Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation: A case report

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Massive hemothorax due to splenic rupture is exceedingly rare.

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Delayed or missed diagnosis of massive hemothorax due to splenic rupture is fatal.

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Isolated diaphragmatic injury is very rare.

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Diaphragmatic rupture signifies underlying serious injuries.

Background

Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation is quite an uncommon life-threatening condition usually associated with blunt thoracoabdominal trauma. Mortality is generally associated with coexistent vascular and visceral injuries that could be rapidly fatal. Timely, and proper diagnosis is mandatory as survival depends on prompt diagnosis and treatment.

Presentation of case

We describe a case of massive left hemothorax secondary to blunt thoracoabdominal injury with left diaphragmatic and splenic rupture, gastric, greater omentum and splenic herniation into the left thoracic cavity in a 32 years old male car driver after sustaining a road traffic accident and presented with shortness of breath of 4 h’ duration. He also had zone 3 retroperitoneal hematoma and left acetabular fracture. He was treated surgically and discharged home improved.

Discussion

Diaphragmatic ruptures following blunt injuries are larger leading to herniation of visceral organs into the thoracic cavity and the most common organ to herniate on the left side is the stomach followed by omentum and small intestine. Splenic rupture is a very rare cause of hemothorax and is often missed in the differential diagnosis.

Conclusion

Massive hemothorax following splenic and diaphragmatic rupture with visceral herniation following either blunt or penetrating trauma is rare. Delayed or missed diagnosis is associated with higher morbidity and mortality. A high index of suspicion and proper use of diagnostic studies are crucial for early and correct diagnosis.

Acute and Delayed Traumatic Diaphragmatic Ruptures Presenting at the Emergency Service: What are We Missing?

Introduction

Diaphragmatic rupture is rarely a cause of death by itself. It is especially difficult to diagnose diaphragmatic ruptures in patients with unstable vital signs who present at the emergency service with concurrent chest, abdomen, and extremity injuries as a result of blunt trauma. We evaluated the diagnostic processes, clinical findings and treatment results of acute and delayed traumatic diaphragmatic ruptures (TDR) cases that presented at the emergency service.

Methods

A total of 29 patients that underwent surgical treatment with a diagnosis of TDR among 1021 patients that presented at the Canakkale State Hospital Emergency Service with acute or delayed thoracoabdominal trauma were retrospectively investigated. The age, gender, trauma etiology, diagnosis duration, injury severity score (ISS), rupture location, accompanying organ injuries, operation type, inpatient duration, morbidity and mortality were recorded on prepared forms to analyse the cases.

Results

The mean age of the 29 patients with TDR was 45.31 + 17.76 years with and 20 (69%) males and 9 (31%) females. The trauma was blunt in 22 (76%) and penetrating in 7 (24%) cases. The TDR was acute in 16 (55%) and delayed in 13 (45%) patients. The surgery for TDR treatment consisted of with thoracotomy in 16 (55%) patients, laparotomy in 11 (38%) patients and both thoracotomy and laparotomy in 2 (7%) cases. Mortality occurred in 3 (10%) patients that presented at the acute stage.

Conclusions

The patients undergoing thoracoabdominal trauma, should be explained the probability, although low, of rupture of the diaphragm. These patients should be followed up and it should be emphasized that they should absolutely tell this trauma history to the physician who examines them when they present at the emergency service.

Missed diagnosis of a large, right-sided diaphragmatic rupture with herniated liver and concomitant liver laceration after blunt trauma: consequences for delayed surgical repair

Diaphragmatic injuries are relatively rare and as such frequently missed, particularly if they occur as a rare event on the right-sided dome. Even if detected in the early phase, the concomitant injury of other organs may delay the time to repair. The delay in surgical correction may aggravate additional adherences between thoracic and abdominal organs and cause the diaphragmatic muscle to retract, causing a larger tissue defect that may prevent primary suture repair. This should be taken into consideration when choosing access to repair (thoracic, abdominal or both cavities), mode (open or laparoscopic) and type of repair (primary suture or use of mesh material to close the defect). Here we present a case of delayed right-sided, blunt diaphragmatic injury with herniation of liver. Repair was performed in a delayed manner with an initial laparoscopic exploration converted to open abdominal repair with closing of defect with Gore-tex mesh material.

Blunt Diaphragmatic Injuries: Pericardial Ruptures

Blunt traumatic diaphragmatic injuries (BTDIs) can be misdiagnosed. Careful evaluation of associated injuries in BTDI is important. In this study, we evaluated treatment options and difficulties in the diagnosis of patients with BTDI. We evaluated ten patients retrospectively with BTDI admitted to our departments, between January 2004 and 2015. Age, gender, trauma type, symptoms, radiological findings, diagnosis time, location and grade of the diaphragmatic injury, surgical type of repair, associated injuries and pericardial rupture, and morbidity and mortality rates were recorded. The mean age of the patients was 46.7 years, and all were males. Ninety percent of BTDI was left sided, and 10 % was on the right side. The diagnosis was confirmed with chest radiograph in 50 % and computed tomography in 70 %. Radiological examination revealed hemothorax in 80 %, the loss of diaphragmatic shadow in 60 %, and visceral organ herniation to the thorax in 60 %. Multiple organ injuries were present in 90 % of cases. Pericardial rupture seen in 30 % was remarkable. Early surgery was performed for eight patients and late surgery for two patients. There were six patients with grade 4 or 5 central diaphragmatic injuries (CDIs). Multiorgan injury was present in all patients developing acute CDI. Multiple organ injury is much higher in patients with severe acute blunt trauma with CDI. Pericardial rupture rate is high in cases with acute BTDI and CDI. Proper diagnosis and early surgical management reduce morbidity and mortality.

Traumatic rupture of the diaphragm resulting in the sub-acute presentation of an incarcerated intra-thoracic transverse colon

The traumatic rupture of the diaphragm after blunt or penetrating injuries is a well described but uncommon entity. Its presentation in the form of herniated abdominal contents into the thoracic cavity is generally obscure and the recognition of this condition is often challenging. Although many cases remain asymptomatic, significant morbidity and mortality ensues with patients who present with incarceration, strangulation and eventual visceral compromise. Definitive guidelines in the management of traumatic diaphragmatic injuries are still lacking. This report outlines a case of sub-acute presentation of a traumatic diaphragmatic rupture in an elderly female following a motor vehicle accident that required urgent surgical intervention. We reviewed the pertinent literature, with an emphasis on the operative approach and the type of repair of the traumatic diaphragmatic defect.

Traumatic diaphragmatic rupture in pediatric age: review of the literature

PURPOSE

Traumatic diaphragm rupture (TDR) is a rare complication of trauma in pediatric age and may be easily missed by the severity of associated injuries so that delayed emergent presentation can occur with increased rate of morbidity and mortality. No review has been available to guide clinicians through the pitfalls and the initial diagnostic approach to pediatric TDR.

METHODS

A Medline thorough search on TDR was conducted using different queries. English language citations were identified during the period of January 2000 through December 2014 limiting the search to pediatric age (0-18 years). Abstracts were reviewed to determine eligibility and texts were obtained for further review. Differences were resolved by consensus and only reliable data were included.

RESULTS

Most frequently reported presenting symptoms of TDR are respiratory and abdominal. While respiratory symptoms are among the most frequently described at the onset in pediatric and adult series, abdominal symptoms result to be more frequent in adult than pediatric patients. Chest X-ray (CXR) is the first-line imaging exam which is reported to show pathognomonic or suspect findings in 85 %. CT was the second main radiological technique used, in particular to confirm the suspicion of TDR.

CONCLUSIONS

A high clinical index of suspicion is needed to diagnose and effectively manage diaphragmatic rupture. TDR should be kept in mind while dealing with patients assessed for abdominal or respiratory symptoms whenever there is history of trauma or blunt injury especially in children as the increasing of non-operative management of blunt abdominal trauma could result in missing important injuries as TDR.

An undiagnosed left sided traumatic diaphragmatic hernia presenting as small intestinal strangulation: A case report

INTRODUCTION

Post traumatic diaphragmatic hernia is very often missed particularly in polytrauma patients. We present case of an isolated post traumatic diaphragmatic hernia with strangulation, a very rare finding.

PRESENTATION OF CASE

A 35 year old man presented with features of intestinal obstruction with past history of a seemingly trivial blunt thoracic injury 15 years back. Findings of X-ray abdomen and chest with high leukocyte count raised suspicion of obstructed diaphragmatic hernia which on exploration revealed obstructed diaphragmatic hernia with gangrenous bowel segment.

DISCUSSION

Blunt injury of diaphragm is relatively common and is considered as a marker of severe trauma and it can clinically be occult as other violent injuries may mask and disguise its initial clinical presentation(1) resulting in late presentation with obstruction and/or rarely strangulation. An early diagnosis of the condition is prudent to avoid morbidity and mortality associated with late presentations.

CONCLUSION

In a patient of intestinal obstruction with history of even trivial throraco- abdominal injury, diagnosis of diaphragmatic hernia should be kept in mind.

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTION

Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.

PRESENTATION OF CASE

A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.

DISCUSSION

We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.

CONCLUSION

A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

Delayed diagnosis of a right-sided traumatic diaphragmatic rupture

Right-sided traumatic diaphragmatic rupture in childhood is a very rare injury. Diaphragmatic rupture often manifests itself later, after an organ progressively herniates into the pleural cavity. When the patient is tubed, the ventilation pressure does not allow herniation of an organ, which occurs when the patient is ex-tubed. We present a patient with a delayed diagnose of right sided diaphragmatic rupture with a complicated post-operation state.