Delayed Presentation of Traumatic Diaphragmatic Rupture

doi:10.1016/j.jemermed.2007.09.044

The Journal of Emergency Medicine

Volume 39, Issue 1, July 2010, Pages 21-24

https://doi.org/10.1016/j.jemermed.2007.09.044 Get rights and content

Abstract

We present the case of a 57-year-old woman who suffered a delayed presentation of a traumatic diaphragmatic rupture (TDR). Because TDR is frequently missed on initial presentation, a delay between trauma and diagnosis can present a unique diagnostic dilemma for the emergency physician. Important historical clues and physical examination findings are the keys to making this diagnosis.

Introduction

Although acute diaphragmatic rupture is a relatively common occurrence in a level 1 trauma center, delayed diaphragmatic rupture can be extremely difficult to recognize. Acute diaphragmatic rupture is usually diagnosed within the first few hours after a high-velocity motor vehicle crash, whereas patients with delayed diaphragmatic rupture typically do not become symptomatic for months or years after the inciting trauma. Oftentimes, the patient presenting with a delayed diaphragmatic rupture does not provide the history of remote abdominal or chest trauma, making the diagnosis much more difficult.

Traumatic diaphragmatic rupture (TDR) is a rare but known consequence of high-velocity blunt trauma to the chest and abdomen, usually the result of a motor-vehicle crash (1). It has been reported to occur with an incidence of 3–8% after blunt trauma, or 5% of patients requiring laparotomy for blunt or penetrating trauma to the chest and abdomen (2, 3). Proposed mechanisms of injury include shearing of a stretched membrane and avulsion of the diaphragm from its points of attachment due to the sudden increase in intra-abdominal pressure, which is then transmitted through the viscera (2, 3, 4). Left-sided rupture is up to nine times more common than right-sided rupture, possibly due to an inherent weakness in the left hemi-diaphragm or due to the relative protection of the right hemi-diaphragm via the liver (2, 4, 5). Interestingly, a disproportionate number of patients that present with delayed diaphragmatic rupture are found to have right-sided rupture (4). One possible explanation for this is that right-sided TDR is simply less likely to be visualized by today's testing modalities and remains occult until patients become symptomatic (5).

Section snippets

Case Report

A 57-year-old woman with a history of hypertension, diabetes, reflux, and anxiety presented with constant, severe 10/10 substernal chest pain, which she characterized as “heaviness and tightness.” The patient's symptoms began on the day before presentation while watering her garden. The pain radiated down her right arm, was associated with shortness of breath, and was exacerbated by movement as well as lying supine. She reported dyspnea on exertion, paroxysmal nocturnal dyspnea, and four-pillow

Discussion

TDR is a rare but serious injury that can remain asymptomatic for a long period of time. The longest documented delay in presentation that we found was a case report with a 50-year interval from the initial trauma to discovery of the TDR. This case was similar to ours in that both patients presented with sudden hemodynamic instability (4).

Delayed presentation can make the diagnosis even more difficult for the clinician, as the events of the initial injury are usually not known. Specific

Conclusion

Delayed TDR is a rare but serious injury that can cause rapid hemodynamic deterioration and a frightening presentation for both the patient and the emergency physician. It is important to recognize the signs and symptoms of this condition and suspect it when there is significant trauma, regardless of how remote.

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Cited by (19)

Diaphragmatic Rupture: Too Much to Stomach
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Delayed presentation of diaphragmatic rupture with stomach herniation and strangulation
2015, American Journal of Emergency Medicine
Missed right post-traumatic diaphragmatic injuries: A review of six cases
2012, Revue de Pneumologie Clinique
Les lésions diaphragmatiques (LD) post-traumatiques droites sont rares ; la littérature rapporte surtout des cas isolés ou de petites séries et le plus souvent il s’agit de rupture succédant à un traumatisme fermé. Cette série est particulière par le nombre de cas et par l’existence de deux lésions après plaie par arme blanche.
Étude rétrospective entre janvier 2002 et septembre 2010. Nous avons recueilli les données du traumatisme, cliniques, radiologiques, opératoires, et celles du suivi de six patients pris en charge pour lésion diaphragmatique post-traumatique droite.
Toutes les lésions ont été de présentation tardive. Quatre ont été secondaires à un accident de la voie publique, et deux après plaie par arme blanche. Le délai diagnostique a été entre 47 jours et 15 ans. La thoracotomie postérolatérale droite a été la voie d’abord élective pour les cas de hernie diaphragmatique (5 patients). Dans un cas, la chirurgie thoracoscopique vidéoassistée a permis le diagnostic de la lésion et sa réparation. La mortalité a été nulle et la morbidité a été d’un cas sur six. La durée de suivi allant de huit mois à 42 mois n’a pas objectivé de complications à long terme.
La hernie diaphragmatique droite est une séquelle redoutable après traumatisme thoraco-abdominal. La chirurgie devient complexe à ce stade et ne peut se faire que par thoracotomie. Devant des signes de forte suspicion au stade initial du traumatisme, une exploration par thoracoscopie peut toujours éviter la survenue des séquelles à long terme.
Right posttraumatic diaphragmatic injuries are rare; literature relates mainly isolated cases or small series and most often rupture are succeeding of blunt trauma. This series is interesting because the number of cases and the existence of two injuries following a right stab wound.
Retrospective study between January 2002 and September 2010. We collected the data of initial trauma, clinical, radiological, operative and follow-up for six patients supported for right posttraumatic diaphragmatic injuries.
All injuries were in late presentation. Four injuries were secondary to road traffic accident, and two after stab wound. The time to diagnosis was between 47 days and 15 years. Right posterolateral thoracotomy was the elective approach in the cases with diaphragmatic hernia (5 patients). In one case, video-assisted thoracoscopic surgery permits the diagnosis and repair of injury. Mortality was null and morbidity was present in one case from six. Follow-up ranging from 8 months and 42 months don’t objectified complications.
Right diaphragmatic hernia is terrible sequelae after thoracoabdominal trauma. Surgery becomes more complex at this stage and can be done by thoracotomy. With strong suspicious signs at the first assessment of trauma, exploration by thoracoscopy can always avoid the occurrence of long-term sequelae.
Avulsion injuries of the male external genitalia & rupture of the diaphragm following road traffic accident
2011, Journal of Forensic and Legal Medicine
Citation Excerpt :
Blunt trauma to the abdomen increases the transdiaphragmatic pressure gradient between the abdominal compartment & the thorax.6 This causes shearing of a stretched membrane & avulsion of the diaphragm from its points of attachments due to sudden increase in intra-abdominal pressure, transmitted through the viscera.7 The objective of the present paper is to highlight an unusual case of degloving lesion of the male external genitalia, rupture of the diaphragm, herniation of the abdominal viscera into the thoracic cavity & tearing of the heart & liver from their respective anatomic attachments, following run over by the tyre of a heavy vehicle.
Injury to the male external genitalia and rupture of the diaphragm, are two very uncommon autopsy findings. To the best of our knowledge such a combination of injuries has not been reported in one particular case of autopsy in an English scientific literature. Degloving of the male external genitalia & rupture of the diaphragm may result from motor vehicle accidents, industrial accidents, gunshot & stab injuries. A rare case of traumatic degloving injury of the male external genitalia associated with rupture of the diaphragm & intermingling of thoracic & abdominal viscera is presented here.
Complicated Diaphragmatic Hernia in Emergency Surgery: Systematic Review of the Literature
2020, World Journal of Surgery
Delayed presentation of traumatic diaphragmatic rupture with tension colothorax and strangulation of the transverse colon
2020, BMJ Case Reports

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Clinical communication: AdultDelayed Presentation of Traumatic Diaphragmatic Rupture

Abstract

Introduction

Section snippets

Case Report

Discussion

Conclusion

Injury

Clin Radiol

Injury

Radiol Clin North Am

Clinical communication: Adult
Delayed Presentation of Traumatic Diaphragmatic Rupture