Multitrauma with diaphragmatic rupture

Case contributed by Dr Heather Pascoe

Presentation

MVA. Car vs pole.

Patient Data

Age: 85
Gender: Female
CT

Brain and Cervical spine

Brain

  • No acute intracranial pathology

C-Spine

  • Undisplaced fracture through the tip of the left C7 transverse process.
  • Hematoma and stranding on the left side of the neck superficial to sternocleidomastoid and tracking deeply, anterior to the scalene muscles.
  • Multilevel degenerative changes. Grade 1 (2 mm) anterolisthesis of C7 on T1.
CT

Chest, Abdomen and Pelvis

Chest

  • Moderate left hemopneumothorax.
  • Left lung contusions.
  • Traumatic left hemidiaphragm rupture with herniation of mesenteric fat and large and small bowel into the left hemithorax.
  • Non-displaced fracture of the manubrium, extending more to the left, with associated anterior mediastinal hematoma.
  • There is a small gas locule in the right side of the posterior mediastinum and a small locule of left-sided retrocrural gas. No definite esophageal injury identified.
  • Soft tissue stranding in the lateral aspect of the right breast is likely due to hematoma/contusion.
  • Multiple right-sided anterolateral rib fractures: 2-7th ribs.
  • Multiple left-sided rib fractures: 1st rib posteriorly, 2nd and 3rd ribs anteriorly and 6th-10th ribs laterally. There is marked displacement of the inferior rib fractures with herniation of small and large bowel into the left lateral thoracic and abdominal wall.

Abdomen/Pelvis:

  • Large volume of free intraperitoneal gas.
  • Splenic flexure perforation.
  • Defect in the left lateral abdominal wall with herniation small and large bowel into the left lateral thoracic and abdominal wall.
  • Small splenic laceration (AAST Grade I).
  • Very small volume of free intraperitoneal fluid.
  • Left lower anterior abdominal wall contusion (seat-belt sign) with contrast blush and left rectus hematoma with foci of active bleeding. Right linear semilunaris blush.
  • Collapsed IVC consistent with hypovolemia.

Thoracic spine:

  • Non-displaced avulsion fracture of the left transverse process of T12.

Lumbar spine:

  • Compression fracture of the superior endplate of L3 associated with 40% loss of vertebral body height.
  • Compression fracture of the superior endplate of L4 with minimal displacement or loss of height.
  • Left L1 and L2 transverse process fractures.

Incidental findings:

  • Grade 1 (4 mm) anterolisthesis of L4 on L5.
  • Incompletely imaged 15 mm right lobe of thyroid nodule.

Case Discussion

Diaphragmatic injury can result from blunt or penetrating trauma. It can be a difficult diagnosis to make (not in this case) and is often missed. It is associated with other life threatening injuries in 44-100% of cases 1. With left sided diaphragmatic injury, splenic injuries are the most common associated injury, whilst with right sided injuries, the liver is most commonly injured 1.

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Case information

rID: 32903
Published: 9th Feb 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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