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• Look again! Delayed traumatic rupture of the diaphragm
  ALOK ARORA
  Published on: 29 April 2016

• Published on: 29 April 2016

  Look again! Delayed traumatic rupture of the diaphragm

  • ALOK ARORA, ST2 Anaesthetics
  • Other Contributors:
    • K. Kada, A. Ferguson

  Dear Sir,

  Please find enclosed our article submitted to European Journal of Anaesthesia, which was presented as a poster in Euro anaesthesia conference in Copenhagen on 31 May 2008 and also published in their May supplement, including the images.( A.Arora, K.Kada, A.Ferguson; Look again! Delayed traumatic rupture of diaphragm radiologically simulating a pneumothorax; Eur J Anaesthesiology 2008; 25 (suppl 44): 1...

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  Dear Sir,

  Please find enclosed our article submitted to European Journal of Anaesthesia, which was presented as a poster in Euro anaesthesia conference in Copenhagen on 31 May 2008 and also published in their May supplement, including the images.( A.Arora, K.Kada, A.Ferguson; Look again! Delayed traumatic rupture of diaphragm radiologically simulating a pneumothorax; Eur J Anaesthesiology 2008; 25 (suppl 44): 13AP1-3).

  Our case is similar to yours except for the fact that a CT scan was done based on clinical finding and X-ray before considering drainage and hence it avoided the complication described in your presentation.

  Background and Goal of Study:

  Diaphragmatic injury with herniation is a well-documented complication of both penetrating and blunt trauma. It occurs in approximately 3% of abdominal and 1.5% of thoracic injuries with a 2:1 ratio of penetrating to blunt trauma. It is left-sided in 70-80% of cases. Diagnosis requires a high index of suspicion as many cases are missed at first presentation.

  We describe a case of delayed traumatic diaphragmatic hernia radiologically simulating tension pneumothorax.

  Materials and Methods:

  6 months prior to presentation a 52 year old bricklayer had fallen from a ladder. Chest X-ray at that time demonstrated undisplaced rib fractures with no pneumothorax and follow-up was not thought necessary.

  He came to hospital on this occasion with a one month history of dull upper abdominal pain. Repeat chest X-ray showed unilateral radiolucent hemithorax on the left with a few broken ribs on that side and mediastinal shift to the right; a scaphoid abdomen was noted on examination.

  After review of the film, needle thoracocentesis was deferred and a CT scan performed. This showed a diaphragmatic hernia containing transverse colon. He underwent thoraco-abdominal repair of diaphragmatic hernia.

  Results and Discussion:

  The injury is uncommon, occurring in about 4% of victims of major closed chest or abdominal trauma.(1-4) Large pressure differentials between the chest and abdomen, generated at the time of injury, cause tearing of the dome of the diaphragm, more commonly on the left as the liver protects the right side by spreading the forces more evenly. The injury is indicative of severe trauma and injuries that accompany such trauma often take priority at presentation, resulting in injury to the diaphragm being overlooked.

  In some series this has been overlooked in up to roughly two thirds of patients. The patient may present months or years later in one of two ways. The first way is with mild symptoms typically in the lower chest, or epigastric pain occurring intermittently and often brought on by taking food; physical signs are minimal. This is the so called "latent" stage.

  The clinical picture may change dramatically and the patient present in the so called "late" stage with severe symptoms of pain, breathlessness, and intestinal obstruction or gastrointestinal haemorrhage.

  Examination may show that the patient is in shock. There may also be evidence of mediastinal shift, and bowel sounds may be audible in the chest. Nearly all such patients will have presented previously with minor "latent" symptoms.

  Treatment at any stage of the illness requires an operation. Reduction of herniated contents and closure of the defect is undertaken at the time of diagnosis through a laparotomy incision in the case of an acute onset and by an appropriate thoracotomy in chronic cases.

  Surgery performed during the "latent" stage carries a perioperative mortality of under 10%4. When surgery is undertaken in the presence of strangulation, in the "late" stage, there is a mortality of between 20% and 80%.(3)

  Conclusion:

  As most patients will present with minor symptoms before presenting with a severe illness the diagnosis must always be borne in mind. In all cases an accurate history (particularly trauma), clinical alertness, and a chest radiograph are the key to diagnosis.

  References:

  1. Alyono D, Perry JF Jr. Impact of speed limit. 1. Chest injuries, a review of 966 cases. J Thorac Cardiovasc Surg 1982; 83:519-22.

  2. McCollum C, Anyarnwy CH, Umeh BUO, Swarup AS. Management of traumatic rupture of the diaphragm. BrJ3 Surg 1987; 74:181-3.

  3. Payne JH, Yellin AE. Traumatic diaphragmatic hernia. Arch Surg 1982; 117: 18-24.

  4. De la Rocha AG, Creel RJ, Mulligan GWN, Burns CM. Diaphragmatic rupture due to blunt abdominal trauma. Surg Gynecol Obstet 1982; 154:175- 80

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  Conflict of Interest:
  None declared.

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