Right diaphragmatic injury initially missed

Case contributed by Dr Andrew Dixon

Presentation

Trauma patient transferred from a non-trauma hospital with pulmonary contusion and one undisplaced rib fracture on initial CT (not available).

Patient Data

Age: 30 years
Gender: Male
X-ray

Day 1

Airspace opacity in the right mid-lower zone with the medial aspect of the right hemidiaphragm not well visualised. Appearance is in keeping with pulmonary contusion in this setting. No haemothorax or pneumothroax seen. No rib fracture identified.  

X-ray

Day 3

A right sided chest tube has been positioned in the midzone and a small volume of associated subcutaneous emphysema is present. Ongoing airspace opacity within the right to lower zone in keeping with pulmonary contusion. Again the medial portion of the right hemidiaphragm is not well seen. 

X-ray

Day 4

The chest tube has been removed. Small volume chest wall subcutaneous emphysema. Some reduction in the right mid-lower zone airspace opacity (pulmonary contusion) is seen. There is now a more obvious focal bulge elevating the medial portion of the right hemidiaphragm. Appearance is suspcious for traumatic diaphragmatic injury in this setting and CT is recommended for confirmation.  

CT confirms a defect in the dome of the right hemidiaphragm with herniation of a small portion of liver through the defect. There is airspace opacity in the right middle lobe and to a lesser degree the right lower lobe in keeping with pulmonary contusion. Trace volume right pleural fluid and subcutaneous and mediastinal emphysema related to recently removed intercostal catheter. Subtle fracture of the right 12th rib posteriorly. 

Case Discussion

An example of a right hemidiaphragm injury not picked up until 4 days after initial injury. The day 1 CT (not available) did not detect the injury. It is very common for diaphragmatic injuries to be missed on initial trauma CT and then to present later as the defect grows and herniation of abdominal contents into the chest develops. The diaphragm is an important check area on trauma CT and follow-up chest x-rays after trauma. This case is slightly rare in that the diaphragm rupture is on the right rather than the more commonly effected left side. This case was confirmed surgically and was repaired. 

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Case information

rID: 55566
Case created: 14th Sep 2017
Last edited: 15th Sep 2017
System: Trauma
Inclusion in quiz mode: Included

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