Traumatic diaphragmatic hernia jama surgery jama network. The left hemidiaphragm was injured in 24 cases 57%, the right in 15 36%, and both sides in three 7%. Halfacree, in feline soft tissue and general surgery, 2014. The transthoracic approach might be used in most cases with latent diaphragmatic rupture. Somford and coworkers presented a case of a rightsided diaphragmatic rupture with a delayed diagnosis 4.
In the acute setting, because ct is more readily available and because there is a high frequency of acute diaphragmatic rupture with concurrent lifethreatening associated injuries, ct is the next imaging study performed to evaluate patients with chest radiographic findings suggestive of a diaphragmatic injury, 2, 11. The leading cause of diaphragmatic rupture is penetrating abdominal trauma, including gunshot and stabrelated wounds. Rare case of diaphragmatic rupture following resuscitation in. A 66yearold male patient presented with recurrent coughing, dyspnoea, and intermittent fever. One of the most trying and difficult symptoms to interpret is pain. Traumatic rupture of diaphragm the annals of thoracic. Early diagnosis is a clinical challenge as findings from chest xrays can mimic haemo or pneumothorax 4, such as in this patient. A tension pneumothorax is a known lifethreatening condition which requires a needle decompression. We report a rare case of diaphragmatic rupture in a 29yearold pregnant patient who experienced a fullblown diaphragmatic defect and herniation of the abdominal organs into the thoracic cavity, as a complication of cpr. The presence or absence of diaphragmatic rupture was subsequently determined on the basis of unequivocal radio. A case of spontaneous diaphragmatic rupture article pdf available in nihon rinsho geka gakkai zasshi journal of japan surgical association 759. The cause of the rupture was a penetrating trauma in 51 75%, and blunt trauma in 17 25% patients in our study, which is different to most of the published series 9,11,15. This kind of injury is sometimes diagnosed at the time of the initial trauma referral due to its acute presentation, but sometimes it can escape detection, especially if occurring as an isolated injury. The sequelae from diaphragmatic rupture and subsequent herniation of intraabdominal contents are.
Ideal sources for wikipedia s health content are defined in the guideline wikipedia. Blunt diaphragmatic rupture is an uncommon occurrence. Diagnosis and treatment are similar regardless of mechanism, although many management issues are specific to blunt trauma. A diaphragmatic retroperitoneal cyst fp robertson1,2, d tsironis2, br davidson1,2 1 2 the liver unit, wellington hospital hca, wellington place, uk division of surgery and interventional science, royal free campus, university college london, uk abstract diaphragmatic lesions are usually congenital bronchogenic cysts. This is a rare congenital anomaly of the diaphragm that occurs due to poor embryogenesis with atrophy of the diaphragm muscle fibers and loss of muscle tone. The frequency with which either of these mechanisms lead to diaphragmatic injury varies according to the geographic location 1. A diaphragmatic rupture is a relatively rare injury and is difficult to diagnose. Epidemiology given that the most common mechanism is motor vehicle collisions, it is perhaps unsurprising that youn. Tension pneumothorax and life saving diaphragmatic rupture. Diaphragm rupture an overview sciencedirect topics.
Gastric disorders associated with diaphragmatic rupture. There are few reported cases of diaphragmatic rupture after cardiopulmonary resuscitation but none in pregnant woman. Spontaneous diaphragmatic rupture complicated with. The most common approach is the transabdominal approach, which allows a complete exploration of the abdominal organs for associated injuries. Diaphragmatic injuries are more common on the left. Their delayed presentation can be due to the delayed rupture of the diaphragm or delayed detection of diaphragmatic rupture, making the accurate diagnosis of di challenging to the trauma surgeons. Diaphragmatic injury is mostly caused by blunt or penetrating traumas. Diaphragmatic injury is an unusual life threatening complication of blunt trauma abdomen. Diaphragmatic excursion and chest wall expansion increase the negative intrathoracic pressure required for inhalation. Right axial ct in the same patient shows the typical signs of diaphragmatic injury, including the fallen viscus sign.
Diaphragmatic rupture also called diaphragmatic injury or tear. Olgu sunumu ferhat icme1, sevilay vural1, fatih tanr. Diaphragmatic rupture may result from traumatic injury usually from thoracoabdominal trauma, with an incidence of 0. In 14, acute hernias were diagnosed, but the diagnosis was made one month to 15 years after injury in 22 patients with chronic hernia. Diaphragmatic rupture an overview sciencedirect topics. Traumatic diaphragmatic rupture is frequently encountered in the cat see chapter 45 and is associated with herniation of abdominal contents. A retrospective study was performed to analyze our experience with patients suffering from traumatic diaphragmatic rupture. Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of. Such pain is referred pain and is found in diaphragmatic pleurisy. In this article, we will discuss a patient who sustained diaphragmatic rupture as a result of violent coughing. Anterior and lateral attachments inferior sternum, xiphoid process, lower six ribs, and costal cartilage. Treatment is a topic depend size and location of the defect, size and location of the defect, some pediatric surgeons do not operate if the patient is asymptomatic and only plicate the symptomatic patients.
Spontaneous diaphragmatic rupture complicated with perforation of the stomach during pilates abstract diaphragmatic rupture dr is most commonly seen after a blunt trauma. Blunt traumatic injury of the diaphragm has an incidence ranging from 1 to 7 percent and is considered a marker of severe injury with other concomitant injuries thoracic aorta, lung, spleen, hollow viscus, bladder, and pelvis. Traumatic injuries of the diaphragm remain an entity of difficult diagnosis despite having been recognised early in the history of surgery, especially when it comes to blunt trauma and injuries of the right diaphragm. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture was suggested before operation by unilateral elevation of the diaphragm, supradiaphragmatic densities, and displacement of abdominal organs into the thorax, as shown by chest films and gi series in 18 cases 43%. Traumatic right diaphragmatic rupture with hepatothorax. The posttraumatic diaphragmatic hernia ptdh is relatively uncommon and may be caused by blunt, penetrating or iatrogenic trauma. Traumatic diaphragmatic rupture tdr occurs in approximately 1% to 7% of patients with major blunt trauma, including in 10% to 15% of patients with trauma that results in penetration of the lower chest.
The incidence of posttraumatic blunt diaphragmatic injury varies from 0. Diaphragmatic hernia rupture during labor is a serious but rare complication that requires emergency surgery to prevent visceral perforation and cardiorespiratory failure. Rare case of diaphragmatic rupture following resuscitation. The patient went to have a successful diaphragmatic repair. Traumatic injuries of the diaphragm remain an entity of difficult diagnosis especially when it comes to the right diaphragm. Imaging of diaphragmatic rupture after trauma sciencedirect. When the pain is not felt by the patient at the site of its origin but is referred to other and perhaps distant parts of the body, the difficulty obviously increases. Traumatic diaphragmatic rupture with underlying lung. Diaphragmatic rupture also called diaphragmatic injury or tear is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in respiration. The association of gastric perforation along with diaphragmatic injury increases the mortality as well as morbidity manifold as compared to an isolated diaphragmatic injury. All penetrating diaphragmatic injuries require repair in order to avoid the major morbidity and mortality of a chronic diaphragmatic hernia. Diaphragmatic rupture and its complications following.
However, a double blow injury occurring simultaneously such as diaphragmatic hernia and gastric injury is a rare injury. The left diaphragm is involved more often because of the protective effect of the right lobe of the liver. When a conservative approach to trauma management is taken, blunt diaphragmatic rupture bdr remains undiagnosed at initial presentation in 7%66% of cases. The diagnosis can be difficult to make as the physical examination may be unremarkable, and imaging, that is, a conventional chest xray andor ct imaging, may initially fail to reveal the injury. Violent and paroxysmal coughs are associated with many complications. Drawing view from below shows the large central tendon, which is formed by the transverse septum. Consistent findings in animals with diaphragmatic rupture were irregular or asymmetric cranial aspect of the liver and abdominal viscera in the thorax. Therefore, the etiological factor of a diaphragmatic hernia, which refers as delayed case, is mostly a penetrating injury. Case report the journal of academic olgu sunumu emergency medicine spontaneous diaphragmatic hernia. Diaphragmatic rupture and its complications following blunt. The most common cause of blunt diaphragmatic rupture is road traffic accidents 2.
Multiple rib fractures noted in the left 3rd, 4th, 5th, 6th and 7th ribs. Diaphragmatic rupture definition of diaphragmatic rupture. Seven acute tdhs were due to blunt and seven to penetrating trauma. Zukoski, md, and believe that it does seem to emphasize an important diagnosis rupture of the right diaphragm. Delayed diagnosis and treatment of diaphragm rupture is associated with increased rates of morbidity and mortality. Download as pdf print show related cases notify admin. Rupture of the left hemidiaphragm after a motor vehicle. In recent scrutiny of our patients, we noted rupture of the right diaphragm to be as frequent as. We report a case of a 37yearold man with right diaphragmatic rupture after blunt injury 31 years prior to admission.
Upon manual exploration we felt a doughy sensation. Traumatic diaphragmatic hernia apparently was described by sennertus, who in 1541 reported an. In addition, an overlooked small defect on the diaphragm in the acute phase may enlarge later due to repeated minor trauma or blunt trauma. There have been occasional reports of bilateral injury fig. Diagnosis of diaphragmatic rupture is difficult, and delays could result in a catastrophic outcome. Congenital diaphragmatic hernia cdh is a defect that occurs in 1 in 3,000 live births, of which approximately 60% occur in isolation without other congenital anomalies.
In blunt trauma, diaphragm rupture due to a sudden increase in intraabdominal pressure is mostly leftsided, with the leftright rupture ratio being 31. The frequency with which either of these mechanisms leads to diaphragmatic injury varies according to the geographic location. In the study by hanna, which included 105 patients with diaphragmatic injury over a period of years, only 22. The diagnosis is challenging because of nonspecific and low sensibility clinical features. Traumatic rupture of diaphragm the annals of thoracic surgery. Blunt trauma in the young male population drivers is the usual cause of traumatic diaphragmatic rupture incidence. We report the case of a patient with blunt trauma with right diaphragmatic rupture that required urgent surgical treatment for hepatothorax and iatrogenic severe liver injury. The incidence rates of traumatic diaphragm rupture is between 0. Penetrating traumatic diaphragm injuries springerlink. Traumatic diaphragmatic injuries are rare, but potentially life threatening due to herniation of abdominal organs into the.
Diaphragmatic rupture is a topic covered in the pediatric surgery nat to view the entire topic, please sign in or purchase a subscription apsa pediatric surgery library combines pediatric surgery not a textbook nat with apsa expert, a powerful platform for earning moc cme credits all powered by unbound medicine. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 5% of cases of severe blunt trauma to the trunk. Oct 08, 2015 diaphragmatic injuries are relatively rare and result from either blunt trauma or penetrating trauma. Jan 09, 2012 the aim of this retrospective study was to analyze the clinical presentation, diagnostic methods and surgical management of patients with diaphragmatic rupture at our institution. Traumatic diaphragmatic rupture is difficult to diagnose in polytrauma.
Blunt diaphragmatic rupture is a serious condition that requires surgical repair. Unfortunately, the diagnosis is often delayed because. The mechanisms underlying blunt and penetrating diaphragmatic rupture are completely different. It is a recognized consequence of high velocity blunt trauma to the abdomen, usually as a result of road traffic collisions or lateral intrusions into the vehicle and occasionally, penetrating thoracoabdominal trauma. Tdi is commonly associated with multiple organ injuries. Diaphragmatic injuries are relatively rare and result from either blunt trauma or penetrating trauma.
Spontaneous diaphragmatic rupture sdr is a very rare surgical emergency. Traumatic diaphragmatic rupture is a possible lifethreatening condition that occurs up to 5% of major thoracoabdominal traumas. Efast scan could be useful as a rule in diagnostic tool. Diaphragmatic injury may occur due to both penetrating and blunt trauma. Of the 11 cases of diaphragmatic rupture, diaphragmatic discontinuity was seen in eight, visceral herniation was seen in six, and the collar. Traumatic diaphragmatic injuries are rare, but potentially lifethreatening due to herniation of abdominal organs into the. Therefore, diagnosis of diaphragmatic injury requires a high index of suspicion. Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of latent cases is dependent on the consequence of the diaphragmatic rupture. Traumatic diaphragmatic rupture is uncommon with leftsided injuries more frequently reported than the right due to the protective nature of the liver. Rightsided diaphragmatic rupture after blunt trauma. The mechanism of injury is typically a motorvehicle collision.
The cough is a complex physiologic response designed to protect airways from unwanted secretions and foreign materials. Unfortunately, the diagnosis is often delayed because clinical and radiographic evaluations are insensitive. The trip database provides clinical publications about. A possible explanation for sdr might be a sudden increase of intraabdominal pressure due to intense coughing, physical exercise, vomiting, or delivery. Traumatic diaphragmatic injury department of surgery at. Many cases of spontaneous dr followed by strenuous sports activity have been reported in the medical literature. The entity of diaphragmatic rupture posttrauma was first described by sennertus in 1541. To highlight the various signs and imaging features of diaphragmatic rupture in patients after blunt trauma to the thoracic and abdominal regions. Diaphragmatic rupture and its complications following blunt trauma findings on helical ct poster no c1907. Diaphragmatic injuries are estimated to occur in 0. Diaphragmatic injury may occur due to both penetrating and blunt traumas.
Article information, pdf download for diaphragmatic injuries. Traumatic diaphragmatic injury di is a unique clinical entity that is usually occult and can easily be missed. Management of diaphragmatic rupture from blunt trauma tan k k, yan z y, vijayan a, chiu m t abstract introduction. Management of diaphragmatic rupture from blunt trauma. The possible mechanisms of this rare complication are explained. The most commonly herniated abdominal structures are stomach, omentum and colon.
Diaphragmatic rupture often results from blunt abdominal trauma. Missed blunt diaphragmatic rupture results in herniation of the abdominal organs into the chest due to the abdominothoracic pressure gradient, which progressively enlarges the diaphragmatic defect 7. Article views article views pdf downloads pdf downloads. Although acquired diaphragmatic rupture is often associated with trauma, rarely it may be spontaneous atraumatic. Patients with diaphragmatic rupture present ing in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy. Note that it has fallen medially and posteriorly to lie against the posteromedial chest wall. The true incidence of traumatic diaphragmatic rupture is unknown. The patient went directly to the operating room where she underwent a splenectomy and repair of her diaphragm rupture. The incidence of post trauma blunt diaphragmatic injury. A combination of a tension pneumothorax in presence of an ipsilateral diaphragmatic rupture can be called lifesaving since the air in the pleural space is able to escape to the abdomen. Although initial ct scan was inconspicuous, a followup ct scan revealed.
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