Presentation
Motor vehicle accident.
Patient Data
Left sided pneumothorax, lower rib fractures and chest wall / neck subcutaneous emphysema.
The expected normal contour of the left hemidiaphragm is not present and the stomach is elevated from its typical location.
Patient went on to have a CT scan. No IV contrast given due to the patient's acute renal impairment. Some oral contrast was passed down the NG tube.
There is a defect in the left hemidiaphragm through which a significant portion of the stomach has herniated. The herniated portion appears markedly thick walled and there is extensive inflammatory change surrounding it. In addition no contrast passes through into the distal stomach or duodenum suggesting that there may well be an associated obstructive component. No definite twist can be demonstrated. The other intra abdominal organs which are unenhanced appear within normal limits. There is no free gas. There is a little fluid around the abnormal stomach. There is left lower zone consolidation and linear atelectasis with a small left pleural effusion, but the lung bases are otherwise clear. No bone lesion.
Case Discussion
Delayed presentation of hemidiaphragm rupture following chest trauma is not unusual and emphasizes the importance of evaluating the diaphragm carefully on initial trauma CT scans. This patient went on to have a laparoscopic diaphragmatic repair, and recovered uneventfully.
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