Presentation
High speed car accident.
Patient Data
Supine trauma chest X-ray.
ETT in appropriate position. Density in right upper zone with volume loss (mediastinal and tracheal deviation, elevated right diaphragmatic peak) in keeping with collapse of the right upper lobe.
Left hemithorax appears normal with good visualization of the left diaphragm.
CT chest/abdo/pelvis.
Volume loss demonstrated in right hemithorax with mediastinal shift to right. Partial collapse of the right upper lobe, and areas of partial bilateral lower lobe atelectasis. Multiple nodular densities visualized in the right middle lobe, favored to be pulmonary contusion.
On close examination of coronal and sagittal CT imaging, subtle contour change is noted in the left hemidiaphragm dome which is directly adjacent to the underlying stomach. This may represent a tiny defect in the diaphragm in the setting of trauma. No other intraabdominal injury or acute fractures identified.
Day 3 erect chest X-ray.
Patient has been extubated. Right upper lobe collapse has resolved. New apparent elevation of the left hemidiaphragm seen, with a visible gastric bubble. Left hemidiaphragm contour is not well defined. Associated blunting of the left costophrenic recess. Given recent history of trauma, the possibility of rupture of the diaphragm should be revisited.
CT chest.
Large defect involving the dome of the left hemidiaphragm is noted with associated herniation of the body of the stomach and intrabadominal fat into the left hemithorax. Appearance in keeping with traumatic rupture of the left hemidiaphragm. Mild left lower lobe atelectasis is also visualized.
Day 9 erect chest x-ray post repair of the left ruptured hemidiaphragm. Clear lung bases bilaterally with a small left pleural effusion, associated with blunting of the left costophrenic angle.
Case Discussion
This case emphasizes that diaphragmatic rupture can be extremely subtle on the initial CT imaging, and can take several days, weeks or months to present itself in trauma patients. Interestingly, left hemidiaphragm is more commonly involved than the right hemidiaphragm, likely due to the buffering effect of the liver.
It is therefore important to consider delayed diaphragmatic rupture on follow up x-rays for trauma patients, if there is evidence of an elevated or unclear hemidiaphragm border or intrathoracic herniation of a hollow viscus.
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