply with a large monofilament non-absorbably suture, placed as locked stitches or horizontal mattress sutures. Care should be taken if the laceration extends into the central tendon of the diaphragm, where the myocardium is easily caught in poorly placed sutures. It is important to adequately wash out the thoracic cavity prior to closure, to remove any clot or contamination. In cases where the diaphragmatic hernia has been present for a long time (years) simple closure may be difficult or impossible, and non-absorbably mesh may be required. References 1. Shanmuganathan K, Killeen K,
Mirvis SE, White CS. Imaging of diaphragmatic
injuries. J Thorac Imaging. 2000;15:104-11 trauma.org (7:1) January 2002 |
