Case: 55-year-old restrained driver is reporting severe shortness of breath and right sided chest pain after a high-speed motor vehicle collision. Her respiratory rate is 26 breaths/min and her oxygen saturation is 96% on a 15-liter non-rebreather. She has decreased breath sounds on the right, epigastric tenderness, and an abdominal seatbelt sign. What is the diagnosis?

Poll Results

Diaphragmatic Rupture

Explanation

[plot id=”1″] [su_spoiler title=”Answer” style=”fancy” icon=”caret”]

The CXR shows a prominent elevation of the right hemidiaphragm (red arrow) and consolidation in the right upper lobe (yellow arrow) with no visible pneumothorax or fracture. Ruptured diaphragm or significant hemothorax should be at the top of the differential.

The CT scan confirms the diagnosis of right sided diaphragm rupture and shows

Significant superior extension of the liver with the dome reaching the level of the carina

Mediastinal shift to the left

Small right pleural effusion

Almost complete consolidation of the right lung

Fractures of the right fourth, seventh, eighth ribs, and a fracture of the left L5 transverse process

Traumatic right-side diaphragmatic ruptures are less common than left sided ones because the liver behaves like a shield absorbing the intra-abdominal force in blunt trauma.1

Diaphram rutpture by the numbers

70-80% – cases are left-sided diaphragmatic ruptures

– cases are left-sided diaphragmatic ruptures 15-25% – cases are right-sided ruptures

– cases are right-sided ruptures 5-8% – cases are bilateral ruptures 2

– cases are bilateral ruptures 10x – increase in intra-abdominal pressure in deceleration injuries, especially if the patient is holding his/her breath and/or contracts abdominal muscles at the time of impact 3

This increase in the pressure gradient across the diaphragm causes shearing of the diaphragm from its attachments.4 The significant force required to rupture the diaphragm usually causes other significant injuries, including:5

Shock

Respiratory failure

Visceral injury

Neurological injury.

Consequently, diaphragmatic injuries are easily missed in the acute presentation due to other organ injuries that may complicate the clinical picture.5

Master Clinician Bedside Pearls

Danielle Campagne, MD FACEP

Assistant Clinical Professor of Emergency Medicine

University of California San Francisco – Fresno

1. J Natl Med Assoc. 1984;76(12):1163-1164. PubMed] Fajolu O. Traumatic diaphragmatic hernia.. 1984;76(12):1163-1164. 2. Case Rep Pulmonol. 2013;2013:814632. PubMed] Dwari A, Mandal A, Das S, Sarkar S. Delayed presentation of traumatic diaphragmatic rupture with herniation of the left kidney and bowel loops.. 2013;2013:814632. 3. World J Emerg Surg. 2011;6:3. PubMed] Vilallonga R, Pastor V, Alvarez L, Charco R, Armengol M, Navarro S. Right-sided diaphragmatic rupture after blunt trauma. An unusual entity.. 2011;6:3. 4. Ulus Travma Acil Cerrahi Derg. 2012;18(2):175-177. PubMed] Kuppusamy A, Ramanathan G, Gurusamy J, Ramamoorthy B, Parasakthi K. Delayed diagnosis of traumatic diaphragmatic rupture with herniation of the liver: a case report.. 2012;18(2):175-177. 5. Ann Surg. 1993;218(6):783-790. PubMed] Meyers B, McCabe C. Traumatic diaphragmatic hernia. Occult marker of serious injury.. 1993;218(6):783-790.

Share This Facebook

Twitter

Pocket

Print

Instagram



[/su_spoiler]