Traumatic diaphragmatic ruptures: clinical presentation, diagnosis and surgical approach in adults

A Case of Traumatic Diaphragm Rupture: A Differential Diagnosis Not to Be Missed

Traumatic diaphragmatic rupture is a rare condition with clinical stigmata that overlaps with a similarly fatal condition such as tension pneumothorax. Although the former is much rarer, early differentiation between a ruptured diaphragm and a tension pneumothorax is crucial to avoid incorrect interventions. In this case, we present a middle-aged male construction worker who fell from the roof of a two-story building and presented to our emergency department with a clinical presentation similar to that of tension pneumothorax. However, a chest X-ray later revealed a left diaphragmatic hernia, which completely altered the management. This case helps highlight the importance of widening one's list of differential diagnoses, especially in the setting of a hectic environment and a vague presentation.

Acute Diaphragmatic Injuries Associated with Traumatic Rib Fractures: Experiences of a Major Trauma Centre and the Importance of Intra-Pleural Assessment

Background

Diaphragmatic injuries following blunt or penetrating thoraco-abdominal trauma are rare, but can be life-threatening. Rib fractures are the most common associated injury in patients with a traumatic diaphragmatic injury (TDI). We hypothesized that the pattern of rib fracture injuries could dictate the likelihood of acute TDIs.

Methods

A retrospective study was carried out between April 2014 and October 2018 to analyze patients with TDIs and rib fractures at a major trauma center in London, United Kingdom.

Results

Over the study period, 1,560 patients had rib fractures, of whom 14 had associated diaphragmatic injuries. Left-sided diaphragmatic injuries were found in 8 patients (57%) . A significant proportion of the rib fractures were located posterolaterally (44.9%). The highest frequency of fractures was found in ribs 5–10, which accounted for 74% of all the fractures. Ten patients underwent surgery, of whom 7 were diagnosed with a diaphragmatic injury intraoperatively after video-assisted thoracoscopic surgery assessment of the pleural cavity. Two patients died due to severe injuries of other organs and the remaining 2 patients were managed conservatively.

Conclusion

Our series of patients demonstrates a relationship between significant rib fractures and diaphragmatic injuries in trauma patients, and the diagnostic difficulties in identifying the condition. We found that the location of the rib fractures and the pattern of injury in patients with TDIs were much lower and posterolateral in the chest wall without a preference for laterality. We suggest using a thoracoscope in patients undergoing chest wall surgery post-trauma to aid in diagnosing this condition.

Surgical Approach in Management of Posttraumatic Diaphragmatic Hernia: Thoracotomy versus Laparotomy

Breach in diaphragmatic musculature permits abdominal viscera to herniate into the thoracic cavity. Time of presentation and associated injuries determines the surgical approach in management. This case report sets to highlight the challenges in clinical diagnosis, radiological interpretation, and surgical management approaches of posttraumatic diaphragmatic hernia. We report a case of a 43 years old male who was diagnosed with traumatic diaphragmatic hernia 6 months post blunt thoracoabdominal trauma due to motor traffic accident. He was initially diagnosed with haemothorax, drained with an underwater thoracostomy tube, and discharged. He continued to experience on and off chest pain worsening postfeeding, difficulty in breathing and abdominal pain for the next six months until his eventual diaphragmatic hernia diagnosis. He was scheduled for an elective thoracotomy. A left posterolateral thoracic over the 7^th intercostal space incision was used. Intraoperatively, the stomach, left lobe of liver, part of transverse colon, small bowel, and omentum had herniated into the thoracic cavity adhering into thoracic viscera and wall. Adhesiolysis was done, and abdominal organs reduced into abdominal cavity. Rent was closed by interrupted Prolene sutures reinforced with a mesh. In patients with delayed presentation of diaphragmatic hernia post blunt thoracoabdominal injury without associated intra-abdominal visceral injury, we recommend the thoracic diaphragmatic repair approach as long-standing herniated bowels might adhere with thoracic cavity walls or viscera. In such cases, adhesiolysis and rent repair is easier through thoracotomy.

Spleen in the thorax: A case report on traumatic diaphragmatic rupture

•

Diaphragmatic rupture is a rare complication of abdominal trauma.

•

Herniation of abdominal contents can occur following diaphragmatic rupture.

•

Spleen was present in the thorax in a case following blunt abdominal trauma.

•

Care should be taken when inserting a chest tube in suspected cases.

•

Treatment is surgical via Laparotomy or Thoracotomy.

Introduction

Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur.

Presentation of case

Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax.

Discussion

Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents.

Conclusion

Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

Successful management requiring multidisciplinary cooperation between seven departments for a large right-sided incarcerated traumatic diaphragmatic hernia: a case report and review of literature

We present a rare case of incarcerated traumatic diaphragmatic hernia (TDH) at the right-side presenting as dramatic dyspnea and acute gastrointestinal obstruction, which required urgent operative repair. This entity is sometimes difficult to ascertain after acute trauma and then consequently give rise to diagnostic delays with life-threatening outcomes. Successful management required a coordinated effort between anesthetist, sonographer, intensive care specialist, thoracic, urological, hepatobiliary and gastrointestinal surgeons. Tight and active multidisciplinary cooperation in this case manifested the positive energy in emergent resuscitation.