Tuberc Respir Dis.  2009 Mar;66(3):241-245. 10.4046/trd.2009.66.3.241.

Delayed Diagnosis of a Traumatic Diaphragmatic Injury

• Park SW
• Kim CH
• Kim JY
• Lee SH
• Kim YW
• Hyun IG
• Shin HS

• KMID: 1846388
• DOI: http://doi.org/10.4046/trd.2009.66.3.241

Abstract

Traumatic diaphragmatic rupture is uncommon, but requires a prompt diagnosis and repair. Diaphragmatic injury is most commonly associated with automobile accidents. The diagnosis is difficult and may be delayed because there are no specific symptoms, signs, or radiographic studies that are pathognomic for diaphragmatic injury. The most important factor in the diagnosis is a high suspicion and the use of proper diagnostic studies. We report a case involving the delayed presentation of diaphragmatic rupture in a 54 year old man, requiring surgical repair 12 days following multiple blunt trauma. It should be noted that early recognition for diaphragmatic injury is important in patients with multiple trauma to avoid the potential fatal complications.

Keyword

Diaphragm; Injury; Trauma

MeSH Terms

Automobiles
Delayed Diagnosis
Diaphragm
Humans
Multiple Trauma
Rupture

Figure

• 

  Figure 1 Chest radiographs showing multiple rib fractures and increased opacity in left lower lung (A: admission), and some rib calluses and cleared left lower lung opacity (B: 1 year after discharge).

• 

  Figure 2 Chest computed tomography showing rib fracture and pleural effusion of left lung (A: admission), and rib fracture, interrupted line of diaphragm (white arrow) and herniated spleen in left hemithorax (B: follow-up on the 12th hospital day).

• 

  Figure 3 Operative findings showed diaphragmatic rupture (10×5 cm sized defect [black arrow] along the posterior lateral border of left diaphragm) and the herniation of stomach fundus, omentum and spleen, into the thoracic cavity through the ruptured diaphragmatic opening.

Reference

1. Brandt ML, Luks FI, Spigland NA, DiLorenzo M, Laberge JM, Ouimet A. Diaphragmatic injury in children. J Trauma. 1992. 32:298–301.

2. Park SS, Kang JG, Chung JM. Clinical review and evaluation of the blunt traumatic diaphragmatic injury. J Korean Soc Emerg Med. 1997. 8:217–227.

3. Flancbaum L, Dauber M, Demas C, Boyarsky AH, Trooskin SZ. Early diagnosis and treatment of blunt diaphragmatic injury. Am Surg. 1988. 54:195–199.

4. Rappaport WD, Lee S, Coates S, McIntyre K. Diagnosis of diaphragmatic injury using intraperitoneal technetium. Am Surg. 1989. 55:621–624.

5. Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg. 1995. 60:1444–1449.

6. Kim YW, Ah SH, Ryu SY, Kim HY, Jeon BM. Clinical evaluation of traumatic diaphragmatic injury. J Korean Soc Traumatol. 2001. 14:108–118.

7. Athanassiadi K, Kalavrouziotis G, Athanassiou M, Vernikos P, Skrekas G, Poultsidi A, et al. Blunt diaphragmatic rupture. Eur J Cardiothorac Surg. 1999. 15:469–474.

8. Cerón Navarro J, Peñalver Cuesta JC, Padilla Alarcón J, Jordá Aragón C, Escrivá Peiró J, Calvo Medina V, et al. Traumatic rupture of the diaphragm. Arch Bronconeumol. 2008. 44:197–203.

9. Goh BK, Wong AS, Tay KH, Hoe MN. Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma. CJEM. 2004. 6:277–280.

10. Haciibrahimoglu G, Solak O, Olcmen A, Bedirhan MA, Solmazer N, Gurses A. Management of traumatic diaphragmatic rupture. Surg Today. 2004. 34:111–114.

11. Crandall M, Popowich D, Shapiro M, West M. Posttraumatic hernias: historical overview and review of the literature. Am Surg. 2007. 73:845–850.

12. Kozak O, Mentes O, Harlak A, Yigit T, Kilbas Z, Aslan I, et al. Late presentation of blunt right diaphragmatic rupture (hepatic hernia). Am J Emerg Med. 2008. 26:638e3–e5.

13. Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Bühler MW. Missed diaphragmatic injuries and their long-term sequelae. J Trauma. 1998. 44:183–188.

14. Matsevych OY. Blunt diaphragmatic rupture: four year's experience. Hernia. 2008. 12:73–78.

15. Sadeghi N, Nicaise N, DeBacker D, Struyven J, Van Gansbeke D. Right diaphragmatic rupture and hepatic hernia: an indirect sign on computed tomography. Eur Radiol. 1999. 9:972–974.