Thoraco-abdominal multitrauma with diaphragmatic rupture
The patient was involved in a high speed motor vehicle accident. A CT trauma series was performed.
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- Small right and moderate left hemopneumothoraces
- Bilateral multilevel rib fractures
- T8 and T10, L1 and L4 single column vertebral fractures
- Right adrenal hemorrhage
- Left anterolateral diaphragmatic rupture
2 case question available
Adrenal injury is uncommon due to the retroperitoneal location of the adrenal gland 2. It has been noted to occur in 2-3% of blunt abdominal injury 3, with motor vehicle accident being the most common cause. It is worth noting that right sided adrenal trauma is much more common than the left, with a ratio of 3-4:1 being quoted 1,2. This has been suggested to be caused by the short right adrenal vein which directly connects to the inferior vena cava. In blunt trauma, rapid increases in IVC pressure are likely associated with right adrenal trauma.
Complications of adrenal injury include uncontrolled hemorrhage and adrenal insufficiency.
This complex multitrauma case highlights a case of right adrenal hemorrhage. Adrenal hemorrhage is the most common type of adrenal trauma.
Diaphragmatic rupture is another traumatic finding, commonly found in blunt trauma (motor vehicle accidents and falls from height). The left sided diaphragm is usually involved. This has been speculated because of an intrinsically weaker left sided diaphragm, or because the liver on the right side provides protection 4. Diaphragmatic rupture is clinically relevant because it may result in herniation and strangulation of intra-abdominal viscera into the thoracic cavity 5. While the gold standard of diagnosis and treatment has been laparotomy, minimally invasive methods including video-assisted thorascopic surgery are gaining favor 6.
Case contributed by A/Prof. Pramit Phal.
- 1. Radiopaedia - Adrenal Gland trauma; http://radiopaedia.org/articles/adrenal-gland-trauma
- 2. Lee YS, Jeong JJ, Nam KH et-al. Adrenal injury following blunt abdominal trauma. World J Surg. 2010;34 (8): 1971-4. doi:10.1007/s00268-010-0537-x - Pubmed citation
- 3. Sinelnikov AO, Abujudeh HH, Chan D et-al. CT manifestations of adrenal trauma: experience with 73 cases. Emerg Radiol. 2007;13 (6): 313-8. doi:10.1007/s10140-006-0563-z - Pubmed citation
- 4. E-Medicine: Diaphragmatic Injuries; http://emedicine.medscape.com/article/822999-overview
- 5. Dwivedi S, Banode P, Gharde P et-al. Treating traumatic injuries of the diaphragm. J Emerg Trauma Shock. 2010;3 (2): 173-6. doi:10.4103/0974-2700.62122 - Free text at pubmed - Pubmed citation
- 6. Leppaniemi AK. Thoracoscopy in chest trauma: an update. Trauma. 2001;3:111–7